Cytokines, growth factors, and plastic surgery.

Numerous inflammatory cytokines and growth factors have been identified and are known to be essential for normal wound healing and host defense, and many have been implicated in disease states treated by plastic surgeons. Cytokines and growth factors are members of a large functional group of polypeptide regulatory molecules secreted by different cell lines. These peptides exert their influence through autocrine and paracrine fashions within sites of injury and repair. Although cytokines and growth factors are crucial in initiating, sustaining, and regulating the postinjury response, these same molecules have been implicated in impaired wound healing, abnormal scarring, and chronic cutaneous diseases. Therapeutic manipulation of inflammatory mediators in normal and impaired wounds has been performed, with mixed clinical results, but evolving strategies such as gene therapy, as well as further characterization of the cellular-mechanism cytokines and growth-factor triggers, will further add to our therapeutic options. This article discusses the current understanding of important cytokines and growth factors involved in the normal injury response and then addresses pathological states associated with an inappropriate expression of these mediators. Finally, a summary of various cytokine and growth factor-directed strategies being used in impaired wound healing states is presented.

Quality-of-life outcomes after cosmetic surgery.

Cosmetic surgery is an increasingly common medical procedure whose benefits to patients have not been quantified objectively. The purpose of this study was to prospectively examine long-term quality-of-life outcomes for patients undergoing elective cosmetic surgery. In this prospective, correlational study of 105 consecutive patients undergoing elective cosmetic surgery, the parameters of quality-of-life index, depression, social support, and coping were determined preoperatively and at 1- and 6-month intervals postoperatively. The data from the four study instruments were analyzed using Pearson correlation and repeated measures of multivariate analysis of variance for differences in each variable over time. The multivariate analysis of variance quality-of-life index scores for patients improved from baseline preoperative mean levels of 3.24 to a mean of 2.56 at 1 month, and then to 2.11 (f = 518.5, p = < 0.0001) at 6 months postsurgery. Mean scores for depression [determined by using the Center for Epidemiologic Studies Depression Scale (CESD)], improved from 11.2 preoperatively to 6.5 at 1 month, and to 6.3 (f= 79.3, p = < .0001) at 6 months after surgery. Surgical intervention produced no significant differences between preoperative and postoperative ways of coping and social support scores. Cosmetic surgery produces positive psychological benefits by significantly improving quality-of-life outcomes that persist long term, without adversely affecting social support and ways of coping.

Research priorities and concerns of plastic surgical nurses.

The advancement of nursing knowledge to improve clinical plastic surgical nursing practice was identified as a priority for the American Society of Plastic and Reconstructive Surgical Nurses (ASPRSN). The purpose of this investigation was to determine the specific research priorities and perspectives of practicing plastic surgical nurses. In addition, nurses were asked to rank their current concerns for the future of plastic surgical nursing.

Sentinel lymph node mapping in melanoma of the ear.

Primary nodal drainage basins in melanoma of the head and neck are often unpredictable. The ear is a notorious example of an anatomic site with ambiguous patterns of lymphatic drainage. Preoperative lymphoscintigraphy has recently emerged as one modality to assist in identifying clinically relevant nodes. We propose that the addition of intraoperative lymph node mapping techniques that utilize radioactive tracers ("intraoperative lymphoscintigraphy") can increase the accuracy of identifying sentinel nodes and help to determine which patients may benefit from a complete neck dissection. This report demonstrates the ambiguity in identifying drainage patterns in melanoma of the ear and offers a reliable method of sentinel lymph node mapping. This report also addresses current issues regarding treatment protocols of patients with micrometastatic disease in the periauricular region.

Pediatric peripheral neuropathy in proteus syndrome.

Proteus syndrome is a rare congenital disorder comprised of subcutaneous and internal hamartomas, pigmented skin nevi, skull exostoses, hemihypertrophy, and macrodactyly of the hands and feet. A 5-year-old girl diagnosed with Proteus syndrome presented with distal median compression neuropathy with the primary complaint of severe pain involving the left hand. Surgical exploration of the hand revealed a lipofibromatous hamartoma of the median nerve. The transverse carpal ligament was released and epineurectomy of the median nerve was performed. The patient remains symptom free at the 9-month follow-up. This report is the first description of a hamartoma directly involving a peripheral nerve in Proteus syndrome. Decompression of the nerve with the removal of the fibrofatty neural sheath resulted in the resolution of the symptoms in this patient. The surgeon should consider this approach as a potential first line of treatment before a more radical resection of the nerve is contemplated.

Anxiety disorders in plastic surgery.

