Anthony P. Sclafani

Prevention of Earlobe Keloid Recurrence with Postoperative Corticosteroid Injections Versus Radiation Therapy A Randomized, Prospective Study and Review of the Literature

BACKGROUND Simple excision of earlobe keloids can result in recurrence rates approaching 80%. Many modalities have been suggested to reduce the risk of recurrence postoperatively, including intralesional steroids and radiotherapy. OBJECTIVE In order to determine the most reliable method to prevent keloid recurrence, we have conducted the first randomized, prospective trial comparing corticosteroid injections versus radiation therapy. RESULTS Thirty‐one keloids were treated and followed for a minimum of 12.0 months. Two of 16 keloids (12.5%) recurred after surgery and radiation therapy, while 4 of 12 (33%) recurred after surgery and steroid injections. No alteration of skin pigmentation, wound dehiscence, chronic dermatitis, or neoplastic changes was observed in any patient in either group. Although a statistically significant difference was not observed, radiotherapy appeared to be more effective than steroid injections in preventing keloid recurrence. CONCLUSIONS Radiotherapy is a simpler treatment modality with better patient compliance, and patients were much more likely to complete treatment than with corticosteroid injections. We believe that radiotherapy can play an important role in the prevention of earlobe keloid recurrences, and that with current techniques, complications can be minimized. Further randomized study with additional patients is needed to compare the effectiveness of corticosteroid injections and radiotherapy in preventing keloid recurrence.

Treatment of Injectable Soft Tissue Filler Complications

BACKGROUND Increasing use of dermal fillers, especially with the U.S. introduction of long‐term and permanent fillers, is expected to increase the number of complications seen after treatment with these materials. OBJECTIVES To provide physicians with an overview for treatment of dermal filler complications. RESULTS Complications of dermal filler use can be treated successfully based on a firm understanding of the mechanisms and limitations of filler action and wound healing. Complications can be classified as immediate, early, or delayed onset; available treatment options are presented. CONCLUSION Short‐ and long‐term dermal fillers are increasingly becoming popular treatment options for signs of facial aging. Complications, although not common, can be treated effectively and excellent outcomes achieved. Dr. Sclafani is on the Speakers Panel for Medicis. Dr. Fagien is a consultant for Allergan, Bioform, and Medicis. He is also a clinical investigator for Allergan, Dermik, Medicis, and Mentor.

Use of Porous High-Density Polyethylene in Revision Rhinoplasty and in the Platyrrhine Nose

Abstract: Nasal reconstruction presents a significant challenge to the facial plastic surgeon. Reestablishment of the desired aesthetic nasal contour and restoration of respiratory function are the dual goals of this endeavor. While autologous cartilage or bone is considered optimal grafting material, the supply is often limited and harvesting entails additional morbidity. Many synthetic materials have been introduced for use in nasal reconstruction, but high infection and extrusion rates have left most surgeons dissatisfied with conventional implants. Porous polyethylene (Medpor) implants were used for nasal reconstruction in 187 patients; 66 (35.3%) patients underwent primary rhinoplasty, while revision surgery was performed in 121 (64.7%) patients. Most patients required multiple implants, including columella struts, plumper grafts, dorsal tip implants, and nasal valve battens. Postoperative follow-up ranged from 6 months to 3.5 years. Complications occurred in five (2.6%) patients. Three early and two delayed infections necessitated implant removal in five patients, all of whom had compromised skin–soft tissue envelopes secondary to heavy smoking, cocaine abuse, or prior surgery. One case of an overly augmented nasal dorsum and tip required implant removal, reduction, and reinsertion. All implants were easily removed. No other complications including implant extrusion or skin erosion have been noted. Porous polyethylene (Medpor) implants allow for fibrovascular ingrowth, which lends stability to the implant. Porous polyethylene implants are well tolerated and provide an ideal material for nasal reconstruction.

Evaluation and Management of the Lingual Thyroid Gland

Lingual thyroid gland is a rare clinical entity that is due to failure of descent of the gland anlage early in the course of embryogenesis. It may present with symptoms of dysphagia, upper airway obstruction, or even hemorrhage at any time from infancy through adulthood. We present two illustrative cases of lingual thyroid gland along with a protocol for diagnosis and management of the condition. Elements in the diagnostic and therapeutic evaluation are described with attention to the clinical findings, laboratory tests, and radiographic imaging studies employed in confirming the diagnosis and planning appropriate treatment The natural history of the condition is reviewed and a treatment strategy is outlined that focuses on the use of suppressive doses of thyroid hormone as the initial therapy. Surgical excision of the gland is reserved for more advanced cases of gland enlargement resulting in airway compromise, severe dysphagia that limits oral intake, or ongoing hemorrhage.

Clinical and histologic behavior of exposed porous high-density polyethylene implants

&NA; Reconstruction in the head and neck is difficult and often requires complex solutions to restore functional and aesthetic form. While autogenous tissue is preferred, many alloplasts have been investigated. These materials, however, are foreign bodies, and most alloplasts tolerate exposure and infection poorly. An alloplasts in vivo behavior is a function not only of its composition but also of its form and macrostructure, as well as the interaction at the host‐implant interface. Porous high‐density polyethylene is well tolerated by surrounding tissue, and its porous core is rapidly infiltrated by host tissue. In order to further investigate the response of porous high‐density polyethylene under adverse conditions, we implanted three porous high‐density polyethylene disks and one silicone disk underneath the dorsal skin in each of 12 rats. The implants were exposed at differing times after implantation. After 7 days, the exposed areas were either skin grafted or allowed to close by secondary intention. Silicone implants all tolerated exposure poorly. Porous high‐density polyethylene implants exposed soon after implantation also tolerated exposure poorly; however, none of these extruded. Porous high‐density polyethylene implants exposed after the host tissue had invaded the pores tolerated exposure well, healing either by secondary intention or by skin grafting. Porous high‐density polyethylene is a safe and reliable material for use in aesthetic and functional reconstruction of the head and neck. Porous high‐density polyethylene and possibly other porous alloplasts tolerate exposure well once host fibrovascular tissue has invaded the implant pores. Further investigation of differing clinical settings and implant behavior is currently in progress.

