Facial asymmetry, the right-side dominance: A retrospective analysis of 315 consecutive series of patients.

Background: Asymmetry of the face is a common finding that has been discussed in a variety of fields including art, poetry, philosophy, and medicine. In the surgical literature, facial asymmetry in general and the laterality of this observation were described mostly as a casual note, without profound discussion. In our study, we hypothesis that facial asymmetry in the normal unbiased population has a unique laterality appearance. Patients and methods: A consecutive series of 315 patients were included in the study, and all had anterior facial digital pictures taken in the same technique and loaded onto Image-J Software™. Four measurements were taken from the midline, to the right and left sides, to the Zygoma point in the middle face, and to the Gonion point in the lower face. The results given by pixels were loaded onto an excel sheet, office 2016 software™, and processed and analyzed by SPSS software™. Results: Using the paired t-test, the middle and lower thirds of the face on the right side had a significant dominance size wise with p-values of < 0.019 and < 0.039, respectively. Conclusion: Our study results support our main hypothesis and strongly demonstrate right side, size wise, and dominance in the middle and lower face.

Total lip reconstruction with tendinofasciocutaneous radial forearm flap.

INTRODUCTION: Squamous cell carcinoma is a common tumour of lower lip. Small defects created by surgical resection may be readily reconstructed by linear closure or with local flaps. However, large tumours resection often results with microstomia and oral incompetence, drooling, and speech incomprehension. The goal of this study is to describe our experience with composite free radial forearm-palmaris longus tendon flap for total or near total lower lip reconstruction. PATIENTS AND METHODS: This procedure was used in 5 patients with 80-100% lip defect resulting from Squamous cell carcinoma. Patients' age ranged from 46 to 82 years. They are three male patients and two female. In 3 cases chin skin was reconstructed as well and in one case a 5 cm segment of mandible was reconstructed using radius bone. In one case where palmaris longus was missing hemi-flexor carpi radialis tendon was used instead. All patients tolerated the procedure well. RESULTS: All flaps totally survived. No patient suffered from drooling. All patients regained normal diet and normal speech. Cosmetic result was fair to good in all patients accept one. CONCLUSION: We conclude that tendino-fasciocutaneous radial forearm flap for total lower lip reconstruction is safe. Functional and aesthetic result approaches reconstructive goals.

Acute esophageal dilation mimicking serious pulmonary complication after post-bariatric abdominoplasty.

UNLABELLED: Abdominoplasty is a frequent operative procedure among patients with massive weight loss following laparoscopic adjustable gastric banding (LAGB) surgery. After abdominoplasty, patients are carefully monitored and usually discharged from the clinic after overnight hospitalization. We report a case of acute esophageal dilation after abdominoplasty, following LAGB, mimicking a serious pulmonary complication. Three hours after a complete uneventful abdominoplasty, including reinforcement of the abdominal wall and removal of apron skin, a 39-year-old female patient developed cough and signs of respiratory distress. These symptoms were successfully treated by ventolin (salbutamol) inhalation. During the first night the patient required additional inhalation and was discharged from the hospital in good and stable condition. Three hours later she noticed respiratory distress and fever and was referred to the emergency room (ER). In the ER, a pulmonary embolism was suspected and the patient underwent CT angiography. On examination, acute severe esophageal dilation with fluid level was found. The esophageal diameter was 47 mm and the esophagus was compressing the mediastinum and trachea. The acute esophageal dilation was resolved after the gastric band was released by evacuation of saline solution from the subcutaneous port. The above-mentioned symptoms quickly disappeared during the next 2 h and the patient was discharged from the ER. We suggest complete gastric band release as a standard component of a bariatric surgery patient's preparation for abdominoplasty surgery. LEVEL OF EVIDENCE V: 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 .

Selectivity of a bromelain based enzymatic debridement agent: a porcine study.

BACKGROUND: Debridement of the burn eschar is a cornerstone of burn wound care. Rapid enzymatic debridement with a bromelain-based agent (Debriding Gel Dressing-DGD) has recently been investigated. The current study was designed to further investigate the selectivity of DGD to burned eschar in a larger number and more varied types of wounds. METHODS: A systematic animal experiment was conducted to determine the effects of DGD on normal, non-injured skin, burns, exposed dermis of donor sites, and skin punch biopsy wells. Partial thickness dermal burns and partial thickness skin graft donor sites were created on a pig and treated with a 4-h application of DGD or its control hydrating vehicle that does not have any activity except hydration. Punch biopsy samples were taken before and after treatment and microscopically assessed for evidence of tissue viability and its respective components thickness. RESULTS: Rapid dissolution of the burn eschar was noted in all DGD but not vehicle treated burns. There was no apparent damage to the underlying sub eschar dermis, donor sites, normal skin or punch biopsy wells after exposure to DGD. While the thickness of the treated tissues slightly increased due to edema, the increase in dermal thickness was similar after treatment with DGD or its vehicle. The increase in the cross section surface area of the treated punch biopsy wells was similar after treatment with DGD and its control vehicle. CONCLUSIONS: Exposure of the burn eschar to DGD results in its rapid dissolution. Exposure of normal skin or non-burned dermis to DGD has no effects demonstrating its selectivity to eschar.

