Salvage of compromised free flaps in trauma cases with combined modalities.

Using the microsurgical technique for reconstruction in trauma cases represents a challenge for the reconstructive surgeon. Several methods of salvaging of a compromised free flap have been reported, among them: intravenous heparin washing, thrombolitic therapy, thrombectomy, use of grafts and others. Here, we present our experience from nine cases and a review of the literature regarding the use of various modalities for free flap salvage in trauma cases, and their results. Data was collected from trauma cases in our institutions over a period of 2 years, where reconstruction was performed using microsurgical techniques, and where subsequent complications required some type of salvage procedure. The techniques that were used for the salvage included: intravascular irrigation with heparin, papaverine and lidocaine; administration of continuous intravenous heparin, use of the Fogarty catheter, flap washing with streptokinase, and adventitia stripping. The free flaps used were latissimus dorsi, serratus anterior, and the anteromedial thigh flap. Either vein or artery thromboses were identified during the procedure or immediately after surgery in seven patients. Two patients had prolonged spasms of the recipient artery with low flow. In all cases, the No. 2 Fogarty catheter was used for thrombectomy and also for release of the vessel spasm. There was only one complete failure among these patients, and partial necrosis was encountered in three. From our experience and review of the literature, we offer an algorithm for determining treatment strategies in a range of flap salvage situations.

Different models of training and certification in plastic surgery.

A varying period of training followed by examinations is the usual way to become a specialist in one of the many fields of Medicine. Plastic Surgery is one of the surgical fields that require good technical and cognitive skills. The best way to train and evaluate a candidate is hard to judge. The model of training and board examination varies, every country having its own method. This is a descriptive report presenting the ways of training residents in Plastic Surgery and then examining them in Romania, Israel, U.S.A., Germany and the Netherlands. Specific points regarding the structure and the format are addressed for all models and also for factors that might influence the objectivity of the examination. The authors bring their thoughts on these issues.

Patient satisfaction after removal of skin lesions.

BACKGROUND: Removal of skin lesions is one of the most common surgical procedures, with the number increasing progressively since the 1980s. OBJECTIVE: We tried to evaluate the satisfaction level of patients after removal of skin lesions and to identify the factors influencing it. STUDY DESIGN: The study group consisted of 138 patients who had skin lesions removed by shaving or primary excision and closure. They were evaluated 1 year after the procedure. Two questionnaires were completed independently by the patient and the surgeon. RESULTS: The main indication for the procedure was suspicion of malignancy, functional disturbance, or aesthetic reason. The satisfaction level (general and specific areas) for patients who had a malignant tumour removed was similar to those who had a benign tumour removed. Females were less satisfied than males (P = 0.05). Younger people were less satisfied with the aesthetic results (P = 0.007). Patients who had at least one significant side-effect were less satisfied than those who did not mention any side-effects (P = 0.038). The higher the level of patient satisfaction, the higher the level of surgeon satisfaction (P = 0.012). CONCLUSION: Skin lesion removal, although considered to be a minor procedure, leaves scars that sometimes disturb the patient. According to our study, the most prevalent population for dissatisfaction is females and young males.

Electrical impedance scanning for melanoma diagnosis: a validation study.

BACKGROUND: A multicenter study was conducted to test the ability of electrical impedance scanning to differentiate between benign and malignant skin lesions. The performance of a dual electrical impedance scanning/image analysis device was also assessed. METHODS: Electrical impedance scanning measurements of 449 preoperative lesions found on 382 patients and including 53 melanomas from the trunk and extremities were performed. Results were correlated with histopathologic findings. In addition, ABCD parameters for the lesions were automatically calculated by the system. RESULTS: Electrical impedance scanning detected melanomas of the trunk and extremities with 91 percent sensitivity and 64 percent specificity. Moreover, sensitivity of electrical impedance scanning was increased to 100 percent for in situ and thin melanomas of smaller size (n = 27). Visual examination identified as malignant only 67 percent of these early tumors (p = 0.002). Clinical examination detected 96 percent of the larger or thicker melanomas (n = 26), whereas electrical impedance scanning detected only 81 percent of them. Combined electrical impedance scanning and image analysis detected 100 percent of the melanomas, independent of their thickness, and with no significant decrease of specificity. Because of electrical differences between the head/neck and the rest of the body, the assessed electrical impedance scanning parameters were not adequate for the diagnosis of melanomas from the head and neck. CONCLUSIONS: A validation study proved the value of electrical impedance scanning as a noninvasive technique for detection of melanoma lesions of the trunk and extremities, specifically, of in situ and thin type. In addition, image analysis was shown to be a valuable, complementary procedure. New parameters should be designed to optimize the performance of electrical impedance scanning for melanomas of the head and neck.