A graduated approach to the repair of nasal septal perforations

Septal perforation is an avoidable complication of septal surgery, but it can also occur because of a variety of traumatic, iatrogenic, caustic, or inflammatory reasons. Symptoms usually are related to disruption of the normally laminar flow of air through the nasal passages. Crusting, bleeding, parosmia, and neuralgia can develop, leading the patient to seek medical care. When local hygiene and conservative care are unsuccessful in relieving symptoms, closure of the perforation is considered. Repair is often difficult because of the limited exposure and limited amounts of friable mucosa with impaired vascular supply. The failure of attempted closure of septal perforations can be as high as 80 percent. The authors have developed a graduated approach to the closure of septal perforations that tailors the surgical approach to the size and location of the defect. Perforations 0.5 to 2.0 cm in size were closed in 92.9 percent (13 of 14) of patients using an extended external rhinoplasty approach and bilateral posteriorly based mucosal flaps. Larger perforations (2.0 to 4.5 cm) were closed in 81.8 percent (18 of 22) of patients by a two-staged technique, using a midfacial degloving approach to medially advance posteriorly based, expanded mucosal flaps. With careful preoperative management and selection of the appropriate surgical technique, even moderate-to-large perforations can be repaired reliably with limited operative morbidity.

Endoscopic foreheadplasty: a histologic comparison of periosteal refixation after endoscopic versus bicoronal lift.

Endoscopic brow lift techniques using temporary fixation rely on rapid readherence of the periosteum to calvarial bone. Little is known about the histologic events that occur during the early postoperative period after these procedures. An animal study was designed to compare and contrast periosteal fixation to bone and unelevated periosteum, with endoscopic and bicoronal brow lift techniques. One method of temporary fixation is the use of absorbable (polylactic/polyglycolic acid copolymer) LactoSorb screws; a histologic analysis of implanted LactoSorb screws was also performed. Sixteen rabbits underwent brow lifts; eight underwent endoscopic brow lift and fixation with LactoSorb screws without skin excision, and another eight underwent traditional bicoronal brow lift with skin excision and closure under tension. Animals were killed 1, 2, 6, and 12 weeks after the procedures were performed to evaluate the interaction of periosteum and bone and the normal, unelevated periosteum/calvarium interface at a site distant from the operative area. Histologic specimens were examined for the degree of apposition of periosteum to bone and for any fibrous or bony reaction at this interface. Histologic analysis showed various degrees of periosteal fibrosis and fixation to calvarial bone. After an initial phase of minimal periosteal adherence and moderate inflammation, the periosteum became progressively more adherent to bone in both groups, with no significant differences between treatment groups in rates of fixation. Fixation required at least 6 weeks. LactoSorb screws were surrounded by an area of mild inflammation and were progressively hydrolyzed and digested. Periosteal fixation increases over time for bicoronal and endoscopic brow lifts with minimal differences between the two techniques. With this animal model, periosteal adherence to calvarium requires at least 6 weeks with complete adherence by 12 weeks. In addition, the use of absorbable fixation screws seems to be both effective and well tolerated. The histologic changes associated with periosteal healing observed in this study suggest that permanent or semipermanent fixation may improve the accuracy and early postoperative maintenance of forehead advancement.

Applications of platelet-rich fibrin matrix in facial plastic surgery.

Platelet concentrates enjoyed some clinical popularity in facial plastic surgery several years ago. However, interest waned due to expense, amount of blood required, equipment, space, and staff needed, and lack of clinically significant benefit. A novel, simple method of preparing an autologous platelet derivative (Selphyl; Aesthetic Factors, Princeton, NJ) allows rapid and inexpensive generation of a platelet-rich fibrin matrix (PRFM) that can be used to enhance healing after facial procedures as well as to rejuvenate the face without tissue manipulation. PRFM provides autologous, natural, but concentrated platelet growth factor release and stimulation of surrounding tissue. This article describes its use for cosmetic facial applications.

Platelet-rich fibrin matrix for improvement of deep nasolabial folds

Background  Dermal augmentation continues to grow as an aesthetic facial procedure. Many exogenous filler materials rely on an autologous fibrotic response for volume augmentation.

Hashimoto's thyroiditis and carcinoma of the thyroid : optimal management

Several authors have noted a high incidence of thyroid carcinoma in patients with Hashimotos thyroiditis (HT), and some have even considered HT a premalignant condition. The authors evaluated all patients with surgically proven HT at Beth Israel Medical Center in New York from 1985 through 1990. Of these 48 patients, 8 (17%) had thyroid carcinoma in addition to HT. No statistically significant difference between patients with and without concurrent carcinoma was noted in the percentage of patients with a dominant mass, irregular thyromegaly, compressive symptoms, suspicious fine needle aspiration biopsies (FNABs), or a cold nodule on thyroid scintigraphy. However, patients with neither a positive FNAB nor a cold nodule were much less likely to have carcinoma than patients with one or both of these tests positive (0% vs. 26%, P±.05). A management scheme for patients with HT is proposed to adequately and efficiently evaluate and treat patients for concurrent thyroid carcinoma.