Dermabrasion for Scars and Wire Loop Electrocautery for Rhinophyma.

Dermabrasion and wire loop electrocautery are controlled scalpel-less procedures to remove superficial skin layers to treat dermal surface irregularities. Their postprocedure healing involves healing by secondary intention. The purpose of this paper is to discuss the use of diamond fraise dermabrasion to improve scars and the use of wire loop electrocautery to treat rhinophyma surface irregularities. Both techniques are minimally invasive and low cost, and at the same time, can significantly improve facial skin deformities. An advantage in using wire loop electrocautery for rhinophyma excision is that it is a simple, economic, and very effective technique to sculpt the nose, with minimal intraoperative bleeding. With dermabrasion, pretreatment and postregimens can help improve postprocedure results. Future efforts to modulate the healing from both of these techniques include the potential use of topical growth factors, autologous platelet-rich plasma, or using stem cells to accelerate collagen formation and reepithelization during the postprocedure period.

Reducing Risks for Poor Surgical Wound Healing.

This review summarizes common risk factors for poor surgical healing on the face and neck and a generalized approach to treating a delayed healing wound. During the preoperative evaluation patients should be screened for prior irradiation, cigarette or e-cigarette use, chronic steroid use, alcoholism, diabetes, malnutrition, and other chronic medical conditions and medications. Despite the surgeon's best efforts to prevent poor surgical healing, some wounds may display signs of persistent inflammation. The facial plastic surgeon should be astute in recognizing delayed healing and identifying intrinsic and extrinsic risk factors so that timely intervention can be performed.

Reducing Risks of Facial Scarring.

Risk factors for the formation of facial scars include skin type, ethnicity, scar location, and certain medical conditions that contribute to poor or delayed healing. Risk of scar can be reduced with appropriate surgical planning, including proper placement and design of incisions, meticulous skin closure, aseptic technique, and wound care to improve healing. Common pathologic scars include hypertrophic scars and keloid scars, each of which has unique approaches to surgical revision and medical treatment due to their respective risks of recurrence. Topical scar therapies, medical therapies, and surgical revision techniques for improvement in final scar appearance are discussed.

Reducing Risks for Local Skin Flap Failure.

Local tissue flaps are a fundamental technique in cutaneous reconstruction. Reducing the risk of flap failure is of critical importance. The intrinsic vascularity of a flap is the most important determinant of success. Good surgical techniques, including flap design, delicate tissue handling, and tension-less closure, help reduce the risk of flap compromise. Determining the etiology of compromise, including arterial, venous, hematologic, or infectious, is the first step in salvaging a failing flap. Common causes include pedicle kinking, hematoma, pressure/tension, systemic patient factors, and poor surgical technique. Swift action to restore perfusion or venous outflow through numerous strategies is required.

Effects of Altering Magnesium Metal Surfaces on Degradation In Vitro and In Vivo during Peripheral Nerve Regeneration.

In vivo use of biodegradable magnesium (Mg) metal can be plagued by too rapid a degradation rate that removes metal support before physiological function is repaired. To advance the use of Mg biomedical implants, the degradation rate may need to be adjusted. We previously demonstrated that pure Mg filaments used in a nerve repair scaffold were compatible with regenerating peripheral nerve tissues, reduced inflammation, and improved axonal numbers across a short-but not long-gap in sciatic nerves in rats. To determine if the repair of longer gaps would be improved by a slower Mg degradation rate, we tested, in vitro and in vivo, the effects of Mg filament polishing followed by anodization using plasma electrolytic oxidation (PEO) with non-toxic electrolytes. Polishing removed oxidation products from the surface of as-received (unpolished) filaments, exposed more Mg on the surface, produced a smoother surface, slowed in vitro Mg degradation over four weeks after immersion in a physiological solution, and improved attachment of cultured epithelial cells. In vivo, treated Mg filaments were used to repair longer (15 mm) injury gaps in adult rat sciatic nerves after placement inside hollow poly (caprolactone) nerve conduits. The addition of single Mg or control titanium filaments was compared to empty conduits (negative control) and isografts (nerves from donor rats, positive control). After six weeks in vivo, live animal imaging with micro computed tomography (micro-CT) showed that Mg metal degradation rates were slowed by polishing vs. as-received Mg, but not by anodization, which introduced greater variability. After 14 weeks in vivo, functional return was seen only with isograft controls. However, within Mg filament groups, the amount of axonal growth across the injury site was improved with slower Mg degradation rates. Thus, anodization slowed degradation in vitro but not in vivo, and degradation rates do affect nerve regeneration.

Simulation-based workshop for emergency preparedness in otolaryngology.

