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Basal cell carcinomas (BCCs) are one of the most frequent cutaneous malignancies. The majority of BCCs are reported to occur on the auricular helix and periauricular region due to ultraviolet light exposure. Despite the frequency of BCCs, those that develop within scar tissue are rare, and the phenomenon of keloid BCCs has rarely been reported in the literature. Keloid collagen within BCCs is associated with morphoeiform characteristics, ulceration, or necrosis. Extensive keloid collagen is often seen in BCCs of the ear region, a site prone to keloid scarring. This article presents a rare case of a secondary tumor (BCC) which arose on top of a primary tumor (keloid scar) on the right auricle region in a healthy 23-year-old female after an ear piercing 2 years prior. To our knowledge, the tumor described in this case, in contrast to keloidal BCCs, has never been reported in the literature.

// Josef Haik 1,2,3 , Gil Nardini 1 , Noga Goldman 4 , Gilli Galore-Haskel 5 , Moti Harats 1 , Isaac Zilinsky 1 , Oren Weissman 1 , Jacob Schachter 3,5 , Eyal Winkler 1,3 and Gal Markel 2,3,5 1 Department of Plastic Surgery, Tel Aviv University, Tel Aviv, Israel 2 Talpiot Medical Leadership Program, Tel Aviv University, Tel Aviv, Israel 3 Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 4 Department of General Surgery C, Tel Aviv University, Tel Aviv, Israel 5 Ella Institute of Melanoma, Sheba Medical Center, Ramat Gan, Israel Correspondence to: Gal Markel, email: // Keywords : burns, immune suppression, natural killer, lysis receptors, MICB, Immunology and Microbiology Section, Immune response, Immunity Received : September 26, 2015 Accepted : December 23, 2015 Published : December 29, 2015 Abstract Immune suppression following major thermal injury directly impacts the recovery potential. Limited data from past reports indicate that natural killer cells might be suppressed due to a putative soluble factor that has remained elusive up to date. Here we comparatively study cohorts of patients with Major and Non-Major Burns as well as healthy donors. MICB and ULBP1 are stress ligands of NKG2D that can be induced by heat stress. Remarkably, serum concentration levels of MICB and ULBP1 are increased by 3-fold and 20-fold, respectively, already within 24h post major thermal injury, and are maintained high for 28 days. In contrast, milder thermal injuries do not similarly enhance the serum levels of MICB and ULBP1. This kinetics coincides with a significant downregulation of NKG2D expression among peripheral blood NK cells. Downregulation of NKG2D by high concentration of soluble MICB occurs in cancer patients and during normal pregnancy due to over production by cancer cells or extravillous trophoblasts, respectively, as an active immune-evasion mechanism. In burn patients this seems an incidental outcome of extensive thermal injury, leading to reduced NKG2D expression. Enhanced susceptibility of these patients to opportunistic viral infections, particularly herpes viruses, could be explained by the reduced NKG2D expression. Further studies are warranted for translation into innovative diagnostic or therapeutic technologies.

Alopecia-neurological defects-endocrinopathy (ANE) syndrome is a rare inherited hair disorder, which was shown to result from decreased expression of the RNA-binding motif protein 28 (RBM28). In this study, we attempted to delineate the role of RBM28 in hair biology. First, we sought to obtain evidence for the direct involvement of RBM28 in hair growth. When RBM28 was downregulated in human hair follicle (HF) organ cultures, we observed catagen induction and HF growth arrest, indicating that RBM28 is necessary for normal hair growth. We also aimed at identifying molecular targets of RBM28. Given that an RBM28 homologue was recently found to regulate miRNA biogenesis in C. elegans and given the known pivotal importance of miRNAs for proper hair follicle development, we studied global miRNA expression profile in cells knocked down for RBM28. This analysis revealed that RBM28 controls the expression of miR-203. miR-203 was found to regulate in turn TP63, encoding the transcription factor p63, which is critical for hair morphogenesis. In conclusion, RBM28 contributes to HF growth regulation through modulation of miR-203 and p63 activity.

Background The Burns Specific Health Scale-Brief (BSHS-B) questionnaire is a suitable measurement tool for the assessment of general, physical, mental, and social health aspects of the burn survivor. Aim To translate, culturally adapt and validate the BSHS-B to Hebrew (BSHS-H), and to investigate its psychometric properties. Methods Eighty-six Hebrew speaking burn survivors filled out the BSHS-B and SF-36 questionnaires. Ten of them (11.63%) completed a retest. The psychometric properties of the scale were evaluated. Internal consistency, criterion validity, and construct validity were assessed using interclass correlation coefficient, Cronbach's alpha statistic, Spearman rank test, and Mann–Whitney U test respectively. Results BSHS-H Cronbach's alpha coefficient was 0.97. Test–retest interclass coefficients were between 0.81 and 0.98. BSHS-H was able to discriminate between facial burns, hand burns and burns >10% body surface area (p < 0.05). BSHS-H and SF-36 were positively correlated (r2 = 0.667, p < 0.01). Conclusions BSHS-H is a reliable and valid instrument for use in the Israeli burn survivor population. The translation and cross-cultural adaptation of this disease specific scale allows future comparative international studies.

