Postoperative Scar Management Protocol for Asian Patients.

BACKGROUND: Postoperative scar formation remains a morbidity for patients even with the advent of minimally invasive techniques. Furthermore, the significant difference between the Asian and Caucasian skin results in poorer postoperative scar outcomes in Asians, supporting the need for an evidence-based scar management protocol. METHODS: Following a literature review of the PubMed and the Cochrane databases over the past 10 years, we constructed a novel postoperative scar management protocol for the Asian skin, utilized in a Singaporean tertiary healthcare institution. RESULTS: We describe a timeline-based scar protocol from the point of skin closure to a minimum of 1 year of follow-up. We support the use of intraoperative botulinum toxin for selected high-risk individuals upon skin closure with a follow-up regimen in the postoperative setting. For recalcitrant keloids, we have described a multimodal therapy comprising elements of intralesional steroids, botulinum toxin, lasers, surgery, and radiotherapy. CONCLUSIONS: A consolidated postoperative scar management protocol provides the necessary guidance for improved scar outcomes in the Asian skin. There is inherent potential in expanding the protocol to include post-traumatic and burn wounds or support other skin types including the Caucasian skin. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Mapping the Posterior Ledge and Optic Foramen in Orbital Floor Blowout Fractures.

Background The posterior ledge (PL) is a vital structure that supports the implant posteriorly during orbital floor reconstruction. This study describes a technique for mapping the PL in relation to the infraorbital margin (IM) in patients with orbital floor blowout fractures. This study establishes the location of the optic foramen in relation to the PL. Methods Facial computed tomography (FCT) scans of 67 consecutive patients with isolated orbital floor blowout fractures were analyzed using Osirix. Planes of reference for orbital fractures, a standardized technique for performing measurements on FCT, was used. Viewed coronally, the orbit was divided into seven equal sagittal slices (L1 laterally to L7 medially) with reference to the midorbital plane. The distances of PL from IM and location of optic foramen were determined. Results The greatest distance to PL is found at L5 (median: 30.1 mm, range: 13.5-37.1 mm). The median and ranges for each slice are as follows: L1 (median: 0.0 mm, range: 0.0-19.9 mm), L2 (median: 0.0 mm, range: 0.0-21.5 mm), L3 (median: 15.8 mm, range: 0.0-31.7 mm), L4 (median: 26.1 mm, range: 0.0-34.0 mm), L5 (median: 30.1 mm, range: 13.5-37.1 mm), L6 (median: 29.0 mm, range: 0.0-36.3 mm), L7 (median: 20.8 mm, range: 0.0-39.2 mm). The median distance of the optic foramen from IM is 43.7 mm (range: 37.0- 49.1) at L7. Conclusion Distance to PL from IM increases medially until the L5 before decreasing. A reference map of the PL in relation to the IM and optic foramen is generated. The optic foramen is located in close proximity to the PL at the medial orbital floor. This aids in preoperative planning and intraoperative dissection.

Prophylactic Intraoperative Nasolacrimal Duct Intubation in Surgical Treatment of Facial Fractures-Is There a Role?

Nasolacrimal duct (NLD) damage is associated in the majority of type II and III naso-orbito-ethmoid (NOE) fractures. 1 Our study aims to investigate the efficacy and safety of prophylactic NLD intubation in the setting of facial fractures, by comparing incidence of postoperative epiphora and wound infection. A retrospective matched control study was conducted on all patients with surgically treated facial fractures from 2008 to 2013 ( n = 280) (IRB ref number: DSRB 2013/01198). Patients with the following fracture types were included: NOE ( n = 16), frontal sinus ( n = 2), Le Fort II/III ( n = 8), and > 1 type ( n = 48). All patients in this study were included with the intention to treat. The study group comprised patients who were intubated, while the control group patients were not intubated. Each group had 37 patients matched for age, gender, fracture type, and injury type. A single oculoplastic surgeon skilled in lacrimal surgery performed the procedure for all intubated patients. Patients with more severe and complex facial fractures were intubated with bicanalicular Crawford stents. Postoperative epiphora and infective complications (both facial wound and dacryocystitis) were assessed at 1, 3, 6, and 12 months. There was no significant difference in incidence of either postoperative epiphora ( p = 0.152) or wound infection ( p = 0.556) comparing both groups. Reduced incidence of postoperative epiphora in the study group is statistically not significant and does not support the need for prophylactic intubation. If radiographic evidence of NLD disruption or regurgitation seen on syringing on the NLD intraoperatively is present, intubation is safe and efficacious only if performed by an expert.

