A comparison of scar revision with the free electron and carbon dioxide resurfacing lasers.

Laser scar revision was studied to measure the effects of targeting extracellular matrix protein versus tissue water on scar revision. We compared the free electron laser used at 7.7 microm (the amide III protein absorption band) to the carbon dioxide (CO2) laser and dermabrasion.Nude mice (n = 40) that had rejected skin grafts on their dorsal surface and developed mature scars were used as a model for scar revision. One-half of each scar was revised with either the free electron laser at 7.7 microm (32 to 38 mJ, nonoverlapping pulses delivered with a computerized adjustable pattern generator at 30 Hz, and two to three passes), a 100-microsec CO2 resurfacing laser (500 mJ, 5.0 Hz, and two to five passes), or dermabrasion. The untreated portion of each scar served as an internal control. Evaluation was by measurement of the clinical size of the scar using photography with quantitative computer image analysis to compare the data and histology to evaluate the quality and depth of the scars. The free electron laser at 7.7 microm was significantly better than the CO2 laser and dermabrasion for scar size reduction (p < 0.046 and p < 0.018). The CO2 laser and a highly skilled dermabrader were not statistically significantly different (p < 0.44). The result seen with less skilled dermabraders was significantly worse than all other methods (p < 0.009). The free electron laser at 7.7 microm, which is preferentially absorbed by the proteins of the extracellular matrix, provided better scar reduction than the CO2 resurfacing laser and dermabrasion. Dermabrasion by a skilled operator resulted in improvement similar to the results obtained with the CO2 resurfacing laser, but less skilled operators had significantly poorer results.

Analysis of the effects of deep mechanical massage in the porcine model.

Deep mechanical massage has been advocated as an alternative or adjunctive therapy for the contouring of subcutaneous fat and as a treatment for cellulite. We evaluated the effects of deep mechanical massage using two pig models. Yucatan pigs were divided into three groups (n = 4). One side of each body received 4, 10, or 20 treatments and the other side served as a control. Full-thickness tissue sections, including the underlying muscle, were harvested from identical treated and untreated regions. Examination of these regionally matched samples revealed an accumulation of dense, longitudinal collagen bands in the middle dermal and deep subdermal regions, which progressively increased with the number of treatments. Distortion and disruption of adipocytes was noted. In Yorkshire pigs, force-transducing balloon catheters were surgically placed between the deep subcutaneous tissue and muscle fascia. Catheters were inserted into two regions with different skin and subcutaneous tissue characteristics, the midflank and the hip. Standardized maneuvers were performed at suction settings 3, 5, 7, and 9 to record baseline tissue forces. Each maneuver carried a unique force signature. The measurement of tissue forces was repeated on the opposite side after 10 standardized treatment sessions. Analysis showed a significant reduction of measured forces at the midflank after the treatments. The actual force measured with each particular maneuver varied between different operators but not with different suction settings, suggesting that the technique of administering the treatments is the primary factor in creating the force within the tissue. This leads to the conclusion that deep mechanical massage is highly dependent on the individual operator of the device.

Endermologie: taking a closer look.

Recent laboratory investigations have shown that various maneuvers in Endermologie treatment, such as smoothing, kneading, and bouncing, create unique waveforms. Furthermore, the amount of pressure generated with each maneuver depends more on the operator's technique than on the suction setting or the force of the spring-loaded rollers. This might explain the variable clinical results for Endermologie that have been reported. (Aesthetic Surg J 2001;21:259-260.).

Analysis of the cutaneous and systemic effects of Endermologie in the porcine model.

LEARNING OBJECTIVES: The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying the article, the participant should be able to: Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 421. Endermologie has been touted as an alternative to or adjunctive therapy with liposuction for the removal of subcutaneous fat, body contouring, and tissue toning. In this study we examined the effects of Endermologie treatment with the Yucatan mini-pig model. Pigs were divided into three treatment groups (n = 4) and underwent 4, 10, or 20 treatment sessions, respectively. Blood and urine analysis was conducted during the study to obtain evidence of tissue trauma or breakdown and excretion of subcutaneous fatty tissue. Matched en bloc tissue sections from treated and untreated areas were examined for possible wound healing, inflammatory response, and tissue architecture changes. Examination of tissues revealed changes of architecture with accumulation of dense, longitudinal collagen bands in the mid and deep subdermal tissue layer; some distortion and disruption of adipocyte cell membranes were also observed. The degree of tissue change found was dependent on the number of treatment sessions performed. Endermologie treatments did not elicit a classical wound healing or inflammatory response, with no evidence of either increased tissue vascularity or cell division. No evidence of mobilization of fatty tissue was found, and no fat breakdown products or metabolites were detectable in blood or urine. Treatments did not cause a decrease in subcutaneous tissue thickness. No evidence of skin or muscle injury was noted. Further studies are warranted to determine whether the changes noted are short term or permanent.

Free temporoparietal fascia flap in reconstruction of the lower extremity.

