Vascular pressure monitorization for necessity of vascular augmentation in a rat extended abdominal perforator flap model.

In case blood perfusion compromises, vascular enhancement with arterial supercharge or venous superdrainage can increase viability of the flap. In this study, vascular pressure monitorization was used in a rat extended abdominal perforator flap model to reveal intraoperative vascular compromise and the need for vascular augmentation. A rat abdominal perforator flap was designed, which was based on the right second cranial perforator of epigastric artery. Vascular pressures of the flap were monitored continuously for 60 min, by catheters placed in the right superficial inferior epigastric artery and vein. Forty rats were divided into four experimental groups, as follows: group 1 (n = 10, no vascular augmentation), group II (n = 10, arterial supercharge), group III (n = 10, venous superdrainage), and group IV (n = 10, arterial and venous augmentation). Arterial supercharge and/or venous superdrainage were performed by using the left superficial inferior epigastric artery and vein. After the rats were sacrificed on the 7th day, total flap area and necrotic regions were evaluated. Mean arterial blood pressure was found significantly lower (P < 0.05) and mean venous blood pressure was measured significantly higher (P < 0.05) in group I than the groups II, III, and IV. Flap survival area was also larger in the groups II, III, and IV than the group I (P < 0.05). The results of this experimental study demonstrate that arterial insufficiency and venous congestion are almost always present in the rat extended abdominal perforator flap model, similar to deep inferior epigastric perforator flap. When such an extended perforator flap is used, arterial and venous pressure monitorization may be considered as a tool to support intraoperative clinical findings to reveal the need of vascular augmentation and ascertain flap viability.

Is elective neck dissection in T1-2, N0 patients with lower lip cancer necessary?

The significance of elective neck dissection in the early stages of lower lip cancer is generally underestimated. In the classic textbooks of plastic surgery it has been generally accepted that lymphatic spread to neck is negligible and therefore it is not imperative to perform any kind of neck dissection. However, in some recent studies high rates of clinically positive neck that were initially negative began to appear in the literature especially in otorhinolaryngology and head and neck journals. Our clinical series consisted of 21 lower lip cancer cases with T1-2, N0 tumors; the rate of lymphatic spread to neck was found to be 19%. Because of this high rate, we conclude that it is not sound to discard the importance of neck dissection even in the early stages of lower lip cancers. At least, a suprahyoid neck dissection should be performed in all patients with lower lip cancer.

Randomized, evaluator-blind, split-face comparison study of single cross-linked versus double cross-linked hyaluronic acid in the treatment of glabellar lines.

BACKGROUND At present, various hyaluronic acids are being used to rejuvenate facial skin. There is no comparative study of single cross-linked hyaluronic acid (SCHA) versus double cross-linked hyaluronic acid (DCHA). The objective of our study is to compare the effectiveness and complications of SCHA versus DCHA in the treatment of glabellar lines. METHODS Ten female patients were enrolled in this randomized, evaluator-blind study. One side (left vs. right) of each patient's glabellar lines was treated with SCHA and the other side was treated with DCHA. Two independent blinded observers reviewed the clinical photographs at 3, 6, 9, and 12 months after the treatment and assessed for degree of improvement as well as complications. RESULTS The two products were equally effective in producing an optimal cosmetic result, although at 6, 9, and 12 months posttreatment, a higher proportion of patients showed over 50% improvement with DCHA than with SCHA. At 12 months posttreatment, DCHA was considered superior in 70% of patients, whereas SCHA was superior in 10% of patients. CONCLUSIONS Both SCHA and DCHA are equally effective in producing an optimal cosmetic result. DCHA provides a more durable esthetic improvement when compared to SCHA in the treatment of glabellar lines.

Paraumbilical perforator-based pedicled abdominal flap for extensive soft-tissue deficiencies of the forearm and hand.

A new paraumbilical-based pedicled abdominal flap was used in 11 patients with extensive soft-tissue defects of the forearm and hand. With a relatively narrow pedicle, large flaps up to 5- x 14-cm can be raised. Another advantage of this flap is the comfortable position of the hand and forearm for the patient. The main disadvantage is the conspicuous abdominal scars like the other pedicled abdominal flaps.

