Steven P. Davison

Keloid pathogenesis and treatment

Background: Keloid management can be difficult and frustrating, and the mechanisms underlying keloid formation are only partially understood. Methods: Using original and current literature in this field, this comprehensive review presents the major concepts of keloid pathogenesis and the treatment options stemming from them. Results: Mechanisms for keloid formation include alterations in growth factors, collagen turnover, tension alignment, and genetic and immunologic contributions. Treatment strategies for keloids include established (e.g., surgery, steroid, radiation) and experimental (e.g., interferon, 5-fluorouracil, retinoid) regimens. Conclusion: The scientific basis and empiric evidence supporting the use of various agents is presented. Combination therapy, using surgical excision followed by intradermal steroid or other adjuvant therapy, currently appears to be the most efficacious and safe current regimen for keloid management.

Prevention of venous thromboembolism in the plastic surgery patient.

The term venous thromboembolism refers to a spectrum of disease that includes deep venous thrombosis and pulmonary embolism. Both deep venous thrombosis and pulmonary embolism are often clinically silent and thus difficult to diagnose, which leads to a substantial delay in treatment that results in high rates of morbidity and mortality. The purposes of this article are to help physicians determine the proper venous thromboembolism prophylaxis and to simplify the complex problem of treating venous thromboembolism. The tools provided in this article will help expedite and clarify the decision-making process.

Efficacy and safety of venous thromboembolism prophylaxis in highest risk plastic surgery patients.

Background: The purpose of this study was to stratify plastic surgery patients into venous thromboembolism risk categories; identify patients at highest risk for venous thromboembolism; and quantify rates of postoperative all-cause mortality, venous thromboembolism, and hematoma/bleeding on different forms of thromboprophylaxis. Furthermore, this study aimed to determine the compliance and average duration of outpatient chemoprophylaxis. Methods: A retrospective cohort study was carried out on a single plastic surgeons experience. Venous thromboembolism risk stratification identified patients at highest risk. Records were reviewed for regimen of thromboprophylaxis and for occurrences of all-cause mortality, venous thromboembolism, and hematoma/bleeding. Outpatient compliance and duration of low-molecular-weight heparin chemoprophylaxis was also documented. Results: During the study time period, 173 operations involved 120 patients at highest risk for venous thromboembolism. Among highest risk patients, one (0.8 percent) suffered a pulmonary embolism, eight (6.7 percent) experienced a deep vein thrombosis, and 15 (12.5 percent) endured a hematoma/bleed. Thirteen of 14 outpatients (92.9 percent) were compliant with low-molecular-weight heparin and remained on chemoprophylaxis for an average of 7.4 days. Conclusions: Mechanical prophylaxis plus subcutaneous heparin (unfractionated or low-molecular-weight heparin) conferred a statistically significant reduction in the rate of venous thromboembolism without a significant increase in bleeding versus mechanical prophylaxis alone. Subgroup analysis of patients placed on mechanical prophylaxis plus low-molecular-weight heparin revealed similar statistically significant findings. Outpatients placed on low-molecular-weight heparin chemoprophylaxis demonstrated excellent compliance and comfort with self-administration. Therefore, the use of mechanical prophylaxis supplemented with low-molecular-weight heparin is strongly recommended as the first-line regimen for thromboprophylaxis in plastic surgery patients at highest risk for venous thromboembolism.

Barbed suture tenorrhaphy: an ex vivo biomechanical analysis.