Surgery is a stressful event, with the potential for profound disturbance to the patient's psychological and physiologic homeostasis. Cosmetic surgery is a particularly intense psychological experience because, in addition to the usual concerns about surgical side effects, cosmetic patients bring their hopes and expectations for improved self-image, putting them at risk for the added anxiety of disappointment. High levels of anxiety coupled with the perception of vulnerability or threat to self can cause significant psychological reactions complicating care for the plastic surgical patient. This paper outlines the diagnostic features of the common types of anxiety disorders seen in plastic surgical patients, and it offers treatment strategies for the practitioner, delineating when referral to a mental health expert is advised. Specific clinical case studies of panic attack, posttraumatic stress disorder, and acute stress disorder are presented to illustrate the variety of abnormal anxiety responses that may be encountered in the perioperative setting. Interventions for the anxious patient are part science and part art. Careful questioning and psychosocial assessment can identify those patients who are at greater risk for psychological problems after surgery. However, some patients may mask or keep secret their concerns, which can be manifested with resulting anger and hostility. Plastic surgeons must use appropriate indicators of psychological anxiety and measure a specific patient's reactions to surgery to make the diagnosis of abnormal anxiety. Close follow-up by the plastic surgical team is an essential part of the anxiety disorder patient's psychological treatment, but it is imperative that these problematic patients be referred promptly to a qualified mental health professional to limit their adverse experience and promote their well-being. Patients who are less anxious during the perioperative period report less emotional distress and fewer defensive behaviors and are likely to be more satisfied with the outcome of their surgery.

Immediate breast reconstruction in the high-risk adjuvant setting.

High-dose chemotherapy with autologous stem cell support (or bone marrow transplantation) in the treatment of primary breast cancer has been developed in the hopes of increasing survival among patients traditionally regarded as "high risk". These patients have locally advanced disease (stage IIB or higher) and have a greater than 50% risk of developing systemic illness. This report addresses the issue of whether reconstructive breast surgery can be offered to high-risk patients. It is hoped that as survival among women with advanced or high-stage primary breast cancer increases, options for immediate breast reconstruction can be routinely offered.

Pseudoaneurysm of the anterior superficial temporal artery.

Pseudoaneurysm of the superficial temporal artery must be considered in the differential diagnosis of masses of the lateral forehead and temporal fossa. While the first reported case of a temporal artery aneurysm was reported by Thomas Bartholin in 1740, there is scant mention of this lesion in the plastic and maxillofacial surgical literature. Pseudoaneurysms can arise in the forehead and scalp as a result of blunt traumatic impingement of the superficial temporal artery against the calvarium. The anterior branch of the artery is most vulnerable, because in the lateral forehead it courses over the frontal osseous ridge in the galea aponeurotica formed by the fusion line of the deep and superficial temporalis muscle fascia. This dense fascial investment has a tethering effect in the gap between the temporalis and frontalis muscles and prevents the artery from displacing laterally in response to traumatic forces. A history of recent blunt trauma or surgery to the forehead, combined with a pulsatile bruit, should direct the physician to the diagnosis of pseudoaneurysm of the superficial temporal artery. Treatment is surgical resection of the involved segment without the need for reconstruction. This report includes a review of the literature and presents the first documented case of a bicycle helmet as the cause of a superficial temporal artery pseudoaneurysm.

The fate of teeth transfixed by osteosynthesis screws.

Rigid internal fixation with plates and screws for osteosynthesis of facial fractures and osteotomies in the cranio-maxillofacial skeleton is often undertaken in situations in which the exact position of the underlying tooth roots cannot be determined. Therefore, a screw may be inadvertently placed into a root. There is scant data in the literature addressing the consequences of tooth impingement. This 5-year retrospective study documents the long-term outcome of teeth transfixed by osteosynthesis screws in a series of 387 consecutive facial fractures at a Level I trauma center. The incidence of root impingement per screw was 0.47 percent (13 transfixed teeth per 2340+ screws). Mandibular teeth were more "at risk" than maxillary teeth by a ratio of 10:3. No transfixed teeth became infected or required extraction in this series. In conclusion, inadvertent tooth root impingement by osteosynthesis screws appears to have minimal adverse consequences.

Reconstruction of extensive scalp defects with rectus free flaps.

This review represents the largest reported series involving reconstruction of complex scalp and calvarial defects with rectus abdominis free flaps. Sixteen patients presented with extensive (up to 300 cm2) scalp and calvarial defects requiring free tissue transfer for closure. All of the 11 patients who underwent a rectus abdominis free flap had a technically successful microvascular transfer. The defects encountered involved a wide spectrum of complexities including extensive multilaminar defects with exposed brain and dura, irradiated fields, and infection. In our institutions, the rectus abdominis muscle has evolved as a uniquely superior donor choice for restoring extensive scalp defects for several reasons: (1) accessibility, which eliminates intraoperative patient repositioning and allows for a simultaneous two-team approach; (2) minimal donor-site morbidity; (3) vascular reliability; and (4) the ability to supply abundant, easily contoured tissue.

