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Objective Postoperative ecchymoses or hematomas can prolong healing from surgery, and a search for locally administered agents that decrease bleeding is warranted. The objective of this study is to evaluate whether preoperative subcutaneous injection of tranexamic acid (TXA) reduces intra- and postoperative bleeding or ecchymoses in skin-only upper eyelid blepharoplasty surgery. Design This is a prospective randomized, double-blind, controlled study. Participants We included 34 consecutive patients who were referred to an upper eyelid blepharoplasty surgery in our institution. Methods The patients were equally randomized to a preoperative local injection of lidocaine mixed with either TXA or normal saline. All patients stopped antiaggregates 1 week before surgery. All surgeries were performed by a single surgeon who was unaware of group assignment. Total surgical time, cumulative time of cautery use, blood loss, the surgeon’s assessment of bleeding extent, pain level reported by the patient, periocular ecchymoses during the first postoperative week, and time for patient’s return to normal daily activity were recorded. Results There was a trend toward smaller ecchymoses in the TXA group compared with the placebo group on the seventh day (p = 0.072). There were no group differences in total surgery time, cumulative cautery time, net blood weight in surgical pads, patient-reported pain level, surgeon’s assessment of hemostasis, or periocular ecchymosis size on the first postoperative day. Conclusions Subcutaneous TXA was associated with similar intra- and postoperative hemorrhage in upper eyelid blepharoplasty compared with placebo. The effect of TXA in patients who did not stop antiaggregate use before surgery warrants further study.

Mechanisms of platelet activation are triggered by thrombin, adenosine diphosphate (ADP), epinephrine, thromboxane A2, and other soluble agonists which induce signaling via heterotrimeric Gαq, Gαi, and Gα12/13 proteins. We have undertaken a study addressing the contribution of these G proteins to platelet activation and clot formation in the presence of eptifibatide, thus excluding outside-in signaling provided by integrin αIIbβ3–fibrinogen engagement.Selective and combined activation of the G proteins was achieved by using combinations of platelet agonists and inhibitors. Platelet activation in platelet-rich plasma was evaluated by P-selectin expression using flow cytometry. Contribution of platelets to whole blood clotting was assessed by rotation thromboelastometry (ROTEM).Selective signaling of Gαq or Gαi but not Gα12/13 promoted P-selectin expression. Further enhancement of P-selectin expression was achieved by ADP-induced combined signaling of Gαq and Gαi, and to more extent by U46619 at hig...

The anatomical basis for auricular flaps used in multiple aesthetic and reconstructive procedures is currently based on a random distribution of the underlying arterial network. However, recent findings reveal a systematic pattern as opposed to the present concepts. Therefore, we designed this study to assess the arterial vascular pattern of the auricle in order to provide reliable data about the vascular map required for surgical interventions. Sixteen human auricles from eight body donors (five females/three males, 84.33 ± 9.0 years) were investigated using the unique ‘Spalteholz’ method. After arterial injection of silicone, a complete transparency of the tissue was achieved and the auricular arteries and branches were visible. Qualitative and quantitative evaluation of the arterial vascular pattern was performed. The superior and the inferior anterior auricular artery provided the vascular supply to the helical rim, forming an arcade, i.e. helical rim arcade. On the superior third of the helical rim another arcade was confirmed between the superior anterior auricular artery and the posterior auricular artery (PAA), i.e. the helical arcade. The perforators of the PAA were identified lying in a vertical line 1 cm posterior to the tragus, supplying the concha, inferior crus, triangular fossa, antihelix and the earlobe. The results of this study confirmed the constant presence of the helical rim arcade (Zilinsky‐Cotofana), consistent perforating branches of the PAA, and the helical arcade (Erdman), and will help and guide physicians performing auricular surgeries toward fast and simple procedures with optimal patient satisfaction.