Objectives: This study aimed to evaluate the outcomes of a hands-on simulation-based course with emphasis on procedural techniques, clinical reasoning, and communication skills developed to improve junior Otolaryngology - Head and Neck Surgery (OHNS) residents' preparedness in managing otolaryngologic emergencies. Methods: Junior OHNS residents and faculty from residency programs in California, Nevada, and Arizona participated in this workshop in 2020 and 2021. The stations featured airway management techniques, ultrasound-guided needle aspiration, nasoseptal hematoma evacuation, and facial fracture repair using various models and cadavers. Participants completed a pre-workshop survey, post-workshop survey, and 2-month follow-up survey that assessed resident anxiety and confidence in three OHNS emergency situations across knowledge, manual skills, and teamwork using a 5-point Likert scale. Results: Pre-workshop surveys reported the least anxiety and most confidence in teamwork, but the most anxiety and least confidence in technical skills and knowledge related to foreign body retrieval and airway management. Immediately post-workshop participants reported significant reductions in anxiety and increases in confidence, largest in the manual skills domain, in foreign body retrieval (anxiety: -0.99, confidence: +0.95, p < .01) and airway management stations (anxiety: -0.68, confidence: +1.07, p < .01). Data collected for the epistaxis station showed decreasing confidence and increasing anxiety following the workshop. Conclusion: Our findings demonstrate the effectiveness of a workshop in preparing junior residents in potentially lifesaving otolaryngologic techniques that residents will encounter. Optimizing use of simulation centered training can inform the future of residency education, improving confidence and decreasing anxiety in residents responsible for the safety of patients. Level of Evidence: III.

Inpatients with gunshot wounds to the face.

Microvascular free tissue transfer (FTT) is an increasingly used method of reconstruction for traumatic defects of the head and neck. We describe the immediate management, FTT reconstruction techniques, and outcomes of 6 individuals who sustained maxillofacial gunshot trauma and were treated at a single tertiary-care level I trauma center. All 6 patients were white men with a mean age of 33 years. The mandible, nose, and orbital contents were the most frequently affected critical structures. All patients initially underwent primary wound debridement and tracheostomy, with concurrent maxillomandibular wire fixation and/or midface or mandible plate fixation in 5 patients. The mean time from injury to definitive FTT was 38 days. Five patients underwent fibula osteocutaneous FTT and 1 underwent radial forearm fasciocutaneous FTT. One patient also underwent concurrent local tissue rearrangement and pedicled flap surgery for nasal reconstruction. The mean hospital length of stay after FTT was 6 days. All FTT survived without necrosis. Oral incompetence and poor cosmesis from undesirable scarring patterns were the most common long-term complications. In summary, successful reconstruction of head and neck defects caused by gunshot trauma begins with airway stabilization, wound management, and bony fracture reduction and fixation. Definitive microvascular FTT is a useful method of repairing traumatic head and neck defects, although long-term functional and cosmetic complications may still occur.

Principles to minimize scars.

Principles to minimize scars include attention to a multitude of intrinsic and extrinsic patient factors preoperatively, operatively, and postoperatively. Preoperatively the goal is to maximize the treatment of patient specific comorbidities and limit the usage of medications that can have negative effects on healing. Operatively, the focus is on proper incisional planning, meticulous surgical technique and hemostasis, judicious use of prophylactic antibiotics, and focus on tensionless closures. Postoperatively, we must maximize the healing environment by keeping the wound well hydrated and closely monitoring and intervening early in high-risk wounds. We also have the responsibility to provide evidence-based recommendations, to the best of our ability, regarding the myriad of over-the-counter products. The field of scar prevention is ever changing and the new frontier focuses on controlling the microenvironment of wounds and altering signaling molecules to promote near scarless healing.

Location Propensity for Keloids in the Head and Neck.

Importance: The difficulty associated with concealing keloids located in the face and neck regions often results in disfigurement and psychological stress for patients. Objective: The purpose of this review is to determine if specific regions on the head and neck have a greater propensity to develop keloids to alert the facial plastic surgeon of regional keloid risk. Evidence Review: PubMed, Ovid, Cochrane, and Embase computerized searches were performed through January 2020. Two independent reviewers conducted data extraction following a predetermined protocol identifying 1445 keloid studies. Findings: The prevalence of keloids in different regions of the head and neck was evaluated among 1598 head and neck keloids in the final analysis. Three of nine studies evaluated keloids specific to the ear and described a combined 1194 ear keloids locations (53.0% lobule, 22.9% cartilaginous region, 0.3% both, and 23.7% unspecified). One study reported exclusively on 82 neck keloids 72% of which were located in the submental or submandibular region. The remaining five studies evaluated 322 head and neck keloids more generally and showed 70.2% ear, 9.6% unspecified, 6.5% peri-/postauricular, 5.6% beard area, 2.2% scalp/forehead, 2.2% chin, 1.6% lateral face, 1.6% neck, and 0.3% central face keloids. Conclusions and Relevance: The ear, periauricular regions, bearded facial regions, and submandibular and submental sites show the highest propensity for keloid development in the head and neck region. The lowest keloid risk occurred in the central face region. Risk factors in relation to facial and neck regions associated with the formation of keloids should be taken into consideration before performing elective procedures in keloid susceptible individuals.

