A Comparative Study of Autologous and Acellular Dermal Matrix Static Cheek Slings in Corrective Surgery for Facial Palsy.

BACKGROUND: Facial palsy causes devastating disability due to loss of facial function as well as social and psychological impairment. Cheek slings are a secondary technique that provide static support to the midface. This study aimed to describe our technique and compare a traditional sling material (tensor fascia lata) with a porcine-derived acellular dermal matrix alternative (Strattice). METHODS: A 5-year case-control retrospective review of consecutive static cheek slings in a tertiary cancer and facial palsy center was performed. Demographic data, risk factors, and complications were collected and compared. Improvement in static smile position was assessed by Emotrics (Massachusetts Eye and Ear Infirmary, Boston, MA) at 3 months. Long-term sling failure was assessed by need for reoperation. RESULTS: The study group comprised 41 patients on which 33 autogenous fascia lata slings and 12 Strattice slings were performed. Medium-term improvement in static smile position was similar between the 2 groups (judged by the Emotrics software), as was complication rate (P = 0.496). Need for revision due to stretching was higher in the Strattice group but did not achieve significance (P = 0.087). Mean follow-up was 38.02 ± 19.17 months. Twelve of 41 patients were deceased at study conclusion. CONCLUSIONS: Fascia lata and Strattice slings provide satisfactory results in restoring symmetry at rest and functional oral competence. Our results suggest that Strattice is a safe sling material with an acceptable risk profile and comparable medium-term maintenance of tensile strength to fascia lata, and should be considered where life expectancy, donor site morbidity, and procedure length are important considerations.

Calf Perforator Flaps: A Freestyle Solution for Oral Cavity Reconstruction.

BACKGROUND: Reconstruction of oral cavity defects requires a thin, pliable flap for optimal functional results. Traditional flap choices are imperfect: the anterolateral thigh flap is excessively thick, whereas the radial forearm flap has a poor donor site. The authors therefore favor calf perforator flaps such as the medial sural artery perforator flap to provide thin tissue with an acceptable donor site. This two-part study aims to demonstrate their suitability for intraoral reconstruction. METHODS: In the radiologic part of the study, the authors compared thigh and calf tissue thickness by examining lower limb computed tomographic scans of 100 legs. For their clinical study, they collected data prospectively on 20 cases of oral cavity reconstruction using calf perforator flaps. RESULTS: The mean thickness of the calf tissue envelope was significantly less than that of the thigh (8.4 mm compared with 17 mm) based on computed tomographic analysis. In the clinical study, a medial sural artery perforator was used in the majority of cases (17 of 20). The mean pedicle length was 10.2 cm and the mean time to raise a flap was 85 minutes. There were no flap losses. One patient was returned to the operating room for management of late hematoma and wound dehiscence. CONCLUSIONS: Calf perforator flaps provide ideal tissue for intraoral reconstruction and are significantly thinner than anterolateral thigh flaps. In addition to medial sural artery perforator flaps, the authors raised both sural and soleal artery perforator flaps in this series. Opportunistic use of the calf donor site allows the harvest of thin tissue with minimal donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Free sural artery perforator flap: An occasional gift in oral cavity reconstruction.

BACKGROUND: The medial sural artery perforator (MSAP) flap is becoming a popular strategy for reconstructing intraoral defects. We present a case in which no MSAPs were present, however, a perforator-based calf flap was successfully raised on the sural artery and used for tongue reconstruction. A corresponding anatomic study was undertaken to establish if this finding was reproducible. METHODS: A 58-year-old woman underwent left hemiglossectomy for a squamous cell carcinoma of the tongue. Subsequently, 6 fresh frozen cadaveric limbs were dissected examining the blood supply of the posterior calf skin. RESULTS: The sural artery perforator (SAP) flap successfully reconstructed the defect. Our cadaveric study similarly demonstrated a septocutaneous SAP supplying the posterior calf skin in 1 of 6 limbs. CONCLUSION: SAPs allow a favorable flap dissection, as opposed to the musculocutaneous course of MSAPs. Our findings provide further evidence of the versatility of the calf donor site. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2454-E2456, 2016.

A single pre-operative antibiotic dose is as effective as continued antibiotic prophylaxis in implant-based breast reconstruction: A matched cohort study.

PURPOSE: Infections following implant-based breast reconstruction can lead to devastating consequences. There is currently no consensus on the need for post-operative antibiotics in preventing immediate infection. This study compared two different methods of infection prevention in this group of patients. METHOD: A retrospective matched cohort study was performed on consecutive women undergoing implant-based breast reconstruction at University Health Network, Toronto (November 2008-December 2012). All patients received a single pre-operative intravenous antibiotic dose. Group A received minimal interventions and Group B underwent maximal prophylactic measures. Patient (age, smoking, diabetes, co-morbidities), oncologic and procedural variables (timing and laterality) were collected. Univariate and multivariate logistic regression were performed to compare outcomes between the two groups. RESULTS: Two hundred and eight patients underwent 647 implant procedures. After matching the two treatment groups by BMI, 94 patients in each treatment group yielding a total of 605 implant procedures were selected for analysis. The two groups were comparable in terms of patient and disease variables. Post-operative wound infection was similar in Group A (n = 11, 12%) compared with Group B (n = 9, 10%; p = 0.8). Univariate analysis revealed only pre-operative radiotherapy to be associated with the development of infection (0.004). Controlling for the effect of radiotherapy, multivariate analysis demonstrated that there was no statistically significant difference between the two methods for infection prevention. CONCLUSIONS: Our findings suggest that a single pre-operative dose of intravenous antibiotics is equally as effective as continued antibiotic prophylaxis in preventing immediate infection in patients undergoing implant-based breast reconstructions.