Rejuvenative procedures of the face are increasing in numbers, and a plethora of different therapeutic options are available today. Every procedure should aim for the patient's safety first and then for natural and long-lasting results. The face is one of the most complex regions in the human body and research continuously reveals new insights into the complex interplay of the different participating structures. Bone, ligaments, muscles, fat, and skin are the key players in the layered arrangement of the face. Aging occurs in all involved facial structures but the onset and the speed of age-related changes differ between each specific structure, between each individual, and between different ethnic groups. Therefore, knowledge of age-related anatomy is crucial for a physician's work when trying to restore a youthful face. This review focuses on the current understanding of the anatomy of the human face and tries to elucidate the morphological changes during aging of bone, ligaments, muscles, and fat, and their role in rejuvenative procedures.

Topical application, oral, and IV injection of tranexamic acid (TXA) have been used to reduce surgical bleeding.To evaluate the safety and efficacy of TXA injected subcutaneously to reduce bleeding during dermatologic surgery.In this double-blinded, placebo-controlled, randomized prospective study, 131 patients were randomized to subcutaneous injection of lidocaine 2% diluted 1:1 with either saline (placebo) or TXA 100 mg/1 mL before surgery. Before the second stage or closure, size measurements of bloodstain impregnation on Telfa and surgical wound size were recorded and analyzed using mixed-effects linear regression. Subjective evaluation of hemostasis was performed using 4-point scale grading and analyzed using Fischer's exact test.One hundred twenty-seven patients completed the study. The bloodstain to surgical wound size ratio was smaller in the TXA group (1.77) compared with the placebo group (2.49) (p.001). An improved effect of TXA on bleeding was observed in the subgroup of patients receiving anticoagulants (mean difference; 95% confidence interval; -0.83; -1.20 to -0.46 p.001). The subjective hemostasis assessment was significantly better in the TXA group overall (p = .043) and anticoagulant subgroup (p = .001) compared with the placebo group.Subcutaneous injection of TXA was safe, reduced bleeding during dermatologic surgery, and particularly effective for patients receiving anticoagulation treatment.

// 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.

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.

Josef Haik,1–3 Stav Brown,1,2 Alon Liran,1 Denis Visentin,4 Amit Sokolov,2 Isaac Zilinsky,1,2 Rachel Kornhaber1,4 1Department of Plastic and Reconstruction Surgery, The National Burns Center, Sheba Medical Center, Tel Hashomer, 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 3Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Israel; 4School of Health Sciences, Faculty of Health, University of Tasmania, Sydney, NSW, Australia Abstract: Acute healthcare environments can be stressful settings with clinicians experiencing deleterious effects of burnout and compassion fatigue affecting their mental health. Subsequently, the quality of patient care and outcomes may be threatened if clinicians experience burnout or compassion fatigue. Therefore, the aim of this descriptive, cross-sectional study was to evaluate the prevalence of burnout and compassion fatigue among burn clinicians in Israel. Fifty-five clinicians from Burns, Plastics and Reconstruction Surgery and Intensive Care completed four validated surveys to assess burnout (Maslach Burnout Inventory), depression (PRIME-MD), health-related quality of life (SF-8), and compassion fatigue (Professional Quality of Life version 5). Burn clinicians were compared with Plastics and Reconstruction Surgery and Intensive Care clinicians. This study identified a high prevalence of burnout (38.2%) among Intensive Care, Plastics and Reconstruction and Burns clinicians, with Burns clinicians having a greatly increased prevalence of burnout compared to Intensive Care clinicians (OR =24.3, P=0.017). Additional factors contributing to compassion fatigue were those without children (P=0.016), divorced (P=0.035), of a younger age (P=0.019), and a registered nurse (P=0.05). Burnout increased clinicians’ risk of adverse professional and personal outcomes and correlated with less free time (P

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.

