SKIN CLOSURE—A Disposable Atraumatic Instrument for Office Procedures

A disposable applicator with a suture clip bearing unusually fine spicules, which can be kept sterile in an envelope on an office shelf or in a physician''s bag, facilitates the carrying out of the cosmetic closure of skin lacerations and incisions as an office procedure.The spicules of the clips are so fine that they cause practically no bleeding when they are placed or removed. The needle-prick scarring and the “ladder” pattern caused by the placing of sutures with a needle are avoided.     

Prevention and correction of temporal hair loss in rhytidectomy

Routine incisions in the temporal area for rhytidectomy often remove hair-bearing skin anterior to the ear. This results in a cosmetic deformity, making the surgical intervention clearly visible. This is especially problematic for revision rhytidectomy or for patients with naturally high hairlines. This article describes a systematic approach to the temporal hairline and introduces a novel, hair-bearing, transposition flap that corrects iatrogenic loss of the preauricular tuft of hair.     

Determinants of poor outcome after laceration and surgical incision repair

The most important outcomes after repair of traumatic lacerations and surgical incisions are their long-term cosmetic appearance and development of infection. However, few studies have attempted to identify patient and wound characteristics associated with increased infection rates and suboptimal scar appearance. The authors determined patient and wound characteristics associated with wound infection or suboptimal appearance after laceration or incision repair. A secondary analysis of data collected from a multicenter randomized clinical trial comparing the outcome of lacerations and incisions closed with tissue adhesive or standard closure methods conducted at 10 clinical inpatient and outpatient sites was performed. The presence of infection and scar appearance were prospectively determined using validated outcomes. Univariate and multivariate analyses were performed to identify patient and wound characteristics associated with poor wound outcome (wound infection at 5 to 10 days or suboptimal appearance at 3 months). Eight hundred fourteen patients with 924 wounds (383 lacerations, 541 incisions) were enrolled. Mean age was 32 years and 47 percent were female. Characteristics associated with suboptimal cosmetic appearance on multivariate analysis were presence of associated tissue trauma [odds ratio (OR), 3.9; 95 percent confidence interval (CI), 1.4 to 10.7], use of electrocautery (OR, 3.4; 95 percent CI, 1.8 to 6.5), incomplete wound edge apposition (OR, 2.9; 95 percent CI, 1.7 to 5.0); extremity location (OR, 2.1; 95 percent CI, 1.2 to 3.7), and wound width (OR, 1.08; 95 percent CI, 1.01 to 1.14). Characteristics associated with wound infection on univariate analysis included associated tissue trauma (8.7 percent versus 1.2 percent, p = 0.04) and incomplete wound apposition (6.6 percent versus 0.5 percent). Suboptimal appearance was more common in infected wounds (relative risk, 3.2; 95 percent CI, 1.8 to 5.6). Suboptimal wound appearance is increased with extremity wounds, wide wounds, incompletely apposed wounds, associated tissue trauma, use of electrocautery, and infection. Type of closure device and use of deep sutures had no effect on infection rates or cosmetic appearance.     

Minimally invasive approach to familial multiple lipomatosis

Thirty-five abdominal wall lipomas were removed from a patient with familial multiple lipomatosis using a minimally invasive approach in a cost-effective, reliable, and cosmetically pleasing manner. The surgical technique used is described in this case report. Clinical findings and prior excisions provided the preoperative diagnosis. The abdominal wall was dissected through two small, vertical midline incisions in the suprafascial plane with the aid of a lighted breast retractor. A complete excision of all palpable lipomas was achieved with this approach. The patient had excellent cosmetic results with minimal postoperative scarring.     