The goal of this literature review is to review and combine case studies of accidental burns to the breast, following mastectomy and immediate breast reconstruction with autologous tissue, implants, or tissue expanders.The authors searched PubMed and Cochrane Library and reviewed cases of burns of reconstructed breasts after mastectomy from July 1985 to May 2015. Only studies in the English language were included in their search. They also report 5 new cases of burns in patients with burns to the breast, which were either reconstructed with implants or tissue expanders at Sheba Medical Center (Ramat Gan, Israel).The authors found 21 publications regarding burns after breast reconstruction dating from 1985 to 2014, which equaled 59 cases of reported burns in the 21 included publications. The most common causes of burns were due to heat conduction (37/59) followed by solar radiation (19/59) and heat convection (3/59). The majority of the cases were treated by a conservative approach. The 5 new cases added were all due to thermal radiation (5/5). Two of these cases were treated conservatively (2/5), and 3 underwent surgery (3/5).The removal of thermoregulatory capabilities of the skin and the thickness of the remaining tissue in the mastectomy procedure are key to understanding the cause of burns to reconstructed breasts.

When inflating multiple tissue expanders in an outpatient basis, correct location of the expander port can be sometimes perplexing, even for experienced personnel. Herein, we review a series of patients whose expanders were dyed with soluble dye added to the injected solution as a further means of verification of needle position during serial expansions. Thirty patients with a total of 81 expanders were followed. The expanders were filled with methylene blue dyed solution in the initial operative procedure. Data regarding patient demographics, surgery etiology, number and location of implanted expanders, and postoperative complications were collected for analysis. At total of 80 (98.7 %) expansions were completed successfully with subsequent reconstructions. Three patients required treatment for surgical site infections, one patient had a wound dehiscence, and one patient required drainage of a postoperative hematoma. One expander was removed due to extrusion. None of the patients had complications related to expander rupture or puncture. None were noted to have side effects related to methylene blue exposure. During subsequent outpatient expander inflations, medical staffs reported a higher confidence in port location thus simplifying the inflation procedure. Although many surgeons currently use methylene blue dyeing technique to facilitate tissue expansion, there are no reports to attest to the safety of this method. The short series presented herein serves to further outline the safe application of this technique to tissue expansion. Level of Evidence: Level IV, risk/prognostic study.

Background: Postoperative positive expiratory pressure (PEP) therapy promotes increased lung volume, secretion clearance, and improved oxygenation. Several commercial devices exist that produce recommended PEP values (10–20 cmH2O) when the patient breathes through a fixed orifice resistor. It was hypothesized that an inexpensive, improvised “blow glove” device would produce similar PEP values over a wider range of expiration volumes and flow rates. Methods: PEP for different expiration volumes (400–2000 mL) and expiratory flow rates (10–80 L/min) was compared between a commercial PEP device (Resistex, Mercury Medical, Clearwater, FL) and an improvised “blow glove” device, recorded by a Vela ventilator (CareFusion, San Diego, CA). Dynamics in positive end expiratory pressure (PEEP) values were evaluated following five consecutive expirations. The “blow glove” device was evaluated using various glove compositions and sizes. Results: The improvised “blow glove” device produced a significantly higher rate of PEP values in the recommended range than the Resistex device (88.9% vs. 20%, p0.05), but the powdered latex glove showed a significantly higher rate of PEP values in the recommended range than the powder-free latex glove (88.9% vs. 44.4%, p

BACKGROUND: The escalation of global terrorist attacks has resulted in a rise of traumatic injuries. Planning for mass casualty incidents (MCIs) is critical to decrease the morbidity and mortality that ensues after large-scale terrorist attacks. This study provides criteria for the management of burn victims following large-scale disasters. METHODS: Mass casualty outcomes from three disasters involving commercial aircraft crashes were analyzed. The three events included the El-Al cargo Aircraft crash near the Amsterdam Schiphol Airport in 1992, the World Trade Center attacks in New York and the attack against the Pentagon in Washington, DC on 9/11/01. RESULTS: Using the data obtained from these events, the severity of injuries in patients were determined. The result is a general template that may be customized with locally or regionally specific data, in order to evaluate the preparedness of a specific burn alignment for such a scenario. CONCLUSION: Recommendations based on the analysis of previous MCI's were put forth. Based on the needs recognized during these past events, suggestions were made to enhance the preparedness of burn units, hospitals and national agencies as well as municipal authorities. Language: en

In recent years the acellular dermal matrix (ADM) has gained popularity in prosthetic breast reconstruction. These procedures involve placement of a closed suction drain in the reconstructed breast. Although it is now widely accepted that ADM has an overall positive effect on the outcome of breast reconstruction, data regarding its effect on postoperative drain secretions is lacking. This study was designed to quantitatively evaluate the influence of ADM on postoperative drain secretions in the setting of immediate prosthetic breast reconstruction (IPBR). This is a prospective, comparative controlled study. Two groups of 16 patients each underwent skin sparing mastectomies (SSM) and IPBR with or without ADM. Closed suction drains were left in all the reconstructed breasts and daily secretion volumes were recorded and compared. Postoperative complications were also noted. Patients in the ADM group showed higher daily and overall secretion volumes compared with patients in the control group (p = 0.014) and the time for removal of the drains was higher by an average of 5 days (13 compared with 8 days, respectively; p = 0.004). There was no correlation between ADM and infection. This study provides the first objective evidence that ADM contributes to elevated and prolonged drain secretions when used for IPBR. This might affect possible prosthesis-related complications (e.g., rotation and malposition, capsular contraction, seroma formation, and infection). This study also noted erythema of the post-mastectomy skin flaps in selected patients, which may be attributable to a local inflammatory reaction to the ADM rather than infection.

