Robotic Follicular Unit Graft Selection.

BACKGROUND: The use of robotic technology to harvest grafts in a follicular unit extraction (FUE) hair transplant procedure has been available since 2011. A new capability of the robotic system is to harvest follicular units based on the number of hairs they contain to increase the hair/wound yield. OBJECTIVE: To assess the benefit of follicular unit graft selection during a robotic FUE procedure. MATERIALS AND METHODS: This bilateral controlled study of 24 patients was designed to evaluate the ability of a robotic system to perform follicular unit graft selection. RESULTS: Compared with random follicular unit harvesting (the method performed by current robotic systems), robotic follicular unit graft selection produced more hairs per harvest attempt (2.60 vs 2.22) and more hairs per graft (2.72 vs 2.44). The clinical benefit of follicular unit graft selection (as measured by the increase in hairs per harvest attempt) was 17.0%. The clinical benefit (as measured by the increase in hairs per graft) was 11.4%. Results were statistically significant at p < .01. CONCLUSION: This study demonstrates the ability of robotic follicular unit graft selection to increase the amount of hairs yielded per donor wounds made in an FUE procedure.

Current status of surgery in dermatology.

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

Topical bimatoprost for the treatment of eyebrow hypotrichosis.

Topical bimatoprost was FDA approved in December of 2008 for the treatment of eyelash hypotrichosis. Since its approval, some physicians have advocated the use of bimatoprost "off label" for hair growth in other areas, such as the scalp or eyebrows, but there has yet to be published scientific evidence to support this use. We report one of the first cases of significant eyebrow hair growth in a patient after use of topical bimatoprost for eyebrow hypotrichosis.

Finasteride in the treatment of female pattern (androgenic) alopecia: a case report and review of the literature.

We describe a case of a 44-year-old woman with biopsy-proven female androgenic alopecia (FAGA), or female pattern alopecia, who was nonresponsive to topical minoxidil. After careful consideration and discussion with the patient, the decision was made to introduce oral finasteride 1.25 mg daily. After only 3.5 months of therapy there was a remarkable reduction in hair shedding and increased hair regrowth without any reported side effects. We also present a comprehensive review of the limited studies and case series that have reported finasteride use for FAGA.

Update on the pathogenesis, genetics and medical treatment of patterned hair loss.

Androgenic alopecia (AGA), or pattern hair loss, is a common condition that affects both men and women has been gradually increasing. The discovery of the androgen receptor (AR) gene and related genes has expanded the knowledge on the genetics of hair loss. These basic science studies, combined with more recent clinical studies, have led to a better understanding of the pathogenesis of AGA in both men and women. These genetic advances have also led to the development of a new screening test for AGA. Recently, in addition to the two currently approved U.S. Food and Drug Administration (FDA) medications (minoxidil and finasteride), a novel device was FDA-approved for the treatment of hair loss, the laser hair comb. Further studies are needed to verify the accuracy and validity of the genetic screening test and the efficacy of the laser hair comb.

Systemic lupus erythematosus: an independent risk factor for endothelial dysfunction in women.

BACKGROUND: Systemic lupus erythematosus (SLE) patients have a significantly increased risk of coronary heart disease (CHD) that is not fully explained by classic risk factors. Endothelial dysfunction is an early stage in the process of atherogenesis. Our aim was to determine whether endothelial dysfunction occurs in SLE and whether it is associated with the occurrence of classic Framingham risk factors. METHODS AND RESULTS: We studied 62 women with SLE (1997 revised criteria) and 38 healthy women. Demographic and risk factor data were collected. In patients, disease activity and treatment-related parameters were also assessed. Endothelial function was assessed by flow-mediated dilation (FMD) in the brachial artery in response to reactive hyperemia. Carotid intima-media thickness (IMT) and the presence of carotid plaques were also assessed in SLE patients. FMD was impaired in SLE patients (median, 3.6%; range, -6.3% to 13.7%; versus median, 6.9%; range, -6.6% to 17.8%, P<0.01). Using multiple regression analysis that included all subjects in which we retained all the classic CHD risk factors, we found that systolic blood pressure (P=0.019) and SLE (P=0.017) were significantly associated with impaired FMD. Within SLE patients, IMT showed a negative correlation with percent FMD (r=-0.37, P<0.01). In stepwise multiple regression of SLE patients only that also included SLE factors and IMT, IMT alone was independently associated with FMD (P=0.037). CONCLUSIONS: Patients with SLE have endothelial dysfunction that remained significant even after adjustment for other classic CHD risk factors. Within SLE patients, endothelial dysfunction correlates negatively with IMT, another marker of early atherosclerosis. Understanding the mechanism(s) of endothelial dysfunction in SLE may suggest novel strategies for CHD prevention in this context.