Treatment of leg veins with the long pulse dye laser using variable pulse durations and energy fluences.

BACKGROUND AND OBJECTIVES: Attempts at using the pulsed dye laser (PDL) operating at 585 nm wavelength and 0.45 milliseconds pulse duration to treat leg veins have been notably unsuccessful. The aim of this study is to evaluate the efficacy and complications of the 595 nm long PDL in the treatment of leg veins. STUDY DESIGN/PATIENTS AND METHODS: Fourteen patients with 38 lesions were treated using a long PDL equipped with a cryogen spray cooling (CSC) device. Variable pulse durations ranging from 1.5 to 20 milliseconds and energy fluences from 10 to 20 J/cm2 were utilized depending on the size of treated vessels. All patients received two laser treatments at an interval of 2 months. RESULTS: Of patients with veins type 1A and type 1, 6 (100%) and 3 (13%) had complete clearing, respectively. Of patients with veins type 1 and type 2, 18 (78.3%) and 2 (22.2%) lesions showed excellent response, respectively. Hyperpigmentation was the only observed complication lasting several months in 57.9% of treated sites. CONCLUSIONS: The long PDL operating at 595 nm is a safe and effective treatment for leg veins, especially in type 1A and type1 vessels.

Revascularization of the testis using a vascular induction technique: a potential approach for staged orchiopexy in high-undescended testis.

The present study was designed to determine whether a fasciovascular flap as a vascular carrier could be used to revascularize the undescended testis for avoiding the hazardous effects of the Fowler-Stephens procedure, high division of the spermatic vessels, and for bringing high-undescended testes into the scrotum. A total of 25 Wistar rats were divided into five groups of five rats each. In each group, surgical procedures were performed bilaterally, i.e. ten testes in each group, as follows: sham-operated controls (group 1), undescended testes (group 2), high division of the spermatic vessels (group 3), vascular induction with immediate division of spermatic vessels (group 4), and with delayed division of spermatic vessels (group 5). Evaluations were done by measuring the testicular weight and volume, testicular blood flow, and testicular biopsy scores and by microangiography. A moderate to severe decrease in testicular weight and volume in all experimental groups was observed compared with the sham-operated controls (group 1), but this was significantly less in groups 2 and 5. High division of the spermatic vessels in groups 3 and 4 resulted in a significantly greater decrease in the testicular blood flow, but this did not occur in group 5. Microangiographically, an impaired vascular supply from the deferential artery in group 3 and insufficient revascularization from the fasciovascular carrier in group 4 were observed. However, efficient revascularization stemming from the superficial epigastric artery of the fasciovascular flap was found in group 5. The testicular biopsy scores of groups 2 and 5 were significantly greater than those of groups 3 and 4. The results of the present study demonstrate that the fasciovascular flap as a vascular carrier revascularizes the testis through spermatic vessels after delayed division and provides an adjuvant treatment modality or first-stage procedure in a salvage operation for high-undescended testis during staged orchiopexy.

The seven flap Z-plasty revisited.

Although multiple Z-plasties are widely used for burn contractures, the seven flap Z-plasty procedure has not gained wide acceptance in plastic surgery practice. However, the technique has the advantage of achieving more elongation than other Z-plasty techniques. The technique safely performed with satisfactory results in 31 cases.

The flashlamp-pumped pulsed dye laser (585 nm) treatment of hypertrophic scars in Asians.

Hypertrophic scars are common and cause functional and psychologic morbidity. Various treatment modalities have been advocated in the past, but the flashlamp-pumped pulsed-dye laser-585 nm (PDL) has been shown to be effective in the treatment of a variety of traumatic and surgical scars. This study was performed to determine the effectiveness of the PDL treatment of hypertrophic scars in Asians and to elucidate possible side effects and complications. Thirteen Asian patients with 19 hypertrophic scars that had no response to conservative therapies, such as pressure therapy, intralesional corticosteroid injection, or silastic gel sheeting for more than 6 months, were treated with the PDL. Three months after the last laser treatment, improvement in the appearance, reduction in scar height, and erythema as a result of the PDL treatment were evaluated and compared with baseline values. Compared with the baseline appearance, hypertrophic scars treated with the PDL showed a satisfactory clinical improvement of 84% (16 of 19), a significant percentage of scar flattening of 58.9 +/- 22.1%, and of erythema elimination of 75.7 +/- 19.9% at month 3 after the last laser treatment. The PDL treatment of hypertrophic scars can effectively improve scar pliability and texture and decrease erythema and associated symptoms. In addition, multiple treatment sessions are suggested for achieving greater response, but lower fluences are recommended for prevention of side effects in Asians with a higher melanin content of the skin.