Ageing of human epidermis: the role of apoptosis, Fas and telomerase.

BACKGROUND: Aged human epidermis is characterized by morphological changes including flattening of the dermal-epidermal junction and a decrease in thickness. OBJECTIVES: To determine the roles of proliferation, apoptosis, Fas (CD95), Fas ligand (FasL) and telomerase in changes of human epidermis during ageing. METHODS: Human epidermis from aged subjects (n = 14; mean age 70.7 years) and young subjects (n = 14; mean age 23.4 years) was studied by histology, immunohistochemistry, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labelling assay for apoptotic cells and reverse transcription-polymerase chain reaction to determine epidermal thickness, proliferation (Ki-67), apoptosis, expression of Fas and FasL, and telomerase activity. RESULTS: Aged skin was associated with thinning of the epidermis, decreased proliferation, and increased apoptosis below the granular layer. This was associated with increased epidermal expression of Fas and FasL. Telomerase activity was similar in aged and young epidermis. CONCLUSIONS: Fas/FasL-mediated apoptosis, along with decreased proliferation, may have a role in changes of human epidermis during ageing. Telomerase activity did not appear to be limiting in young vs. old human epidermis.

The role of frozen storage in preserving adipose tissue obtained by suction-assisted lipectomy for repeated fat injection procedures.

BACKGROUND: The injection of autologous free fat obtained by suction-assisted lipectomy for the correction of soft tissue defects is a common procedure in plastic surgery. However, unpredictable partial absorption of the injected fat often necessitates repeated procedures. OBJECTIVE: To examine the role of frozen storage as a means of preserving the fat obtained by suction-assisted lipectomy for repeated procedures. METHODS: Human adipose tissue obtained by suction-assisted lipectomy was stored in a domestic refrigerator at -18 degrees C for 2 weeks. After thawing, the fat was injected into nude mice. In the control group, the fat was injected immediately after the harvesting procedure. Grafts were dissected out and compared 15 weeks postinjection. RESULTS: Injected fat survived in both study and control groups. No significant differences were found between fat graft weight and volume, or in any of the histologic parameters examined. CONCLUSION: Fat obtained by suction-assisted lipectomy may be preserved for future use by freezing.

Stimulated healing of recalcitrant wounds by topical application of enriched cell culture medium: a clinical report.

This study was designed to test the efficacy of enriched cell culture medium as a wound dressing. The rationale was to create within the wound space an optimal microenvironment, conducive to cellular proliferation, vascular granulation tissue formation, and epithelialization. This study was performed on various wounds that failed to respond to previous conventional treatments.A total of 288 wounds were within the inclusion criteria, with only contaminated and neoplastic wounds excluded. Most of the patients (80 percent) were ambulatory, and the wounds were examined by the attending physician once every 7 to 14 days at an outpatient clinic. The remaining 20 percent of patients were admitted to the study while hospitalized. Cell culture medium MCDB, supplemented with insulin, thyroxin, and growth hormone, was gelled. The gel was self-applied once a day to freshly washed wounds, covered with a gauze pad, and anchored with netting. Healing started 7 to 14 days after the initiation of treatment with enriched cell culture medium. However, the criterion for success of the treatment was determined on complete wound closure, which was achieved in 189 of 288 wounds (65.6 percent). Wound closure was correlated with the initial wound volume, stage, and origin. The average time required for closure of wounds caused by systemic pathologies (n = 181) and those based on regional status (n = 107) were 12.0 and 4.4 weeks, respectively, compared with 290 and 10.3 weeks of the previous conventional treatment. In 19 extensive wounds, when vascularized granulation tissue was established, a successful surgical closure was attained. Most wounds of patients who did not continue the enriched cell culture medium treatment (34.4 percent) manifested reduced wound volume, ranging from 11 to 98 percent of initial volume. Discontinuation of treatment was associated with difficulties in reaching the clinic for the weekly examination, rather than for reasons directly related to the treatment itself, and occurred significantly earlier during the treatment period.Thus, enriched cell culture medium was effective in stimulating wound healing in recalcitrant wounds. The healing was rapid with minimum scarring and pain. No side effects or allergic reactions were reported or observed.