DERMABRASIVE ABLATION OF ACNE SCARS

Dermabrasion offers cosmetic improvement of acne pits and scars, but only well-adjusted patients should be selected for this esthetic improvement. In the dermabrasion operation the deep cup-shaped pits are made shallow by saucerization, for the deep sharp shadows are eliminated as the pits are shallowed. It is the elimination of the shadow effect which is so gratifying to the patient.Although dermabrasion is a superficial skin operation, it involves dangerous instruments and thousands of minute incisions. The procedure is a surgical operation, whether done in an office or in a hospital. The author performs the operation entirely as a hospital procedure, using pentothal anesthesia with meperidine added in small increments during the operation. Thus the operation may be unhurriedly and meticulously performed.     

Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates

Surgeons have constantly sought to achieve the most aesthetic scar. A major factor determining the final cosmetic appearance of a cutaneous scar is the tension acting on the wound edges during the healing phase. Since Theodor Kocher pioneered the alignment of skin incisions with Langer's lines in 1892, surgical techniques that attempt to overcome closing tension have become standard. Yet, no treatment has been available to minimize underlying muscle contractions, which are the major cause of this tension. Botulinum toxin A is a potent drug that produces temporary muscular paralysis when injected locally. It has proven to be safe and effective in the treatment of a variety of disorders, including hyperkinetic facial lines. The objective of this randomized, double-blind, placebo-controlled primate study was to investigate the efficacy of a single injection of botulinum toxin A to improve the cosmetic appearance of cutaneous scars. Symmetric pairs of standardized excisions were performed on either side of the forehead of six primates. The half foreheads were randomized to the botulinum toxin A treatment side versus the placebo injection side. A panel of three blinded facial surgeons assessed the cosmetic appearance of the mature scars 3 months postoperatively. The wounds that had been immobilized with botulinum toxin A were rated as significantly better in appearance than the control wounds (p < 0.01). Histologic examination confirmed that all scars were mature. Blinded, randomized, placebo-controlled human clinical trials are presently under way at the Mayo Clinic.     

Cosmetic and reconstructive breast surgery in blacks

Black women have not embraced cosmetic and reconstructive surgery of the breast with the same enthusiasm as their Caucasian counterparts because of fear of hypertrophic scars. The authors offer suggestions on how to minimize the scarring associated with breast surgery in black women. They feel that intraareolar incisions should be used whenever circumareolar incisions are indicated in augmentation mammaplasty, because the areola, being a favored area, is less likely to produce hypertrophic scars. The Marchac technique of reduction mammaplasty is recommended because it produces a short horizontal scar of 5 to 8 cm confined to the breast without medial and lateral extension, which may hypertrophy in black women. In the reduction of large breasts, secondary excision of dogears 6 or more weeks after mammaplasty reduces the medial and lateral extents of the scar. The use of liposuction as an adjunct to reduction mammaplasty may also accomplish the same thing. Amputation and free nipple-areola grafting should be used with caution in black patients because of the tendency of the grafted areola to hypopigment. In postmastectomy reconstruction, the authors suggest that the techniques described by Ryan and Radovan should be considered first before the techniques of reconstruction utilizing myocutaneous flaps. In these procedures, no new scars which may hypertrophy are created away from the site of reconstruction. Staples should not be used in skin closure in blacks because they cause cross-hatching of the wound even when removed early.     

Short-scar face lift with extended SMAS platysma dissection and lifting and limited skin undermining

In the past 8 years, short-scar cervicofacial rhytidectomy has been used with great success and a high level of patient satisfaction. The operation involves limited incisions in the sideburn and preauricular areas, extending just around the fold of the ear lobule. Extensive undermining of the superficial musculoaponeurotic system (SMAS)/platysma is performed, and lifting of the face and neck is performed mainly at this level. Skin undermining is kept to a minimum, eliminating the need for extended incisions to reduce dog-ears. The preservation of fibrous bands between the skin and the SMAS/platysma unit is an important factor in making such an operation practical and is the reason why the skin incisions can be kept short. Dissection of large areas of skin and separation of the skin from the underlying SMAS necessitate larger incisions. The operation is safe, speedy, less traumatic, and well tolerated among patients at high risk, such as smokers. The risks of complications are also reduced with this operation.     

