Combined rhytidectomy and full-face laser resurfacing.

A series of patients undergoing a combined face lifting procedure with simultaneous laser resurfacing is described. Although resurfacing is accepted as safe for deep-plane face lifts and forehead lifts, there are reports of preauricular skin loss with a standard face lift. In this series, 26 consecutive cases are described. A superficial musculoaponeurotic system (SMAS) face lift technique was used. A skin flap was developed no more than 3.0 cm from the preauricular area, and most of that was excised. Full-face laser resurfacing was done with the SilkTouch laser. An 8-mm square pattern was used at 16 to 18 W. Three to four passes were done. Care was taken, however, to do very superficial lasering of the periphery, especially over the small amount of undermined skin that remained. There was no preauricular skin loss. This series demonstrates the safety of combining laser resurfacing with the SMAS technique face lift in regard to preauricular skin loss.

Determination of burn depth with noncontact ultrasonography.

Early excision and grafting is the current treatment of choice for deep dermal and full-thickness burn wounds that will not heal spontaneously within 3 weeks. The time needed for the burn wound to heal is estimated with clinical assessment of the burn depth; this is often an inaccurate method. Therefore we have developed a new and unique noncontact ultrasonographic method to estimate burn depth. This study was designed to determine the practical utility and accuracy of noncontact ultrasonography for the assessment of burn depth. Seventy-eight burn sites and 42 normal skin sites (control sites) of 15 patients (age, 18-63 years) with burns of 2% to 35% total body surface area were evaluated. The burn sites were scanned with a prototype noncontact ultrasonographic system 1 and 3 days after the burn injuries. The probe was held 1 inch from the skin, and the time spent on each site was approximately 5 minutes. The ultrasonographic results were interpreted by an investigator who was blinded to the clinical findings. Clinical assessment of the burn wounds was made on the same days by 2 experienced physicians who were blinded to the results of the ultrasonography. The investigators were asked to categorize the burn wounds into those that would heal within 3 weeks and those that would not. With this method, we were able to visualize the epidermis, dermis, and dermal-fat interface in normal skin. The destruction of the dermal-fat interface was interpreted as a deep burn, which would not heal within 3 weeks. The overall accuracy of the noncontact ultrasonography in the prediction of which burn wounds would heal within 3 weeks was 96%. The results of this study show that noncontact ultrasonography will allow for the rapid evaluation of burn depth with high accuracy, without contacting the patient, and without causing pain or discomfort.

Carbon dioxide and ER:YAG laser resurfacing. Results.

Laser resurfacing is exciting "futuristic" surgery. The CO2 laser resurfaces using different parameters from the Er:YAG laser. When the surgeon understands these parameters, each laser can be used as a powerful tool for specific clinical applications. The Er:YAG laser was initially thought to be for the patient who has minimal skin laxity, but who desires skin resurfacing and needs a speedy return to social life. The CO2 laser has typically been thought to work best for skin laxity as well as rhytids, at the price of a longer recovery period. As the hardware and techniques continue to evolve, the differences between the clinical scope addressed by each laser diminishes. Both lasers deserve a place in the plastic surgeon's armamentarium. This new combination CO2/Er:YAG technique is intriguing and deserves further in-depth investigation. Laser resurfacing is not a cureall, but, when applied appropriately, it is an excellent tool that the plastic surgeon can use for skin rejuvenation.

Care of microvascular surgical instruments.

Reconstructive microsurgery, a specific category of surgery that uses revascularized tissue to repair functional or cosmetic defects, requires specialized training and continued competence of the surgeon, assistant and surgical team. Proper care of microsurgical instruments is paramount to the success of the surgery. Areas of importance such as microsurgical instrumentation, suture, operating microscope, and producing an atraumatic anastomoses will be explored indepth.

Intralesional photocoagulation of periorbital hemangiomas.

The purpose of this study was to examine the effects of intralesional bare fiber photocoagulation with the KTP and Nd:YAG lasers on periorbital hemangiomas of infancy. Initial reports by Apfelberg and Gregory suggest that intralesional laser therapy may have a role in the treatment of hemangiomas. Intralesional photocoagulation may be preferred to superficial laser treatment for several reasons. It may decrease cutaneous skin damage and more effectively reduce bulky, deep lesions. Twenty-three patients with periorbital hemangiomas were treated (KTP, n = 7; Nd:YAG, n = 16). An 18-g Angiocath was placed into the lesion to pass the fiber through. Laser energy was delivered by means of a 0.6-mm bare fiber at 10 to 15 J (KTP) or 7 J (Nd:YAG). Treatments were done under general anesthesia. Patients were followed closely for 1 month and then monthly to assess results and complications. Results are as follows: 61 percent demonstrated 50-percent or more reduction at 3 months; 22 percent demonstrated 50-percent or more reduction in 3 to 8 months, i.e., 83 percent of patients had 50-percent or more reduction within 8 months. To achieve these results, two patients required two treatments. The remaining 17 percent had 10- to 14-percent reduction at 1 to 3 months. Two of these patients had two treatments. A subgroup of patients had a very dramatic response. Thirty-five percent (8 of 23) had 50- to 90-percent reduction in 1 month. It is unclear why these patients responded so dramatically. We expected some ulceration during the healing phase. Seventeen percent developed ulceration. Complications were limited (4 percent) to one wound infection. Intralesional photocoagulation treatment with the KTP and Nd:YAG lasers is effective and safe for the treatment of periorbital hemangiomas in the majority of patients with minimal complications. Further study is necessary to identify factors that result in dramatic or limited responses.