Navigating telemedicine for facial trauma during the COVID-19 pandemic.

Importance: The COVID-19 pandemic is changing how health care providers practice. As some telemedicine and telecommunication support tools have been incorporated into the otolaryngology practice in response to safety and access demands, it is essential to review how these tools and services can help facilitate facial trauma evaluation during a time when clinical resources are limited. Objective: To review applications of telemedicine for the evaluation of facial trauma to better direct utilization of these methods and technologies during times of limited access to clinical resources such as the COVID-19 pandemic. Methods: A systematic review was conducted using PubMed, Embase, and Web of Science. Results: After screening 158 titles and abstracts, we identified 16 eligible studies involving facial trauma evaluation using telemedicine. Telemedicine opportunities for facial trauma evaluation have the potential to be developed in the areas of multidisciplinary remote consultations, facial trauma triage, patient engagement, and postoperative follow-up. Conclusion: The COVID-19 pandemic is posing obstacles for both providers and patients in the delivery of health care at a time of limited clinical resources. Telemedicine may provide a potential useful tool in the evaluation and triage of facial injuries and patient engagement.

Change in surgeon for revision rhinoplasty: The impact of patient demographics and surgical technique on patient retention.

OBJECTIVES: A subset of patients who require revision rhinoplasty will change surgeons for their second procedure. We sought to investigate the rate of surgeon change and identify associated predictors using a population-based, ambulatory surgery database. METHODS/STUDY DESIGN: In this retrospective review, 9172 rhinoplasty procedures over a 5-year period were analyzed using the Healthcare Cost and Utilization Project (HCUP) Florida State Ambulatory Surgery and Services Database (SASD). We identified 380 patients who had at least two rhinoplasty procedures between 2009 and 2014. Logistic regression analysis was used to identify predictors of patients changing surgeons for their second documented rhinoplasty. RESULTS: Among the 380/8531 (4.4%) patients who underwent a revision rhinoplasty, 117/380 (30.8%) patients changed surgeons for their subsequent procedure within a 5-year period. Multivariable logistic regression identified a lower likelihood of surgeon change in patients undergoing functional or cosmetic cartilage grafting procedures (OR 0.342, 95%CI 0.155-0.714, P = .006) and in patients who self-paid for their procedure (OR 0.476, 95%CI 0.225-0.984, P = .048). One hundred twenty-four patients underwent a cosmetic revision rhinoplasty and were twice as likely to change surgeons as those who underwent functional revision rhinoplasty (OR 2.042 95%CI 1.046-4.050, P = .038). Time elapsed (>2 years) was positively correlated with likelihood of surgeon change (OR 1.236, 95%CI 1.153-1.333, P < .001). CONCLUSION: In our analysis, 30.8% of patients changed surgeons for their revision rhinoplasty. Cartilage grafting at the time of index procedure and cash payment correlated with a decreased likelihood of surgeon change. Patients were more likely to change surgeons with increased time elapsed or for an aesthetic revision. Clarifying features associated with surgeon change may help improve patient satisfaction and retention.

Electric scooter craniofacial trauma.

OBJECTIVE: The use of standing electronic scooters associated with micromobility applications (e-scooters) has risen nationally. The aim of this study was to obtain a detailed view of soft tissue and bony craniofacial injury associated with e-scooter-related trauma. METHODS: Single-institution retrospective case series of patients presenting to a level 1 trauma center emergency department or trauma unit with documented e-scooter-related craniofacial injury. RESULTS: Of 203 included patients, 188 (92.6%) patients sustained craniofacial injury. One hundred thirty-one (64.5%) had exclusively soft tissue injury, 3 (1.5%) exclusively bony injury, 51 (25.1%) both soft and bony injuries, and twenty-five (12.3%) patients sustained dental injury. Aesthetic units most frequently sustaining acute soft tissue injury were the forehead (n = 106, 34.6%), scalp (n = 36, 11.8%), chin (n = 34, 11.1%), upper lip (n = 32, 10.5%), and cheek (n = 31, 10.1%). Aesthetic subunits most often sustaining acute soft tissue injury included the brow (42, 13.7%), central forehead (39, 12.7%), lateral forehead (n = 25, 8.2%), and upper lip vermillion (n = 23, 7.5%). Craniofacial osseous fracture most often occurred in the orbit (n = 42, 24.6%) and maxilla (n = 40, 23.4%). Individual osseous segments most frequently sustaining acute fracture included the anterior maxillary sinus wall (n = 22, 12.9%), nasal bone (n = 20, 11.7%), lateral orbital wall (n = 16, 9.4%), orbital floor (n = 15, 8.8%), and zygomatic bone (13, 7.6%). CONCLUSIONS: Our analysis demonstrates that most patients presenting to our center with craniofacial trauma sustained acute bony fracture, most often to the midface. Our data of common injuries associated with e-scooter trauma could inform implementation in the form of facial safety equipment or safety skills training for e-scooter riders. LEVEL OF EVIDENCE: 4.

