Patrick Cole

Keloids: Pathogenesis, Clinical Features, and Management

Cutaneous wound healing is a complex response to skin injury. Deregulation of this process can lead to excessive scar formation, as seen in keloids. Keloids are common skin lesions that are difficult to treat and are associated with high recurrence rates despite the large number of available treatment options. With increased knowledge of the disease process and further scientific advancements, future approaches will hopefully improve keloid treatment. In this article, we review the epidemiology, genetic basis, etiology, clinical features, pathogenesis, and management of keloids.

Comprehensive management of orbital fractures.

Summary: Orbital fractures are some of the more challenging injuries faced by the plastic surgeon. As such a prominent facial feature, even the most minor asymmetries following trauma can be distressing to the patient. In treating these patients, there are certain crucial aspects of both diagnosis and management that are critical to obtaining an optimal result. These include a careful preparative eye examination focusing on extraocular motility and any evidence of optic nerve compression. Candidates for surgery must be carefully selected based on firm indications such as a large orbital floor defect (>1 cm2), early enophthalmos, significant hypoglobus, or persistent diplopia in the primary field of gaze. Reconstruction should focus on anatomical restitution of the floor, taking great care to place the implant along the correct superior inclination of the orbit.

Nasal trauma and the deviated nose.

Summary: As the most prominent facial feature, the nose carries an increased risk of traumatic injury. Nasal fracture is the most common bone injury of the adult face and frequently results from motor vehicle accidents, sports-related injuries, and altercations. Although often initially considered minor, nasal fracture may eventually result in significant cosmetic or functional defects. Optimal management of nasal trauma in the acute setting is critical in minimizing secondary nasal deformities. In recent years, numerous guidelines have been described to refine and optimize acute nasal trauma management. However, restoration of pretraumatic form and function remains a challenge. Commonly the product of a poorly addressed underlying structural injury, posttraumatic nasal deformity requiring subsequent rhinoplasty or septorhinoplasty remains in as many as 50 percent of cases. In this article, the authors review the anatomic, diagnostic, and management considerations as well as discuss their own experience in approaching nasal trauma and the deviated nose.

Principles of facial trauma: orbital fracture management.

Often, complex, optimal management of the orbital fracture is directly dependent on thorough initial evaluation, correct injury assessment, and timely initiation of chosen therapy. Most often, secondary to assault or motor vehicle collision, these fractures are frequently associated with additional traumatic injury. With recent advances in imaging, alloplastic materials, and bone fixation technology, the evolution of orbital fracture management now enables reconstruction of even the most severe injuries.

Is primary thinning of the anterolateral thigh flap recommended

Background:Although primary thinning of the anterolateral thigh (ALT) flap has been successful in Asia, clinical and anatomic studies have demonstrated that this may be inadvisable in Western patients. Recent reports have demonstrated successful thinning of the ALT using smaller flaps. A systematic review was attempted, to assess whether ALT size affects the incidence of vascular compromise after primary thinning. Methods:A systematic review was undertaken to examine the relevant literature. Student t-test was used to compare flaps that did and did not have complications. Fisher exact test was used to compare outcomes of flaps measuring less than and greater than 150 cm2. Results:Eleven articles met the inclusion criteria. Eighty-eight ALT flaps were reported, and vascular compromise was seen in 11 (12.5%). The average size of flaps that demonstrated necrosis was 180.73 cm2; those without necrosis averaged 123.19 cm2 (P = 0.06). Flaps >150 cm2 had a significantly increased rate of compromise (25.93% vs. 6.56%; P < 0.05). Conclusions:A systematic literature review confirms that it is inadvisable to primarily thin large ALT flaps in the Western population. When large ALT flaps are required, primary thinning must be avoided to keep linking vessels intact.

Treatment of prominent and constricted ear anomalies.

Although the physiologic effects of ear deformity are negligible, the aesthetic and psychological impact on the patient can be profound. Significant ear malformations are prevalent in todays society and affect more than 5 percent of the population. Although the prominent ear results from either underdevelopment of the antihelix or an enlarged conchal bowl, the constricted ear is a product of helical down-folding and height deficiency. After a thorough evaluation, surgical management of the prominent ear must be approached in a careful, rational fashion. Although the surgeon may enjoy the wide latitude that hundreds of corrective techniques offer, he or she must always proceed with an algorithmic application of technique best suited to the specific auricular deformity. By using this approach, correction of the prominent ear can go beyond patient satisfaction to predictably maximize outcome in both form and symmetry. From the clinical evaluation and anatomical basis to surgical management of the deformed ear, the true art of otoplasty is in the surgeons ability to thoroughly understand auricular structure and appropriately apply technique for maximal aesthetic outcome.

Contemporary management of pediatric facial trauma.