Although fat grafting is a common technique to repair defects after breast cancer reconstruction surgery and has a low complication rate, the relation between fat grafting and the risk of breast cancer is unknown. Clinical trials to investigate this connection can elucidate the benefits and potential risks of fat grafting in oncology patients.To establish an efficient experimental model, using magnetic resonance imaging (MRI) scans, for comparing different breast tumor study groups post-fat grafting.Breast tumor cells were injected into immunocompromised mice. After tumors formed they were removed. Liposuction was performed in a female human donor and fat was collected. Cells were extracted from the fat by enzymatic digestion. Immunocompromised mice were randomized into four groups: a preliminary experiment group and three equal groups according to the type of fat graft: (i) fresh fat enriched with adipose-derived mesenchymal stem cells (AdMSCs), (ii) fresh fat without cell enrichment, and (iii) no fat injected. Tumor volume was assessed by serial MRI scans.The rate of tumor growth was higher in the enriched fat group compared to the non-enriched fat group.This experimental model is an effective measurable method, allowing future investigation of the effect of autologous fat on breast cancer.

Suction-assisted lipoplasty (SAL; liposuction) is an established aesthetic procedure in plastic surgery. The main parameters differentiating one method of lipoplasty from another are safety, consistency of results, and other more technical parameters. Due to the recent popularity of lipotransfer, the quality of extracted fat has become a relevant parameter. We compare the viability of extracted adipocytes after dry SAL, hyper-tumescent PAL (power-assisted lipoplasty), and water-assisted lipoplasty (WAL). We used fluorescent microscopy to differentiate viable from necrotic/apoptotic cells after liposuction using each of the mentioned methods. The ratio of living cells between the three methods was significantly different with dry liposuction yielding inferior ratios (p = 0.011). When omitting extreme results, we found that the body-jet technique (WAL) yielded higher ratios of living cells than the hyper-tumescent technique (p

The treatment of tinea capitis using radiotherapy was introduced at the beginning of the twentieth century. In Israel, between 1949 and 1960, approximately 17,000 children underwent radiotherapy treatments for tinea capitis (actual numbers are probably higher due to irradiation in countries of origin as a prerequisite for immigration). Skin cancer presents a major problem for patients who underwent irradiation for the treatment of tinea capitis [aggressive biological behavior, multiple basal cell carcinomas (BCCs), up to 40 lesions in a single patient, with no predisposing condition such as Gorlin's or Bazex's syndromes]. There are ample data in the literature concerning the molecular changes in ultraviolet (UV) radiation-induced BCCs. However, similar data regarding ionizing radiation-induced BCCs are scarce. One work found higher rates of p53 and PTCH (both are tumor suppressor genes whose alterations are associated with BCC formation and frequency, but not biological behavior) abnormalities in post ionizing radiation BCCs. The absence of documented differences in gene expression that would account for a different biological behavior of radiotherapy-related BCCs, coupled with the aggressive and recurrent nature of these lesions, has propelled us to examine these differences by comparing gene expression in BCCs of the scalps of patients who were previously irradiated for tinea capitis in their childhood and of the scalps of patients who were not.Tissue samples of excised scalp BCCs from seven previously irradiated patients (five male, two female) and seven not previously irradiated patients (six male, one female) were frozen upon excision and genetically analyzed using DNA microarray chips.No correlation was found between previous ionizing irradiation and gene expression.The negative results of this study, coupled with the observation of aggressive biological behavior of BCCs in previously irradiated patients merit further attention. Other explanations for the aggressive biological behavior of radiotherapy-induced BCCs come to mind. One such explanation could be that the difference between the groups lies not in the tumor itself, but in the host, who is more susceptible to the local destruction caused by the tumor due to changes in the surrounding tissue (e.g., impaired blood supply due to radiation, structural damage in seemingly healthy skin). This hypothesis will be the focus of further research.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Many women have a dwindled ptotic breast. The surgical solution for these two concurring problems has two separate procedures: augmentation and mastopexy. Combining these two procedure into one surgery is considered unpredictable and avoided by many physicians. This study presents a revised mastopexy-augmentation technique found to be safer and more simple, enabling these two procedures to be performed together. A retrospective review of 60 patients who underwent surgery by a single surgeon is presented. The presented method has yielded a relatively low reoperation rate of 10% and a high satisfaction rate.

Both cosmetic facial resurfacing and facial burns cause an injury to the dermal layer of the skin. This injury renders the patient susceptible to primary herpes simplex virus (HSV) infection or, more commonly, to HSV reactivation. This in turn can lead to bacterial superinfection, possibly resulting in scarring and systemic dissemination in the immunosuppressed burn patient. HSV reactivation rates have been reported to be up to 50% in cosmetic procedures without acyclovir prophylaxis and up to 25% in patients with burn injury. Currently, acyclovir prophylaxis is a common practice in facial resurfacing, but no such recommendations have been issued for patients with burn injury. HSV usually presents in a febrile burn patient between the first and third postburn weeks as a cluster of small, umbilicated vesicles or vesicopustules on an erythematous base found within or around the margins of healing partial-thickness wounds. Diagnosis is confirmed through viral culture from the base of an unroofed vesicle, and treatment is begun with intravenous acyclovir. Antiviral prophylaxis should be strongly considered for HSV infection prevention in patients with major burn injury, particularly with burns involving the face. Acyclovir is the primary drug of choice, and contact precautions should be practiced. High suspicion levels and alertness to this entity can help prompt diagnosis and timely treatment while alleviating late complications.

We conducted a study to test whether new third generation (3G) mobile phones could be integrated into service as a working tool between plastic surgeons. During an eight-month period, 58 multimedia consultations were performed involving 57 patients. The majority of the consultations were for trauma or wounds. All consultations comprised a digital photograph taken with the integrated camera and sent via the Multimedia Messaging Service (MMS). In 86% of the cases the residents reported that multimedia information contributed to their ability to independently handle similar cases in future. Satisfaction scores were high among all participants. We believe that a multimedia consultation in a hospital setting adds information to an ordinary telephone call, thus decreasing medico-legal risks. We recommend it for routine use.