Embedding magnesium metallic particles in polycaprolactone nanofiber mesh improves applicability for biomedical applications.

Magnesium (Mg) metal is of great interest in biomedical applications, especially in tissue engineering. Mg exhibits excellent in vivo biocompatibility, biodegradability and, during degradation, releases Mg ions (Mg2+) with the potential to improve tissue repair. We used electrospinning technology to incorporate Mg particles into nanofibers. Various ratios of Mg metal microparticles (<44 µm diameter) were incorporated into nanofiber polycaprolactone (PCL) meshes. Physicochemical properties of the meshes were analyzed by scanning electron microscopy (SEM), Fourier-transform infrared spectroscopy (FTIR), mechanical tensile testing, X-ray diffractometry and UV-VIS spectrophotometry. Biological properties of meshes were evaluated in vitro and in vivo. Under mammalian cell culture conditions, Mg-containing meshes released hydrogen gas and relative amounts of free Mg2+ that reflected the Mg/PCL ratios. All meshes were non-cytotoxic for 3T3 fibroblasts and PC-12 pheochromocytoma cells. In vivo implantation under the skin of mice for 3, 8 and 28 days showed that Mg-containing meshes were well vascularized, with improved measures of inflammation and healing compared to meshes without Mg. Evidence included an earlier appearance and infiltration of tissue repairing macrophages and, after 28 days, evidence of more mature tissue remodeling. Thus, these new composite nanofiber meshes have promising material properties that mitigated inflammatory tissue responses to PCL alone and improved tissue healing, thus providing a suitable matrix for use in clinically relevant tissue engineering applications. STATEMENT OF SIGNIFICANCE: The biodegradable metal, magnesium, safely biodegrades in the body, releasing beneficial byproducts. To improve tissue delivery, magnesium metal particles were incorporated into electrospun nanofiber meshes composed of a biodegradable, biocompatible polymer, polycaprolactone (PCL). Magnesium addition, at several concentrations, did not alter PCL chemistry, but did alter physical properties. Under cell culture conditions, meshes released magnesium ions and hydrogen gas and were not cytotoxic for two cell types. After implantation in mice, the mesh with magnesium resulted in earlier appearance of M2-like, reparative macrophages and improved tissue healing versus mesh alone. This is in agreement with other studies showing beneficial effects of magnesium metal and provides a new type of scaffold material that will be useful in clinically relevant tissue engineering applications.

The healing effects of autologous platelet gel on acute human skin wounds.

OBJECTIVE: To compare the healing of full-thickness skin punch wounds treated with topical autologous platelet gel (APG) vs conventional therapy (antibiotic ointment and/or occlusive dressings) in healthy volunteers. METHODS: A prospective, single-blind, pilot study comprising 80 full-thickness skin punch wounds (4 mm diameter) was conducted on the thighs of 8 healthy volunteers. With each subject serving as his or her own control (5 punch sites per leg), APG was applied topically on one thigh, and an antibiotic ointment and/or a semiocclusive dressing was applied on the other thigh. Healing was monitored for spontaneous wound closure by clinical assessment and by digital photographs over 6 months. Over 35 days, 64 serial dermal biopsy specimens (6 mm diameter) were analyzed (using hematoxylin-eosin, Mason trichrome, CD-34, and Ki-67 stains) to measure differences between treated and control sites for cellularity, granulation formation, vascularity, epithelialization, and cellular replication. RESULTS: Over a 42-day period, the APG-treated sites had statistically increased wound closure compared with controls by visual clinical assessment and by digital planimetry photographic measurements (P

Soft Tissue Principles to Minimize Scarring: An Overview.

This article is a broad overview of measures and techniques that can be used to minimize soft tissue scarring.