The superior lateral genicular artery flap for reconstruction of knee and proximal leg defects.

Reconstruction of defects around the knee region requires thin and pliable skin. The superior lateral genicular artery (SLGA) flap provides an excellent alternative to muscle-based flaps. The anatomy and the surgical techniques of the SLGA flap were reviewed and the results of cases using the SLGA flap for coverage of knee and proximal leg defects were analyzed. SLGA flaps were performed in two cases and followed up for at least 6 months. Twelve articles on the use of the SLGA flap were also identified. A review of 39 cases showed that the mean diameter of the perforator supplying the skin of the flap was 1.04 mm, while the mean diameter of the SLGA at its origin was 1.78 mm. The mean length of the pedicle measured from the origin of the popliteal artery was 7.44 cm. The average dimensions of the flap were 14.8×6.6 cm with primary closure of the donor site in 61.5% of cases. Of these cases, 38.5% were due to trauma, 23.1% were post-burn complications, 12.8% were defects after resection of tumors, and 10.3% were for ulcers post-bursectomy. The most common complication was flap tip necrosis. All studies reported favorable outcomes with complete wound healing.

Submammary placement of implantable cardioverter defibrillators: a Singapore plastic surgeon experience

The use of implantable cardioverter defibrillators (ICDs) in young women has been increasing in recent years owing to greater awareness about inherited cardiac conditions that increase the risk of sudden death. Traditional placement of ICDs in the infraclavicular region among young women often leads to visible scars, a constant prominence that causes irritation from purse or bra straps and can result in body image concerns and device-related emotional distress. In this case series, two women with long QT syndrome required placement of ICDs for prevention of sudden cardiac death. Submammary placement of ICDs was performed in collaboration with electrophysiologists. We describe our local experience and technique in submammary placement of ICDs as well as the challenges faced.

Use of Intraoperative Frozen Section in the Surgical Management of Patients with Nonmelanoma Skin Cancer.

BACKGROUND: Intraoperative frozen section (IFS) is often utilised in the surgical treatment of nonmelanocytic skin cancer (NMSC) in sensitive facial regions when Mohs micrographic surgery (MMS) is not available. OBJECTIVE: To compare the outcome of NMSC patients with excision performed with and without IFS. MATERIALS AND METHODS: A retrospective, single-centre study was performed on all patients who had undergone resection of NMSC with and without IFS control at the National University Hospital (NUH) from 2010 to 2015. RESULTS: 116 patients were recruited, of which 86 had IFS and 30 did not. The complete excision rate of patients with IFS was higher at 87.2% (p=0.0194), need for secondary operation was lower at 1.2% (p=0.005), and need for postsurgery radiotherapy or chemotherapy was lower at 1.2% (p=0.001). The average duration of surgery in patients who underwent IFS was 95.4 minutes compared to 70.1 minutes in cases which did not undergo IFS. CONCLUSION: Our study showed an increased complete excision rate and reduced need for secondary surgeries and adjuvant therapy in patients with IFS. However, a longer operative duration was required. Use of IFS may be useful in patients with NMSC lesions in sensitive regions requiring complex reconstruction after tumour excision.

Breast reconstruction rate and profile in a Singapore patient population: a National University Hospital experience.

INTRODUCTION: Breast reconstruction is an integral part of breast cancer management with the aim of restoring a breast to its natural form. There is increasing awareness among women that it is a safe procedure and its benefits extend beyond aesthetics. Our aim was to establish the rate of breast reconstruction and provide an overview of the patients who underwent breast reconstruction at National University Hospital (NUH), Singapore. METHODS: We evaluated factors that impact a patient's decision to proceed with breast reconstruction, such as ethnicity, age, time and type of implant. We retrospectively reviewed the medical records of women who had breast cancer and underwent breast surgery at NUH between 2001 and 2010. RESULTS: The breast reconstruction rate in this study was 24.3%. There were 241 patients who underwent breast reconstruction surgeries (including delayed and immediate procedures) among 993 patients for whom mastectomies were done for breast cancer. Chinese patients were the largest ethnic group who underwent breast reconstruction after mastectomy (74.3%). Within a single ethnic patient group, Malay women had the largest proportion of women undergoing breast reconstruction (60.0%). The youngest woman in whom cancer was detected in our study was aged 20 years. Malay women showed the greatest preference for autologous tissue breast reconstruction (92.3%). The median age at cancer diagnosis of our cohort was 46 years. CONCLUSION: We noted increases in the age of patients undergoing breast reconstruction and the proportion of breast reconstruction cases over the ten-year study period.

