Using Modified Skin-Stretching Technique as an Alternative Solution for the Closure of Moderate and Extensive Skin Defects.

External skin-stretching devices have been developed and used for wound closure since 1970s. Devices such as Miami STAR®, SureClosure®, TopClosure®, and WiseBand® have their own advantages and disadvantages. The modified external skin-stretching technique of this case series study has the advantage to improve tension distribution and simplified the application. Between January 2014 and June 2017, 20 patients were treated with the modified external skin-stretching device for the closure of the skin defects of the trunk (n = 6) and extremities (n = 14). Skin defects ranged from 8 × 5 to 19 × 16 cm achieved primary closure with the utilization of the modified skin-stretching device without major complications. Subsequent minor revisions were performed under local anesthesia between 6 and 12 months postoperatively. The modified skin-stretching device utilized biomechanical properties and mechanical creep of skin tissue to achieve a reliable and effective primary closure for moderate to extensive skin defects. Therefore, this modified external skin-stretching technique provided, in the appropriate setting, an effective alternative to skin grafts or free flaps.

Septal Reconstruction With Folded Porous Polythylene Implants: An Alternative Technique for the Correction of Severe Saddle Nose Deformities in Asian Populations.

BACKGROUND: Congenital or secondary deficiency in septal cartilage leads to an unpleasant cosmetic appearance and compromised function as well. Rhinoplasty maneuvers such as spreader graft and septal extension graft with autologous tissue have been exhibited to correct the deformities. However, the relatively severe donor site morbidity stands as a main concern for both surgeons and patients. METHODS: From January of 2014 to April of 2018, 52 patients presenting septal deformities underwent rhinoplasty with our modified technique. A piece of Medpor (8438) was tailored, folded and then placed as a combination of spreader and septal extension graft. The surgical outcomes were evaluated both objectively and subjectively. RESULTS: All the patients were followed up for 12 to 24 months postoperatively. The ratio of tip projection and the nasal length exhibited significant improvement in all our patients. Nasal obstruction subjectively mended among the 24 patients who had airway obstruction complaint preoperatively. Only 2 patients had severe adverse events and the implants were removed instantly. CONCLUSIONS: With our modified technique, Medpor proved to be an effective and reliable material for the reconstruction of septal cartilage, which provides us an alternative way to achieve extended spreader and septal extension graft with one single implant in the correction of saddle nose.Level of Evidence: Level IV, therapeutic study.

Pre-expanded bipedicled visor flap: an ideal option for the reconstruction of upper and lower lip defects postburn in Asian males.

BACKGROUND: Reconstruction of upper and lower lip subunits is a complicated and elusive challenge. For patients affected by defects involving upper and lower lip subunits, a technique able to reconstruct both aesthetic units with matched colour, sufficient contours and similar texture would be ideal. In this study, we present our experience with upper and lower lip reconstruction using the pre-expanded bipedicled visor flap. METHODS: From January 2014 to January 2017, 12 male patients presenting with defects of the upper and lower lip subunits were treated using this surgical technique. After a period of expansion of the scalp flap of over 6 months, the bipedicled visor flap was raised from both the parietal regions and rotated to resurface the defect. Delay and section of the pedicle were then performed. RESULTS: Twelve male patients with postburn scars aged 22 to 48 years (mean: 34 years) were successfully treated with no major complications. The donor site was closed primarily in all cases. Subsequent flap debulking and minor revisions were performed under local anaesthesia between 6 and 12 months postoperatively. CONCLUSIONS: The pre-expanded bipedicled visor flap provides an effective and reliable option for upper and lower lip reconstruction with excellent colour and texture. It is feasible to achieve these results simultaneously from a single donor site by using a pre-expanded bipedicled visor flap.

Application of a Porous Polyethylene Spreader Graft for Nasal Lengthening in Asian Patients.

BACKGROUND: Rhinoplasty maneuvers to lengthen the nose include placing an alloplastic implant, caudally rotating the lower lateral cartilage (LLC), and stretching the soft tissue skin envelope (STSE) downward. Tissue tension associated with these procedures can result in implant extrusion or tip retraction. OBJECTIVES: The authors performed rhinoplasty with implantation of porous polyethylene (Medpor). The Medpor device enabled transfer of tension from the LLC and STSE to the juncture of the septal cartilage and upper lateral cartilage (ULC), thereby stabilizing the nasal structures. METHODS: Twenty-six patients who underwent rhinoplasty with nasal augmentation and lengthening were evaluated in a prospective study. Two pieces of Medpor were placed as a spreader graft, and a third piece was inserted as a columellar strut. The released LLC was rotated caudally, and the domal segments were wrapped over the caudally projected tip of the implant. Surgical outcomes were assessed with a patient satisfaction questionnaire and by photogrammetry. RESULTS: Patients were monitored for an average of 9.6 months. The patients' mean nasolabial angle (NLA) was 106.2° ± 4.7° preoperatively and 94.3° ± 3.7° postoperatively (t < 0.0001). Most patients were fairly or completely satisfied with the operative outcome. One patient had impending implant extrusion and underwent explanation. CONCLUSIONS: Medpor material is easy to shape and is sufficiently strong to function as a spreader graft and withstand the tension associated with repositioning of the LLC and STSE.