Subciliary versus subtarsal approaches to orbitozygomatic fractures

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the anatomic differences in the subciliary versus the subtarsal approach. 2. Discuss the difference between the "skin-only" and the "skin-muscle flap" variations of the subciliary approach. 3. Discuss the potential complications of both approaches. 4. Discuss the advantages of the subtarsal approach versus the subciliary approach. Many incisions have been described for approaches to orbitozygomatic fractures, the most frequently used being the subciliary incision with its modifications, the subtarsal incision, and the transconjunctival incision with or without lateral canthotomy. Each of these approaches has its advantages and disadvantages that may make it more or less appealing to use depending on the patient's age and severity of fracture. A balance must be struck between adequate exposure and acceptable cosmetic result. This article reviews the literature with particular respect to the transcutaneous approaches of subciliary versus subtarsal techniques in the treatment of orbitozygomatic fractures.     

不同类型的下颌骨骨折的手术治疗

目的：评估不同类型的下颌骨骨折的手术入路及固定方法。方法：对于52例不同类型下颌骨骨折患者采用不同的口外或口内切口及相应的固定方法。结果：52例患者伤口全部一期愈合,51例咬合关系恢复到伤前咬合关系,1例出现咬合关系不良,X线检查骨折线队位良好。结论：对于不同部位的下颌骨骨折应采用相应的手术切口及固定方法,以获得最好的疗效。     

Another indication for liposuction: small facial lipomas.

The treatment of facial lipomas at times requires the use of incisions that are less than satisfactory in either size or location. In an effort to minimize scarring, the authors have been removing these lesions with liposuction. The purpose of this study was to review the authors' experience in treating small facial lipomas using liposuction. Over the last 10 years, the authors treated five patients with forehead lipomas by removal with liposuction through hair-bearing scalp incisions. All patients were evaluated after the procedure for bleeding, paresthesias, recurrence, scarring, and overall satisfaction with the procedure. All of these patients had lipomas that measured 4 cm or less at the time of surgery. No patient experienced hematoma, nerve injury, or recurrence. All patients were completely satisfied with their result and scar. The literature describes an advantage to using liposuction for the treatment of medium (4 to 10 cm) and large (>10 cm) lipomas. Because small lipomas (<4 cm) can be extracted through small incisions, the literature reports no advantage to removal with liposuction. However, favorable aesthetic results can be obtained by removing small facial lipomas with liposuction through strategically placed incisions.     

Effect of annular incision type on the change in biomechanical properties in a herniated lumbar intervertebral disc

The technique used to incise the disc during discectomy may play a role in the subsequent healing and change in biomechanical stiffness of the disc. Several techniques of lumbar disc annulotomy have been described in clinical reports. The purpose of this paper was to study the influence of annulotomy technique on motion segment stiffness using a finite element model. Four incision methods (square, circular, cross, and slit) were compared. The analyses showed that each of the annular incisions produced increase in motions under axial moment loadings with circular incision producing the largest change in the corresponding rotational motion. Under shear loading mode, cross and slit-type annular incisions produced slightly larger changes in the principal motions of the disc than square and circular incisions. All other incision types considered in the current study produced negligibly small increase in motion under rest of the loading conditions. In addition to annulotomy, when nucleotomy was also included in the analyses, once again cross and slit incisions produced larger change in motion under shear loading mode as compared to the other two incision types. A comparison between the four types of annular incisions showed that cross incision produced an increase in motion larger than those produced by the other three incisions under flexion/extension and lateral moment loading and both shear force loadings. Circular incision produced the largest increase in motion under axial moment load in comparison to those produced by square, cross, and slit incisions. Sagittal plane symmetry was influenced by the incision injury to the motion segment leading to coupled motions as well as increased facet loads. From the study it can be concluded that the increase inflexibility of the disc due to annulotomy depends on the type of annulotomy and the annulotomy also produce asymmetrical deformations leading to increased facet loading.     

