Keloid Intralesional Excision Reduces Recurrence: A Meta-analytic Study of the Available Literature on 608 Keloids.

Background: The objective of this meta-analysis was to examine the effectiveness of keloid intralesional excision (KILE) in preventing recurrence. Treatment of keloids using surgical excision alone leads to high rates of recurrence. To date, there are no widely accepted guidelines for keloid treatment, and a multitude of adjunctive therapies are used to reduce recurrence. Despite these efforts, recurrence remains high. In this study, we conducted a meta-analysis of the existing literature on KILE to determine its role in recurrence reduction. Methods: A literature review using PubMed, Scopus, and Web of Science databases was performed. Two authors independently evaluated studies for eligibility. Incidence of keloid recurrence was recorded, and a comprehensive meta-analysis was performed to assess the pooled keloid recurrence rate, as well as the effect of additional therapies. Results: Twenty-two studies evaluating intralesional excision of 608 keloids were included in the study. Average time to follow-up was 19.2 months (range 6-35 months). A meta-analysis of proportions was conducted, demonstrating a pooled recurrence rate of 13% (95% confidence interval, 9%-16%). There was no evidence that using therapies in addition to KILE had a significant effect on the overall pooled recurrence rate. Conclusions: A meta-analysis of 608 keloids shows that KILE is an effective technique in preventing keloid recurrence, with a pooled recurrence rate of 13% compared with previously reported rates of 45%-100% after complete excision. Although there are no standard guidelines for keloid treatment, our meta-analysis shows that KILE is promising in recurrence reduction.

Thoracic Outlet Syndrome in the Pediatric and Young Adult Population.

PURPOSE: This study aimed to assess both nonsurgical and operative treatment outcomes of pediatric and young adult patients with thoracic outlet syndrome (TOS) at a tertiary care pediatric hospital. METHODS: A retrospective chart review of patients diagnosed with TOS, who were seen between January 2010 and August 2022 at a tertiary care pediatric hospital, was conducted. Collected pre- and postoperative data included symptoms, provocative testing (ie, Roo's, Wright's, and Adson's tests), participation in sports or upper-extremity activities, additional operations, and surgical complications. Assessment of operative treatment efficacy was based on pre- and post-provocative testing, pain, venogram results, alleviation of symptoms, and return to previous activity level 6 months after surgery. RESULTS: Ninety-six patients, (70 females and 26 males) with an average age at onset of 15 ± 4 (4-25) years, met the inclusion criteria for TOS. Among them, 27 had neurogenic TOS, 29 had neurogenic and vasculogenic TOS, 20 had vasculogenic TOS, 19 had Paget-Schroetter Syndrome, and one was asymptomatic. Twenty-six patients were excluded because of less than 6 months of follow-up. Of the remaining 70, 6 (8.6%) patients (4 bilateral and 2 unilateral) underwent nonoperative management with activity modification and physical therapy only, and one was fully discharged because of complete relief of symptoms. Sixty-four (90.1%) patients (45 bilateral and 19 unilateral) underwent surgery. A total of 102 operations were performed. Substantial improvements were observed in provocative maneuvers after surgery. Before surgery, 79.7% were involved in sports or playing musical instruments with repetitive overhead activity, and after surgery, 86.2% of these patients returned to their previous activity level. CONCLUSIONS: Few patients were successfully managed with nonoperative activity modification and physical therapy. In those requiring surgical intervention, first or cervical rib resection with scalenectomy using a supraclavicular approach provided resolution of symptoms with 86.2% of patients being able to return to presymptom sport or activity level. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Characterization of Auricular Growth within the Pediatric Population Using Computed Tomography Scan Measurements.

Background: In patients with microtia, auricular reconstruction is ideally performed promptly to prevent impaired socialization during formative childhood years. The earliest viable age for reconstruction is widely accepted from 7-10 years of age, as full auricular size is achieved around age 8, with some variability dependent on sex. This retrospective study aims to provide an auricular growth curve that accounts for age and sex, enhancing the individualized approach to ear reconstruction. Methods: A total of 319 images of unaffected patients who underwent computed tomography angiography of the head and neck were reviewed, with bilateral cartilage height and width measured according to a consensus-standardized image measurement protocol. Means and SDs of cartilage height and width were calculated for both sexes, and analysis of ear growth was performed through plotting the mean cartilage height, width, and width:height ratio over time. Results: Cartilage height and width differed significantly between male and female groups. Maximum cartilage height was reached at age 11 for female and at age 12 for male patients, whereas maximum cartilage width was reached at ages 10 and 8, respectively. On average, the width:height ratio for female group was 0.58. For male group, the average width:height ratio was 0.59. Conclusions: An auricular growth map was designed using computed tomography measurements demonstrating maximum auricular size at age 11 and 12 respectively for female and male patients, with both sexes having a width:height ratio maintained at approximately 0.6 throughout growth.