A giant melanocytic nevus treated with combined use of normal mode ruby laser and Q-switched alexandrite laser.

We report a combination procedure that can improve the effectiveness of laser removal of giant congenital melanocytic nevi (CMN). A 2-year-old girl with a giant CMN was seen in our outpatient clinic. Histological findings showed a compound nevus without any evidence of malignancy or dysplastic changes. The patient was treated with the normal mode ruby laser and Q-switched alexandrite laser. The lesion was significantly improved in color and cosmetic appearance. Partial hypopigmentation and texture changes were observed. Histological findings showed a marked decrease in the number of junctional melanocytes and the nests in the papillary and reticular dermis. The combined laser treatment is an effective method for the treatment of giant CMN, but further study is warranted to follow-up questions of recurrence and malignant change.

Efficacy of the flashlamp-pumped pulsed-dye laser in nonsurgical delay of skin flaps.

OBJECTIVE: The purpose of this article was to determine the effectiveness of laser delay by use of the flashlamp-pumped pulsed-dye laser operating at a wavelength of 585 nm; to elucidate the comparable or dissimilar macroscopic, microscopic, and hemodynamic changes between laser and surgical delay methods; and to clarify the possible mechanisms underlying the delay effect of laser. METHODS: A standardized caudally based random dorsal rat flap model was used in this study: Acute random skin flaps served as control subjects (group 1). Surgical delay was employed by incision of lateral longitudinal borders both without (group 2) and with (group 3) undermining, and laser delay methods were performed by laser irradiation of both lateral longitudinal borders (group 4) and the entire surface (group 5) of the proposed flap. Evaluation was done by histologic examination, India ink injection, laser Doppler perfusion imaging, and measurement of flap survival. RESULTS: Histologically, dilation and hypertrophy of subpapillary and subdermal vessels were evident in groups 2, 3, and 4; on the other hand, degranulation of mast cells in the vicinity of occluded vessels at the 1st hour of laser delay and a striking mast cell proliferation and degranulation in association with newly formed vessels (angiogenesis) at the 14th day of laser delay were prominent in group 5. India ink injections revealed longitudinally arranged large-caliber vessels and cross-filling between the vessels of adjacent territories in groups, 2, 3, and 4, but only small-caliber vessels in group 5. Compared with the acute flaps, both surgical and laser delay significantly increased the mean flap perfusion to the maximal levels after a 14-day delay period, and all delay procedures improved flap survival; the most significant increase in surviving area was observed in group 3, whereas the less significant increase in surviving area was in group 5. CONCLUSION: This study demonstrates that laser delay is as effective as surgical delay and that laser delay by lasering lateral borders leads to dilation and longitudinal rearrangement of the existing vessels rather than angiogenesis, whereas laser delay by lasering the entire surface results in delay effect by inducing angiogenesis due to activation and degranulation of the mast cells.

Treatment of phacomatosis pigmentovascularis: a combined multiple laser approach.

BACKGROUND: Phacomatosis pigmentovascularis (PPV) consists of a capillary malformation with a variety of melanocytic lesions, which involve various regions of the body and are difficult to treat with conventional therapeutic tools. OBJECTIVE: We described two cases with PPV (type IIa and IIb) that were successfully treated with different lasers. METHODS: The areas involved by both melanocytic lesions and port-wine stains were treated using the Q-switched ruby laser, the Q-switched Alexandrite laser, and the flashlamp pumped pulsed-dye laser. RESULTS: Removal of a good portion of cutaneous and vascular lesions using combined multiple laser approach was achieved after 6 sessions in the first case under general anesthesia and after 31 sessions under local anesthesia in the second case. CONCLUSION: PPV type II can be treated successfully by laser treatment. We prefer to start combined multiple laser treatment of PPV in childhood period under general anesthesia because it will reduce the number of treatment, improve the patient's quality of life, and increase the cost-effectiveness of the treatment.

