The efficacy of 5% imiquimod cream in the prevention of recurrence of excised keloids.

OBJECTIVE: To evaluate the efficacy of 5% imiquimod cream in the prevention of recurrence of excised keloids. MATERIAL AND METHOD: The patients with keloids that had occurred over 1 year and could be excised and primary sutured were enrolled in the study. Imiquimod 5% cream was applied to the scar 7 days after stitches removal. The patients were follow-up for recurrence and drug side effect at 4, 6, 8, 16, and 24 weeks. RESULTS: Forty-five patients enrolled to the study but only 35 patients finished the study. The keloids were at the pinnas in 22 patients, at the backs or shoulders in 7 patients, and at chest walls or necks in 6 patients. Imiquimod 5% cream was applied on the wound area 2 weeks after the operation, at alternate night for 8 weeks. The follow-up period ranged from 6 to 9 months. Ten of the treated keloids recurred (28.6% recurrent rate). The lesion at the pinna had the lowest recurrent rate (2.9% recurrent of the total patients). The highest recurrent rate occurred at the chest wall or neck (83.3% recurrent of the chest wall or neck or 14.3% of the total patients). Side effects were found in thirteen patients (37.1%). These were abrasions of the skin around the wound areas in ten patients and hyperpigmentation of the skin around the wounds in three patients. CONCLUSION: Imiquimod 5% cream could effectively prevent recurrence of the excised keloids, especially in the area that had less tension such as pinna.

The nasoendoscopy study of velopharyngeal closure patterns in normal Thai volunteers.

The purpose of this study is to assess patterns of velopharyngeal closure in normal Thai subject. Ten volunteers with normal speech and no history of cranio-maxillo-facial abnormality, injury or surgery were included in this study. Their velopharyngeal closures were reviewed b y nasopharyngoscopy. Their articulation and resonation characteristics were also evaluated. The patterns of closure and related anatomy were studied. The results showed that all subjects achieved complete closure without a gap or nasal emission. Three patterns of velopharyngeal closure were found. A circular pattern was found in the majority of the subjects. More specifically, 6 subjects demonstrated circular closure patterns and 1 had a circular closure pattern with the Passavant’s ridge. The coronal pattern was found in the last 3 subjects. There was no correlation between patterns of closure and demographic data related to anatomy and resonation characteristics. In conclusion, 3 patterns of velopharyngeal closure were found and the circular type was the common. Further study was recommended with a larger group for gathering a database of Thai people.

Management of velopharngeal insufficiency in velocardiofacial syndrome.

This report presents an analysis of the treatment of a patient with velocardiofacial syndrome. The patient had a cleft palate and an articulation disorder with hypernasal speech. The cleft palate repair was successful but the post-operative course was complicated by velopharyngeal insufficiency. Thus, further management including reassessment and treatment for better speech quality was required.

Correction of unilateral cleft lip nasal deformity with double V-Y open tip rhinoplasty.

The correction of unilateral cleft lip nasal deformity is a challenging task. Many different technique to correct this deformity. The V shape incision was made at the columella and alar web. Lower lateral cartilage on cleft site was sutured to the upper cartilage and lower cartilage on non-cleft site. The incision was closed in V-Y fashion. Thirty-two patients (20 females, 12 males) were operated on during 1997-2000. All the patients were satisfied with the results. Five patients needed more correction. No complication was founded. All scars were un-noticeable.

Otitis media in cleft palate children: A prospective survey.