Acute Flaccid Myelitis: A Multidisciplinary Protocol to Optimize Diagnosis and Evaluation.

Acute flaccid myelitis is an emerging neurologic disease, first described in 2014 and predominantly affecting young children. Acute flaccid myelitis cases tend to spike every 2 years, in the late summer to fall, and the next peak is expected in 2020. The diagnosis of acute flaccid myelitis is often delayed, leading to suboptimal evaluation, including incomplete laboratory assessment. Acute and chronic morbidity are high, and a standardized, multidisciplinary approach to evaluation and treatment is essential to optimizing outcomes. In a review of acute flaccid myelitis patients treated in 2018 at our institution, we noted considerable variability in days to presentation, evaluation, and treatment. In response, the authors developed a protocol for the evaluation and management of pediatric patients suspected of having acute flaccid myelitis. The protocol was developed using local experience/case review, expert consensus, and the relevant literature. The protocol spans the spectrum of care, from initial evaluation in a primary care or emergency setting, to acute hospital management and evaluation and long-term inpatient and rehabilitation settings. The purpose of this report is both to share the findings from our 2018 case review and to disseminate our acute flaccid myelitis protocol. Our hope is that publication of our protocol will both inform the development of a standardized approach to acute flaccid myelitis and to encourage other centers to form a multidisciplinary acute flaccid myelitis team to provide expert care throughout the disease process, from presentation to recovery.

Pediatric trichodysplasia spinulosa: A report of 2 cases and review of the literature.

Trichodysplasia spinulosa is a rare disorder caused by the ubiquitous trichodysplasia spinulosa-associated polyomavirus (TSPyV) and characterized clinically by predominately centrofacial, but often generalized, folliculocentric papules with protuberant keratinaceous spines. Although seroprevalence reaches up to 70% in adult populations, TSPyV causes clinical manifestations in a small percentage of patients who are immunosuppressed. Diagnosis can be made using typical clinical and histologic features, SV40T antibody immunostaining, and PCR of various tissues including the keratinaceous spine, skin, serum, urine, and CSF. Various topical and systemic medications have demonstrated variable success. Decreasing or discontinuing immunosuppression has also been shown to improve or alleviate clinical manifestations.

Clinical course of porokeratosis ptychotropica over 7 years in an otherwise healthy child.

Porokeratosis ptychotropica is an unusual variant of porokeratosis characterized by papules and plaques located on the buttocks and gluteal cleft and showing multiple coronoid lamellae on histology. In this case report, we present the longitudinal clinical course of porokeratosis ptychotropica in a pediatric patient with individual red-brown hyperkeratotic lesions that enlarged and became confluent prior to surgical intervention. We also discuss the etiology of porokeratosis ptychotropica and review current as well as future treatment options for the disease.

Collagen VII Expression Is Required in Both Keratinocytes and Fibroblasts for Anchoring Fibril Formation in Bilayer Engineered Skin Substitutes.

The blistering disease recessive dystrophic epidermolysis bullosa (RDEB) is caused by mutations in the gene encoding collagen VII (COL7), which forms anchoring fibrils that attach the epidermis to the dermis. Cutaneous gene therapy to restore COL7 expression in RDEB patient cells has been proposed, and cultured epithelial autograft containing COL7-modified keratinocytes was previously tested in clinical trials. Because COL7 in normal skin is expressed in both fibroblasts and keratinocytes, cutaneous gene therapy using a bilayer skin substitute may enable faster restoration of anchoring fibrils. Hypothetically, COL7 expression in either dermal fibroblasts or epidermal keratinocytes might be sufficient for functional anchoring fibril formation in a bilayer skin substitute. To test this, engineered skin substitutes (ESS) were prepared using four combinations of normal + RDEB cells: (1) RDEB fibroblasts + RDEB keratinocytes; (2) RDEB fibroblasts + normal keratinocytes; (3) normal fibroblasts + RDEB keratinocytes; and (4) normal fibroblasts + normal keratinocytes. ESS were incubated in vitro for 2 weeks prior to grafting to full-thickness wounds in immunodeficient mice. Biopsies were analyzed in vitro and at 1, 2, or 3 weeks after grafting. COL7 was undetectable in ESS prepared using all RDEB cells (group 1), and macroscopic blistering was observed by 2 weeks after grafting in ESS containing RDEB cells. COL7 was expressed, in vitro and in vivo, in ESS prepared using combinations of normal + RDEB cells (groups 2 and 3) or all normal cells (group 4). However, transmission electron microscopy revealed structurally normal anchoring fibrils, in vitro and by week 2 in vivo, only in ESS prepared using all normal cells (group 4). The results suggest that although COL7 protein is produced in engineered skin when cells in only one layer express the COL7 gene, formation of structurally normal anchoring fibrils appears to require expression of COL7 in both dermal fibroblasts and epidermal keratinocytes.