Augmentation of facial soft-tissue defects with Alloderm dermal graft.

Numerous materials, both autologous and nonautologous, have been used for augmentation of soft-tissue defects in the facial region. Each has its limitations. There is no ideal material for soft-tissue augmentation. Alloderm dermal graft (LifeCell Corporation, Woodlands, TX) combines the benefits of autografts and allografts. The authors report its use in 11 patients who have soft-tissue defects or scarring on the face. No serious complications such as rejection, mobilization, absorption, dislocation, or extrusion were encountered. The use of Alloderm in these patients minimized two problems: donor site morbidity and lack of adequate tissue for reconstruction. Alloderm is shown to be an excellent augmentation material for soft-tissue defects. The absence of a donor site defect, and adequate tissue for reconstruction are particularly helpful in the pediatric population.

Hot-press hand burn treatment.

Hand injuries are common in the workplace. Modern industrial machines cause complex occupational hand injuries. Hot-press contact hand burns generally are encountered by workers in the dry-cleaning industry. Seventeen patients with hot-press hand burns were treated at the University of California-Irvine Medical Center Burn Center. Eight patients (47%) required skin grafting, seven (41%) were treated with hydrotherapy only, and two (12%) needed flaps. These results were not what we expected.

Intralesional bare fiber laser treatment of hemangioma of infancy.

The purpose of this study is to examine the effects of intralesional fiber with the KTP laser on treatment of hemangiomas in infancy. A series of 12 patients (1 month to 3 1/2 years) were treated for hemangioma of the head and neck regions. Results were as follows: 92 percent, > 50 percent reduction at 3 months; 8 percent, > 50 percent reduction at 6 months. To achieve these results, 50 percent required two treatments (six cases), and 8 percent required three treatments (one case). Improvement of function was clearly in the proliferative phase. Lesions on three patients (25 percent) ulcerated following laser therapy. No other side effects or complications were noted. Intralesional fiber therapy is determined to be effective and safely used to induce involution of voluminous hemangiomas of the face and neck regions.

Laser resurfacing of the face.

Pulsed mode carbon dioxide laser allows precise ablation of fine facial tissue while minimizing thermal damage to the skin. Changes in the structure of dermal collagen may account for the overall tightening effect observed. Preoperative preparation of the skin is important to prevent postoperative pigment changes. Prophylactic antivirals are used to reduce the risk of Herpes infection. The carbon dioxide laser produces pain when applied to the skin and various anesthetic techniques may be used. After lasing, the face can be dressed with occlusive dressings or left open. Sunscreens are required after reepithelization.

Hair removal with the ruby laser (694 nm).

Hair removal with the ruby laser is one of the newest uses of laser technology. The laser seeks melanin in the hair shaft, and melanin content is highest during the growth phase of the hair follicle. Nursing care focuses on preparing the patient for the procedure, maintaining a safe operative environment, and teaching the patient skin care after the laser therapy.

Use of a semipermeable dressing (Biobrane) following laser resurfacing of the face.

Biobrane provides a suitable, reliable method of postoperative wound coverage for the laser resurfaced patient. Pain and drainage are minimized.

Digital imaging for plastic and reconstructive surgery.

Digital imaging provides many benefits to plastic surgical practice. While problems arise, there are many advantages. The ethical use of digital imaging may be a cost-effective, valuable asset to the practice of plastic surgery.

Prevention of accidental extubation in burn patients.

The purpose of this paper is to examine the rate of accidental extubation in the burn patient population and to propose solutions. We found that the extubation rate was higher in burn patients (27%) than in the general surgical intensive care patient population (6%). Extubations occurred most frequently (66%) in conjunction with painful or invasive procedures. Methods of endotracheal tube stabilization are reviewed. Two techniques for stabilization in the patient with a burned face are presented.

Reconstruction of head and neck hemangiomas with tissue expansion in the pediatric population.

A retrospective study of 245 patients with 299 hemangiomas treated from May 1981 to April 1994 was done. A subset of 175 of these patients (58.5%) had hemangiomas of the head and neck. Six of the 175 (3%) required reconstruction following laser therapy. Tissue expansion was chosen for each of these reconstructions. Five females and 1 male underwent tissue expansion. The age of the patients at the time of tissue expansion ranged from 2.5 to 12 years, with an average of 6 years. Tissue expander sizes were 50 cc and 100 cc. Infection was seen during the course of expansion in 1 patient. Satisfactory results were achieved after reconstruction in all cases. Tissue expansion is the treatment of choice for reconstruction of head and neck hemangioma deformities following laser or other surgical procedures as well as involution.

Traumatic tattooing: treatment with the Q-switched ruby laser: a case study.

This case report details the successful treatment of extensive, facial traumatic tattooing in an adult male. The Q-switched ruby laser was utilized. It is demonstrated to be an excellent tool for the treatment of traumatic tattooing. The results achieved are superior to other methods and complications reported with other treatment options are minimized.

Breast reconstruction: the contralateral breast.

Evaluation and treatment of the contralateral breast is an integral component of the reconstructive process. Communication and planning with the patient in regards to management of the CB will maximize the reconstructive result and patient satisfaction.