Children with cleft palate and craniofacial anomalies are more prone to otitis media due to the anatomical defect of the cranial base and the eustachian tube. This prospective study was conducted in the cleft palate patients of the Craniomaxillofacial Clinic from January 2001 to April 2002. Pneumatic otoscopic examination was done monthly in every patient since they registered in the clinic for cleft palate correction. Thirty-eight children were included. Mean age was 21.4 + 33.7 months and 89.5% of the children were under 24 months old. Mean time for follow up was 150 + 132 days (mean + S.D.). Twenty-six patients (68.4%) had ear diseases at least once during the study period. Otitis media with effusion (OME) was the most common ear disease found in this series. Twenty-one percent of the patients had at least one episode of OME by the age of one and 47.5% of the patients had at least one episode of OME by the age of two. The incidence of OME was 3.85 per person per year. Acute otitis media and atelectatic ear drum were found with the incidence of 0.51 and 0.30 per person per year respectively. Tympanogram type B was found in 47.4% and type C was found in 10.5%. Periodical ear examination in cleft palate children is recommended for early detection of otitis media in order to prevent irreversible middle ear damage or hearing loss in the future.

Nasoendoscopy: Clinical implications.

The purpose of this study is to discuss the clinical use of nasoendoscopy examination of the velopharyngeal closure in patients with nasal speech and to describe the clinical implications of this technique. Three difference patients with hypernasal speech, one with cleft palate, one with hearing loss and one mental retardation, were studied velopharyngeal incompetence through direct assessment of the velopharyngeal closure by nasoendoscopy. An Olympus Nasoendoscope model ENFP3 was used and the Siriraj Speech Stimuli Resonation Test (Manochiopinig & Chuangsuwanich 2001) was used as a standard speech sample. After an explanation and informed consent, 10% of xylocaine was sprayed into a nostril for tropical anaesthesia. The first author performed the nasoendoscopy, meanwhile the second author stimulate the speech sample and velopharyngeal function. The same procedure and condition was conducted to each subject in an operation room. Excursion of the soft palate and pharyngeal wall, completeness, asymmetrical, leakage, adequacy, patterns of closure were observed during speech production. Descriptive analysis was used. The results indicate that intelligible speech production depend on a normal velopharyngeal closure mechanism. Abnormal coupling of the oral and nasal cavities of these patients are characterized by hypernasality, nasal emission, imprecise speech production and decrease speech intensity. These typical signs of velopharyngeal insufficiency could be due to either structural defect (cleft palate), physiological dysfunction (hearing loss) or mental status (mental retardation). Nasoendoscopy provides a direct approach to visualize the velopharyngeal closure. This technique helps clinicians to distinguish between those patients with nasal speech who appear to have the physiological potential for satisfactory velopharyngeal closure from those who do not. This distinction is clinically important because of the marked difference in treatment. Furthermore, in patients considered for a pharyngeal flap operation, pre-operative evaluation of the closure is vital. In conclusion, hypernasal speech alone is not a sign of velopharyngeal insufficiency from structural defect. Thus, a diagnosis is suggested to be made by a cranio-maxillo-facial team after complete evaluation. In addition, nasoendoscopy has been valuable in distinguish different groups of patient as well as planning treatment.

Effect of Oral Cilostazol on the Patency of Microvascular Anastomoses in Rats.

In order to evaluate the effect of cilostazol on patency of microvascular anastomoses, a double blind control study was performed on microanastomoses of the femoral artery in rats. Thirty female Spraque- Dawley rats were divided into two groups according to a blind protocol. One group (group A) was given cilostazol orally (10 mg/ kg) 2 hours before the operation and for 7 days post-operatively. The other group (group B) received normal saline solution orally in the same amounts and at the same times as group A. The femoral artery anastomoses were performed under standard microvascular conditions. Seven days post-operatively, the patency of the arterial anatomoses was evaluated by Acland\\\'s test and histological study. The patency rate by Acland\\\'s test was 73% in group A, and 53% in group B. There was no significant difference between the patency rates of these two groups (p = 0.082). The area of the patency of the lumen by histological study was 61.67% in group A and 48% in group B. There was no significant difference between the groups in relation to patency of the microanastomoses (p = 0.381). There were no complications observed in this study.

The efficacy of wall-typed suction and polyurethane foam in vacuum assisted wound dressing system.

