Skin contraction with pulsed CO2 and erbium:YAG laser.

The purpose of this study was to assess the physical response of skin to laser resurfacing in a real-time, quantitative fashion. The study was designed to assess skin contraction from two opposite standpoints. First, change in tension was measured during laser application while samples were held at constant length. Second, change in length of a sample under no tension was measured during laser treatment. These two disparate analyses represent the two possible extremes of the clinical situation in which skin exists under some tension with some laxity to allow for decrease in length. A custom apparatus with digital interface for skin tension measurements was used to produce single sample tracings of change in skin tension with laser treatment. Length change was measured for individual samples by continuous sonomicrometer readings. Individual sample data were then plotted in a time versus tension/length graph. Skin contracts immediately to a peak level and then relaxes to a sustained plateau level for both CO2 and erbium:YAG lasers. Increased contraction was noted when the beam penetrated into the dermis. Greater peak and plateau contraction is observed after the beam has penetrated into the dermis. Skin contraction varies directly with energy for CO2 and erbium:YAG laser. Findings were similar when skin tension was measured with the sample held at constant length and when length change was measured with the sample under no tension. Char left on the skin after a pass with CO2 laser substantially decreases skin contraction. High-density settings with CO2 laser yield pulse stacking, which effectively irradiates the same portion of tissue with char on it. Skin contraction varies inversely with computer pattern density settings for CO2 laser due to this pulse stacking effect. Density has little effect on skin contraction for the erbium:YAG laser because little char is generated. Histologic analysis identified a zone of coagulated dermis that correlates linearly with skin contraction.

Bilateral radial forearm free flaps for oral-cavity reconstruction.

Simultaneous primary tumors (tumors found at the same time or within 1 month of each other) are not uncommon in head and neck cancer. Most frequently, one lesion is small relative to the other; however, this is not always the case When two anatomically separate simultaneous primary tumors are large, a challenge for the reconstructive surgeon exists. The authors present a case of simultaneous primary tumors arising along the left and right mandibular gingiva. Following extirpation of the tumors, the defects were reconstructed with bilateral free radial forearm flaps. They conclude that this procedure is an excellent option for reconstruction of anatomically separate simultaneous defects of the head and neck region. This reconstruction provides an excellent tissue match for the intraoral region, and can be accomplished with minimal morbidity in a relatively short operative time.

Early excision and grafting versus conservative management of burns in the elderly.

Elderly burn patients have significantly higher mortality rates than younger patients with similar burns over the total body surface area. Two theories exist regarding treatment of burns in the elderly: a traditional approach to limit physiologic stress by avoidance of operative intervention in the early post-burn stage and eschar excision and wound closure within the first week of hospitalization. We examined retrospectively the outcome in patients 70 years or older, hospitalized in the University of Kentucky Burn Unit between 1975 and 1995. In the first decade (1975 to 1983), patients were managed conservatively, namely, with spontaneous eschar separation and late skin grafting. In the second half of the study period (1984 to 1994), elderly patients were managed by early operative excision (<7 days) and grafting. A total of 73 elderly patients were admitted to the unit, 6 of whom were not resuscitated and died shortly (<96 hours) after admission. Twenty-eight patients had early excision and grafting (average age 78.1 years, total body surface area 23.6 percent), and 39 were managed conservatively (average age 79.3 years, total body surface area 20.9 percent). The mortality rate was 57 percent in the first group and 41 percent in the second group (p = 0.22). In an effort to further define the two groups, the other patient variable that contributes to burn mortality besides age and total body surface area, inhalation injury, was subtracted and the mortality rates were recalculated. Excluding patients with inhalation injury, the mortality rate was 48 percent in the first group and 27 percent in the second group (p = 0.15). We conclude that, in our unit, the management of elderly patients by early excision and grafting was of no benefit and may have resulted in a higher mortality rate.

Bone anchors: new application in craniofacial surgery.

Postoperative ptosis of the soft tissues of the face after subperiosteal exposure of midfacial fractures may result in loss of zygomatic projection due to malposition of the soft-tissue envelope with respect to the underlying skeleton. Resuspension of the soft tissues of the face to their preinjury position has previously been suggested to alleviate this problem. We present a modification of our original technique, which uses suture anchors to simplify this procedure.

A new method of skin-graft stabilization: the Reston technique.

We describe a new staple-on dressing technique for skin-graft stabilization, using gas-sterilized polyurethane foam as bolster material. The method has all the attributes of a satisfactory skin-graft dressing: compression to prevent hematoma and seroma, resistance to shear forces, splinting properties, and protection from the outside environment. Although we have not completed a randomized, prospective study, skin-graft "take" appears to be excellent in most cases. The technique is cost effective, and application requires a fraction of the time required for a traditional bolster dressing.