Follicular unit transplantation: 2005.

The recognition that the follicular unit is a discrete, anatomic and physiologic entity, and that preserving it through stereomicroscopic dissection is the best way to ensure the naturalness of the restoration, has brought hair transplantation into the twenty-first century. Issues yet to be resolved include determining the maximum density and number of grafts that can be used safely in a single session, deciding whether it is preferable to premake recipient sites or immediately place grafts into sites as they are made, and defining the precise role of follicular unit extraction. The essence of providing the best care for patients rests on proper patient selection, establishing realistic expectations, and using nonsurgical management for young persons who are just starting to thin.

Rigid fixation improves outcomes of spinal fusion for C1-C2 instability in children with skeletal dysplasias.

BACKGROUND: Upper cervical instability is common in many skeletal dysplasias, and surgical treatment can be difficult because of small, fragile osseous elements. In this study of children with skeletal dysplasia and upper cervical instability, we compared fusion rates and complications between (1) patients treated with no instrumentation or with wiring techniques and (2) those who underwent rigid cervical spine instrumentation. We also sought to characterize the presentation and common parameters of upper cervical instability in this population. METHODS: A multicenter study identified twenty-eight children with skeletal dysplasia who underwent surgery from 2000 through 2011 for C1-C2 instability and were followed for a minimum of two years. Fourteen children were treated with no instrumentation or with instrumentation with wires or cables (nonrigid-fixation group) and fourteen were treated with screws (or hooks) and rods (rigid-fixation group). All patients received autograft, and twenty (twelve in the nonrigid group and eight in the rigid group) were treated with a halo-body jacket. RESULTS: Fourteen children had C1-C2 fusion, and fourteen had occipitocervical fusion. Eleven (39%) underwent spinal cord decompression. The nonunion rate was significantly higher in the nonrigid-fixation group (six of fourteen) than in the rigid-fixation group (zero of fourteen; p = 0.0057). Complications, including nonunion, occurred in nine patients in the nonrigid group and one patient in the rigid group. However, two of the complications in the nonrigid-fixation group were vertebral artery bleeding episodes that actually occurred during an attempt at rigid fixation (the fixation was subsequently done with wiring). No new neurologic deficits were observed. Five of the seven children with a preoperative neurologic deficit showed at least partial recovery, with significant improvement in the Japanese Orthopaedic Association upper-extremity score (p = 0.047). CONCLUSIONS: The nonunion rate is relatively high after patients undergo spinal fusion for C1-C2 instability with nonrigid instrumentation, even if a halo-body jacket is applied. Rigid fixation with screws and rods improves fusion rates.

Arthrogryposis and amyoplasia.

Arthrogryposis (multiple congenital joint contractures) is an uncommon problem. Because there are many causes, correct diagnosis is important to predict the natural history and determine appropriate treatment. Inconsistent terminology has caused confusion about both diagnosis and treatment. Amyoplasia, the most common type of arthrogryposis, is characterized by quadrimelic involvement and replacement of skeletal muscle by dense fibrous tissue and fat. Early physical therapy and splinting may improve contractures, but surgical intervention is often necessary. Aggressive soft-tissue releases in addition to casting may improve joint position. In more severe contractures, osseous surgery also may be needed. Deformity recurrence is common, particularly in skeletally immature patients.

Splitting of the common peroneal nerve by an osteochondroma: two case reports.

Multiple exostoses is an autosomal dominant disease in which bony protuberances arise from the metaphyseal periphery. Most are asymptomatic but occasionally the tumors become troublesome, causing irritation to the surrounding tissues. While nerve compression by an adjacent osteochondroma has been reported, to our knowledge there are no reports of the tumor growing through the mid-substance of a nerve. This article reports two occurrences of an osteochondroma of the proximal fibula that was noted at surgery to grow through the common peroneal nerve, splitting it into two limbs. By reporting these cases, it is our hope to alert surgeons that this problem may occur, and care should be taken to identify the entire nerve prior to removal of the osteochondroma.