Retropharyngeal Contralateral C7 Nerve Transfer to the Lower Trunk for Brachial Plexus Birth Injury: Technique and Results.

PURPOSE: Brachial plexus birth injuries with multiple nerve root avulsions present a particularly difficult reconstructive challenge because of the limited availability of donor nerves. The contralateral C7 has been described for brachial plexus reconstruction in adults but has not been well-studied in the pediatric population. We present our technique and results for retropharyngeal contralateral C7 nerve transfer to the lower trunk for brachial plexus birth injury. METHODS: We performed a retrospective review. Any child aged less than 2 years was included. Charts were analyzed for patient demographic data, operative variables, functional outcomes, complications, and length of follow-up. RESULTS: We had a total of 5 patients. Average nerve graft length was 3 cm. All patients had return of hand sensation to the ulnar nerve distribution as evidenced by a pinch test, unprompted use of the recipient limb without mirror movement, and an Active Movement Scale (AMS) of at least 2/7 for finger and thumb flexion; one patient had an AMS of 7/7 for finger and thumb flexion. Only one patient had return of ulnar intrinsic hand function with an AMS of 3/7. Two patients had temporary triceps weakness in the donor limb and one had clinically insignificant temporary phrenic nerve paresis. No complications were related to the retropharyngeal nerve dissection in any patient. Average follow-up was 3.3 years. CONCLUSIONS: The retropharyngeal contralateral C7 nerve transfer is a safe way to supply extra axons to the severely injured arm in brachial plexus birth injuries with no permanent donor limb deficits. Early functional recovery in these patients, with regard to hand function and sensation, is promising. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Effects of Autologous Fat and ASCs on Swine Hypertrophic Burn Scars: A Multimodal Quantitative Analysis.

Background: Hypertrophic scar formation is unpredictable and poorly understood, afflicting both the pediatric and adult populations. Treatment methods with conservative and invasive approaches have low rates of compliance and high rates of morbidity. The purpose of this study was to test a reproducible scar model and investigate a new technique of scar modification through the use of adipose- derived progenitor stromal cells (ASCs). Methods: Twenty thermal deep-partial thickness contact burns were created on the dorsum of three 8-week-old domestic swine and allowed to mature for 10 weeks. Scars were then injected with 2 cc saline, expanded autologous ASCs, or 2 cc fresh lipoaspirate and sampled at 2 week intervals up to 10 weeks postinjection. Volumetric analysis with a 3-D scanner, mechanical elasticity testing through negative pressure transduction, and standardized photography evaluation with Image J was performed. RNA sequencing was performed on scar tissue samples, cultured cells, and fresh lipoaspirate to determine relevant gene transcription regulation. Immunohistochemistry was used to verify expression level changes within the scars. Results: Volumetric analysis demonstrates a reduction in average scar thickness at 6 weeks when injected with ASCs (-1.6 cc3) and autologous fat (-1.95 cc3) relative to controls (-0.121 cc3; P < 0.05). A decrease in overall tissue compliance is observed with fat or ASC injection when compared with unburned skin at 8 weeks (35.99/37.94 versus 49.36 mm Hg × mm; P < 0.01). RNA sequencing demonstrates altered regulation of fibroblast gene expression and a decreased inflammatory profile when scars are injected with autologous fat/ASCs over controls. Conclusion: Early results suggest that autologous fat and/or ASCs may improve healing of hypertrophic scarring by altering the cellular and structural components during wound remodeling up to 20 weeks after injury. This may have beneficial applications in early treatment of large or cosmetically sensitive immature burn scars.

Genetic Advances in the Understanding of Microtia.