Using the Ilizarov external fixation device for skin expansion.

Addressing war injuries requires tailoring treatment that provides the best functional and aesthetic results within a reasonable period of time. The authors report a young soldier who sustained a gunshot injury that caused an open fracture of the proximal tibia and patella (Gustilo type B-III). A local muscle flap could not be used, and thus the authors decided to use the already applied Ilizarov device for gradual expansion of the wound edge. The expanded skin covered the exposed fracture successfully, and later enabled solid union of the fracture. This reconstructive method seems to be an original solution for the management of open fractures, and additional proof that well-vascularized skin may be equivalent to a muscle flap, and may be considered for selected patients.

The effect of hyperbaric oxygenation on the viability of human fat injected into nude mice.

Autologous free-fat injection for the correction of soft-tissue defects has become a common procedure in plastic surgery. The main shortcoming of this method for achieving permanent soft-tissue augmentation is the partial absorption of the injected fat, an occurrence that leads to the need for both overcorrection and repeated fat reinjection. Improving the oxygenation of the injected fat has been suggested as a means of helping to overcome the initial critical phase that occurs postinjection (when the fat cells are nourished by osmosis), increasing phagocyte activity, accelerating fibroblast activity and collagen formation, and enhancing angiogenesis. In addition, the hyperbaric oxygen-mediated decrement in endothelial leukocyte adhesion will decrease cytokine release, thereby reducing edema and inflammatory responses. The purpose of the present study was to examine the effect of hyperbaric oxygenation on improving the viability of injected fat. Adipose tissue obtained from human breasts by suction-assisted lipectomy was injected into the subcuticular nuchal region in nude mice. The mice were then exposed to daily hyperbaric oxygen treatments, breathing 100% oxygen at 2 atmospheres absolute (ATA) for 90 minutes. The duration of the administered hyperbaric oxygen therapy was 5, 10, or 15 days, according to the study group. Mice exposed to normobaric air alone served as the control group, and each group included 10 animals. The rats were killed 15 weeks after fat injection. The grafts were dissected out, weight and volume were measured, and histologic evaluation was performed. In all of the study groups, at least part of the injected fat survived, giving the desired clinical outcome. No significant differences could be found between the groups regarding fat weight and volume. Histopathologic examination of the dissected grafts demonstrated a significantly better integrity of the fat tissue in the group that received hyperbaric oxygen for 5 days (p = 0.047). This finding was manifested by the presence of well-organized, intact fat cells, along with a normal appearance of the fibrous septa and blood vessels. The worst results were found in animals treated by hyperbaric oxygenation for 15 consecutive days. An inverse correlation was found between an increased dose of the high-pressure oxygen and fat tissue integrity (r = -0.87, p = 0.076). The toxic effects of highly reactive oxygen species on fat cells might explain the failure of an excessively high dose of hyperbaric oxygen to provide any beneficial outcome. The clinical relevance of these results should be further investigated.

Evaluation and comparison of aesthetic results and patient satisfaction with bilateral breast reduction using the inferior pedicle and McKissock's vertical bipedicle dermal flap techniques.

In the last two decades, McKissock's technique for reduction mammaplasty was largely replaced by Robbins's inferior pedicle technique. However, a substantial number of plastic surgeons still perform McKissock's technique in the belief that it is superior to the inferior pedicle technique in terms of aesthetic results and complication rate. In this study, the authors compared the aesthetic results, complication rates, and patient satisfaction with the two techniques. Numerous studies in the past few years have shown an improvement in physical symptoms in addition to excellent patient satisfaction after breast reduction. However, almost all of these studies have used questionnaires that were mailed to the patients for evaluation. In the present study, aesthetic evaluations by the surgeon and an objective observer were performed in addition to evaluations by the patients themselves, thereby increasing the objectivity and the significance of the patients' evaluations. Two groups of 24 and 27 patients were compared. The groups were almost identical in terms of demographic data and the amount of breast tissue removed. The aesthetic results were good to excellent in both groups, and the groups had similar complication rates. When the patients' evaluations were compared with those of the surgeon and the objective observer, no significant difference was found between the observer and the patients. In one of the groups, the surgeon's evaluations were significantly higher than those of the patients, although they were not significantly higher than the observer's. In terms of aesthetic results, complication rates, and patient satisfaction, no differences existed between the groups. In addition, the patients' evaluations were determined to be a reliable index of aesthetic results and, in these cases, they were often identical to objective evaluations.