An Algorithm for the Management of Concomitant Maxillofacial, Laryngeal, and Cervical Spine Trauma.

Concomitant maxillofacial, laryngeal and cervical spine injuries may occur after high-energy accidents. Although this presentation is uncommon, the multiple injuries may compromise airway, breathing, circulation, and neurologic function. We identified 8 adult trauma patients admitted to the National University Hospital with the concomitant injuries. We reviewed the patient data and existing literature to identify the important factors that must be considered for management. Seven resulted from high velocity accidents, whereas 1 was assaulted. An algorithm that prioritizes in-tandem diagnosis and acute management of the adult trauma patient with maxillofacial, laryngeal, and cervical spine trauma was developed. The first priority is to assess airway, breathing, and circulation with cervical spine immobilization. Early diagnosis of patients with severe laryngeal injury, confirmation by video endoscopy, and establishing a surgical airway prevents airway obstruction or even a laryngotracheal dissociation. Urgent computed tomography scans of the head and neck are essential for definitive diagnosis and surgical planning for the 3 injuries. Prudent sequencing of surgery is important to avoid complications and to achieve better functional outcomes.

Retained broken implants in the craniomaxillofacial skeleton.

Facial fracture patients are seen in a Level 1 trauma hospital. In our institution, we manage many patients with facial fractures and carry out more than 150 surgical procedures every year. Open reduction and internal fixation is our management of choice. All surgical procedures involve drilling of bone and implant insertion to keep the fractured bones in an anatomically reduced position to aid healing. Occasionally, drill bits used to create the pilot hole break and are embedded in the bone. We present a situation in which such an incident occurred and review the literature on retained broken implants and devices.

Infraorbital nerve schwannoma presenting as an upper lip mass in an adolescent boy.

BACKGROUND: Schwannomas of the head and neck are uncommon tumors that arise from the nerve sheath and may afflict peripheral, autonomic, or cranial nerves. It is important to consider the possible differential diagnoses of a nasolabial lump in a child because its appropriate treatment varies widely. METHODS: The authors describe a case of a 12-year-old boy who presented with a 2.5-cm right nasolabial subcutaneous lump of 3 months in duration. Computed tomographic scan showed a homogeneously attenuated lesion. RESULTS: An intraoral incision was used for complete extirpation of this tumor while preserving the infraorbital nerve and facial aesthetics in this adolescent boy. Histopathologic examination showed palisades of spindle cells and Verocay bodies characteristic of schwannomas. The patient has been followed up for 2 years with no clinical evidence of recurrence. CONCLUSIONS: Only 9 cases of infraorbital nerve schwannoma have been described in literature, and the sublabial intraoral incision was attempted in only 1 case. The authors describe a rare case of an extraosseous schwannoma arising from the infraorbital nerve that presented as a cheek lump, its workup, its differentials, its treatment, and a review of literature. The use of a preoperative computed tomographic scan permitted the use of a sublabial intraoral incision with good visual access to the lesion and facilitated its complete extirpation without incurring external scars.

Innovative intraoperative titanium mesh preparation for safer implantation.

Titanium meshes have been extensively used in craniomaxillofacial surgery. The benefits of these titanium implants include being inert, stable, and radiopaque and having good drainage properties. The titanium mesh is cut to shape and bent before implantation, which may give rise to the cut edges being jagged and sharp. This can lead to soft tissue being caught or lacerated by these sharp ends. A change in technique to cut and shape the implant may reduce this problem. The implant should be cut right at the end of the bars flush with the remaining parts of the implant. We present a new and simple method for smoothing these troublesome edges. We use the diathermy scratch pad or tip cleaner, a tool used frequently in every major surgery. This scratch pad can be used as a rasp to smoothen the edges of the titanium mesh once it is cut into shape.

Maxillary artery injury associated with subcondylar mandible fractures: a novel treatment algorithm.

