Abraham Amir

Effect of facial pressure garments for burn injury in adult patients after orthodontic treatment

Pressure garments are commonly used to prevent and control hypertrophic scar tissue. Complications are unusual, though in children with facial burns, pressure garments may lead to skeletal and dental deformities. Studies in adolescents and adults are sparse. We describe a 24-year-old woman who sustained facial burns. Prior to injury, the patient had undergone premolar extraction in preparation for orthodontic treatment. Her post-burn care consisted of application of a Jobst pressure garment. After 2 months treatment, severe deformation of the dental-alveolar structure was observed. This reports suggests that adults after dental extraction are at a high risk of dental-alveolar deformities from pressure garments and might benefit from the use of occlusal wafers.

Anterior conchal reconstruction using a posteroauricular pull-through transpositional flap.

A normal complete appearance of the human ear includes a scapha, concha, helix, antihelix, and lobule. The concha is a shallow, almost triangular, cuplike structure with a depth of 1.5 cm. Conchal integrity affects both the aesthetic appearance of the human ear and air conduction to the auditory canal. Trauma, infection, lesions, or surgery may adversely affect conchal appearance. Skin lesions arising in the conchal cavity may involve the perichondrium, and thus adequate excision usually requires the removal of underlying conchal perichondrium or cartilage. Maintaining the structural firmness of the conchal cavity is of the utmost importance to earpiece equipment, air conduction to the external auditory canal, and aesthetic appearance. Reconstruction of the conchal cavity defect by skin graft is subject to centripetal contraction, loose conchal framework, and aesthetic impairment. Using a local flap is therefore safe and leads to better physiologic and aesthetic results. The traditional posteroauricular “revolving door” island flap described by Masson1 is ideal for large conchal defects and usually requires skin graft coverage to the donor site. For smaller lesions, this technique bears more risk for flap necrosis because of a short pedicle.2 The authors present a modified technique previously described by Renard3 suitable for all defect sizes.

Congenital Volkmann-Lesser ischemic contracture of the upper limb.

Neonatal vascular compromise to limbs has been associated traditionally with perinatal injury of the brachial plexus, fracture of the clavicle or humerus, or iatrogenic causes. Congenital Volkmanns ischemic contracture is an exceptional etiology of ischemic limb in the newborn. Fewer than 10 cases had been described in the literature. The authors report a newborn presenting at birth with partial bluish discoloration of the right forearm. The clinical picture and laboratory studies lead to the diagnosis of congenital Volkmann-Lesser ischemic contracture.

The digital pulp as a presenting site of metastatic esophageal carcinoma.

An unusual skin lesion may be a primary skin cancer or a sign of internal malignancy. Metastatic lesions to the hand are rare. The authors describe a patient who presented with a nodule of the digital pulp. Workup, including X-ray films and biopsy, revealed a metastatic squamous cell carcinoma invading the distal phalanx. The primary site of the tumor was the esophagus. To the best of their knowledge, this is the second case described in the literature of a metastatic carcinoma of the esophagus presenting as a lesion of the digital pulp.

Use of the SpaceMaker balloon in sternal wound closure: comparison with other techniques.

&NA; Sternal wound infection is surgically treated by debridement of the infected sternum and closure of the defect with a muscular flap. These operations tend to be long, stressful, and time‐consuming and to involve heavy blood loss. To facilitate wound closure, the SpaceMaker balloon was applied intraoperatively to expand the pectoralis major muscles and enable tensionless closure with musculocutaneous flaps. The aim of the present study was to compare the effectiveness and feasibility of this technique with a variety of others described in the literature. The study population consisted of 40 consecutive patients with sternal wound infection following median sternotomy who were treated with the advancement flap, turnover flap, transposition flap, or SpaceMaker balloon‐assisted advancement flap technique (n = 10 each). The balloon‐assisted technique was associated with a shorter length of operation and fewer blood transfusions than the other methods. Furthermore, there was no need for reoperation and there were no cases of skin necrosis. In conclusion, closure with the SpaceMaker balloonassisted bilateral pectoralis major musculocutaneous flap may serve as an adjunctive measure in the treatment of sternal wound infection. This technique seems to have advantages over simple pectoralis major musculocutaneous advancement, particularly for midsternal wounds. (Plast. Reconstr. Surg. 108: 1582, 2001.)

Balloon expansion of the pectoralis major muscle flap in sternoplasty: a biomechanical and histologic study in a rat model.