Reduction mammaplasty improves symptoms of macromastia.

The condition macromastia has not been defined and characterized precisely by the medical community. Whether the patient with hypertrophic breasts is a candidate for or can be helped by reduction mammaplasty is unclear to both the medical and the lay community. A prospective study of 39 women undergoing reduction mammaplasty surgery was initiated to answer these questions. Patients rated the severity of their somatic pain symptoms and discomfort before reduction mammaplasty and again after complete recovery. The severity of their symptoms and complaints was numerically graded and analyzed. These data were compared with similar data obtained from 40 "small-breasted" women of similar age. Headache, neck pain, back pain, shoulder pain, and bra strap groove pain were present in 60 to 92 percent of patients, and 97 percent of patients had at least three of these pain symptoms preoperatively. All the patients had reduction of their pain symptomatology postoperative, and 25 percent of the study patients had total elimination of pain symptoms by reduction mammaplasty. The postoperative incidence and severity of pain symptoms and discomfort complaints were statistically equivalent to or less than the levels in the control group.

Reorganization of craniofacial/cleft care delivery: the Massachusetts experience.

Until 1989, the Commonwealth of Massachusetts operated a mandated care program known as Services for Handicapped Children (SHC) for children with cleft lip/palate or craniofacial anomalies. During the mid 1980s, the federal government reduced its block grant funds and encouraged the Commonwealth of Massachusetts to develop Project SERVE to address this changing fiscal reality. The principal outcome of Project SERVE was the recommendation that the SHC direct care programs, including all craniofacial and cleft palate clinics, should be dismantled over a number of years. However, due to the economic recession, all government funding was suddenly withdrawn from cleft palate teams and the state-run SHC clinics were abruptly dissolved. To treat patients left without coordinated care, former team members reassembled and began a new craniofacial team based at the University of Massachusetts Medical Center. Difficulties with the transition of the clinic included recruiting and retaining team members; remuneration procedures for team members; maintenance of patient records previously kept by the state; coordination of clinical/clerical responsibilities; identifying a physical locale to hold the clinics; and solicitation of referring health care provider referrals and follow-up. All these issues required specific interventions that are presented in this paper. Project SERVE, begun under federal auspices, in the Commonwealth of Massachusetts, has recently been promoted as a model for a new and improved approach to the management of cleft palate and craniofacial care delivery nationwide. Awareness of the potential for abrupt, radical change in funding for federally mandated cleft/craniofacial care is essential, and a successful transition to a medical center-based model is possible using the procedures established at our center.

Thumb replantation after cardiac transplantation.

Generally, severe medical illnesses, including chronic immunosuppression and heavy steroid use, have been deemed relative contraindications for replantation surgery. We report the successful replantation of an amputated thumb in a patient who had previously undergone heart transplantation and was on therapeutic immunosuppression. Despite extensive soft-tissue damage and joint involvement, thumb function and sensibility returned to acceptable levels. This case demonstrates that digital bony union, tendon repair healing, and nerve regeneration are not significantly altered by the standard immunosuppressive regimen following major organ transplant. The implications raised by this case for possible transplantation of allograft digits or limbs are discussed in detail.

Island scalp flap for superior forehead reconstruction.

An island scalp fasciocutaneous flap, based on the posterior superficial temporal vessels, is described for single-stage reconstruction of full-thickness forehead and scalp defects. The hairline can be precisely determined and tailored to restore symmetry. By removing the hair-bearing dermis of the forehead portion of the flap and placing a full-thickness skin graft, aesthetic reconstitution of the forehead skin is achieved. This flap is especially useful when exposed calvarium limits other techniques.

Autogenous vein graft repair of digital nerve defects in the finger: a retrospective clinical study.

Twenty-two digital nerve repairs were performed in the finger using autogenous vein grafts. Eighty-two percent of the repairs were available for follow-up. Results of sensibility return were assessed using moving two-point discrimination, Semmes-Weinstein monofilaments, and vibratory testing. Two-point discrimination averaged 4.6 mm for 11 acute digital nerve repairs using vein conduits 1 to 3 cm in length. Delayed digital nerve repair with vein conduits yielded poor results. Semmes-Weinstein values demonstrated comparable levels of return of slowly adapting fiber/receptors to the quickly adapting fiber/receptors, as evidenced by moving two-point discrimination tests. Vibratory sensibility was present in all. A review of previous experiences with end-to-end digital neurorrhaphies and digital nerve grafting suggests that repair of 1- to 3-cm gaps in digital nerves with segments of autologous vein grafts appears to give comparable results to nerve grafting. Further laboratory and clinical research is necessary to better define the role of interpositional vein conduits for repair of peripheral nerves.