Scar management practice and science: a comprehensive approach to controlling scar tissue and avoiding hypertrophic scarring.

A meta-analysis of the literature forms the basis of a treatment regimen focused on the principles of support, controlled inflammation, hydration, and hastened collagen remodeling. The presented clinical trial avoided hypertrophic scarring in more than 80% of cases, validating the theory of targeting many areas of scar control in 1 approach.

Chemoprotection of flexor tendon repairs using botulinum toxin.

BACKGROUND: After flexor tendon repair, tendon gapping or rupture may be replaced by joint stiffness and poor function. After surgical repair of injured flexor tendons, botulinum toxin type A was injected into the forearm flexor muscles. This selectively decreased the force of muscle contraction. During this period of partial muscle denervation, patients could generate enough force to allow for early active mobilization (with its attendant benefits) but insufficient force to induce gapping or rupture of the repaired tendon. METHODS: Eighteen adult patients with zone 2 flexor tendon injuries (34 digits) were studied prospectively for up to 3 years. Tendons were repaired using the modified Kessler technique and marked with stainless steel wire. Botulinum toxin was injected into the appropriate proximal flexor muscle belly under localizing electromyographic control. A matched cohort consisted of 53 patients (104 digits). RESULTS: Results were assessed according to range of joint motion (Kleinert and Verdan criteria) and electromyographic and radiologic studies. Ninety-four percent had excellent results and 6 percent of digits had good results. There were no patients with fair or poor results. Average active range of motion was 244 degrees at 18 months. No gapping or ruptures occurred and no tenolyses were required. The control group of matched controls (modified Kessler repair; no botulinum injection) showed that 81 percent of digits had excellent results, 6 percent had good results, 8 percent had fair results, and 6 percent had poor results. CONCLUSIONS: Botulinum toxin injection statistically significantly improves the results of flexor tendon repair. The authors have termed this technique "chemoprotection" of flexor tendon repairs.

Hemipalate deformity caused by a teratoma.

Congenital intraoral tumors derived from embryological germ layers are very rare. These lesions include teratomas, dermoids, epignathi, and teratoid tumors. These embryological neoplasms may interfere with normal development and elevation of the palatal shelves, resulting in a cleft palate. We report the case of a patient with an intraoral teratoma associated with a hemipalate deformity and describe the treatment that was carried out. The classification and sometimes the confusing terminology associated with these lesions are discussed, as are the principles of managing them.

Multimodality scar management program.

BACKGROUND: This trial was undertaken to assess the efficacy of a multimodality management regime used for the prevention of hypertrophic scars. It follows previous research and experience (A.D. Widgerow et al, Aesthetic Plast Surg, 24(3):227-234, 2000) with a similar program but with the addition of active agents with specific effects against prolonged inflammation and enhanced hydrative capacity. The modalities specifically targeted are tension on the scar, hydration of the scar, collagen maturation, and controlled inflammation. METHODS: Tape was impregnated with a combination of agents providing an occlusive dressing aimed at combatting exaggerated scarring. Patients who had undergone surgery were stratified into four groups: Group 1, 60 patients/60 scars following simple skin excisions, 30 treated scars, 30 untreated scars; Group 2, 20 patients/40 scars, each patient with two excisions, one treated, one untreated; Group 3, 10 patients/20 scars following bilateral breast surgery, one side treated with tape alone, one side treated with tape and gel; Group 4, 30 patients with varying cosmetic procedures/50 scars, all treated and compared with historical outcomes for hypertrophic scarring. Thus, 170 scars were assessed in 120 patients. RESULTS: Results were assessed at 1, 2, and 6 months using a combination of accepted scar assessment techniques. By amalgamating the Vancouver, Manchester, and morphologic table systems together with Patient and Observer Scar Assessment analyses, a comprehensive assessment of scar outcomes was undertaken and comparisons were made with control groups. CONCLUSION: Treated groups showed improvement outcomes in all variations of assessment. Patient and observer assessments correlated well, and morphologic appearances of the scars following the final assessment at 6 months showed statistically significant positive scar outcomes in the treatment groups. The multimodality approach to scar control showed significant benefits in the patient groups tested in this series.

Modifying the two-stage cleft palate surgical correction.

OBJECTIVE: This paper reports the experience with a two-stage approach to surgical correction of the complete cleft palate, wherein timing of the second stage is dependent on the judgment of the speech pathologist and the orthodontist together with the surgeon. PATIENTS: Of a total of 35 patients having complete unilateral clefts a sample of 22 were available for postsurgical assessment. The first-stage repair of the palate was carried out at an average age of 10.7 months (range 6 to 17 months), and the second-stage repair of the residual cleft was completed at an average age of 32.7 months (range 26 to 34 months). INTERVENTIONS: The first-stage repair of the soft palate defect involved mobilizing two short posteriorly based flaps, which extend onto the posterior quarter of the hard palate thus including up to 1 cm of mucoperiosteum. Careful freeing of the muscle is followed by an intravelar veloplasty. The later closure of the residual cleft involved turnover hinge flaps and small mucoperiosteal flaps. RESULTS: Eighty-seven percent of the sample had good to excellent speech as assessed by the Great Ormond Street screening method. Only two patients showed evidence of recessive maxillae with Class III malocclusions. CONCLUSIONS: A two-stage surgical closure of the palate using this procedure would appear to confer several valuable advantages to the patient. These include favorable outcomes for speech in the large majority of cases and minimal adverse effects on the growth of the midface region.