Between stages of Mohs micrographic surgery, the wound is dressed and the patient waits for the histopathological results.br/To investigate the efficacy of a hemostatic-anesthetic solution-impregnated gauze in decreasing bleeding between Mohs stages.br/Twenty patients were treated with a hemostatic-anesthetic solution composed of tranexamic acid, adrenaline, and lidocaine (TAL), and 20 others were treated with a saline solution for control. At the second Mohs stage, size measurements of the blood stain on a Telfa pad and the defect were recorded. The Rotation Thromboelastometry Method (ROTEM) was used to investigate a possible effect of lidocaine and adrenaline on the clot stability induced by tranexamic acid.br/The ratio of blood stain size to Mohs defect size in the hemostatic anesthetic solution group was 1:1.47, whereas the ratio in the control saline group was 1:3.37 (Plt;.001). Results of the ROTEM test showed that lidocaine and adrenaline did not interfere with the effect of tranexamic acid on clot formation and stability.br/The application of gauze impregnated with tranexamic acid, adrenaline, and lidocaine on a surgical wound may be effective in reducing bleeding between Mohs stages.br /br /emJ Drugs Dermatol./em2016;15(7):851-855.

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.

Tissue expansion using implantable expanders is a useful means of generating surplus tissue for reconstruction of defects such as scarring following burns. The authors describe their technique of incisions distant to the desired location of expander placement, and remote dissection of the expander pocket with hydrodissection and blunt forceps. A total of 81 expanders were placed in 30 consecutive patients, 81% of whom had burn scars due for reconstruction. During preparation, no complications, such as bleeding, were encountered, except one case with severe subdermal fibrosis, in which bleeding was stopped through brief application of pressure. Postoperatively, no complications were encountered in 76% of patients; however, 16.6% exhibited surgical site infection, which was managed conservatively and was correlated with a high number of expanders implanted at once. One patient experienced hematoma formation that resolved spontaneously, and one instance of expander extrusion and subsequent removal occurred. Receiving ≥2 expanders at the same time was statistically associated with higher risk for complication(s). The authors' complication rates were moderate and comparable with open or endoscopic approaches. Time of expansion is reduced compared with the open approach due to distant incision placement and immediate usability. Cost effectiveness appeared to be better using only inexpensive forceps, rather than elaborate and costly endoscopic equipment.L’expansion tissulaire à l’aide d’implants produit un excédent de tissus utile pour reconstruire des lésions telles que des cicatrices consécutives à des brûlures. Les auteurs décrivent leur technique d’incisions éloignées du foyer de l’expanseur et leur méthode d’hydrodissection par pinces mousse à distance de la poche d’expanseur. Au total, ils ont inséré 81 expanseurs chez 30 patients consécutifs, dont 81 % pour reconstruire des cicatrices consécutives à des brûlures. Pendant la préparation, les chercheurs n’ont relevé aucune complication, telle qu’une hémorragie, à part un cas d’importante fibrose sous-cutanée dont l’hémorragie a été interrompue par une brève pression. Après l’opération, ils n’ont observé aucune complication chez 76 % des patients, mais 16,6 % ont présenté une infection au site chirurgical, liée à l’implantation de plusieurs expanseurs en une même intervention et traitée avec prudence. Un patient a présenté un hématome qui s’est résolu spontanément, et un autre, une extrusion de l’expanseur qu’il a fallu retirer. L’implantation simultanée d’au moins deux expanseurs s’associait statistiquement à un risque plus marqué de complication(s). Le taux de complications des auteurs était modéré et comparable à celui des chirurgies ouvertes ou des endoscopies. L’expansion était de plus courte durée que par chirurgie ouverte, grâce à l’incision à distance et à l’utilisabilité immédiate. Le rapport coût-efficacité semblait supérieur au moyen de pinces bon marché que de matériel endoscopique élaboré et coûteux.

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. .

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.

Lentigo maligna melanoma (LMM), a melanoma subtype that arises on sun-damaged facial skin, is difficult to diagnose clinically. Patients and physicians are reluctant to perform unnecessary facial biopsies. Reflectance confocal microscopy (RCM) is a novel technique for non-invasive skin imaging at cellular-level resolution. RCM increases the accuracy of melanoma diagnosis.To describe the diagnostic utility of RCM in cases of clinically and dermatoscopically equivocal pigmented skin lesions suspicious for LMM.This is a retrospective case series derived from the population of patients undergoing periodic skin cancer screening at a tertiary hospital clinic that specializes in skin cancer diagnosis. All patients consented to RCM imaging as an ancillary test prior to the decision on performing a biopsy in the facial lesion.We report on four patients who presented clinically and dermatoscopically equivocal pigmented skin lesions in the head and neck region, with differential diagnosis of LMM. Furthermore, in two patients, a prior incisional biopsy indicated a benign diagnosis upon histopathological analysis. In all cases, RCM examination showed specific criteria for LMM. The RCM diagnosis of LMM allowed direct referral for excisional surgery in three patients. In another patient, RCM findings guided incisional biopsy-site selection to a focus that revealed histopathology clear-cut criteria for LMM.RCM is a very useful adjunct to the non-invasive diagnosis of LMM.