The pectoralis major advancement flap is currently the most popular technique for reconstruction of the anterior chest in patients with sternotomy wounds. Recently, the SpaceMaker balloon was introduced for rapid expansion of the pectoralis major muscle intraoperatively. The aim of the present study was to investigate the biomechanical and histologic effects of this expansion technique in a rat model. The upper 2 cm of the sternum was resected in 54 male rats. Reconstruction with balloon-assisted pectoralis muscle expansion was performed in 24 rats (study group). Another 24 rats underwent reconstruction with simple muscle advancement without expansion. Submuscular insertion of a catheter for expansion, without inflation, was performed in the remaining six rats (sham group). Rats were killed either immediately or 2 to 4 weeks after surgery. Thirty-eight rats, including 16 after reconstruction with expansion, 16 after reconstruction without expansion, and six in the sham group, were killed immediately after surgery. Sixteen rats were killed 2 to 4 weeks after surgery, eight rats for each reconstruction technique. Before the animals were killed, the biomechanical properties of the muscles were tested with weights to calculate stiffness (in newtons per meter) and compliance gain (in percent). After the animals were killed, biopsy specimens were obtained for histologic analysis. Results indicated significantly lower muscle stiffness in the study group compared with the others immediately after surgery (p = 0.0000), although the difference failed to achieve statistical significance 2 to 4 weeks later (p = 0.76). In the study group, the compliance gain was 74.4 percent immediately after surgery but only 3.4 percent 2 weeks to 1 month postoperatively. Histologic examinations in all groups immediately and 2 to 4 weeks after surgery revealed regular muscle striation with no signs of inflammation. The elastic stiffness of the rat pectoralis major muscle is significantly reduced following rapid intraoperative expansion and returns to normal 2 to 4 weeks later.

Subdermabrasion in the treatment of post-burn facial hypertrophic scars.

Abstract. Hypertrophic scars cause great discomfort to the patient and pose a challenge for the reconstructive surgeon. This is particularly true in the facial area. Optimal function and aesthetic appearance are the main goals of reconstruction.We suggest an adjunct to the surgical management of facial hypertrophic scars which involves abrasion of the subdermal plane. The technique consists of removal of all scarred skin from the aesthetic unit, dermabrasion of subcutaneous tissues, including the muscular surface (subdermabrasion), and a full thickness skin grafting. This technique was applied in a young patient with hypertrophic burn scars of the chin. Biopsy confirmed our basic assumption that hypertrophic scars extend into the muscular plane.

Apron flap and Re-creation of the inframammary fold following TRAM flap breast reconstruction

To the best of our knowledge, the recreation of an inframammary fold after TRAM flap breast reconstruction has not yet been described. This article offers a technique for the creation of an inframammary fold as a secondary procedure. The technique has been performed thus far in two patients with good aesthetic outcomes and no postoperative complications. It may also be suitable for adding bulk to the TRAM flap, especially in bilateral breast reconstruction, and for other minor chest deformities.

Use of the SpaceMaker® balloon dissector for repair of sacral pressure sores

Most of the techniques that have been suggested for closure of sacral pressure sores use musculocutaneous flaps. We report our experience in three patients using the SpaceMaker® balloon dissector. The dissector was inserted into the subgluteal maximus muscle plane to expand the muscle and overlying skin, thereby forming bilateral sliding and tension‐free musculocutaneous flaps. The procedure is simple, safe, bloodless, and combines the advantages of advancement of a muscle flap and expansion.

Criss-cross scoring of postburn necrotic tissue.

grafts with a partial-thickness sponge. The main advantages of this technique are the convenient facial contour adjustment and the ability to generate various pressures over the structures of the face. We begin by outlining over a sponge (Reston dressing, 3M, St. Paul, Minn.) the total area of the skin graft and the margins of the anatomic structures within this area. Next, a partial-thickness design of the sponge is made by the use of a Goulian dermatome (Fig. 1, above and center). The sponge is made thick where high pressure is desired and is curved thin where low pressure is preferred (e.g., over the auricle). The sponge is applied over a Vaseline gauze mesh and secured in place with fine nylon sutures for 7 days (Fig. 1, below). Meir Cohen, M.D., M.P.S. Andrew Organek Division of Plastic Surgery, Suite 1524 The Hospital for Sick Children 555 University Avenue Toronto, Ontario Canada M56 1X8