Bipedicled Preexpanded Forehead Flaps for Simultaneous Reconstruction of Total Nasal and Upper Lip Subunits: A Novel Approach to Complex Facial Resurfacing.

Background Reconstruction of the central facial subunits is a complex and challenging task. In cases in which both the nasal and upper lip subunits are involved, a technique that can reconstruct both aesthetic units with tissue of similar color and texture from a single donor site will be ideal. In this article we present our experience with the bipedicled preexpanded forehead flap for simultaneous nasal and upper lip resurfacing. Patients and Methods Between January 2012 and January 2015 we used this technique in the simultaneous reconstruction of total nasal and upper lip subunits in five patients. All cases were for burns scar resurfacing. Results Good aesthetic results were achieved in each of our five cases to date and no complications were encountered. All donor sites closed primarily with aesthetically pleasing well-concealed linear scars. In all cases small modifications such as philtral shaping and further flap thinning were performed under local anesthesia between 6 and 12 months postoperatively Conclusion The preexpanded forehead flap provides an unparalleled color and texture match when it comes to facial resurfacing. When both total nasal and upper lip resurfacings are required, it is possible to achieve this in a single sitting from a single donor site by using a bipedicled preexpanded forehead flap.

Alteration of Skin Mechanical Properties in Patients Undergoing Botulinum Toxin Type A Injections of Forehead Rhytides.

BACKGROUND: Although application of botulinum toxin type A (BTX-A) for the treatment of forehead rhytides has become very popular, the effects of its intramuscular injections on the skin mechanical properties remain unclear. OBJECTIVES: We prospectively investigated the alterations in the mechanical properties of the skin of patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides and compared two injection doses. METHODS: Of the 42 enrolled patients, one randomly assigned half received intramuscular injections of two units (group I), and the other half received four units (group II) of BTX-A in each injection point. The baseline and post-treatment skin mechanical parameters, including gross elasticity (R2), net elasticity (R5), viscoelastic ratio (R6) and biological elasticity (R7), were measured using the Cutometer(®) and compared. RESULTS: Treatment with BTX-A resulted in significant overall alterations in the mechanical properties of skin at the injection sites of both treatment groups during the 16-week period, and no significant differences were observed between groups. Significant decreases in biological elasticity, net elasticity and viscoelasticity properties were observed at 2 weeks follow-up and began to recover at that time. All of the skin mechanical properties recovered to baseline levels by 16 weeks of follow-up in both dosage groups, which indicates that the higher dosage (4 units) did not delay relapse compared to the two-unit dosage. CONCLUSIONS: We concluded that intramuscular injections of BTX-A significantly regulated the gross elasticity, net elasticity, functional elasticity and viscoelastic elasticity at the injection point over a radius of 1.5 cm at 2, 4 and 8 weeks follow-up. The alteration in the skin measurements had completely diminished by the 16-week follow-up. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Surgical strategy for postburn cervical scar contracture].

OBJECTIVE: To explore the surgical strategy for postburn cervical scar contracture. METHODS: Sixty-five patients with scar contracture as a result of burn injury in the neck were hospitalized from July 2013 to July 2014. Release of cervical scar contracture was conducted according to different demands of the 3 anatomic subunits of neck, i.e. lower lip vermilion border-supramaxillary region, submaxillary region, and anterior region of neck. After release of contracture, platysma was released. For some cases with chin retrusion, genioplasty with horizontal osteotomy was performed. The coverage of wound followed the principle of similarity, i.e. the skin tissue covering the wound in the neck should be similar to the characters of skin around the wound in terms of color, texture, and thickness. Based on this principle, except for the preschool children in whom skin grafting was performed, the wounds of the other patients were covered by local skin flaps, adjacent skin flaps, or free skin flaps. RESULTS: All patients underwent release of scar and platysma, while 9 patients underwent genioplasty with horizontal osteotomy. Wounds were covered with local skin flaps in 32 patients, with adjacent skin flaps in 7 patients, with free skin flaps in 11 patients, and with skin grafts in 15 patients. All skin grafts and flaps survived. Good range of motion was achieved in the neck of all patients, with the cervicomental angle after reconstruction ranging from 90 to 120°. All patients were followed up for 6 to 24 months. Six patients who had undergone skin grafting were found to have some degrees of skin contracture, while none of the patients who had undergone flap coverage showed any signs of contracture recurrence. CONCLUSIONS: Restoration of the cervicomental angle is critical in the treatment of postburn cervical scar contracture, and the release of scar contracture should conform to the subunit principle. The coverage of wound should be based on the principle of similarity, with repair by skin flaps as the first choice, and skin grafting as the second choice. Satisfactory effect of repair would be achieved by following the above surgical principles.