Hypertrophic and keloid scars still are among the banes of plastic surgery. In the treatment arsenal at the disposal of the plastic surgeon, topical silicone therapy usually is considered the first line of treatment or as an adjuvant to other treatment methods. Yet, knowledge concerning its mechanisms of action, clinical efficacy, and possible adverse effects is rather obscure and sometimes conflicting. This review briefly summarizes the existing literature regarding the silicone elastomer's mechanism of action on scars, the clinical trials regarding its efficacy, a description of some controversial points and contradicting evidence, and possible adverse effects of this treatment method. Topical silicone therapy probably will continue to be the preferred first-line treatment for hypertrophic scars due to its availability, price, ease of application, lack of serious adverse effects, and relative efficacy. Hopefully, future randomized clinical trials will help to clarify its exact clinical efficacy and appropriate treatment protocols to optimize treatment results.

The newly reconstructed nipple is extremely sensitive to mechanical pressure and shearing forces, which can cause flap necrosis and sloughing of the skin, eventually promoting infection. Current available dressing solutions are cumbersome, inefficient, displeasing, or otherwise not readily obtainable.In this study, 10 patients with newly reconstructed nipples were instructed to use breastfeeding nipple shields as the sole means of nipple dressing after the reconstruction procedure.No complications were observed overall. Patients reported full adherence to the postoperative dressing regimen as well as ease of use, availability, low costs, and pleasing aesthetic appearance under garments.Silicone breastfeeding nipple shields offer an efficient, affable, cheap, widely available, and aesthetically pleasing form of postoperative dressing for reconstructed nipples. Their use may enhance patient compliance with the dressing regimen and lower the postoperative complication rate.

It was previously shown that CEACAM1 on melanoma cells strongly predicts poor outcome. Here, we show a statistically significant increase of serum CEACAM1 in 64 active melanoma patients, as compared to 48 patients with no evidence of disease and 37 healthy donors. Among active patients, higher serum CEACAM1 correlated with LDH values and with decreased survival. Multivariate analysis with neutralization of LDH showed that increased serum CEACAM1 carries a hazard ratio of 2.40. In vitro, soluble CEACAM1 was derived from CEACAM1(+), but neither from CEACAM1(-) melanoma cells nor from CEACAM1(+) lymphocytes, and directly correlated with the number of CEACAM1(+) melanoma cells. Production of soluble CEACAM1 depended on intact de novo protein synthesis and secretion machineries, but not on metalloproteinase function. An unusually high percentage of CEACAM1(+) circulating NK and T lymphocytes was demonstrated in melanoma patients. CEACAM1 inhibited killing activity in functional assays. CEACAM1 expression could not be induced on lymphocytes by serum from patients with high CEACAM1 expression. Further, expression of other NK receptors was impaired, which collectively indicate on a general abnormality. In conclusion, the systemic dysregulation of CEACAM1 in melanoma patients further denotes the role of CEACAM1 in melanoma and may provide a basis for new tumor monitoring and prognostic platforms.

Bio-Alcamid (Polymekon, Milan, Italy) is a relatively new, nonabsorbable hydrogel polymer that is used as a permanent filler for cosmetic and reconstructive purposes. The polymer, derived from acrylic acid, has a reticulated structure. It is an alkylic resin containing 96% pyrogen-free water and 4% alkylimide-amide groups. Owing to these chemical properties, Bio-Alcamid is stable and resistant to hydrolysis. It has been suggested that the filler should be considered totally biocompatible as far as the effects on cell proliferation and cell functions are concerned, thus rendering it suitable for long-term reconstruction of tissue damage even when large amounts of the polymer are used.

An ingrowing toenail is an excessive lateral nail growth into the nail fold. It acts as a foreign body and exerts a local pressure sore-like effect, which may result in inflammation and granulation. Several treatment modalities exist, including chemical ablation and different surgical procedures. Here we describe and compare a simple and effective method of partial matricectomy using the CO2 laser (group A) versus a similar method with the addition of lateral nail fold vaporization (group B).Outcome evaluation of a modified laser treatment modality for ingrowing toenails and determination of the role of lateral fold vaporization in reducing the recurrence of symptoms.Forty patients (mean age 32.45 years) were treated with CO2 laser ablation of toenails between 1999 and 2005 by four physicians. One physician implemented a method that includes lateral nail fold vaporization and resection of the nail segment with its nail bed from 1999 to 2005. Three physicians implemented a similar technique but without lateral fold vaporization between 1999 and 2003, and added lateral fold vaporization to the performed procedure starting in 2004.The recurrence rate was 37.5% in group A and 6.2% in group B. The overall average disease-free follow-up period was 42.2 months.The use of CO2 laser in the treatment of ingrowing toenails offers an effective modality. We demonstrate the importance of lateral fold vaporization with the CO2 laser both in improving efficacy and in decreasing recurrence rates over a long follow-up period.

