Intracranial pseudoaneurysm associated with orbitozygomatic complex fracture.

Fractures of the orbitozygomatic complex are one of the most common facial fractures encountered by plastic surgeons. Many would consider this to be primarily a cosmetic deformity; however, these injuries can be associated with acute life-threatening complications. Intracranial pseudoaneurysm, although rare, is a well-documented complication of blunt facial trauma, which most plastic surgeons are unaware of. We present the case of a 20-year-old woman who developed an intracranial pseudoaneurysm after blunt facial trauma to illustrate the importance of (1) understanding this rare but highly morbid complication, (2) assessing high-risk patients for pseudoaneurysm, and (3) delaying reconstruction in high-risk patients.

The use of laser Doppler imaging as a predictor of burn depth and hypertrophic scar postburn injury.

Hypertrophic scarring (HTS) is a fibroproliferative disorder that commonly develops after severe burn injuries. Overexpression of transforming growth factor-ß (TGF-ß) by an increased number of fibrocytes has been associated with increased extracellular matrix molecule expression leading to HTS. The most widely accepted adjuvant to clinical assessment of burn depth is laser Doppler imaging (LDI) and may predict injury to the dermis that corresponds to cellular and molecular changes associated with HTS. A prospective, blinded, control trial was performed comparing LDI and clinical assessment for the decision to operate. Immunohistochemistry and real-time reverse transcription polymerase chain reaction was performed to determine whether there is a correlation between histological assessment of burn depth and LDI, and the presence of fibrocytes was detected using confocal microscopy. The positive predictive value for a burn requiring a graft was calculated to be >90%. Immunohistochemistry on biopsy samples revealed an increased expression of TGF-ß, connective tissue growth factor, heat shock protein 47, and collagen type I in deep burn wounds compared to superficial burns. Using the fibrocyte-specific markers procollagen type I and lymphocyte-specific protein-1, there was an increased number of fibrocytes in deep burn areas compared to superficial burn. In deep burn injuries, increased infiltration of fibrocytes occurs leading to an overexpression of TGF-ß1 and connective tissue growth factor. More importantly, LDI was >90% accurate at predicting the need for excision and grafting. The accuracy of the decision to debride deep dermal burns to avoid HTS using both clinical parameters and LDI was supported by histological and biochemical measurements.

Complications of chlorine inhalation in a pediatric chemical burn patient: a case report.

The majority of burn injuries in the pediatric population occur at home, and a significant proportion are the result of exposure to household cleaning products. A common injury-causing agent is bleach, which has the potential to release chlorine gas, a potent respiratory irritant that leads to the added risk of inhalation injury. The survival of pediatric patients with chemical burns is extremely high, and the 3 strongest predictors of mortality are large burn size, age <48 months, and the presence of inhalation injury. The authors present a rare case of a pediatric fatality from a chemical bleach burn that resulted in acute respiratory distress syndrome as well as hemodynamic and pulmonary instability that required extracorporeal membrane oxygenation. The authors critically appraised the management of this patient to determine the possible effect certain events had on the unexpected and poor outcome of this patient, including fluid resuscitation, the effect of the chemical inhalation injury, sedation, and the need for invasive extracorporeal membrane oxygenation life support.

Modified Von Langenbeck cleft palate repair using an anterior triangular flap: decreased incidence of anterior oronasal fistulas.

OBJECTIVE: A complication following cleft palate surgery is the development of oronasal fistulas. Despite recent advances aimed at addressing this concern, rates of postoperative fistulas have remained unchanged and are reported at between 3% and 60%. Oronasal fistulas commonly occur between the hard and soft palate and at the anterior portion of the cleft. These fistulas lead to functional problems with nasal emission, hypernasal speech, and food regurgitation through the nose. For clefts of the secondary palate, we developed a modification of the Von Langenbeck technique in which an anterior triangular flap is used to decrease the incidence of postoperative fistulas. METHOD: A triangular flap composed of oromucosa was designed for isolated clefts of the secondary palate only. It is based at the anterior margin of the cleft and is used as a turnover flap to allow closure of the often very tight anterior nasal side. A retrospective chart analysis was performed from 2000 to 2007. All patients who had isolated clefts of the secondary palate and had undergone a modified Von Langenbeck procedure were included in the study. Patients were evaluated 4 to 8 weeks postoperatively for the presence of oronasal fistulas. RESULTS: With the introduction of the anterior triangular flap, we show that 0 of 182 patients developed a postoperative oronasal fistula. CONCLUSIONS: This modification of the standard Von Langenbeck uses an anterior triangular flap and confers the advantage of assisting in nasal side closure of the anterior margin of the cleft; in doing so, it reduces the rate of fistula formation.