Deficiency in incisions produced by XPF at the site of a DNA interstrand cross-link in Fanconi anemia cells

Repair of DNA interstrand cross-links is a multistep process, critical to which is production of incisions at the site of the lesion resulting in the unhooking of the cross-link from DNA. We have previously shown that XPF is involved in production of incisions at the site of a psoralen interstrand cross-link and that in Fanconi anemia, complementation group A (FA-A) cells, there is a deficiency in these incisions. We now demonstrate that in FA complementation group B, C, D2, F, and G cells there is also a deficiency in production of these incisions. Involvement of FA proteins in this process is demonstrated by the ability of FA cells, corrected with the appropriate FANC cDNAs, to produce these incisions and by inhibition of these incisions by antibodies against these proteins. This incision deficiency correlates with reduced levels of DNA repair synthesis in these cells and is not due to reduced levels of XPF. FA proteins could be influencing this incision process by interacting either with proteins involved in the unhooking step or with damaged DNA, acting as a damage sensor. The results also demonstrate that FA cells are undergoing apoptosis by 12 h after interstrand cross-link damage. It is thus proposed that the single-strand breaks known to be created in DNA during apoptosis could mask the deficiency in ability of FA cells to incise cross-linked DNA and could account for the reported discrepancy as to whether FA cells are deficient in the incision step of the repair process.     

Finite element simulation of arcuates for astigmatism correction

In order to simulate the corneal incisions used to correct astigmatism, a three-dimensional finite element model was generated from a simplified geometry of the anterior half of the ocular globe. A hyperelastic constitutive behavior was assumed for cornea, limbus and sclera, which are collagenous materials with a fiber structure. Due to the preferred orientations of the collagen fibrils, corneal and limbal tissues were considered anisotropic, whereas the sclera was simplified to an isotropic one assuming that fibrils are randomly disposed. The reference configuration, which includes the initial strain distribution that balances the intraocular pressure, is obtained by an iterative process. Then the incisions are simulated. The final positions of the nodes belonging to the incised meridian and to the perpendicular one are fitted by both radii of curvature, which are used to calculate the optical power. The simulated incisions were those specified by Lindstrom's nomogram [Chu, Y., Hardten, D., Lindquist, T., Lindstrom, R., 2005. Astigmatic keratotomy. Duane's Ophthalmology. Lippincott Williams and Wilkins, Philadelphia] to achieve 1.5, 2.25, 3.0, 4.5 and 6.0D of astigmatic change, using the next values for the parameters: length of 45 degrees , 60 degrees and 90 degrees , an optical zone of 6mm, single or paired incisions. The model gives results similar to those in Lindstrom's nomogram [Chu et al., 2005] and can be considered a useful tool to plan and simulate refractive surgery by predicting the outcomes of different sorts of incisions and to optimize the values for the parameters involved: depth, length, position.     

CARCINOMA OF THE EYELID TREATED BY IRRADIATION—Analysis of 157 Primary and 22 Recurrent Cases

The eyelid is a frequent site for skin cancers of the face. Its location presents certain special problems in treatment from a cosmetic and functional standpoint. If untreated, a major deformity with possible loss of sight can result. This paper is a report of our treatment with irradiation of 157 primary tumors and 22 recurrent tumors. In 98 per cent of patients there was control of the tumor for more than five years and a good cosmetic and functional result.     