Vacuum assisted wound dressing was introduced as one of the methods for wound management in problematic wounds. This system which was expensive included a controllable vacuum suction unit and polyurethane foam. In this study we evaluated the efficacy of a controllable wall-typed suction that was available in the patient ward to be used with various types of polyurethane foam in the market. One type of the polyurethane foam that had suitable pore size and good porosity was selected and used in 4 patients with sacral pressure ulcers and 1 patient with both sacral and trochanteric pressure ulcers. These patients were not candidates for surgery and their ulcers were not improved by conventional dressing. The vacuum dressing system was applied to the ulcers for 2 months. The sizes of the ulcers were reduced statistically (p=0.042) without complication. In conclusion, the controllable wall-typed suction and polyurethane foam could be used effectively for wound dressing in problematic wound and ulcer.

Single artery digital replantation.

Microvascular replantations of amputated distal fingers were reviewed in 11 cases in which single arterial repair without venous repair was done. usually, the standard replantation consists of re-anastomosis of arteries and veins. In this study, venorrhaphy could not be achieved since no vein of sufficieny size was found. Survival rate of replanted digits was 68.8 percent (11 from 16 digits), which compared favorably to other reports. This technique offers better cosmetic and functional outcome than reattachment as a composite graft or stump closure. The result of our study confirms the possiblitity of single arterial digital replantation with an acceptable outcome in selected cases. Cases analysis and surgical technique will be discussed in detail.

Frontalis muscle transfer for the treatment of upper eyelid ptosis.

The management of severe blepharoptosis is problematic. A variety of surgical approaches do not yield good results especially in the presence of poor levator function. In this report, direct frontalis muscle transfer was used for the treatment of severe blepharoptosis with poor levator function. Twenty-one patients with severe blepharoptosis and poor levator function were operated during the period from 1995 to 1998 using this technique. Excellent and good results were achieved in 8 and 13 patients (38.1% and 61.9%), respectively. Two patients (9.5%) had complications. One was entropion and the other was hematoma, both of which were improved by reoperations. All patients had lagophthalmos postoperatively which subsided one month after surgery without complication. The patients were all satisfied.

Skull base surgery: Access to anterior and middle cranial fossa.

Although skull base lesions, which differ in comparison to other areas of pathology, are difficult to deal with, much has been published of the subject in the last two decades. Access, visualization, surgical skill, and technique are keys of surgical success. Since June 1995 – December 1996, 47 cases were performed by the basal skull group; (neurosurgeon, ENT, ophthalmic and plastic surgeons). Among these cases, 28 fronto-orbito-zygotomies were performed for anterior and middle cranial fossa lesions including tumors of the cavernous sinus, vascular aneurysms and orbital tumours, etc. Most benign lesions were totally removed and functional preservation was achieved in most cases. Only one case of morbidity from injury to the frontal nerve and two mortalities from intracerebellar haemorrage and sepsis occurred. Access is the major crucial factor which can determine the functional result, and involvement of multidisciplinary fields will provide good cosmetic results.

Lateral supramalleolar flap.

Soft tissue coverge of the heel and ankle area is one of the most difficult problems encountered in reconstruction particularly when the major arterial trees of the lower extremity are injured. Lateral supramalleolar flap, an axial pattern skin flap, based on the cutaneous branch of the perforating branch of the peroneal artery, can be effectively utilized as a mean of resolution. Sacrifice of the main arteries (anterior, posterior tibial artery, or peroneal artery) is avoided, which is the great advantage of this flap. Twelve patients, ages 8 to 55 years, underwent the operation employing this type of flap. Four cases of soft tissue lost on the foot, were covered with such flaps. The flap healed satisfactorily except for two cases, one had minor skin slough at the edge of the flap and the other one had necrosis of one had necrosis of one third of the flap, requiring subsequent debridement, but healing took spontaneously. The only one disadvantage of this flap is the donor site scar.