Closure of fasciotomy wounds poses a challenge, particularly in pediatric cardiac patients who are too high risk for general anesthesia and often require anticoagulant treatment. The adhesive skin closure technique enables wound closure without the need for a secondary procedure such as surgery requiring anesthesia.This study sought to describe a treatment modality that assists in fasciotomy wound edge approximation without the need for surgery, while additionally aiding in achieving fast and aesthetic results in the aforementioned patient population. A case series of 4 pediatric patients with fasciotomy wounds is presented.Adhesive skin closure strips (Steri-Strips, 3M, St. Paul, MN) were placed perpendicular to the cleansed wound leaving small gaps for drainage, thus achieving complete propinquity. The strips were replaced sequentially with new strips every 2 to 3 days. Digital pictures of the wounds were obtained until complete closure of the wounds was achieved. Outcome variables included wound closure success rates and complication rates including infection, bleeding, and late scar formation.Patient ages ranged from 2 weeks to 2 years, 9 months (mean: 10.5 months), average period of open wound prior to closure was 6.75 days (range: 5-11 days), treatment duration ranged from 15 to 26 days (mean: 21 days), and average follow-up was 4.5 months. One patient died due to their primary condition. No local infections, wound dehiscence with the treatment regimen, or any other immediate complications were encountered. There was a late complication in 1 patient who presented with a hypertrophic scar.Use of the adhesive skin closure method to close fasciotomy wounds in pediatric patients in which surgical procedures were nonadvisable produced favorable results.

Lower T-junction wound dehiscence following breast reduction surgery or mastopexy constitutes a vexing and grievous complication both to the surgeon and the patient. Treatment modalities that can expedite wound healing and reepithelialization rates are highly craved. The objective of this study was to assess wound healing and epithelialization rates of open wounds following breast reduction and mastopexy wound dehiscence treated with charged polystyrene microspheres (CPM).Five female patients with wound dehiscence and subsequent open wounds following breast reduction and mastopexy were treated with daily with CPMsoaked dressings. Wound closure rates were documented.The wounds showed both accelerated granulation tissue formation as well as swift epithelialization rates. No complications or side effects were encountered.Charged polystyrene microspheres may offer a new and efficacious way to heal open wounds due to wound dehiscence following aesthetic breast surgery. Further research with a larger patient population is still needed to verify these findings. .

Terror attacks have changed in the past decade, with a growing tendency toward explosives and suicide bombings, which led to a rise in the incidence of thermal injuries among victims. The Israeli-Palestinian conflict of October 2000 marked a turning point when an organized terror campaign commenced. This article presents data of terror-associated burns from the Israeli National Trauma Registry (ITR) during the years 1997 to September 2000 and October 2000 to 2003.We analyzed demographic and clinical characteristics of 219 terror-related burn patients and 6,546 other burn patients admitted to hospitals in Israel between 1997 and 2003. Data were obtained from the ITR.Burns contributed about 9% of all terror related trauma and about 5% of all other trauma (p0.0001). These percentages have not changed significantly before and after October 2000. Terror-related burns afflict Jewish males more than predicted by their percentage in the population, whereas other burns afflict non-Jewish males more than predicted. Adults and young adults (15-59 years) are the predominant group in terror-related burns (80%), whereas children younger than 15 years are the predominant group in other burns (50%). Large burns (20% to 89% total body surface area) are more common in terror casualties, with greater mortality (6.4% in terror-related versus 3.4% in others; p = 0.0258).Although the incidence of burns has risen because of an organized campaign, this change was noticeable in other trauma forms as well in similar proportions. Terror-related burns afflict a targeted population, and generally take on a more severe course with greater mortality rates, thus requiring appropriate medical treatment.

Background: The Aptos thread technique is a mode of uplifting the flabby soft tissue of the aging face. Permanent suture material made of polypropylene monofilament with dents is used in this technique. This procedure is gaining popularity throughout the world. According to the literature, several hundred Aptos procedures have been performed, and no major complications have been reported yet. Methods: Two adult women presented shortly after the Aptos thread insertion. They sustained devastating results. A close study was performed to understand and learn the potential complications. Results: The authors present two major complications, a rare case of Stensen's duct laceration and a case of chronic inflammation mandating surgical treatment. Conclusions: Describing complications may teach plastic surgeons more about this method and how to avoid similar devastating side effects in the future.

Background The purpose of this study was to investigate a means of providing pain relief during repair of facial lacerations in children in the emergency room. Methods This study was conducted in the emergency room of a tertiary care, university-affiliated hospital. Fifty percent nitrous oxide was administered by the surgeon who sutured the laceration. A nurse monitored the child throughout the procedure. At the end of the procedure, pain scores were evaluated by the surgeon and nurse using the FLACC (face, legs, activity, cry, and consolability) scale, a structured observational-behavioral scale for measurement of pain. Results Sixty patients between the ages of 1 and 16 years participated in the study. Of these, 15 were sutured using standard care (lidocaine infiltration), and 45 children received nitrous oxide in addition to lidocaine infiltration. Nitrous oxide was administered for an average of 11.9 +/- 5.1 minutes (range, 4 to 30 minutes). Forty-three children recovered to preprocedure activity in less than 1 minute. Two children recovered in less than 3 minutes. Average FLACC scores during infiltration and suturing were significantly lower in the nitrous oxide group compared with controls (infiltration, 1.9 of 10 versus 9.7 of 10; suturing, 2 of 10 versus 8.8 of 10). Forceful restraining was necessary in all the controls, whereas in the nitrous oxide group mild force was required in only 15 percent. Seventy percent of the children receiving nitrous oxide had no side effects. Vomiting and nausea were the most common (17 percent), transient side effects. No respiratory or cardiovascular side effects occurred. Conclusions Nitrous oxide can be safely administered by plastic surgeons while suturing facial lacerations in the emergency room. The fast onset and rapid recovery characteristics of nitrous oxide provide a convenient environment for performing short surgical procedures. This safe method for provision of analgesia and anxiolysis may be appealing to plastic surgeons for ambulatory procedures (e.g., suture removal, expander inflation, Botox injection, injection of various fillers) in pediatric and adult populations.