Twenty-one patients with open wounds of the non-weight-bearing foot or the ankle underwent coverage with a free temporoparietal fascia flap and split-thickness skin graft. Our indications for this thin, well-vascularized flap included osteomyelitis and exposed tendon, bone, or fixation hardware. The pliability of the flap allowed superior restoration of natural anatomical contours. Only one flap was completely lost (95.2% overall success). There were four cases (20%) of partial flap loss, none of which required flap revision or a new flap. Four patients (19%) experienced transient donor-site alopecia, and one patient suffered transient palsy of the temporal branch of the facial nerve. One patient (4.7%) had an area of persistent scar alopecia in the temporal scalp after a donor-site hematoma that required revision under local anesthesia. Follow-up was available on 95% of the patients and averaged 20 months (range, 1-54 months). All patients resumed weight-bearing ambulation within 1 month from operation using unmodified footwear. The free TPF flap is a reliable coverage option, with long-term durability and minimal donor-site morbidity, for relatively superficial wounds of the distal lower extremity.

Is aggressive surgical management justified in the treatment of Merkel cell carcinoma?

Since its original description in 1972, we have seen and personally treated a group of 15 patients with Merkel cell carcinoma at the Vanderbilt Medical Center and the Nashville VA Hospital. We will review the demographics, management, and clinical course of this extremely lethal but initially benign appearing cutaneous malignancy. The majority of lesions occur on the head and neck, followed by the extremities and trunk. Location of the primary tumor has no effect on outcome. Despite a high mortality in our series (10 of 15), early recognition and aggressive surgical therapy may be the only way to prolong survival. No other adjuvant therapy has proved effective.

Adjunctive use of laser Doppler flowmetry for debridement of osteomyelitis.

Laser Doppler flowmetry was used intraoperatively to differentiate viable from nonviable bone during the debridement of 12 cases of chronic osteomyelitis and three cases of acute bone infection following trauma. Six weeks of i.v. antibiotic therapy were directed against two cases of gram-positive and 13 cases of gram-negative bone infection. In cases of chronic infection, free muscle flaps were added for soft tissue coverage in five cases and rotational muscle flaps in four cases. At follow-up observation, of 1 to 3 years, no recurrences were seen. Laser Doppler flowmetry is an easy-to-use adjunct to the surgical debridement of bone infection.

Pharyngocutaneous fistulas in advanced cancer: closure with musculocutaneous or muscle flaps.

Two hundred cases of head and neck cancer were reviewed and 16 pharyngocutaneous fistulas identified, for an incidence of 6 percent. The fistulas were closed with pectoralis major muscle flaps in four patients, pectoralis musculocutaneous flaps in seven patients, sternocleidomastoid muscle flaps in four patients, and latissimus dorsi flaps in two patients. Four types of fistulas were identified, and flap selection was determined by fistula location. Successful closure was obtained in 15 patients (88 percent), although one patient died from recurrence with a persistent fistula.

Radiation dermatitis.

Even in this era of modern radiotherapy, injuries associated with the medical and industrial use of radiation devices will continue to pose a difficult problem for the reconstructive surgeon. It must be borne in mind that the single most serious hazard to surgery in irradiated tissue is the lodgement of bacteria in tissue rendered avascular by the radiation and the secondary necrosis from the infection itself. The basic principles of wound management must be augmented by thorough knowledge of the use of well-vascularized muscle and musculocutaneous flap to provide adequate, blood-rich, soft-tissue coverage.

Pectoralis major musculocutaneous flaps: long-term follow-up of hypopharyngeal reconstruction.

We have reviewed our experience with 25 patients who have undergone major head and neck resections and required hypopharyngeal pectoralis major flap reconstruction. Six patients were alive 1 year following reconstruction and five patients consented to evaluation of flap function with endoscopy, with biopsy, barium swallow, and esophageal manometrics. The patients were older (61 +/- 6 years) and the flaps were large (42 +/- 9 cm2). Barium studies were the most useful method of evaluating these patients. Postoperative stricture and laryngeal aspiration were found in two patients. Biopsy of the flap demonstrated loss of keratin in the overlying epidermis, while the gross appearance was more like the surrounding mucosa. A review of dietary intake in these cases revealed that two patients weighed less than their preoperative weights, while another refused oral feedings despite a good functional result. Three of five patients preferred gastrostomy feedings to oral alimentation.

Carcinoma of the tongue and tonsil (oropharynx).