Double-bladed scalpel in mohs micrographic surgery.

Mohs micrographic surgery is a tissue-sparing technique that allows for excision of cutaneous tumors under complete microscopic margins control. Mohs surgery boasts high cure rates and maximum tissue conservation. We introduce the double-blade scalpel in Mohs surgery as a timesaving and easy way to harvest tissue strips of uniform width and therefore increase the intraoperative efficiency of the procedure.

Differential optical spectropolarimetric imaging system assisted by liquid crystal devices for skin imaging.

Skin cancer diagnosis depends not only on histopathological examination but also on visual inspection before and after the excision of suspected lesion. Neoplasm is accompanied with changes in birefringence of collagen, pleomorphicity, and hyperchromatic state of epithelial nuclei. These phenomena can be measured by spectral and polarization changes of light backscattered by the examined tissue. A new differential spectropolarimetric system is proposed using liquid crystal devices, one as a tunable filter and the other as a polarization rotator, both operating at wide spectral ranges from the visible to the near-infrared. Since collagen's fibrils texture orientation depends on its location in the skin and since it is not well organized, our system scans the bipolarization states by continuously rotating the linearly polarized light incident on a skin lesion, and collecting differential contrasts between sequenced images when simultaneously averaging the statistical readout of a video camera. This noninvasive method emphasizes areas on skin where the neoplasm, or tumor, minimizes the statistical polarization change of the scattered light from the lesion. The module can be considered as an assistant tool for epiluminescence microscopy. Images of skin tumors were captured in vivo before the patients having their surgery and compared to histopathological results.

[Axillary web syndrome--a variant of Mondor's disease, following excision of an accessory breast].

Cording, an unusual form of superficial thrombophlebitis, is a variant of the disease first described by Fage in 1870 and subsequently characterized by Henry Mondor in 1939 as sclerosing thrombophlebitis of the subcutaneous veins of the anterior chest wall. Similar lesions have also been found in the penis, groin, abdomen, arm, and axilla and have been reported under a variety of names. In the axilla the condition is termed axillary web syndrome (AWS) and is seen after axillary lymph node dissection and sentinel lymph node biopsy. A recent report suggests that pathophysiology of AWS is lymphatic in origin rather than venous. We report a unique case of unilateral AWS after excision of an axillary accessory breast and discuss the pathophysiology.

[Description of differential optical spectropolarimetric imaging system (DOSI) for non-invasive detection of skin tumors].

BACKGROUND: Most physicians diagnose skin malignancy using theoretical criteria and clinical experience. Apart from dermatoscopy, noninvasive means for skin tumors' diagnosis are highly expensive and are not in daily use. We developed a simple, handy and relatively inexpensive tool for non-invasive diagnosis of skin tumors. The Differential Optical Spectropolarimetric Imaging system (DOSI) is based on collecting information from the surface and depth of skin tumors, using the advantage of liquid crystal devices (LCDs]. OBJECTIVE: DOSI feasibility study in order to diagnose skin tumors non-invasively. METHOD: Skin tumor optical data was collected in order to create image indicators for specific skin tumors. Spectral images of skin tumors are captured before the lesion that was scheduled for removal was surgically excised. Repeating features of images of each tumor type (which was histologically diagnosed) that characterize the specific tumor and show distinction from the features of other tumors are recorded. RESULTS: The feasibility of DOSI has been demonstrated for research, but it is not yet mature for clinical use. Specific images, indicating specific skin tumors could not yet be reliably concluded. One relatively obvious characteristic for malignancy seems to be crescent-like and finger-like growth patterns. In the non-malignant lesions: crescent and finger-like structures are of less pronounced orders of magnitude. Crescents are more open and radius of curvature are of larger orders of magnitude than in malignant specimen. DISCUSSION: The advantage of using LCD is the ability to manipulate light electronically, without any movable components. LCDs are the building blocks of optical filters and polarization controllers. Using optical filters and polarization controllers, we are able to electronically manipulate the polarization and wavelength of our light source without any movable components. The light source emits different wavelengths (colors) that penetrate the tissue at different depths. The camera (CCD) captures the diffused reflected light from a skin lesion as a sequence of images for each polarization stage. By applying our novel method for each polarization stage we are able to overcome the noise of the diffused reflection and emphasize the scattering areas. Emphasizing the scattering areas provided images that may indicate malignancy. CONCLUSIONS: The feasibility of DOSI has been demonstrated. In order to obtain reliable diagnostic image indicators for specific skin tumors, more clinical tests are necessary.

An analysis of pain and analgesia after Mohs micrographic surgery.