Prophylactic antibiotics in aesthetic and reconstructive surgery.

The widespread use of antibacterial agents for prophylaxis has altered surgical practice markedly in the past 20 years and now represents one of the most frequent uses of antibiotics in hospitals, accounting for as many as half of all antibiotics prescribed. The present study was undertaken to determine the patterns of and reasons for antibacterial agent usage by today's practicing plastic surgeons in Israel. A survey of 78 Israeli plastic surgeons certified by the Israeli Association of Plastic Surgery was conducted. Questionnaires were mailed to all the certified plastic surgeons; 66 (84.6%) were completed and returned. The results indicate that prophylactic antibiotics are administered in a high percentage of aesthetic and reconstructive surgeries except for those in eyelids and nose. Most of the surgeons prefer to prescribe cephalosporins as their antibiotics of choice and the timing of administration is before or at the beginning of surgery. Placement of drains did not change the decision to use prophylaxis. Diabetes mellitus, steroid treatment, and chronic lung disease have a direct influence on the decision to use antibiotics; however, conditions such as ischemic heart disease, hypertension, and cigarette smoking do not influence their use. Personal experience was the main reason for prescribing antimicrobial agents. We conclude that although the infection rate in aesthetic and reconstructive operations is extremely low, most Israeli plastic surgeons still prefer to administer prophylactic antibiotics though no scientific hard data is available.

Improved vitality of experimental random dorsal skin flaps in rats treated with enriched cell culture medium.

A defined, serum-free cell culture medium supplemented with nonsteroidal anabolic hormones, insulin, thyroxin, and growth hormone was found to accelerate wound healing by stimulating vascularized granulation tissue formation, epithelialization, and angiogenesis. The aim of this work was to study the effect of cell culture medium on the survival rate of cephalically based random dorsal skin flaps in an animal model. A total of 77 Sprague-Dawley rats were randomized into five treatment groups: pharmacologic delay with cell culture medium, flap enhancement with cell culture medium, surgical delay, biological delay with saline, and control. Statistically significant differences in distal flap necrosis were found among all groups (p<0.003). The rats treated with cell culture medium before flap elevation showed a significant increase in flap viability: a survival rate of 83 percent, compared with the control group, which demonstrated a survival rate of only 58 percent (p<0.0001). The surgical delay and the groups treated with cell culture medium yielded similar results with no significant difference between them. This study indicates that preoperative injection of cell culture medium may play a role in decreasing skin flap necrosis.

Anesthesia for facial surgery.

We describe a reliable, simple, and safe method of monitored anesthesia care, with local anesthesia, which was used for 4500 patients undergoing facial rejuvenation procedure, without major complications and with minor side effects. All procedures were performed in a setup of a private clinic not affiliated with any hospital. The disadvantages of general anesthesia were avoided. Using careful monitoring and drug titration, even aged patients with medical problems, can benefit from this method. We are using classical, inexpensive, and safe compounds, which cope with all goals of anesthesia for aesthetic facial surgery.

In favor of the subcutaneous forehead lift using the anterior hairline incision.

We present our experience with 980 women who had subcutaneous forehead lifts using the anterior hairline incision, during the years 1989-1996. The dissection is easy and fast; the forehead wrinkles are smoothed by the separation of the septa between the frontalis and the skin. The access to the corrugator and the procerus muscles is easy, and the adjustment of the brows to the desired location can be accurate. We use this approach for 90% of women who are eligible for upper face rejuvenation. We have obtained a 96% satisfaction rate; only 1.8% of our patients had minor and reversible complications. The scar, which is supposed to be the main disadvantage of this procedure, is almost unnoticeable, and none of our patients has permanently changed her hairstyle due to this operation. Now, during the peak of interest in forehead lifts with limited scars using the endoscope, is the time to highlight this time-worn, safe, reproducible, and effective approach.

Effect of hyperbaric oxygen on a rat transverse rectus abdominis myocutaneous flap model.