Cutaneous lasers and skin camouflage make-up: a useful alternative intervention for periorbital hairy congenital melanocytic naevus.

Periorbital congenital melanocytic naevi can be very disfiguring and difficult to treat effectively. Although surgical excision and reconstruction is the most widely accepted treatment strategy, we describe a case in which cutaneous lasers treatment followed by the application of cosmetic skin camouflage make-up provided an alternative solution delivering a good cosmetic improvement.

Skin cancers of the hand: a series of 541 malignancies.

BACKGROUND: Skin cancers of the hand are uncommon and poorly documented. The objective of this study was to review a large cohort of patients with hand skin malignancies to determine tumor characteristics, management techniques, and outcomes. METHODS: A retrospective review of consecutive patients with surgically excised primary cutaneous hand malignancies at the John Radcliffe Hospital between 1993 and 2010 was performed. Records were reviewed to determine tumor characteristics, demographics, and management details. Outcome parameters included margins and completeness of excision, recurrence, metastatic spread, and survival. RESULTS: A total of 407 patients (65.8 percent male; mean age, 72.2 ± 0.7 yr) presented with 541 primary cutaneous hand malignancies and were followed up for a mean period of 24 months. Half the cohort had previous skin cancers and almost one in five developed further hand skin cancers. Squamous cell carcinoma comprised 78.0 percent, basal cell carcinoma 11.3 percent, and melanoma 3.9 percent of cases. Incidence was highest on the dorsum of the hand. Surgical margins were proportionate to tumor size, and most defects required soft-tissue reconstruction. Recurrence was uncommon in melanoma and rare in squamous and basal cell carcinomas. Lymph node metastasis and death were rare in patients with squamous cell carcinoma but relatively common in those with melanoma. CONCLUSIONS: Squamous cell carcinomas are the most common skin malignancy of the hand, frequently require soft-tissue reconstruction, and those occurring in the web spaces or on the dorsum of the proximal phalanges are more sinister malignancies with a greater propensity for metastatic spread. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Matrix metalloproteinase inhibition reduces contraction by dupuytren fibroblasts.

PURPOSE: Dupuytren's disease is a common fibroproliferative condition of the hand characterized by fibrotic lesions (nodules and cords), leading to disability through progressive digital contracture. Although the etiology of the disease is poorly understood, recent evidence suggests that abnormal matrix metalloproteinase (MMP) activity may play a role in cell-mediated collagen contraction and tissue scarring. The aim of this study was to investigate the efficacy of ilomastat, a broad-spectrum MMP inhibitor, in an in vitro model of Dupuytren fibroblast-mediated contraction. METHODS: Nodule-derived and cord-derived fibroblasts were isolated from Dupuytren patients; carpal ligament-derived fibroblasts acted as control. Stress-release fibroblast-populated collagen lattices (FPCLs) were used as a model of contraction. FPCLs were allowed to develop mechanical stress (48 hours) during treatment with ilomastat (0-100 micromol/L), released, and allowed to contract over a 48-hour period. Contraction was estimated by measuring lattice area compared with untreated cells or treatment with a control peptide. MMP-1, MMP-2, and MT1-MMP levels were assessed by zymography, Western blotting, and enzyme-linked immunosorbent assay. RESULTS: Nodule-derived fibroblasts contracted lattices (69% +/- 2) to a greater extent than did cord-derived (55% +/- 3) or carpal ligament-derived (55% +/- 1) fibroblasts. Exposure to ilomastat led to significant inhibition of lattice contraction by all fibroblasts, although a reduction in lattice contraction by nodule-derived fibroblasts was most prominent (84% +/- 8). In addition, treatment with ilomastat led to a concomitant suppression of MMP-1 and MMP-2 activity, whereas MT1-MMP activity was found to be upregulated. CONCLUSIONS: Our results demonstrate that inhibition of MMP activity results in a reduction in extracellular matrix contraction by Dupuytren fibroblasts and suggest that MMP activity may be a critical target in preventing recurrent contracture caused by this disease.

Retrospective study of the association between hypertrophic burn scarring and bacterial colonization.

Although the association between hypertrophic burn scarring and infection is well described, an association with colonization has not been established. This retrospective study sought to determine whether a significant association between hypertrophic scarring and bacterial colonization exists. Details from the case notes of all patients seen in our institution's burns unit over a two-year period were recorded and the incidence of hypertrophic scarring and burn bacterial colonization was noted. A total of 127 scars were recorded, and of these, 51 were hypertrophic and 76 nonhypertrophic. The incidence of bacterial colonization in the hypertrophic scar group was 88%, an association that achieved significance (P < .05) in comparison with nonhypertrophic scars (27%). This association holds true for individual organisms such as Staphylococcus aureus and Escherichia coli and for all burn depths and healing times. This study suggests that burn wound bacterial colonization may be more important than previously believed and perhaps suggests that striving toward an aseptic burn wound environment may reduce the incidence of hypertrophic scarring.