Background: Using barbed suture for flexor tenorrhaphy could permit knotless repair with tendon-barb adherence along the sutures entire length. The purpose of this study was to evaluate the tensile strength and repair-site profile of a technique of barbed suture tenorrhaphy. Methods: Thirty-eight cadaveric flexor digitorum profundus tendons were randomized to polypropylene barbed suture repair in a knotless three-strand or six-strand configuration, or to unbarbed four-strand cruciate repair. For each repair, the authors recorded the repair site cross-sectional area before and after tenorrhaphy. Tendons were distracted to failure, and data regarding load at failure and mode of failure were recorded. Results: The mean cross-sectional area ratio of control repairs was 1.5 ± 0.3, whereas that of three-strand and six-strand barbed repairs was 1.2 ± 0.2 (p = 0.009) and 1.2 ± 0.1 (p = 0.005), respectively. Mean load to failure of control repairs was 29 ± 7 N, whereas that of three-strand and six-strand barbed repairs was 36 ± 7 N (p = 0.32) and 88 ± 4 N (p < 0.001), respectively. All cruciate repairs failed by knot rupture or suture pullout, whereas barbed repairs failed by suture breakage in 13 of 14 repairs (p < 0.001). Conclusions: In an ex vivo model of flexor tenorrhaphy, a three-strand barbed suture technique achieved tensile strength comparable to that of four-strand cruciate repairs and demonstrated significantly less repair-site bunching. A six-strand barbed suture technique demonstrated increased tensile strength compared with four-strand cruciate controls and significantly less repair-site bunching. Barbed suture repair may offer several advantages in flexor tenorrhaphy, and further in vivo testing is warranted.

Determinants of aesthetic satisfaction following TRAM and implant breast reconstruction.

Introduction:Several studies have evaluated patient satisfaction following breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap and tissue expander/implant. However, the specific aesthetic determinants of patient satisfaction have not been determined Methods:Patients who had undergone tissue expander/implant or TRAM flap reconstruction were retrospectively polled on their age, type and timing of reconstruction, mastectomy type, laterality of reconstruction, adjuvant therapy, and symmetrizing and nipple-areolar procedures. Aesthetic satisfaction based on breast shape, symmetry of breast shape, breast size, symmetry of breast size, breast scarring, and breast sensation was assessed using a 5-point scale. Results:Two hundred eleven patients with 105 TRAM flaps and 160 expander/implants responded. Unilateral TRAM recipients rated their breast shape, symmetry of breast shape, and symmetry of breast volume significantly higher than did implant patients. When bilateral reconstruction patients were evaluated, no significant differences were seen. The presence of nipple-areolar reconstruction positively influenced every parameter except breast sensation. Immediate reconstruction, skin-sparing mastectomy, and age >60 years at the time of reconstruction were also associated with higher scores, while postoperative radiation therapy resulted in lower satisfaction. Free flap reconstruction produced higher satisfaction in breast shape and breast scarring when compared with pedicle flap reconstruction. Conclusions:Aesthetic satisfaction after breast reconstruction is highly influenced by the presence of nipple-areolar reconstruction and less so by age, timing of reconstruction, adjuvant therapy, or free flap procedures. The type of reconstructive procedure is a significant variable only in unilateral reconstruction.

Implantable Baclofen Pump as an Adjuvant in Treatment of Pressure Sores

Currently, the success of ulcer treatment is limited by the high recurrence and complication rates. Spasticity is an important contributing factor to ulcer recurrence, and intrathecal baclofen is an effective method to reduce spasticity. Spasticity creates friction, shear, and mobility impairment resulting in wound dehiscence, flap loss, infection, and hematoma. Spasticity can be managed pharmacologically and surgically; baclofen is the drug of choice. Baclofen inhibits spasticity by blocking excitatory neurotransmitters in the spinal dorsal horn. Intrathecal baclofen maximizes the dose delivered to spinal receptors and minimizes the side effects associated with oral baclofen. Case reports of intrathecal baclofen used in patients with pressure sores demonstrate the use of intrathecal baclofen to improve reconstructive outcomes in spastic patients.