In this article, the multidisciplinary approach to the management of carcinomas of the tongue and oropharynx has been emphasized. The decision for the primary mode of therapy will depend on the multiple factors discussed herein. However, a surgeon skilled in the management of head and neck tumors, including major reconstructive techniques, should lead the team. Most patients with head and neck carcinoma present with lesions that are relatively far advanced, and the combination of surgical excision and radiation therapy has proved to be the best method of controlling this disease. Even when cure is unlikely, the palliation of the patient by proper resection and immediate reconstruction, followed by adequate radiation therapy, can provide significant palliation and, it is hoped, avoid the horribly painful and agonizing death that ensues from massive local recurrence in the head and neck. Modern reconstructive techniques allow for reasonable aesthetic and functional restoration, which can be performed in a single stage at the time of the ablation of the tumor. Healing with these well-vascularized flaps is predictable and allows the patient to get to the radiation therapist within the early postoperative period. A full tumoricidal dose of radiation therapy can then be instituted with the expectation that the reconstruction with the vascularized tissue will withstand the irradiation well. This avoids the increased complication rates associated with operating in irradiated fields and gives the radiation therapist a better chance for effective therapy with a markedly reduced tumor load. These tumors remain one of the most obstinate problems that surgeons face today. However, an aggressive approach to control local disease remains the best therapy and offers the patient the only chance for cure. These are difficult patients to manage from many aspects. I believe that the statement made by Dr. Charles Mayo in 1905 remains timely: "A large part of abdominal work is recreational as compared with the work of what might be called the heavy surgery of the neck."

Neurofibromas of the head and neck.

Ten patients ranging in age from 7 to 47 years have been treated for neurofibromas of the head and neck at Vanderbilt University Hospital during the last 14 years. Three of them had a positive family history of von Recklinghausen's disease; none has developed malignant degeneration. Serial subtotal excisions of the lesions was the primary treatment.

Epithelioid sarcoma of the upper extremity.

Three cases of epithelioid sarcoma of the upper extremity are presented. Information regarding 112 previously published cases is reviewed. It is concluded that epithelioid sarcoma must be included in the differential diagnosis of soft-tissue tumors of the extremities. Moreover, the diagnosis of epithelioid sarcoma demands prompt and aggressive surgical intervention. Irradiation therapy and chemotherapy have not been proven to be of value in the management of epithelioid sarcoma.

Sagittal fractures of the maxilla and palate.

Sagittal fractures of the maxilla and palate are infrequent and can demonstrate significant instability with conventional methods of treatment. They require that rigid, horizontal stability of the dentition be obtained, as well as restoration of midface projection and height. The most effective and precise management has utilized a combination of open reduction and internal fixation at the piriform aperture and zygomatic buttress and posterior palate, use of a maxillary arch bar as a tension band, and utilization of a palatal splint.

Management of radiation ulcers.

Despite more efficient and safer technics of radiation therapy, the problem of radiation-induced injury to the skin and soft tissue persists. The problem of adequate coverage of these painful, ischemic, and fibrotic ulcers remains challenging. Split-thickness skin grafts are seldom sufficient coverage, as the graft almost always has areas that do not take. Although these areas may eventually heal by epithelialization, the result is never ideal. Most often flap coverage is required, but elevation of local flaps is jeopardized because the tissue surrounding the ulcer crater frequently has been sufficiently compromised to cause loss of at least part of the flap. In the past, this necessitated use of pedicled flaps, tubed and transposed from a distance. With the development of axial-pattern musculocutaneous and muscle flaps, as well as microvascular free flaps, the difficulty in dealing with these ulcers has been decreased. Surgeons can now recommend earlier use of adequate debridement, many times of the entire irradiated area, and immediate coverage with a well vascularized axial-pattern musculocutaneous flap or revascularized free flap.

Management of the brown recluse spider bite.

A model to study the dermonecrotic effects of a crude fraction of venom from the brown recluse spider (Loxosceles reclusa) was developed using female New Zealand white rabbits. In the rabbit model, surgical excision of the sites of intradermally injected crude venom did not always prevent subsequent necrosis or wound dehiscence despite the use of fluorescein to determine the surgical margin. Heparin and steroids did not prevent the venom-induced necrosis and were much less effective than surgical excision or injecting a specific antivenom. When given within 24 hours, the specific antivenom raised against the brown recluse spider venom blocked or markedly attenuated the toxic effects of the venom in the rabbit model system.

Single-stage reconstruction of mandibular and soft tissue defects using a free osteocutaneous groin flap.

Microvascular reconstruction of the mandible and soft tissues using the composite groin flap is ideal in selected patients. No other available bone so closely approximates the mandible in both thickness and curvature as does the iliac crest. The soft tissues are available for reconstruction and may allow the surgeon to avoid a second flap, except in cases where both lining and cover are needed. The deep circumflex artery is of generous size, usually 2 to 2.5 mm in diameter, allowing greater reliability in the microvascular anastomoses. The flap has a fairly long vascular predicle, 6 to 8 cm. The ability of this flap to withstand irradiation and infection because of its blood supply permits early institution of postoperative radiotherapy and prevents bone loss due to small intraoral wound dehisicence or total flap loss. Although the donor site requires extensive dissection, it can be closed primarily, eliminating the need for skin grafts or other flaps. As further experience is gained with this flap, both the functional and cosmetic results should be improved. In patients undergoing resection of the remaining portion of the mandible, the symphysis or the anterior portion of the mandible, a procedure of this type should be done primarily to prevent deformity and to minimize disability for the patient.