BACKGROUND: Pain characteristics and analgesia in patients undergoing Mohs micrographic surgery have not been systematically studied. It is important to know about pain after Mohs micrographic surgery to better serve patient needs. OBJECTIVE: We sought to measure pain in patients after Mohs micrographic surgery, and to investigate the relationship among postoperative pain, surgical characteristics, patient characteristics, and analgesics used. METHODS: The Wong-Baker 0-to-10 pain scale was prospectively administered postoperatively to all patients presenting for Mohs micrographic surgery in a private practice setting between October 1, 2007, and December 31, 2008. Patients recorded their pain level from the day of surgery through postoperative day 4. The age, sex, location of surgery, number of lesions operated on, postoperative size, type of repair, severity of pain, and oral analgesics consumed and dosages used were recorded. RESULTS: A total of 433 patients were included in the final analysis. The highest pain scores were found on the day of surgery and steadily declined until postoperative day 4 (P < .000). In all, 52% of patients took pain medication on the day of surgery, which declined successively with each postoperative day. The highest mean pain scores were statistically significantly associated with repair type (flaps), age (<66 years), number of lesions, and consumption of narcotics for pain relief. No statistically significant differences existed for sex or postoperative defect size. LIMITATIONS: The instrument used to measure pain relied on patient self-report in a private practice surgery center. Only the validated Wong-Baker pain scale was used to assess pain in this study. CONCLUSION: Approximately half of the patients after Mohs micrographic surgery take medication for pain control. Type of closure, location of surgery, age, and type of pain medication taken were significantly associated with postoperative pain.

Skin biomedical optical imaging system using dual-wavelength polarimetric control with liquid crystals.

Spectropolarimetric skin imaging is becoming an attractive technique for early detection of skin cancer. Using two liquid crystal retarders in combination with a dual-band passive spectral filter and two linear polarizers, we demonstrate the spectral and polarimetric imaging of skin tissue in the near infrared. Based on this concept, a compact prototype module has been built and is being used for clinical evaluation.

Leech therapy in cutaneous surgery and disease.

BACKGROUND: Over the ages, the use of leeches in medicine has evolved from haphazard bloodletting to a well-understood physiologic process with defined, rational applications. OBJECTIVE: The authors describe the current role of leech therapy in cutaneous surgery and medicine. METHODS: Case series and review of the literature. RESULTS: Leech saliva contains anticoagulative, anti-aggregative and vasodilatory components. Combined with the annelid's mechanical ability to extract blood, leeches can contribute to patients' health with minimal risks. CONCLUSION: Leeches should be considered as novel therapies for disorders of coagulation and venous congestion. Implementation of leech treatment should be tempered with the potential adverse effects, including Aeromonas infection and a drop in hematocrit that might require a blood transfusion.

Desmoplastic trichoepithelioma.

BACKGROUND: Desmoplastic trichoepithelioma (DTE) is an uncommon adnexal tumor usually found on the face of young women. OBJECTIVE: We sought to describe the clinical and histologic characteristics of DTE and discuss management strategies for these tumors. METHODS: We conducted a retrospective case series and review of the literature. RESULTS: A series of 17 cases of DTE is reported. Of our patients, 82% were female and half of all these cases occurred on the cheek. Unlike previous reports, the patients in our study were slightly older, with 53% older than 51 years and 71% between the ages of 31 and 60 years at the time of surgery (mean age 49 years, median age 52 years, range 14-81 years). Approximately 38% of the tumors had been present for 1 to 2 years before presentation. The average size of the tumors at the time of surgery was 0.8 x 0.6 cm. All cases were treated with Mohs micrographic surgery. To date, none of the tumors have recurred. LIMITATIONS: This is a small case series. The referral patterns of our predominantly Mohs micrographic surgery clinic might further bias this study. CONCLUSION: DTE is a benign tumor that has a predilection for the face. With its rapid growth, aggressive histologic features that may be confused with basal cell carcinoma, and tendency to arise in cosmetically and functionally sensitive areas, these tumors should be removed in a manner that assures clear surgical margins, such as Mohs micrographic surgery.

Basal cell carcinoma arising in a patient with vitiligo.

Patients with vitiligo are predisposed to solar damage, often suffering from actinic keratoses (AK) and squamous cell carcinoma (SCC). However, never have these patients been noted to have an increased risk for basal cell carcinoma (BCC). In fact, no case reports of these 2 diseases occurring together exist in the literature. Here, the authors report a case of basal cell carcinoma arising in a patient with vitiligo. This rare occurrence gives question to the nature of these tumors and their pathogenesis.

Lower extremity positioning to relieve tension during surgical reconstruction.

Surgical wounds on the lower extremity often suffer from prolonged and poor healing secondary to decreased blood flow, the effects of gravity, and excessive tension placed on the wound. Ensuring perfect apposition of wound edges free of tension during the surgical repair can augment this healing process. The authors detail a simple and effective technique for improving repairs and outcomes when operating on the lower limb by relieving tension on the wound through leg positioning.

Galactorrhea complicating wound healing following reduction mammaplasty.

Galactorrhea complicating wound healing following reduction mammaplasty occurs rarely; only isolated cases have been reported in recent years. We report the case of a 25-year-old woman who presented with delayed healing and dehiscence of surgical wounds 3 weeks following vertical scar reduction mammaplasty. During surgical debridement, spontaneous discharge of milk in the wound was noted. Serum prolactin levels were high, and she was treated with carbegoline, a dopamine agonist, which suppressed the prolactin secretion and led to rapid cessation of lactation. A second debridement and delayed primary closure were performed to achieve a satisfactory postoperative result.