Yi Xin Zhang

Recent Developments in the Use of Intralesional Injections Keloid Treatment

Keloid scars are often considered aesthetically unattractive and frustrating problems that occur following injuries. They cause functional and cosmetic deformities, displeasure, itching, pain, and psychological stress and possibly affect joint movement. The combination of these factors ultimately results in a compromised quality of life and diminished functional performance. Various methods have been implemented to improve keloid scars using both surgical and non-surgical approaches. However, it has proven to be a challenge to identify a universal treatment that can deliver optimal results for all types of scars. Through a PubMed search, we explored most of the literature that is available about the intralesional injection treatment of hypertrophic scars and keloids and highlights both current (corticosteroid, 5-fluorouracil, bleomycin, interferon, cryotherapy and verapamil) and future treatments (interleukin-10 and botulinum toxin type A). The reference lists of retrieved articles were also analysed. Information was gathered about the mechanism of each injection treatment, its benefits and associated adverse reactions, and possible strategies to address adverse reactions to provide reliable guidelines for determining the optimal treatment for particular types of keloid scars. This article will benefit practitioners by outlining evidence-based treatment strategies using intralesional injections for patients with hypertrophic scars and keloids.

Objective Breast Volume, Shape and Surface Area Assessment: A Systematic Review of Breast Measurement Methods

AbstractBackground There are many methods of measuring the breast and their clinical applications are well described in the literature. However, there has been no attempt to compare these various methods to allow the user to have a broad overview of the subject. The authors have attempted to summarise all the available methods to measure the breast in this article to provide a useful reference for all.MethodsA comprehensive literature search of PubMed was performed, and the resulting articles were screened and reviewed. The data regarding the methods’ mechanism, reliability, time and cost were evaluated and compared.ResultsA total of 74 articles dating from 1970 to 2013 were included in this study. All of the methods can be classified into those that measure (1) volume, (2) shape and (3) surface area. Each category consists of several methods that work through different mechanisms and they vary in their reliability and feasibility. Based on their mechanism, the volume measurement methods were further grouped into the natural shape methods, the stereological method, the geometrical methods and the mathematical modelling method.ConclusionsMore objective breast evaluation can be achieved if all three dimensions (volume, shape and surface area) are considered. In the volume measurements, 3D modelling and the MRI are the most reliable tools. Linear measurement (geometry) and mathematical modelling are less accurate but are more economical. In the shape measurements, besides the traditional linear measurement, 3D methods that can deliver colour-coded maps and Swanson’s 2D photographic measurement system are capable of depicting and tracking breast shape changes after surgery. Although the surface area metric has not been used extensively, it has potential in clinical and research applications.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Microsurgical reconstruction after bisphosphonate-related osteonecrosis of the jaw: our experience with fibula free flap.

BackgroundBisphosphonate-related osteonecrosis of the jaws (BRONJ) is the most serious complication of bisphosphonates therapy. Despite that several treatment modalities have been described, aggressive surgical treatment approach with wide bone resection and vascularized microsurgical reconstruction are controversial. The aim of this study was to evaluate the clinical outcome of 8 new cases of BRONJ treated with radical resection and mandibular reconstruction with fibula free flap, to enforce the evidence about the reliability of this treatment option. MethodsRetrospective data of 8 patients with BRONJ who underwent segmental mandibulectomy and reconstruction with osteocutaneous fibula free flap from January 2004 to January 2008 were collected, including 6 patients with stage 3 BRONJ and 2 patients with recalcitrant stage 2 BRONJ. ResultsAll patients were white, with a mean age of 64.7 years (range, 53–77 y), and 62.5% were women. All bisphosphonates were administered intravenously, and all patients had mandibular localization. The mean period of follow-up was 28.9 months. No flap loss or minor complications and no BRONJ recurrence were observed. All patients were able to ambulate pain-free. ConclusionsDespite initial concerns regarding reliability of the mandibular free-flap reconstruction after BRONJ, this method seems to be a safe and feasible option in cancer patients with reasonable life expectancy, with complete BRONJ resolution and life quality improvement. Our findings confirm data previously published by other authors, without complication and with a much longer median follow-up time.

Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience.