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.

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.

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.

The skin of the scalp is relatively thick, minimally mobile, with distinct hair distribution. TopClosure® is a novel device for skin stretching and secure wound closure.To evaluate the efficacy of the TopClosure® system in primary closure of moderate and large scalp defects, as a substitute for skin grafts, flaps, and tissue expanders.We report a retrospective series of 8 patients requiring resection of 9 scalp tumors resulting with moderate to large size defects that otherwise would have required reconstruction with skin grafts, flaps, or tissue expanders. TopClosure® was applied for intraoperative cycles of stress-relaxation, followed, when indicated, by additional steps of mechanical creep and scar secure.Skin defects, averaging 3.5 cm, were managed by TopClosure®, enabling, primary closure in all wounds. Immediate wound edge approximation was reached through stress-relaxation in 2 wounds by heavy tension sutures within one hour. Further skin stretching by mechanical creep was required in 7 wounds, achieving staged primary closure in an outpatient setting. TopClosure® was further applied to secure the skin for up to 3 weeks following surgery.The TopClosure system, effectively, aided closure of moderate and large scalp defects by stress-relaxation and mechanical creep and serving as a topical tension-relief platform for tension sutures, allowing mobilization of skin and subcutaneous tissue without undermining or need of drainage, for early, direct wound closure. Local complications were minimal and donor site morbidity was eliminated. Surgical time, hospital stay and costs were reduced, and post-operative wound aesthetics were improved.

The burn trauma is multifactorial and involves pathophysiologic processes of all of the body's systems. The impact it could have on a person's life includes impairments on their esthetic appearance, interpersonal relationships, psychological, social and physical functioning. Previously, the outcomes of burn care were confined in the context of mortality and length of hospital stay. Currently, a shift is afoot from defining good health care as merely the reduction of morbidity and mortality to a more holistic approach that involves aspects of Health Related Quality of Life. In this article we aim to present a concise review of the relevant literature and relevant topics pertaining Health Related Quality of Life and burn.

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.

Second degree facial burns usually impart high wound site pain levels and patient discomfort due to the abundance of facial sensory innervation, as well as the development of edema and inflammation that accompany wound healing. Frequent changing of adherent dressings causes additional procedural pain and may prolong healing due to recurring damage to the wound bed. We applied face masks, made on-site from a drug free polymeric membrane dressing, to 8 patients with superficial and deep 2nd degree facial burns. Time to full re-epithlialization was recorded during treatment. Pain, overall comfort, and result satisfaction were evaluated using a questionnaire (10-point Likert scales. From 1=minimum to 10=maximum) on follow-up (mean follow up 14.4 months, range 9-18). These results were compared to a historical cohort of patients with facial burns that were treated with an antibiotic ointment. Results showed mean re-epithelialization time of 6.5 days (as compared to 8.5 days in the cohort group), low pain ratings (mean: 2.6; range: 4.7 in the control group), mixed comfort levels (mean: 4.7/10; 4 in the control group) and high result satisfaction (mean: 7.8; 6.2 in the control group). Nursing staff described pain-free dressing changes and positively noted non-adherence and high absorbance capacity of the polymer, necessitating less dressing changes. Inflammation was contained to the actual site of injury. No complications in terms of infection or allergic reaction were observed. Overall, the polymeric membrane facial dressing seems to be a promising means of reducing pain and ensuring uninterrupted wound healing in 2nd degree facial burns.