Sebum Production Alteration after Botulinum Toxin Type A Injections for the Treatment of Forehead Rhytides: A Prospective Randomized Double-Blind Dose-Comparative Clinical Investigation.

BACKGROUND: Research has investigated the decrease in human skin sebum after the application of botulinum toxin. Few studies of the mechanism and objective assessments of this phenomenon have been conducted and the correlation between the sebum production and injection dosages or techniques remains unclear. OBJECTIVES: We prospectively investigated the sebum regulation and its gradient around the injection site in patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides, comparing two injection doses. METHODS: Forty-two female volunteers with rhytides on the forehead region were randomly assigned to receive 10 or 20 units of BTX-A, which was administered in five standard injection sites. The baseline and post-treatment sebum production was measured using a Sebumeter. RESULTS: Treatment with BTX-A exhibited significant sebum alteration at the injection site of both groups, with a sebum gradient surrounding the injection point. The efficacy did not improve at higher injection doses, with the four-unit regimen generally not being more potent than the two-unit regimen. The sebum production recovered to normal levels at the 16 week follow-up for both treatment groups, indicating that a higher dosage (four units) did not result in a longer duration until relapse compared with the two-unit dose. CONCLUSIONS: We determined that the sebum production has a positive correlation with the distance away from the injection point. Intramuscular injection of BTX-A significantly reduces sebum production at the injection site but increases the sebum production of the surrounding skin at a radius of 2.5 cm at the 2, 4, and 8 week follow-ups. LEVEL OF EVIDENCE: 2 Therapeutic.

Reversed Z-plasty and its variations to release wide-scar contraction.

BACKGROUND AND AIM: Z-plasty is one of the most widely used techniques in plastic and reconstructive surgery. It is useful especially to release linear-scar contractures, yet difficult to use for wide scars. The aim of this study was to report on a new technique for the effective release of contractures for wide scars using reversed Z-plasty and its variations. METHODS: This report describes a novel technique to release contractures effectively for wide scars using reversed Z-plasty and its variation. The design is a reverse style of conventional Z-plasty. In our case series, the reversed three-flap, four-flap Z-plasty or its variation was chosen depending on the width of the contracted scar. RESULTS: We performed this technique on 28 patients. All wounds healed well and the scar contracture was satisfactorily released. CONCLUSION: This procedure is useful and practical for wide-scar contractures.

Reverse bipaddle posterior interosseous artery perforator flap.

BACKGROUND: The reverse posterior interosseous artery perforator flap is useful for covering defects over the distal forearm, wrist, and hand, but some of its major limitations include short vascular pedicle, inadequate distal reach, difficult pedicle dissection, and risk of venous congestion. Some of these drawbacks have been overcome with refinements over the years, but the problems of donor-site morbidity and inability to reconstruct multiple subunits of the hand in a single stage remain. The authors developed a variant of the original distally based flap to extend its applications and minimize donor-site morbidity. METHODS: Eleven cases of reverse bipaddle posterior interosseous artery perforator flap reconstruction were reviewed. Defect locations included the first web space, proximal thumb, dorsum of the hand, palm, wrist, and the radial or ulnar half of the hand. RESULTS: Eleven patients were successfully treated with the bipaddle posterior interosseous artery perforator flap with no major complications. In seven cases, the type A chain-like variant was used to cover defects involving two different units of the hand. In four patients, the type B "kiss" pattern was required to resurface a large defect of a single unit of the hand. In all type B cases, the donor site was closed directly. All patients were satisfied with their outcomes. CONCLUSIONS: The reverse bipaddle posterior interosseous artery perforator flap is an excellent method of covering large defects of the hand involving multiple subunits. The authors confirm its vascular reliability and highlight several recommendations for skin island location, pedicle dissection, and flap raising and insetting.

Preparation of ethosomes and deformable liposomes encapsulated with 5-fluorouracil and their investigation of permeability and retention in hypertrophic scar.