PURPOSE Rhinophyma is characterized by slowly progressive tumour-like enlargement of the nasal skin that will not resolve spontaneously. Though its treatment consists of surgical removal of the hyperplastic alterations, in the literature there is not general agreement about the best method. We presented our experience with two different treatment modalities such as decortication by scalpel and CO2 laser treatment. METHODS The authors reviewed the long-term results of 67 patients affected by rhinophyma treated with two different methods between 1996 and 2011. Outcomes were determined by case notes, clinical review and patient satisfaction questionnaire. RESULTS Forty-five cases were treated with tangential excision and 22 with a CO2 laser. Minor complications, including scarring and hypopigmentation, were seen in 6 patients. All patients were satisfied with their outcomes at the follow-up visit, and no major complications were detected during follow-up. CONCLUSION Both tangential excision and carbon dioxide laser are well-established, reliable procedures for rhinophymaplasty that preserve the underlying sebaceous gland fundi allowing spontaneous re-epithelialization without scarring with similar outcomes and high patient satisfaction. The original nose shape and nearly normal skin surface texture are preserved by quickly removal of the hypertrophic tissue sparing the pilosebaceous tissue. The CO2 laser is more capital intensive and results in higher fees compared with the simpler cold blade tangential excision. In our experience the ease of use, accuracy and precision of the lasers offer is not justified by the increased costs.

Sebum Production Alteration after Botulinum Toxin Type A Injections for the Treatment of Forehead Rhytides: A Prospective Randomized Double-Blind Dose-Comparative Clinical Investigation

BACKGROUND Research has investigated the decrease in human skin sebum after the application of botulinum toxin. Few studies of the mechanism and objective assessments of this phenomenon have been conducted and the correlation between the sebum production and injection dosages or techniques remains unclear. OBJECTIVES We prospectively investigated the sebum regulation and its gradient around the injection site in patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides, comparing two injection doses. METHODS Forty-two female volunteers with rhytides on the forehead region were randomly assigned to receive 10 or 20 units of BTX-A, which was administered in five standard injection sites. The baseline and post-treatment sebum production was measured using a Sebumeter. RESULTS Treatment with BTX-A exhibited significant sebum alteration at the injection site of both groups, with a sebum gradient surrounding the injection point. The efficacy did not improve at higher injection doses, with the four-unit regimen generally not being more potent than the two-unit regimen. The sebum production recovered to normal levels at the 16 week follow-up for both treatment groups, indicating that a higher dosage (four units) did not result in a longer duration until relapse compared with the two-unit dose. CONCLUSIONS We determined that the sebum production has a positive correlation with the distance away from the injection point. Intramuscular injection of BTX-A significantly reduces sebum production at the injection site but increases the sebum production of the surrounding skin at a radius of 2.5 cm at the 2, 4, and 8 week follow-ups. LEVEL OF EVIDENCE 2 Therapeutic.

Adipofascial Anterolateral Thigh Flap Safety: Applications and Complications

Background A thinned anterolateral thigh (ALT) flap is often harvested to achieve optimal skin resurfacing. Several techniques have been described to thin an ALT flap including an adipocutaneous flap, an adipofascial flap and delayed debulking. Methods By systematically reviewing all of the available literature in English and French, the present manuscript attempts to identify the common surgical indications, complications and donor site morbidity of the adipofascial variant of the ALT flap. The studies were identified by performing a systematic search on Medline, Ovid, EMBASE, the Cochrane Database of Systematic Reviews, Current Contents, PubMed, Google, and Google Scholar. Results The study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and 15 articles were identified using the study inclusion criteria. These articles were then reviewed for author name(s), year of publication, flap dimensions and thickness following defatting, perforator type, type of transfer, complications, thinning technique, number of cases with a particular area of application and donor site morbidity. Conclusions The adipofascial variant of the ALT flap provides tissue to fill large defects and improve pliability. Its strong and safe blood supply permits adequate immediate or delayed debulking without vascular complications. The presence of the deep fascia makes it possible to prevent sagging by suspending and fixing the flap for functional reconstructive purposes (e.g., the intraoral cavity). Donor site morbidity is minimal, and thigh deformities can be reduced through immediate direct closure or liposuction and direct closure. A safe blood supply was confirmed by the rate of secondary flap debulking.

Bipaddle radial forearm flap for head and neck reconstruction.

BackgroundAlthough the radial forearm free flap has become a workhorse flap in head and neck reconstruction, the skin grafting of the donor is the main drawback resulting in an unacceptable contour deformity and an unsightly appearance. Several technical modifications have been therefore applied to the radial forearm (RF) flap marking, elevation, and inset to overcome this major shortcoming. In this article, we report our clinical series with the bipaddle RF flap. MethodsThe authors described their 11 cases of head and neck oncologic reconstruction with the bipaddle RF flap. The skin island is designed longer and narrower and split into 2 separate skin paddles each nourished by a proximal and a distal independent perforators raising from the radial artery so that the donor site could be closed directly. The narrow design of the skin paddle and the subsequent splitting in its 2 components applying the “perforator-pedicle propeller flap method” allow for the changing of the flap shape according to the shape of the recipient site defect. ResultsFrom 2007 to 2013, the bipaddle RF flap method was used in 11 patients to restore head and neck defects following cancer ablation. The mean age of the patients was 43 years, ranging from 31 to 50 years. The location of the defects was the tongue (n = 7) and the intraoral region (n = 4). The defect sizes varied from 4 × 5 cm to 5 × 6 cm, and the flap maximum width was 3 cm with mean area of 26.4 cm2. The healing was uneventful in all patients with excellent cosmetic and functional results of both donor site and recipient site after 20 months of mean follow-up. ConclusionsThe bipaddle RF free flap is a reliable and versatile option for the reconstruction of a wide range of soft tissue defects of head and neck region. This method allows for a customized resurfacing of the defect because of its large variability in shape and size. The harvesting site is closed primarily, and a second donor site for skin graft is avoided.Clinical Question, Level of Evidence: Therapeutic, IV