Microtia is a genetic condition affecting the external ears and presents clinically along a wide spectrum: minimally affected ears are small with minor shape abnormalities; extremely affected ears lack all identifiable structures, with the most extreme being absence of the entire external ear. Multiple genetic causes have been linked to microtia in both animal models and humans, which are improving our understanding of the condition and may lead to the identification of a unified cause for the condition. Microtia is also a prominent feature of several genetic syndromes, the study of which has provided further insight into the possible causes and genetic mechanisms of the condition. This article reviews our current understanding of microtia including epidemiological characteristics, classification systems, environmental and genetic causative factors leading to microtia. Despite our increased understanding of the genetics of microtia, we do not have a means of preventing the condition and still rely on complex staged, surgical correction.

Idiopathic Facial Aseptic Granuloma: Review of an Evolving Clinical Entity.

Idiopathic facial aseptic granuloma (IFAG), originally termed pyodermite froide du visage, describes a generally asymptomatic facial nodule presenting in childhood with clinical resemblance to pyoderma or cystic, granulomatous, or vascular lesions. Clinical understanding is constantly evolving, with recent observations indicating that IFAG may represent a subtype of childhood rosacea. We present a case of IFAG associated with eyelid chalazions in a 19-month-old boy. Although his clinical course paralleled previously reported IFAG cases, we observed a unique ultrasound variation during initial diagnostic examination. Further delineation of clinical, imaging, and histologic properties of IFAG may reveal insights into etiologic associations and ideal management.

Establishing a Reproducible Hypertrophic Scar following Thermal Injury: A Porcine Model.

BACKGROUND: Our complete understanding of hypertrophic scarring is still deficient, as portrayed by the poor clinical outcomes when treating them. To address the need for alternative treatment strategies, we assess the swine animal burn model as an initial approach for immature scar evaluation and therapeutic application. METHODS: Thermal contact burns were created on the dorsum of 3 domestic swine with the use of a branding iron at 170°F for 20 seconds. Deep partial-thickness burns were cared for with absorptive dressings over 10 weeks and wounds evaluated with laser and negative pressure transduction, histology, photographic analysis, and RNA isolation. RESULTS: Overall average stiffness (mm Hg/mm) increased and elasticity (mm) decreased in the scars from the initial burn injury to 8 weeks when compared with normal skin (P < 0.01). Scars were thicker, more erythematous, and uniform in the caudal dorsum. The percent change of erythema in wounds increased from weeks 6 to 10. Histology demonstrated loss of dermal papillae, increased myofibroblast presence, vertically oriented vessels, epidermal and dermal hypercellularity, and parallel-layered collagen deposition. Immature scars remained elevated at 10 weeks, and minimal RNA was able to be isolated from the tissue. CONCLUSIONS: Deep partial-thickness thermal injury to the back of domestic swine produces an immature hypertrophic scar by 10 weeks following burn with thickness appearing to coincide with the location along the dorsal axis. With minimal pig to pig variation, we describe our technique to provide a testable immature scar model.

Thoracic outlet syndrome in the pediatric population: case series.

We present 4 patients, 4 months to 10 years of age, with thoracic outlet syndrome. All were referred to the brachial plexus clinic. Three patients were diagnosed with vascular thoracic outlet syndrome after clinical evaluation and diagnostic imaging. Three had a cervical rib and 1 had an anomalous first rib. All patients were treated surgically through a supraclavicular approach and had resolution of the symptoms. No postoperative complications were noted.

Intralesional laser therapy treatment for hemangiomas: technical evolution.

The authors have treated over 500 consecutive pediatric patients with voluminous hemangiomas (thickness of over 10 mm), since 1996. They were all treated with intralesional laser therapy using the potassium, titanyl, phosphate (KTP) laser. Since the initiation of KTP laser therapy for deep hemangiomas in 1996, the authors have significantly modified their treatment regimen. Changes from our original treatment protocol include lower power settings, and decreased treatment intervals. Additionally, we are now simultaneously treating the deep component, using intralesional KTP laser, and the superficial component using a pulsed dye laser. Fibrosis associated with intralesional therapy has been greatly decreased by injecting small amounts of dilute steroid solution during treatment of the deep component. While maintaining the efficacy of the procedure, we have been able to greatly decrease complications associated with it. The authors detail their current techniques as well as the evolution and rationale for modifying the original treatment regimen.

Perioperative management of the post-gastric-bypass patient presenting for body contour surgery.