Deriving indicators for breast conserving surgery using finite element analysis

Breast conserving therapy (BCT), comprising a complete surgical excision of the tumour (partial mastectomy) with post-operative radiotherapy to the remaining breast tissue, is feasible for most women undergoing treatment for breast cancer. The goal of BCT is to achieve local control of the cancer, as well as to preserve a breast that satisfies a woman's cosmetic concerns. Although most women undergo partial mastectomy with satisfactory cosmetic results, in many patients the remaining breast is left with major cosmetic defects including concave deformities, distortion of the nipple–areolar complex, asymmetry and changes in tissue density characterised by excessive density associated with parenchymal scarring, as well as breast pain. There are currently no tools, other than surgical experience and judgement, which can predict the impact of partial mastectomy on the contour, the deformity of the treated breast and the mechanical stress that it induces. In this study, we use a finite element model to execute virtual surgery and carry out a sensitivity analysis on the resection location, the resection size, the breast tissue mechanical property and the different post-surgery recovery stage. We output the result in two different built-in indicators labelled as the cosmetic and the functional indicators. This study used the breast model for three women with breast cancer who have been elected to undergo BCT and are being treated at the Methodist Hospital in Houston, TX. The goal of this study was to propose a first glimpse of the key parameter leading to satisfactory post-BCT cosmetic results.     

颧骨复合体骨折手术治疗的临床研究

目的：观察和对比头皮冠状切口及小切口联合入路在各种颧骨复合体骨折治疗中的效果。方法：分析2002年～2005年于我院口腔颌面外科救治的62例颧骨复合体骨折病人手术入路及临床效果。结果：根据不同类型的骨折,选择不同术式和切口,术中患者使用微型钛板行坚固内固定,术后均达到面形及功能的恢复。结论：对于大部分颧骨复合体骨折可以采用小切口的单独或联合入路进行治疗,对于颧骨体颧弓粉碎性骨折及陈旧性骨折应采用头皮冠状切口加必要的辅助切口。     

Non-Aqueous Glycerol Monolaurate Gel Exhibits Antibacterial and Anti-Biofilm Activity against Gram-Positive and Gram-Negative Pathogens

Background

Skin and surgical infections due to Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter baumannii are causes of patient morbidity and increased healthcare costs. These organisms grow planktonically and as biofilms, and many strains exhibit antibiotic resistance. This study examines the antibacterial and anti-biofilm activity of glycerol monolaurate (GML), as solubilized in a non-aqueous vehicle (5% GML Gel), as a novel, broadly-active topical antimicrobial. The FDA has designated GML as generally recognized as safe for human use, and the compound is commonly used in the cosmetic and food industries.

Methods

In vitro, bacterial strains in broths and biofilms were exposed to GML Gel, and effects on bacterial colony-forming units (CFUs) were assessed. In vivo,subcutaneous incisions were made in New Zealand white rabbits; the incisions were closed with four sutures. Bacterial strains were painted onto the incision sites, and then GML Gel or placebo was liberally applied to cover the sites completely. Rabbits were allowed to awaken and were examined for CFUs as a function of exposure time.

Results

In vitro, GML Gel was bactericidal for all broth culture and biofilm organisms in <1 hour and <4 hour, respectively; no CFUs were detected after the entire 24 h test period. In vivo, GML Gel inhibited bacterial growth in the surgical incision sites, compared to no growth inhibition in controls. GML Gel significantly reduced inflammation, as viewed by lack of redness in and below the incision sites.

Conclusions

Our findings suggest that 5% GML Gel is useful as a potent topical antibacterial and anti-inflammatory agent for prevention of infections.     

Uni-incisional video-assisted thoracoscopic left lower lobectomy in a patient with an incomplete fissure

Video-assisted thoracoscopic surgery (VATS) was introduced nearly two decades ago. Since then, there has been a rapid development in minimal invasive techniques for lung cancer treatment. The common approach is the one performed through three incisions, including a utility incision of ～3 to 5 cm. However, lobectomy can be performed by using only two incisions (one camera port and working incision). A few clinics perform this approach. We began the two-incision technique in our institution in February 2009. After performing 95 cases with this technique, we observed that for lower lobes the second incision could be eliminated, and we performed the surgery by using only the 4-cm utility incision. This article describes a case report of a 57-year-old woman operated by this uni-incisional approach for a lower lobe video-assisted thoracoscopic surgery lobectomy.