Efficacy of Intralesional 5-Fluorouracil and Triamcinolone in the Treatment of Keloids

BACKGROUND Keloids are a common problem with significant recurrence rates despite intralesional steroid treatment and multimodal therapy. OBJECTIVE The purpose of this study was to evaluate the efficacy of using a 5-fluorouracil (5-FU)/steroid mixture to treat keloids over the past 7 years, comparing the results with use of steroid treatment alone. METHODS Patient charts from 1999 to 2006 were reviewed. Patients were stratified into 3 groups: (1) 5-FU/steroid without excision; (2) 5-FU/steroid with excision; and (3) steroid treatment with excision. The percentage of lesion size reduction and symptoms were evaluated. RESULTS A total of 102 keloids were identified in a retrospective review. Patients who underwent the 5-FU/steroid combination with excision had a 92% average reduction in lesion size compared with 73% in the group of patients who did not receive 5-FU. Patients who received 5-FU/steroid without excision had an average lesion size reduction of 81%. Differences in complication rates were not statistically significant. CONCLUSIONS Combination 5-FU/triamcinolone is superior to intralesional steroid therapy in the treatment of keloids.

Ineffective treatment of keloids with interferon alpha-2b.

Background: Keloids are exuberant, disfiguring scars that result from an abnormal healing process. Current established treatment strategies include surgical resection, triamcinolone steroid injection, pressure therapy, silicone therapy, and radiotherapy. None of these therapies, either alone or in combination, offers consistent recurrence-free rates above 70 to 80 percent. The antiproliferative, antifibrotic cytokine, interferon alpha-2b, may be useful in keloid management because of its ability to interfere with collagen synthesis and fibroblast proliferation. Methods: To determine the efficacy of interferon alpha-2b in keloid management, the authors prospectively evaluated the effects of interferon alpha-2b as postexcisional adjuvant therapy for keloids. Thirty-nine keloids in 34 patients were photographed, measured, and surgically excised. The wound bed was injected twice with either interferon alpha-2b (treatment group; n = 13 keloids) or triamcinolone (control group; n = 26 keloids) at surgery and 1 week later. The patients were followed up in the plastic surgery clinic. Results: The trial protocol was terminated at midtrial surveillance. Among the 13 keloids that were treated with postoperative intralesional interferon alpha-2b, seven recurred (54 percent recurrence rate). In contrast, in the 26 keloids that received triamcinolone (control group), only four recurred (15 percent recurrence rate). Recurrence in either group did not correlate with location of the keloid or race. Conclusion: Interferon does not appear to be effective in the clinical management of keloids.

Prevention of Venous Thromboembolism in the Plastic Surgery Patient: Current Guidelines and Recommendations

Over the last five years, there has been a groundswell of interest in the prevention of venous thromboembolism (VTE). An increased level of understanding of the disease process coupled with data documenting the alarmingly high incidence of VTE has prompted a global awareness of the disease. Consequently, prevention of VTE has been targeted by hospitals, both in the United States and abroad, as a top priority to improve patient care. VTE refers to a continuum of disease that begins with deep venous thrombosis (DVT) and can progress to pulmonary embolism (PE). DVT is the more common form of VTE and is often silent, with only 33% of patients presenting with symptoms. As a result, VTE often goes undetected and, if allowed, can progress to PE. This typically delays treatment and results in high rates of morbidity and mortality. The combination of VTE being both difficult to detect and deadly if untreated makes it a disease that is best addressed with preventive rather than therapeutic measures.

Aesthetic subunits of the breast.

&NA; Surgery for breast cancer has traditionally addressed the breast as if it were a geometric circle with associated quadrants, Cosmetic reconstruction should not follow geometric patterns but should emphasize perceived contour and normal clothing lines. Similar to nasal reconstruction, a subunit principle in breast reconstruction planning may significantly improve the appearance of the result. To better identify the most aesthetic subunits for breast reconstruction, 10 years of autogenous reconstruction in 264 patients was reviewed. Various patterns of breast subunits were identified. The more favorable subunits of the breast in terms of postoperative appearance and camouflage of scars included the nipple, areola, and expanded areola subunits. For larger skin defects, the best subunits were the inferolateral, lower half, and a total breast subunits. Dividing the breast into reconstructive subunits that are to be replaced as a whole rather than as a patch gives superior results. Photographed examples of aesthetic subunits illustrate the placement of scars along natural lines that maximize the advantages of camouflage afforded by clothing. (Plast. Reconstr. Surg. 112: 440, 2003.)