Performance of a new test strip for freestyle blood glucose monitoring systems.

BACKGROUND: a new strip, designed to enhance the ease of use and minimize interference of non-glucose sugars, has been developed to replace the current FreeStyle (Abbott Diabetes Care, Alameda, CA) blood glucose test strip. We evaluated the performance of this new strip. METHODS: laboratory evaluation included precision, linearity, dynamic range, effects of operating temperature, humidity, altitude, hematocrit, interferents, and blood reapplication. System accuracy, lay user performance, and ease of use for finger capillary blood testing and accuracy for venous blood testing were evaluated at clinics. Lay users also compared the speed and ease of use between the new strip and the current FreeStyle strip. RESULTS: for glucose concentrations <75 mg/dL, 73%, 100%, and 100% of the individual capillary blood glucose results obtained by lay users fell within ± 5, 10, and 15 mg/dL, respectively, of the reference. For glucose concentrations ≥75 mg/dL, 68%, 95%, 99%, and 99% of the lay user results fell within ± 5%, 10%, 15%, and 20%, respectively, of the reference. Comparable accuracy was obtained in the venous blood study. Lay users found the new test strip easy to use and faster and easier to use than the current FreeStyle strip. The new strip maintained accuracy under various challenging conditions, including high concentrations of various interferents, sample reapplication up to 60 s, and extremes in hematocrit, altitude, and operating temperature and humidity. CONCLUSIONS: our results demonstrated excellent accuracy of the new FreeStyle test strip and validated the improvements in minimizing interference and enhancing ease of use.

The lengthening of short upper extremity amputation stumps.

BACKGROUND: Short upper extremity amputation stumps are difficult to fit with an appropriate-level prosthesis. Fitting at a more proximal level generally results in decreased function. Options in the past have included stump and prosthetic modification, both of which provide limited improvement in function. Anecdotal reports of lengthening short amputation stumps have been published. This article reviews our experience with lengthening short upper extremity amputation stumps in children. METHODS: All patients who underwent an upper extremity stump lengthening at Shriners Hospital Los Angeles with at least 1-year follow-up were included. Charts and radiographs were retrospectively reviewed and prosthetic use preoperatively and postoperatively, complications, and additional procedures were documented. Stump length was measured on radiographs as the length between the proximal flexion crease and the tip of the bone. RESULTS: Eleven patients with 14 amputation stumps underwent lengthening. Mean stump length increase was 264% (4 cm). Nine patients desired prosthetic fitting; all except 1 were able to be fit with an appropriate-level prosthesis. Two of the 9 patients reported only using the prosthesis on rare occasions. The 2 remaining patients underwent lengthening to improve function but did not desire a prosthesis preoperatively. CONCLUSIONS: Lengthening is a viable but controversial option for very short upper extremity amputation stumps and may result in better function and/or more appropriate prosthetic fitting. Complications and additional procedures are common. Soft tissue coverage seems to be the main limiting factor to lengthening.

Evaluation of back pain in children and adolescents.

Back pain is fairly prevalent in healthy children and adolescents. When children or adolescents seek medical care for back pain, it is highly likely that underlying pathology will be identified. Common causes of back pain include nonspecific pain or muscle strain, herniated disk, spondylolysis, scoliosis, and Scheuermann's kyphosis. Less common causes include tumor, infection, and sickle cell crisis. If nonspecific back pain is suspected, treatment may include home-based exercise, physical therapy, or nonsteroidal anti-inflammatory drugs. If the history and physical examination suggest underlying pathology, radiography, complete blood count, erythrocyte sedimentation rate, and a C-reactive protein measurement should be performed. Follow-up magnetic resonance imaging, computed tomography, or bone scanning may be needed depending on the suspected cause. It is generally accepted that the following factors warrant immediate evaluation: patient age younger than four years, persistent symptoms, self-imposed activity limitations, systemic symptoms, increasing discomfort, persistent night-time pain, and neurologic symptoms.