The single-pedicle transverse rectus abdominis myocutaneous (TRAM) flap is frequently associated with partial flap necrosis. Hyperbaric oxygen has previously been shown to increase the survival of skin flaps, although there has been no investigation of possible beneficial effects of hyperbaric oxygen on survival of the TRAM flap. The present study compares the effectiveness of hyperbaric oxygen therapy, normobaric 100% oxygen, a hyperbaric air-equivalent mixture, and no treatment at all (control group), in the prevention of TRAM flap necrosis in a rat model. Forty-eight animals were randomly assigned to one of the four above-mentioned groups. The surviving area of the flap was evaluated 7 days after surgery. The hyperbaric oxygen treatment protocol consisted of five 9-minute sessions breathing 100% oxygen at a pressure of 2.5 atmospheres absolute during the first 48 hours, starting within 1 hour of surgery. The areas of surviving skin paddles ranged from 38.5 percent in the control group to 52.5 percent in the group treated with hyperbaric oxygen. One-way analysis of variance indicated that flap area survival was significantly greater in the hyperbaric oxygen group (F = 2.69, p = 0.05). Tukey's pairwise comparison and the two-sample t test indicated that the group treated with hyperbaric oxygen differed significantly from the control group (Tukey's critical value = 3.8, rejection level = 0.05, t test p = 0.01). Our results suggest that the hyperbaric oxygen treatment protocol used improves survival in the rat TRAM flap. However, the optimal treatment protocol to achieve this objective even in the rat seems to be variable, and further studies are required before extrapolating these data to human applications.

Enhancing the survival of aspirated human fat injected into nude mice.

Injection of aspirated fat is now the most commonly used technique for the filling of depressed areas. Partial absorption of the injected fat is the main limitation of this procedure. Cariel T.M. is an enriched serum-free cell culture medium, its ability to enhance the survival of human aspirated fat grafts was investigated in the nude mouse model. A volume of 0.75-cc Cariel preprocessed fat was injected under the scalp skin of 16 nude mice in the experimental group, and the same volume of saline preprocessed fat was injected to 15 control group of mice. Significant maintenance of the weight, 46 percent in the experimental group compared with 29 percent in the control group (p < 0.008), and the volume, 44 percent in the experimental group compared with 31 percent in the control group (p < 0.026), was observed, after 15 weeks, in this newly used model. It seems that addition of the nutrients enriched with anabolic hormones enabled the survival and take of more adipose cells in the graft.

Cytokine mRNA expression in normal skin of various age populations before and after engraftment onto nude mice.

Whether the impact of skin biological age on cytokine expression is a result of this tissue's proliferation potential or not is an important issue in dermatology. We investigated these questions by monitoring cytokine marker mRNA expression from human skin samples from healthy groups of individuals. The skin samples studied represented three age groups: fetal (17-21 weeks), young (18-35 years) and aged (76-88 years). Furthermore, upon skin transplantation of tissue from different age groups onto nude mice, we investigated whether cytokine marker RNA levels would change or normalize. Interestingly, both TNF-alpha and P53 mRNA showed a similar pattern of expression. Both were significantly higher in fetal skin (p < 0.0001 and p < 0.05, respectively), and no difference was noted between aged versus young skin. In contrast to this, IL1-alpha mRNA was expressed at its lowest and highest levels in fetal and young skin, respectively. Following skin transplantation, cytokines and P53 mRNA expression were normalized to similar levels in all age groups. This study implies that when cytokine expression was determined directly at the mRNA level, post-natal expression was not significantly different at either age group. Furthermore, it seems that the environmental conditions surrounding the grafted human skin found on nude mice encouraged normalization of donor cytokine expression.

Wrap-around cartilage flap for correction of unilateral cleft lip nose deformity.

A turnover contralateral cephalic alar cartilage flap is suggested for the correction of cleft nose alar deformity. The cartilage flap from the normal side wraps around the deficient medial crus and acting as a pulley reposition and augments the affected alar cartilage. The satisfactory and long-lasting results obtained in our small series seem to justify this approach for improving cleft nasal deformities, and we think it should be available in our surgical armamentarium.

The surgical anatomy of the fat in the upper eyelid medial compartment.

The surgical anatomy of the upper eyelid fat in the medial compartment was investigated in 388 patients and in 12 cadavers. We found two individual fat pads comprising this compartment. The difference among the investigated cases was found to be the extent of their separation. In 16.7 percent of the cadavers' eyelids the fat pads were entirely separated, in 45.8 percent they were separated to about half their length, while in 37.5 percent only the tips were separated. Among the patients in whom only the protruded fat was inspected, 59.8 percent of the fat pads were separated, and in the rest, only the tips were isolated. On histologic examination we could always identify two well-circumscribed fat pads, each surrounded by a fibrocollagenous tissue. At the level of their interconnection, a loose fibroareolar tissue was found. In practice, during blepharoplasty, both fat pads should be addressed in order to achieve the expected results.