The Impact of the Syrian Civil War on One Department in an Israeli Hospital.

During the Syrian civil war, Syrian refugees crossed the Israeli border to receive medical treatment. During this time, Galilee Medical Center (GMC) became the main center for multidisciplinary treatment of these war-wounded patients. This retrospective study compares the demographics of local Israeli and refugee Syrian patients, as well as the volume and types of procedures each group received over a 5-year period. From January 2013 to December 2017, 963 unique patients underwent 1,751 procedures in the GMC Plastic Surgery Department. Of these patients, 176 were Syrian-including 42 children-and 787 were Israeli. These groups underwent 393 and 1,358 procedures, respectively, for a procedure-per-patient ratio of 2.23 versus 1.72, respectively. On average, Syrian patients tended to be younger than Israeli patients (23.6 vs. 49.25 years), had longer median hospitalization time (50 vs. 8 days), longer median operative times (102 vs. 85 minutes), and higher incidence of infection with multidrug-resistant bacteria (52.2 vs. 5.8%). Further, Syrian patients had more trauma-related procedures, such as skin grafts, wound debridement, and microsurgery, than Israeli patients. Through this process, GMC's plastic surgery department gained unprecedented exposure to a variety of complex procedures.

Microsurgery for management of primary and secondary lymphedema.

OBJECTIVE: The objective of this study was to evaluate the efficacy and safety of lymphaticovenular anastomosis (LVA) in patients with lymphedema. METHODS: A retrospective analysis was conducted of 70 patients suffering from primary or secondary lymphedema who underwent LVA surgery with indocyanine green fluorescence lymphangiography. Postoperative evaluation included qualitative and quantitative volumetric assessment and analysis. Limb volume was measured by circumferential tape measurement volumetric method, in which the limb is subdivided into five segments and each segment's circumference is measured. RESULTS: LVA was performed in 70 patients, 22 with primary lymphedema and 48 with secondary lymphedema. The difference in preoperative upper limb volume was 35% with mean postoperative follow-up of 9 months. The mean number of lymphovenous bypasses was 3.9. The reduction in limb volume at 3, 6, and 12 months was 40.4%, 41%, and 45%, respectively. Patients with early-stage lymphedema had significantly higher volume reductions than patients with late-stage lymphedema at 3, 6, and 12 months (48% vs 18%, 49% vs 22%, and 65% vs 31%; P < .001). For lower extremity lymphedema, the preoperative volume differential was 25.5%. The mean postoperative follow-up was 9 months. The reduction in limb volume at 3, 6, and 12 months was 28%, 37%, and 39%, respectively. CONCLUSIONS: LVA surgery is a safe and effective method of reducing lymphedema severity, especially in upper extremity lymphedema at an earlier disease stage.

Delayed immune mediated adverse effects to hyaluronic Acid fillers: report of five cases and review of the literature.

Hyaluronic acid (HA) fillers in cosmetic medicine have been considered relatively safe, though fillers used in European countries and throughout the world are not necessarily approved by the Food and Drug Administration. As their use continues to expand worldwide, physicians in a wide range of medical specialties are authorized to perform HA injections, including general medicine practitioners and even dentists. An increasing number of reports have appeared regarding side effects to these products. It is now known that reactions to Hyaluronic acid are related not only to technical faults of the injections, but also to immune responses, including delayed hypersensitivity and granulomatous reactions. Herein, we describe five cases treated by a variety of treatment modalities, all with delayed reactions to different brands of hyaluronic acid fillers. As there is currently no standardization of treatment options of adverse effects, these cases accentuate the debate regarding the approach to the individual patient and the possible need for pre-testing in patients with an atopic tendency.

Nasal septal perforation repair using oral mucosal flaps.

BACKGROUND: Surgery for the closure of nasal septal perforations is challenging. Numerous techniques have been described. OBJECTIVES: To assess whether nasal septal perforations heal less consistently if a connective tissue scaffold is not placed between the repaired septal flaps. METHODS: We performed closure of a septal perforation via a closed approach using oral mucosal flaps without the interposition of a connective tissue graft in seven patients. RESULTS: Complete perforation closure was achieved in 5 cases (71.4%). There was no significant donor site morbidity. CONCLUSIONS: These initial results suggest that this is an effective technique for closing nasal septal perforations; it obviates the morbidity of the open approach and the added operating time and morbidity associated with the harvesting of a connective tissue graft.

Familial juvenile hypertrophy of the breast.

OBJECTIVE: Juvenile (virginal) hypertrophy of the breast (JHB) is a relatively rare condition leading to gigantomastia in peripubertal females. The pathology is limited usually to the breast, with otherwise normal growth and development and without any other deformities. The rapid growth of the breast (bilateral or unilateral) in adolescent girls leads to significant physical and psychological difficulties. This gigantomastia is treated surgically by breast reduction or mastectomy and its modification. Familial JHB was described only once in the literature, and its etiology is unknown. RESULTS: We report here on a familial pattern of juvenile hypertrophy of the breast accompanied by congenital anonychia. To the best of our knowledge, this is the first report of such a presentation. Our study dealt with four members of the same family, related through their fathers, enduring congenital anonychia of hands and feet with no functional limitation and who showed rapid uncontrolled breast enlargement in prepubertal age. This was severe enough to cause the curtailment of their social activity and cessation of schooling. The mothers of all four patients had normal breasts and nails, whereas their fathers had anonychia. The genetic basis for the association between the two clinical findings is yet to be determined. CONCLUSION: The four girls underwent breast reduction surgery.

Vertical (two-layer) skin grafting: new reserves for autologic skin.

The main, permanent source of burn coverage continues to be autologic skin. In patients with major burns, the amount of available autologic skin may be insufficient. Consequently, severe wounds are covered after debridement with other biological or synthetic skin substitutes. Another source of skin reserves for wound coverage is the use of cultured keratinocyte sheet graft alone or with any dermal substitute. Some of these materials provide only temporal coverage and are often costly and time-consuming in preparation. These factors can be critical in burned patients. To expand the effective means of wound coverage, the authors sought a new source of autologic skin. The dermal grafts that were the marginal product of skin harvesting were meshed and grafted on the debrided third-degree burn, granulated wound, or muscle. The authors observed good dermal grafts "take" with rapid or slow epithelialization. They saw no the delay in donor site healing where the skin grafts overlapped. The histological difference in usual skin grafts and dermal grafts was studied after their harvesting and "taking."