Upper lip wrinkling is a common complaint of patients seeking perioral rejuvenation. Lately, manual dermabrasion has become more popular due to its safety, minimal cost, and favorable results. In several hospitals, the ability to efficiently sterilize sand paper has been questioned.Between 2007 and 2010, 29 patients underwent manual dermabrasion of the skin of the upper lip using an electric cautery scratch pad during their surgeries.The average patient was aged 60.2 years. The average healing period was 5.8 days. Patient satisfaction from the procedure ranged from very good to excellent. No serious or long lasting complications have been encountered during our follow-up period.

Full-Thickness skin grafts are routinely used to reconstruct defects throughout the body. When planning the size of the graft, the surgeon usually copies a template from the defect and measures the graft to fit its full dimensions. This may lead to an oversized graft, resulting an unaesthetic outcome.To evaluate discrepancy in size between the excised full-thickness skin and the excision (donor) site.Data from 20 cases of full-thickness excisions was reviewed and analyzed.There was a considerable difference in length of both the short and long axes between the excised full-thickness skin and the excision site.The initial size of a full-thickness skin graft should be smaller than the defect it is planned to cover.

Defects of the nasal ala present a complex reconstructive challenge. Composite grafts comprise all layers required to successfully reconstruct these full thickness deformities making them the ideal reconstructive method, yet they are usually avoided because of unjustified disreputable failure rates.The authors introduce a stepladder approach for alar reconstruction with a crus of helix composite graft according to the severity and complexity of the defect.Data from 25 patients who underwent correction of full thickness alar defects with composite grafts was collected and reviewed.There were no complete graft failures in any of the cases. Ten patients (40%) had partial graft necrosis ranging from 5 to 50% (average 18%); two of them (20%) were heavy smokers.Composite grafts should be considered for reconstruction of full thickness nasal ala defects, given the correct surgical technique is implemented.

The bilobed and hatchet flaps are well-accepted reconstructive options for the correction of defects of the lower third of the nose. Optimal utilization of these flaps depends on understanding the characteristics of each flap as well as anatomic considerations related to the distal nasal area. Disregarding the limitations of either method may lead to flap failure and unacceptable aesthetic results.We present three original ideas: 1) a bilobed flap may be considered as a hatchet flap with a Z-plasty; 2) the trap door deformity (TDD) associated with a bilobed flap can be used as an advantage; and 3) an easy method for preoperative planning of a bilobed flap.We collected data from patients who underwent excision of basal cell carcinoma (BCC) of the distal third of the nose and reconstruction with a hatchet or a bilobed flap within the last 20 years.Favorable cosmetic results were achieved when a hatchet flap was used to reconstruct defects of the inferior third of the nasal side wall, above or bordered with the alar crease, and when a bilobed flap was used to reconstruct nasal tip para-medial defects above the lower lateral cartilage convexity.We suggest choosing between the hatchet and bilobed flaps for nasal reconstruction according to the defect location as outlined by our findings.

Although Mohs surgery is considered a skin-sparing technique, when dealing with aggressive skin tumor that penetrates the deep tissues, the Mohs surgeon usually sacrifices uninvolved skin. We present our technique of 3D Mohs as a new concept for skin-sparing surgery. After raising a skin flap above the residual tumor, Mohs resection was performed on the deep tissues horizontally and simultaneously on the inner plan of the flap vertically. When "clear" borders were achieved, the skin flap was sutured back into place. The results show that the defect was significantly smaller, and the hair on the Mohs-treated vertical flap continue to grow, thus contributing to a more aesthetic outcome. We conclude that careful use of the 3D Mohs technique as we describe spares the healthy uninvolved skin and offers better aesthetic and functional result.