Use of Q-switched ruby laser in the treatment of nevus of ota in different age groups.

BACKGROUND AND OBJECTIVES: Nevus of Ota is a form of dermal melanocytic hamartoma that appears as a bluish discoloration in the trigeminal region. Although Q-switched lasers provide effective treatment, the appropriate age at which to start that treatment is not known. Our aim is to compare the clinical efficacy and safety of Q-switched ruby laser (QSRL) in the treatment of nevus of Ota in different age groups. STUDY DESIGN/MATERIALS AND METHODS: Our study included 46 children and 107 adults with nevus of Ota, which had been treated with QSRL that achieved excellent (75% or more) to complete response. The laser parameters were 694-nm wavelength, 30 nanoseconds pulse duration, 4-mm spot size, and 5-7 J/cm2 fluence at 3-4 month intervals. We assessed the mean number of treatment sessions and the degree of complications in the two age groups of patients. RESULTS: The mean number of treatment sessions to achieve significance to complete clearing was 3.5 for the younger age group and 5.9 for the older age group (P = 0.0001). The complication rate for the younger age group was 4.8% as compared to 22.4% for the older age group. CONCLUSIONS: The use of QSRL for the treatment of nevus of Ota in children can achieve an excellent result in fewer sessions and at a lower complication rate than later treatment. The risk of recurrence is a concern, however, and further long-term study is necessary to address this issue.

Effectiveness of the normal-mode ruby laser and the combined (normal-mode plus q-switched) ruby laser in the treatment of congenital melanocytic nevi: a comparative study.

The effect of the normal-mode ruby laser (NMRL) and the combined (normal mode plus Q-switched) ruby laser on congenital melanocytic nevi (CMN) was evaluated, and the degree to which both laser treatment regimens remove melanocytes was compared in 15 patients. Each nevus was marked to designate half of the lesion for the NMRL treatment and half of the lesion for combined ruby laser treatment. The efficacy of each laser treatment was correlated with the degree of clinical improvement determined by photographic assessment, histological examination, and melanin reflectance spectrometry before and 3 months after laser treatment. A single treatment using the NMRL with energy fluences of both 20 J per square centimeter and 30 J per square centimeter resulted in a slight, but not significant, improvement in lightening of pigmentation (42.61% and 30.38%, respectively). A better clinical response (excellent to good) and higher percentage of lightening (64.45%-72.43%) was noted in the combined ruby laser-treated areas than the NMRL-treated areas. Histological results showed that the combined ruby laser provided a marked decrease in the number of the nevomelanocytic nests in both the junctional area and the papillary and reticular dermis, whereas the NMRL (with energy fluences of either 20 J per square centimeter or 30 J per square centimeter) caused a decrease in the junctional area and the papillary dermis. None of the nevi had complete clearance of the pigmentation after a single treatment. Therefore, multiple (four to five) treatment sessions are needed to cause complete removal of nevomelanocytic nests in CMN. In conclusion, the combined ruby laser is more effective than the NMRL alone in the treatment of CMN without scarring or textural change of the skin.

The V-Y island dorsal nasal flap for reconstruction of the nasal tip.

The dorsal nasal flap and its modifications have proved reliable in the coverage of defects on or adjacent to the tip of the nose. However, the problems inherent in the nature of the flap are limited rotational movement afforded by the pedicle, visible scars crossing the dorsum and the natural concavity of the alar crease, skin thickness discrepancy between the flap and the skin, and dog-ear deformity created by the rotation. The purpose of this study was to design a new modification of the dorsal nasal flap, in the highlight of a cadaveric study, that can overcome the traditional drawbacks. Ten adult human cadavers were used to study the vascular basis of the flap and to simulate application of the flap. Cadaveric dissections demonstrated that a skin island over the nasal dorsum and glabellar area can be elevated safely based on a dual axial supply (i.e., the terminal branches of the angular artery and vein bilaterally), and can be advanced easily in a V-Y manner to cover the nasal tip defect. The result obtained in the clinical case showed that the V-Y island dorsal nasal flap provided a sizable amount of skin with more appropriate texture and color for coverage of the nasal tip defect without tension or secondary deformity.