Objective: We researched whether the obstetric operating room (OR) qualified as a fire-risk environment so as to take preventive measures accordingly.Methods: We analyzed a series of iatrogenic burns inflicted during birth by collecting clinical data and comparing it with known OR fire risk factors and with other factors that repeated in all cases in search of unique characteristics of the obstetric OR.Results: All three cases shared in common the same type of oxygen-rich open ventilation system, alcohol-based prepping solution, and the hastiness of cesarean delivery while spontaneous vaginal delivery was already in progress.Conclusion: The obstetric OR is, as suspected, a fire-prone zone in more ways than the regular OR. Therefore, preventive measures should be undertaken and awareness for the possibility for such occurrences should be raised.

Background: Burn victims experience immense physical and mental hardship during their process of rehabilitation and regaining functionality. We examined different objective burn-related factors as well as psychological ones, in the form of personality traits that may affect the rehabilitation process and its outcome. Objective: To assess the influence and correlation of specific personality traits and objective injury-related parameters on the adjustment of burn victims post-injury. Methods: Sixty-two male patients admitted to our burn unit due to burn injuries were compared with 36 healthy male individuals by use of questionnaires to assess each group’s psychological adjustment parameters. Multivariate and hierarchical regression analysis was conducted to identify differences between the groups. Results: A significant negative correlation was found between the objective burn injury severity (e.g., total body surface area and burn depth) and the adjustment of burn victims (p

Summary Background Several techniques are currently available for reconstruction of helical rim defects including Antia and Buch's technique. Some of these techniques produce unsatisfying aesthetic results or are time consuming or technically challenging. Herein, we present the earlobe-based advancement flap (ELBAF) technique and its anatomical basis for reconstruction of helical rim defects. Methods A case series of 13 patients with helical rim defects of up to 3.8 cm in length were reconstructed using the ELBAF technique solely or with additional procedures. Patients were followed for the occurrence of complications and evaluation of aesthetic results for up to 8 years. An anatomical assay that included cadaver dissection and anatomical corrosion technique was performed in order to support the ELBAF technique. Results Thirteen patients (68.5 ± 9 years, two females) with full-thickness helical rim defects of up to 3.8-cm length caused by basal cell carcinoma in 92.3% underwent reconstruction surgery using the ELBAF technique solely or with additional procedures. No complications related to the ELBAF technique were encountered during follow-up. Cadaver dissections demonstrated a consistent arterial blood supply emerging from the earlobe area, producing arteries that run circularly along the helical rim. Conclusions Based on the axial vessel pattern, the ELBAF technique seems to be a useful strategy to reconstruct full-thickness helical defects of up to 3.8 cm in length. This procedure can be regarded as a valid addition to the ear reconstruction repertoire, which can be used alone or in combination with other established techniques. Level of evidence: Level 4, case series.

In Israel, there are no uniform guidelines for the treatment policy of children snake-bitten by the Vipera palaestinae, the most abundant venomous snake in the country. We conducted a retrospective study aiming to compare treatment policies in two different medical centers. We found significant differences regarding admission and steroid administration criteria. Although the differences between the centers regarding anti-venom administration did not reach statistical significance, there were substantial differences. Neither of the centers had a well-established policy for the treatment of snake envenomation in children. In the era of cost containment, a policy of routine admission of children to the PICU service following V. palaestinae envenomation is unjustified, especially since the introduction of a specific monovalent anti-venom into the therapeutic armamentarium.

Background. Mohs surgery and other surgical techniques are used for the removal of squamous cell carcinoma of the lower lip and may leave a large defect in the vermilion and underlying tissue. When nearly the entire lower lip is excised, reconstruction of this defect is a challenge. Repair requires the matching of vermilion color, maintenance of oral sphincter function and mouth opening size, and retention of sensation. Several techniques have been suggested. We present a modification of the Webster flap for total lower lip reconstruction using innervated muscle-bearing flaps. Objective. To present a surgical technique for the reconstruction of total lower lip defects after excision of squamous cell carcinoma. Methods. Innervated muscle-bearing flaps are used and demonstrated in one case. The surgical technique is discussed in detail. Results. The reconstructive results were excellent. There were no postoperative complications. Conclusion. The use of innervated muscle-bearing flaps is a useful and effective option for the reconstruction of total lower lip defects.

Background. The nasolabial flap is a versatile and effective option for the closure of nasal defects of the cheek and nasal sidewall following Mohs surgery. However, both extirpation of a tumor in the region of the base of the flap or previous use of the flap often destroy the proximal axial blood supply to the flap, excluding its immediate utilization. We describe a different use of the nasolabial flap and a technique for preserving its capacity in the case of reutilization Objective. To describe the versatility of the nasolabial flap and a delay procedure that enables its exploitation despite prior disruption of the proximal blood supply. Methods. Three different uses of the same nasolabial flap are demonstrated in one patient. The surgical techniques are discussed in detail. Results. The reconstructive results were excellent. There were no postoperative complications. Conclusion. The nasolabial flap is a versatile and effective option for the closure of nasal defects of the cheek and nasal sidewall. When the nasolabial flap has been used before, or its blood supply compromised, the delay procedure can reestablish its applicability.