Bariatric surgery has evolved as an effective and relatively safe treatment for morbid obesity. With nearly every region of the body as a potential operative site and an unprecedented number of surgical procedures available, we must give attention to thoughtful perioperative management. Bariatric surgery is a life-changing event for the morbidly obese patient, and the body contouring that follows weight loss often has an equally profound effect. Plastic surgeons must strive to maintain the highest level of safety in this pursuit. The authors address issues surrounding preoperative evaluation and measures to minimize the risk of complications.

Nitric oxide and wound repair.

NO produced by both iNOS and eNOS plays many important roles in wound healing, from the inflammatory phase through to scar remodeling. NO has cytostatic, chemotactic, and vasodilatory effects during early wound repair, regulates proliferation and differentiation of several cell types, modulates collagen deposition and angiogenesis, and affects wound contraction. The data accumulated thus far indicates that the timing, level, and site of NO production are highly coordinated in normal wound repair. Defining states resulting from either inadequate substrate or depressed enzyme expression appear to contribute to impaired wound repair; however, NO represents only one factor in the complex process of wound healing. Approaches to improve NO availability may be of therapeutic value.

Autologous nitric oxide protects mouse and human keratinocytes from ultraviolet B radiation-induced apoptosis.

Nitric oxide (NO) can either prevent or promote apoptosis, depending on cell type. In the present study, we tested the hypothesis that NO suppresses ultraviolet B radiation (UVB)-induced keratinocyte apoptosis both in vitro and in vivo. Irradiation with UVB or addition of the NO synthase (NOS) inhibitor N(G)-nitro-l-arginine methyl ester (l-NAME) increased apoptosis in the human keratinocyte cell line CCD 1106 KERTr, and apoptosis was greater when the two agents were given in combination. Addition of the chemical NO donor S-nitroso-N-acetyl-penicillamine (SNAP) immediately after UVB completely abrogated the rise in apoptosis induced by l-NAME. An adenoviral vector expressing human inducible NOS (AdiNOS) also reduced keratinocyte death after UVB. Caspase-3 activity, an indicator of apoptosis, doubled in keratinocytes incubated with l-NAME compared with the inactive isomer, d-NAME, and was reduced by SNAP. Apoptosis was also increased on addition of 1,H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ), an inhibitor of soluble guanylate cyclase. Mice null for endothelial NOS (eNOS) exhibited significantly higher apoptosis than wild-type mice both in the dermis and epidermis, whereas mice null for inducible NOS (iNOS) exhibited more apoptosis than wild-type mice only in the dermis. These results demonstrate an antiapoptotic role for NO in keratinocytes, mediated by cGMP, and indicate an antiapoptotic role for both eNOS and iNOS in skin damage induced by UVB.

Maternity policy and practice during surgery residency: how we do it.

BACKGROUND: Pregnancy during general surgery residency has traditionally been discouraged. METHODS: In 2001, using an approved protocol, we anonymously surveyed 25 residents (PGY3 level or greater) concerning their experiences working with each other during episodes of resident pregnancy and maternity leave. RESULTS: From 1995 to 2001, 13 of 59 residents in general surgery were female (22%). While training, 6 of 13 residents reported 8 pregnancies with 2 miscarriages. Five residents (39%) gave birth to 6 children and adopted 1 child. Residents worked until the day of term delivery in 5 of 6 cases; 1 pregnancy was complicated by placental abruption at 33 weeks. Residents were off work postpartum for a median of 6 weeks (range 2-6). Nursing was universal for > or = 3 months but at-work problems with privacy and stress were frequent. On survey, all resident mothers believed they had been treated very fairly, and 94% of surveyed male peers stated that the coworker's status had no effect or a positive effect on their own work life. Fatherhood was reported to occur during residency by 42% of male respondents. CONCLUSIONS: Parenthood during residency is frequent. The complexities of resident maternity can be handled with mutual safety, equity, and satisfaction by the residents and faculty of a surgical training program.

Nitric oxide and wound repair: role of cytokines?

Wound healing involves platelets, inflammatory cells, fibroblasts, and epithelial cells. All of these cell types are capable of producing nitric oxide (NO), either constitutively or in response to inflammatory cytokines, through the activity of nitric oxide synthases (NOSs): eNOS (NOS3; endothelial NOS) and iNOS (NOS2; inducible NOS), respectively. Indeed, pharmacological inhibition or gene deletion of these enzymes impairs wound healing. The wound healing mechanisms that are triggered by NO appear to be diverse, involving inflammation, angiogenesis, and cell proliferation. All of these processes are controlled by defined cytokine cascades; in many cases, NO appears to modulate these cytokines. In this review, we summarize the history and present state of research on the role of NO in wound healing within the framework of modulation of cytokines.