Abdominal fascia plication using a simple continuous suture can sometimes cause tears in the fascia. This problem can be circumvented when the continuous horizontal mattress suture is used. No data exist from comparing the two suturing techniques. The aim of this study was to examine which technique can potentially cause greater tissue damage. The time required to perform each type of suture was also recorded. Wound closure pads were plicated using the simple continuous and continuous horizontal mattress techniques performed by a single operator using Ethilon 2-0 nylon sutures. To verify their resilience, plastic bags were inflated beneath the pads to 30, 60, and 120 mmHg and tears were recorded. The time needed to perform the procedures was recorded using a stopwatch. Mean time for the continuous vertical mattress suture was 87 s and for the simple continuous suture 116 s. Tears in the pad that was plicated with the simple continuous pattern were significantly longer than those in the pad plicated with the continuous horizontal mattress pattern (fissure mean length ± SD = 3.958 ± 0.157 vs. 2.736 ± 0.157, respectively, p

Background: Myxoinflammatory fibroblastic sarcoma (MIFS) is a rare tumor presenting as a painless subcutaneous mass in the extremities first reported in 1998. We report the first case of a MIFS tumor in the groin. Methods: We have performed seven immunohistochemical stains that were not applied before on MIFS. Results: The first case of a MIFS tumor in the groin. Conclusions: MIFS must be considered in the differential diagnosis of a painless mass not only in the distal extremities but also in the groin. The diagnosis of this tumor is difficult and can be missed if not considered because of the unusual location. Due to high recurrence rates and one case of documented metastases, the recommended treatment is wide excision.

Local anesthetic agents are administered before many ambulatory cutaneous operations. The injection of the local anesthetic agent is often the only painful aspect of the procedure. There are various factors that determine how painful the anesthetic administration may be. These include the preparation used, the size of the needle and syringe used, injection technique, depth of injection, attitude of the physician, and more. In this article, we present the different techniques we apply to achieve minimal pain during the injection of local anesthetics.

Keloids are commonly seen as a complication of earlobe piercing. As biopsies are usually not performed routinely in many instances, some of the lesions might, in fact, represent other entities, such as cutaneous pseudolymphoma. Contrary to keloids, for which surgery alone is not recommended, a simple excision or superficial x-ray is sufficient in such cases.

Cervicofacial rhytidectomy procedures have become a mainstay for plastic surgeons during the past 20 years. Evolution in surgical techniques have led to more natural repositioning of facial elements, thus providing long-lasting results. This, in turn, has raised public interest and demand for the procedure. According to the American Society of Plastic Surgeons, in 2011, 119,026 facelift procedures were performed in the United States alone (1). However, facelifts still entail healing periods that sometimes span weeks and can be aggravated by complications. Common complications include postoperative hematoma, flap necrosis, seroma formation, motor and sensory nerve injury, alopecia, auricular deformity or displacement, and dyspigmentation (2–6). Of these, hematoma remains the most common complication and can lead to prolonged facial edema and, eventually, flap necrosis (3). Flap necrosis itself constitutes a vexing and grievous complication for both the patient and the surgeon, with a reported incidence rate of 0% to 3% (1). In these instances, usually after sloughing of the necrotic flap edge, an open preauricular and/or postauricular wound remains. The existing literature regarding the management of flap necrosis includes healing by secondary intention, surgical debridement, local administration of antibiotic preparations, moist dressings, vitamin injections and hydrofibre dressings (7–9). Recently, a new commercially available suspension, Polyheal-1 (Polyheal Ltd, Israel), has been introduced to the market aiming to expedite wound healing. Polyheal-1 is a water-based, sterile 0.025% suspension of charged polystyrene 5-μm microspheres (CPM) in a nutritional medium. There is evidence to suggest that the size and surface properties of the CPM contribute to the provision of a supportive, healing microenvironment on the wound surface by serving as an additional surface for the attachment and migration of epithelial, endothelial and inflammatory cells (10,11). Negatively charged microspheres have been shown to induce a pulmonary inflammatory process in rabbits through enhanced release of inflammatory mediators such as substance P and histamine (12). It is proposed that CPM activate different cell populations in the wound bed (ie, inflammatory cells, fibroblasts and keratinocytes) and, consequrntly, promote the growth of granulation tissue and remodelling of damaged skin tissue. The objective of the present study was to assess wound healing and re-epithelialization rates of open wounds following postrhytidectomy flap necrosis treated with Polyheal-1.