Background and Objective Rhinophyma is a benign, disfiguring disorder of the nose which presents the end stage of acne rosacea, and can also occasionally result in nasal airway obstruction. We describe the first series of patients treated with Erbium laser. Study Design/Materials and Methods Severe-to-moderate rhinophyma in six patients were treated at our institution between 1995 and 1996, using the Erbium:YAG (Erb:YAG) laser. Results All patients achieved marked cosmetic improvement, with no complications. Post-operative healing time was seven to fourteen days-significantly shorter than similar other modalities. Conclusions The Erbium laser provides very accurate tissue ablation and allows the sculpturing of the hypertrophied areas, offering good cosmetic results, with a very short healing period as shown in our study. Lasers Surg. Med. 29:230–235, 2001. © 2001 Wiley-Liss, Inc.

(1) Leiurus quinquestriatus scorpion (LQS) envenomtion is a common public health problem with a similar clinical presentation in the Middle East and worldwide: localized reactions occur in up to 97% of the victims. (2) LQS envenomation in children is potentially fatal since the severity of symptoms is weight-dependent. (3) A common policy is to hospitalize all children stung by the LQS egardless of clinical severity in the pediatric intensive care unit (PICU). (4) Seventeen of 18 children treated at two Israeli medical centers during an 8-year period developed mild to moderate clinical manifestations (antivenin was given in the one severe case; all children survived): all 18 had been transferred to an ICU for surveillance. Since patient care in PICUs is far more costly and manpower-intense than in general emergency rooms, we propose that a protocol of 6 h of surveillance in the emergency department is adequate and safe for most children who had been stung by LQS. Only children who develop systemic manifestations should be hospitalized and transferred to the intensive care unit. (5) Further prospective studies should be conducted to define specific subgroups that may benefit from these recommendations.

Germline mutations in the p16 (CDKN2A) tumour suppressor gene have been linked to inherited predisposition to malignant melanoma (MM). Variable frequencies of p16 germline mutations were reported in different collections of melanoma families but it can be as high as 50%. Here we describe the results of p16 mutation screening in 30 melanoma kindreds in Israel. The entire coding region of the p16 gene, including exons 1, 2 and 3, flanking exon/intron junctions, and a portion of the 3' untranslated (UTR) region of the gene were examined by single-stranded conformation polymorphism (SSCP) analysis and direct sequencing. Two p16 germline mutations were identified: G101W, which has been previously observed in a number of melanoma kindreds, and G122V, a novel missense mutation. Thus, the frequency of mutations identified in this collection of Israeli families was 7%. Functional analysis indicated that the novel G122V variant retained some capacity to interact with cyclin dependent kinases (CDKs) in vitro, yet it was significantly impaired in its ability to cause a G1 cell cycle arrest in human diploid fibroblasts. This partial loss of function is consistent with the predicted impact of G122V substitution on the 3-dimensional structure of the p16 protein.

Gross migration of silicone gel from ruptured breast implants is a rare event. It is associated with extravasation of gel into the breast parenchyma, and to distant locations such as the abdominal wall and inguinal areas. This silicone deposits present as subcutaneous nodules and cause a local reaction known as siliconoma. We evaluated a 56-year-old woman who presented with a 2-year history of painful, firm and ill-defined subcutaneous nodules on the medial aspect of the shins and ankles. Her medical history was notable for bilateral breast augmentation with silicone implants 30 years before presentation. Although there were no signs or symptoms on breast examination, ultrasonography and magnetic resonance imaging confirmed that both implants had ruptured. Histological examination of a punch biopsy from a nodule on the shin found lobular granulomatous panniculitis. An excisional biopsy of the lesion was analysed by scanning electron microscopy and was found to contain silicone. This is a rare case of gross migration of silicone to the shins, originating from ruptured breast implants. To our knowledge, there is no previous report of silicone migration to such a distant location. We discuss the common presentation of silicone migration and highlight the importance of awareness among dermatologists and plastic surgeons about this unusual occurrence.

Thoughthe riskof magnetic resonanceimaging(MRI)inducedburns has been previously published, the overwhelmingnature of this injury combined with its preventable etiology,merit reiteration of the morbidity associated with the use ofnon-MR-compatible devices in MRI sessions. After describingthe patient details, we provide guidelines aimed at decreasingthe potential risk of burns during routine magnetic resonanceimaging.MRI scans expose the patient to electromagnetic (EM)radiation. The EM spectrum contains non-ionizing radiationwhichdoesnotcauseirreversiblecelldamage[1].Itis,however,capable of inducing thermal damage. Various devices wereshown to induce burns in MRI settings. The list includes smallcircularmetallicimplantsinrabbits[2],tattoos[3,4],deepbrainimplanted stimulators [5], halo pins [6], cylindrical and otherimplanted devices [7], EKG monitoring devices [8],andtransdermal patches [9]. Previous studies have shown thatsubstantial heating (with temperature elevation up to 63.1 8C)[10]can becausedbyaresonantconducting loopcoupledtoaninduced EM field [11]. This situation occurs when inductanceand capacitance are equal and opposite: a state which can besustainedbyaconductingwirewithinthemagneticfieldsofanactive MR session. It is further speculated that several wiresbundled together in a linear arrangement are also capable ofthermal damage through a similar mechanism [15].

Partial lateral nasal defects challenge the plastic surgeon both technically and aesthetically. Many methods for reconstruction of these defects have been described. We have used a turnover forehead flap in conjunction with composite auricular graft for the reconstruction of nasal defects. The forehead flap is turned over so that the forehead skin serves as internal lining in the nose. The composite auricular graft serves as external nasal lining and provides mechanical support to the ala. The technique was used in seven patients and is presented here with illustrations, selected cases, results, and conclusions concerning patient selection.