Thoracoacromial Artery Perforator Flap: Anatomical Basis and Clinical Applications

Background: Concerns and criticism have been reported on the feasibility and vascular reliability of the thoracoacromial artery perforator flap because of the inconsistent size of the pectoral branch of the thoracoacromial artery and its cutaneous perforators. The authors have investigated its vascular basis through a cadaver dissection and described their clinical experience in the surgical strategy, range of application, and indications for the thoracoacromial artery perforator flap. Methods: Twelve fresh human cadavers were dissected to define the anatomy of the branches of the thoracoacromial artery and their perforators and the anatomical landmarks for clinical application. Single pectoral branch perforators were injected to measure the extension of the thoracoacromial artery perforator vascular territory. Results: A constant thoracoacromial artery perforator was present in the septum between the clavicular and sternocostal heads of the pectoralis major muscle in 21 of 24 hemichests. The mean caliber of the perforator was 0.7 mm and the mean length of the vascular pedicle was 7.1 cm. The territory of the thoracoacromial artery perforator flap extended up to the fourth intercostal space inferiorly. Between 2006 and 2011, the thoracoacromial artery perforator flap was used to reconstruct head and neck defects in seven patients. All patients healed uneventfully. Conclusions: The authors’ studies provide evidence of the vascular supply and the clinical application of the thoracoacromial artery perforator flap. The recruitment of the chest skin through a thoracoacromial artery perforator flap resulted in an adequate color match, texture, and pliability for local adjacent defect restoration and for head and neck reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prefabricated Neck Expanded Skin Flap with the Superficial Temporal Vessels for Facial Resurfacing

BACKGROUND The achievement of a normal-appearing face after surgical resurfacing remains an elusive goal. This is due in part to insufficient color matching, restoration of contours, and the persistence of visible scars. Flap prefabrication is a staged procedure that provides an independent axial blood supply to local expanded tissues. We describe a new reconstructive alternative with superior reconstructive surgical options for facial resurfacing that better matches damaged or discarded facial tissues. METHODS A superficial temporal fascial flap was harvested as the vascular supply of the prefabricated neck flap and located in a subcutaneous neck pocket over a tissue expander. After a 5-month period for expansion and maturation, the prefabricated skin flap was raised, islanded, and rotated to resurface the facial defect. RESULTS Four patients with hemifacial postburn contracture and two patients affected by hemifacial vascular malformations aged 17 to 42 years (mean 29 years) were successfully treated with no major complication after a mean period of 15 months. CONCLUSION Prefabricated neck-expanded skin flap demonstrated an excellent color and texture match with facial skin that surrounded the repair sites, and optimal aesthetic results were obtained. Importantly, facial expression was completely maintained due to thinness and pliability of the rotated skin.

A novel design of the multilobed latissimus dorsi myocutaneous flap to achieve primary donor-site closure in the reconstruction of large defects.

Background: The main drawback of the latissimus dorsi myocutaneous flap for large defect repairs is the relatively small skin paddle size that can be raised to allow primary closure of the donor site. In this article, the authors describe a novel design of the flap using multiple separate skin paddles, with each paddle nourished by independent perforators, to repair very large defects while maintaining primary donor-site closure. Methods: After the size of the defect was calculated, its total area was split into two or three skin paddles and marked on the back skin so that the largest width of each paddle did not exceed 8 cm. A multilobed skin paddle was designed with a total area that was much larger than traditional latissimus dorsi flaps. After harvesting the flap, several smaller skin paddles were transferred and rejoined at the recipient site. Results: From June of 2009 to March of 2012, this method was used to restore posttraumatic and postoncologic defects of the head in seven cases and lower limb defects in two cases. Seven flaps were raised as bilobed flaps, and two flaps were raised as trilobed flaps. The donor site was closed primarily in all cases. One case was complicated by partial necrosis of one paddle and required further local flap coverage. Donor-site breakdown was not observed in any of the cases. Conclusions: The multilobed myocutaneous latissimus dorsi flap enables a customized reconstruction of large defects for all types of patients and direct closure of the donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.