Purpose of reviewFacial fracture management is often complex and demanding, particularly within the pediatric population. Although facial fractures in this group are uncommon relative to their adult counterparts, a thorough understanding of issues relevant to pediatric facial fracture management is critical to optimal long-term success. Recent findingsChildren are not ‘small adults’, and the management of facial fractures in this population is unique. Injuries tend to be less severe, and can often be managed with soft diet and restriction of activity. Maxillomandibular fixation should be used only when indicated, as it can result in temporomandibular joint (TMJ) disturbances; to minimize this risk, it should be in place no longer than 7 days. Open reduction and internal fixation is indicated in severe injuries, and the surgeon must be cognizant of developing teeth. Small plates and screws are useful in this patient population. SummaryIn this review of modern management of the pediatric facial trauma patient, several issues germane to pediatric facial fractures are discussed. Thorough ophthalmologic and dental/occlusive examinations must be undertaken. Conservative management is optimal for many injuries, as the pediatric fracture is typically not as severe as those seen in the adult facial skeleton. When wiring the jaw to allow for noninvasive fixation, treatment time must be short in order to avoid TMJ ankylosis. Rigid fixation is indicated in the rare comminuted, displaced fracture; when employed, the surgeon must use small plates and screws, and avoid injury to developing teeth. These are challenging cases, but with appropriate knowledge and understanding, they can be appropriately managed.

Orbitozygomatic fracture management.

Summary: Orbitozygomatic fractures are frequently encountered in plastic surgery. Management depends on a thorough preoperative physical examination, with attention to the ophthalmologic assessment. Coronal and axial computed tomography is essential for identifying fracture extent and orbital involvement. Adequate exposure and mobilization of fracture segments is essential for successful anatomical reduction. Failure to perform effective fixation may lead to subsequent complications, such as enophthalmos and diplopia. The authors illustrate the appropriate management of orbitozygomatic fractures in an effort to reduce complications and attain aesthetically satisfying results.

Two hundred twenty-two consecutive pharyngeal flaps: an analysis of postoperative complications.

PURPOSE The most frequent surgical technique used to treat velopharyngeal insufficiency (VPI), the pharyngeal flap is also one of the more dangerous pediatric procedures due to the potential for airway obstruction and patient death. Prompted by recent concerns over high complication rates associated with this procedure, we completed a retrospective cohort study to evaluate the incidence and character of postoperative complications after 222 consecutive pharyngeal flap surgeries. MATERIALS AND METHODS A database review was undertaken of all pharyngeal flap surgeries completed from January 2000 to April 2006 at a tertiary pediatric craniofacial center. Main outcome measures included postoperative complications, such as airway compromise manifested as oxygen desaturation, hemorrhage requiring reoperation, wound infection, pharyngeal flap breakdown, and development of obstructive sleep apnea. RESULTS In 222 consecutive pharyngeal flap patients, the mean age at surgery was 6.4 years (range, 3.1 to 17 years). Postoperative complications were rare in this cohort. Twelve patients (8.0%) required supplemental oxygenation for limited desaturation, and 3 patients (1.35%) demonstrated significant postoperative bleeding. Five patients (3.33%) demonstrated positive findings of OSA at 6 months or longer after postpharyngeal flap surgery. CONCLUSION When coupled with a thorough preoperative evaluation by specialized personnel, pharyngeal flap surgery is a safe and reliable option for the surgical management of VPI.

A Comparative, Long-Term Assessment of Four Soft Tissue Substitutes

BACKGROUND The ideal product for soft tissue replacement is durable, nonimmunogenic, and noninfectious. AlloDerm (LifeCell Corp., Branchburg, New Jersey), Enduragen (Stryker Corp., Kalamazoo, Michigan), and DermaMatrix (Synthes, Inc., West Chester, Pennsylvania) are frequently used for soft tissue replacement, but comparative analysis of these materials over an extended time period has not been reported. DuraMatrix (bovine tendon matrix; Stryker Corp.) is also promising, demonstrating desirable properties not only as a dural substitute but also for soft tissue replacement. OBJECTIVES The authors analyze in vivo gross and microscopic changes over time with four commercially available dermal matrices, utilizing the murine model for a controlled environment. METHODS AlloDerm, Enduragen, DermaMatrix, and DuraMatrix implants measuring 1 × 1 cm were each implanted in 40 adult mice, in individual dorsal submuscular pockets. The mice were then sacrificed in groups of 10 at three, six, nine, and 12 months. The implants and surrounding tissues were excised and evaluated for gross and microscopic appearance. RESULTS Histological analysis of the specimens demonstrated similar encapsulation, implant infiltration, and surrounding inflammation over time. Enduragen implants demonstrated the least amount of host cell infiltration, whereas AlloDerm demonstrated the most. Grossly, Enduragen maintained its original shape and became firmer over time, whereas AlloDerm became spherical and softer. DermaMatrix and DuraMatrix both maintained their original shape and consistency. Implant migration, explantation, infection, or allergic reactions were not noted. CONCLUSIONS All of the materials studied demonstrated high levels of host tolerance and tissue integration. AlloDerm demonstrated signs of resorption, whereas Enduragen maintained its size and became firmer in consistency. Together with the histological results, this suggests a proportional relationship between the amount of host cell integration and implant resorption.