With the aim of comparing scar penetration efficiency and retention between ethosomes and deformable liposomes both encapsulated with 5-fluorouracil (5-FU), the 5-FU ethosomal suspensions (5-FU ES, 81.74 +/- 9.37 nm) and the 5-FU Deformable Liposomal Suspensions (5-FU DS, 73.7 +/- 9.45 nm) were prepared respectively by Touitou method and Cevc method, their sizes were determined by Particle Sizer System (PSS), and their entrapment Efficiency (EE) was detected by ultracentrifugation and microcolumn centrifugation. Their transdermal delivery experiments were done in hypertrophic scars in vitro. The permeated amount of 5-FU and retention contents of 5-FU were both calculated by High Performance Liquid Chromatography (HPLC). Fluorescence intensities of ES and DS labeled with Rodanmin 6GO (Rho) were measured by Laser Scanning Microscopy (LSM). The control groups such as the 5-FU and empty ethosomal vesicles (5-FU + EEV), the 5-FU and empty deformable liposomal vesicles (5-FU + EDV) and 5-FU PBS Solution (5-FU Sol) were set up. Results showed that, prepared 5-FU ES was 81.74 +/- 9.37 nm in size, 5-FU DS was 73.7 +/- 9.45 nm, EE of 5-FU ES was 10.95%, EE of 5-FU DS was 15.05%. Within 24 hours, in the group of 5-FU ES, the penetration amount of 5-FU in scar was 14.12 +/- 0.1 microg/mL/cm2, the retention contents of 5-FU was 10.74 +/- 1.17 microg/cm2, and the fluorescence intensity of Rho in hypertrophic scar tissues were 182 +/- 18.3; in the group of 5-FU DS: the penetration amount of 5-FU was 12.35 +/- 1.21 microg/mLcm2; the retention contents of 5-FU was 17.48 +/- 0.82 microg/cm2, and the fluorescence intensity of Rho was 241.45 +/- 7.63; there existed statistical difference between penetration amount in the group of 5-FU ES and that in the group of 5-FU DS as well as control groups (P < 0.05, P < 0.01), the penetration amount in the group of ES is markedly higher than DS group or control groups. Conversely, the retention contents of 5-FU and the fluorescence intensity of Rho in DS group were higher than those in ES group and control groups (P < 0.05, P < 0.01). In conclusion, both ES and DS could deliver 5-FU into the hypertrophic scars effectively. ES has better permeability of 5-FU than DS, DS has higher entrapment efficiency of 5-FU, and more 5-FU deposition in hypertrophic scar than ES. We should select ES or DS encapsulated with 5-FU according to clinical demand for hypertrophic scar therapy.

Mandibular angle ostectomy for Chinese women: approaches and extent determined by cephalometric analysis.

Giving a square and muscular appearance, a prominent mandibular angle is considered to be unattractive in the Orient. Because of the different aesthetic sensitivities, the problem is reported more frequently in the Orient than that in the West. In most reports, the final choice of surgical procedure, including the approach, position of ostectomy, and volume of bone to be cut, depended subjectively on the experience of the surgeon and the desire of the patient. This article provides a study to make the surgical procedure accurately and objectively, involving 46 female patients asking for reduction of prominent mandibular angle for cosmetic reasons. Measurement and analysis of cephalometric radiographs were performed preoperatively. According to the different characteristics of the prominent mandibular angle in front and lateral views of the radiographs, the patients were classified into 4 types. In each type, ostectomy of different extent via different approaches or masseter botulinum toxin A injection only was given. Postoperative cephalometric analysis was also made to evaluate the result objectively. The results have been generally satisfactory.

Fabrication of a three-dimensional autogenous costal cartilage framework in auricular reconstruction: experience with 250 cases of Asian lobule-type microtia.

BACKGROUND: Ear reconstruction is the necessary choice for patients with congenital lobule microtia. The best results are still obtained by autogenous cartilage ear reconstruction. We developed a three-dimensional autogenous costal cartilage framework for auricular reconstruction with the purpose of achieving a new auricle of high fidelity. METHODS: The patient's sixth to eighth rib cartilages were harvested as auricular framework materials, which were divided into three laminates for carving fine anatomic structures. By connecting and fixing, a three-dimensional auricular framework with a concha, helix, antihelix, triangular fossa, and navicular fossa could be used for the auricular reconstruction. RESULTS: The results obtained were considered satisfactory with vivid individual appearances and neat stable structures. Six frameworks were exposed or modified due to hematoma, infection, or cutaneous necrosis. CONCLUSIONS: With a three-dimensional auricular framework, the minute anatomic structures cited above make the external ear silhouette more vivid.