Since it was first described by Dr. Marjolin in 1828 [1], squamous cell carcinoma (SCC) has been established as a well-recognized late complication of post-operative, posttraumatic and chronic scars. However, identification of SCC arising in a split-thickness skin graft (STSG) donor site is an entity that has been rarely reported in the literature. We report a case of a donor site SCC, which appeared on a patient’s thigh 6 weeks after harvesting skin to cover a groin soft tissue defect.

The assessment of deuteroporphyrin-hemin complex as an agent for the treatment of burn wounds infected with a multiple-drug resistant strain of Staphylococcus aureus was performed. The effect of the porphyrin on the survival of the infectious bacteria was first assayed in culture, and later tested as well in a burned infected animal model. The addition of deuteroporphyrin and hemin, separately or together (as a complex) to a growing culture of S. aureus was monitored during 8 hours. It was found that deuteroporphyrin alone was strongly bactericidal only after photosensitization. On the other hand, hemin alone was moderately bactericidal but light independent. A combination of both deuteroporphyrin and hemin was extremely potent even in the dark and did not require illumination to eradicate the bacteria. The in vivo experiments by application of the above porphyrins in combination to infected burn wounds in guinea pigs was an effective way to reduce dramatically the contaminating S. aureus. Reduction of more than 99% of the viable bacteria was noted after the porphyrin mixture was dropped on the eschar or injected into the eschar, an effect that lasted for up to 24 hours. The deuteroporphyrin-hemin complex may be suggested as a new bactericidal treatment of S. aureus infected burns since it was found to be a potent and promising anti-Staphylococcal agent.

Rhinoplasty is rarely complicated with infection. We present a case of necrotizing periorbital cellulitis that developed in an 18-year-old woman following aesthetic rhinoplasty. The clinical manifestations consisted of swelling of the eyelids and necrosis of the lower eyelid regions, accompanied by high fever. Streptococcus pyogenes was isolated from the wound. The patient responded well to administration of intravenous amoxycillin/clavulanate and conservative local treatment. The infection resolved uneventfully. At 2-year follow-up, the cosmetic result was excellent.

Introduction: Human mesenchymal stromal cells (hMSCs) from adipose cardiac tissue have attracted considerable interest for cell-based therapies. However, the best source of hMSCs for infarct repair is still unknown. Hypothesis: We aimed to test the hypothesis that, because of their proximity to the heart, hMSCs from the heart and epicardial fat would be better cells for infarct repair. Methods and Results: We isolated and grew hMSCs from patients with ischemic heart disease (IHD) from four different sources: 1) epicardial fat 2) pericardial fat 3) subcutaneous fat and 4) the right atrium. hMSCs from the right atrium and epicardial fat secreted the highest amounts of trophic and inflammatory cytokines, while hMSCs from pericardial and subcutaneous fat secreted the lowest (pin vivo , we allocated rats to hMSC transplantation 7 days after myocardial infarction (MI) (n=8-10 per group). Atrial hMSCs induced the highest number of vessels in the infarct, together with the highest inflammation score and macrophage accumulation 27 days after their injection. However, left ventricular (LV) dysfunction was worst after therapy with atrium and epicardial fat hMSCs, and minimal after subcutaneous fat hMSC therapy. Notably, there was a correlation between levels of tumor necrosis factor-α and hepatocyte growth factor, in vitro , and post-transplantation LV systolic dilatation. These surprising findings were supported by gene expression analysis in hMSCs from different sources of a patient with IHD. We found that the relative expression of inflammation and fibrosis-related genes was considerably higher in hMSCs from the right atrium and epicardial fat than in subcutaneous fat hMSCs. Conclusions: The origin of hMSCs affects their reparative and immunomodulatory properties. Because of their pro-inflammatory properties, hMSCs from the right atrium and epicardial fat of IHD patients could impair heart function after MI. Our findings might be relevant to autologous MSC therapy and pathogenesis and progression of IHD.

Close opposition of full-thickness skin grafts to the recipient wound bed is felt to be critical for graft survival. This is usually accomplished by bolster dressings, basting sutures, or both. Herein, we describe a facile and rapid technique for placing quilting sutures in full-thickness grafts on the ear using a plain gut suture with a short, straight needle. This technique is especially valuable in facilitating precise approximation of grafts within the fossae of the anterior ear. In our experience, this approach promotes graft survival and produces excellent cosmetic results.

Local flaps may be required to reconstruct defects on the face, neck, and scalp. Occasionally, delay techniques are indicated to reduce the risk for flap ischemia and subsequent necrosis. Delay may be employed before the flap is raised, as done to improve blood supply to a random flap when length to breadth proportions are not ideal, or after the flap is raised and before separation of the pedicle in the final reconstructive step to improve vascularity in the distal end of an interpolation flap. We present our techniques and results of delay procedures for interpolation and similar flaps.

Reconstruction of full-thickness defects may benefit from integration of dermal substitutes, which serve as a foundation for split-thickness skin grafts, thus enhancing short and long-term results. We present a series of 7 patients who were treated between 2010 and 2012 for complicated full-thickness defects by the second-generation collagen/elastin matrix Matriderm® covered by a split-thickness skin graft. The defects resulted from malignancy resection, trauma, and post-burn scar reconstruction. Overall graft take was excellent and no complications were noted regarding the dermal substitute. Graft quality was close to normal skin in terms of elasticity, pliability, texture, and color. Good contour and cushioning of defects in weight bearing areas was also achieved. Matriderm was found to be a useful adjunct to full-thickness defect reconstruction, especially in difficult areas where the desired result is a scar of the highest quality possible.