Mandible fractures commonly occur in patients who have sustained blunt facial trauma, and the subcondylar region is the most frequently fractured due to its intrinsic biomechanical weakness. The maxillary artery lies in close relation to the medial cortex of the subcondyle and is vulnerable to injury by the sharp edges of the fracture fragments during the initial trauma or during operative fracture reduction. Maxillary artery injuries and subcondylar fractures may be an underdiagnosed phenomenon. Yet, this is of clinical significance as the maxillary artery caliber is usually of significant caliber and may lead to substantial hemorrhage. Surgical access to the artery for hemostasis is challenging and is further compounded by small surgical incisions usually undertaken for fracture fixation, obscuring of the artery by the overlying fracture fragments, and vessel retraction following its transection. In cases where maxillary artery injury is suspected, an open surgical approach may be favored over an endoscopic one. The authors illustrate a case in which brisk hemorrhage from the maxillary artery encountered during a preauricular approach to fixation of the mandible subcondyle was successfully controlled with temporary pressure on the external carotid artery through a neck incision and direct ligation of the lacerated maxillary artery. The authors then discuss diagnosis and treatment of such maxillary artery injuries and propose a novel diagnostic and treatment algorithm.

A novel application of calcium phosphate-based bone cement as an adjunct procedure in adult craniofacial reconstruction.

Secondary corrective osteotomy of malunited craniofacial fractures can be a challenging proposition. The exposure, extrusion, and palpability of the titanium implants used become a genuine concern especially in areas of relatively thin skin, such as the periorbital region. Restoring a satisfactory contour to the midface is another major task for the plastic surgeon. Bone cement used to reconstruct craniofacial defects has existed for many years. However, most applications have been as a substitute for autogenous bone grafts for defects less than 25 cm(2). In this article, we present two cases of malunited facial fractures that underwent corrective osteotomy, during which we felt that despite the conventional osteotomy and reduction techniques, there was still either a small remnant step deformity or suboptimal contour smoothness due to prominence of the implants used. We thus used bone cement as a resurfacing medium over titanium implants to restore good malar contour and reduce the palpability and exposure rate of the titanium implants. We report good patient satisfaction with contour correction with no increase in wound infection rates or any delay in wound healing. There was initial chemosis associated with the use of the bone cement, which resolved in both patients within 3 to 4 weeks. Postoperative computed tomography showed some degree of osteointegration but no fraction of the bone cement. Calcium phosphate bone cement thus presents an attractive adjunctive method for midfacial contour resurfacing, when used in conjunction with conventional osteotomy procedures and as an onlay over prominent titanium implants.

Can superselective embolization be definitive for colonic diverticular hemorrhage? An institution's experience over 9 years.

INTRODUCTION: Superselective mesenteric embolization is effective in arresting colonic diverticular hemorrhage with minimal complications, but long-term results are lacking. We aimed to review the short- and long-term outcome of superselective embolization in arresting colonic diverticular hemorrhage in an Asian population. METHODS: A retrospective review of all patients who underwent superselective embolization for bleeding colonic diverticula from December 2000 to March 2009 was performed. These cases were drawn from a database of embolization for active gastrointestinal hemorrhage. Short-term outcomes (< or =30 days from procedure) identified included rebleeding, ischemia, or any further intervention for any of these two complications. Readmission for rebleeding and/or definitive surgery after 30 days (long-term outcome) was also documented. RESULTS: Twenty-three patients, median age 65 years (range 41-79 years), formed the study group. Nineteen (82.6%) patients had active hemorrhage from right colonic diverticula while four (17.4%) had left-sided diverticular bleeding. Technical success was achieved in all 23 (100%) patients. SHORT-TERM OUTCOME: Five (21.7%) patients rebled within the same admission, and all underwent surgery. One patient perished from ensuing anastomotic dehiscence and septic shock and accounted for the only mortality (4.3%) in our series. There was no patient with ischemic complications. Another two (8.7%) patients underwent elective surgical resection on the advice of their surgeons in the absence of rebleeding. LONG-TERM OUTCOME: The median follow-up was 40 months (5-99 months). Of the remaining 16 (69.6%) patients for whom the procedure was definitive initially, four (25.0%) rebled within 2 years from the primary procedure, and elective surgery was performed in one of them. Another had repeat embolization, while the other two were successfully managed conservatively. These three patients refused surgical intervention. One patient was lost to follow-up, and the remaining 11 patients had no further complications. CONCLUSION: Superselective embolization for active colonic diverticular hemorrhage is safe and effective and should be considered as a first line treatment if possible and available. The procedure could act as a bridge to a subsequent more definitive elective surgery or be definitive as seen in over 50% of our patients over a period of 40 months.