Innovative Techniques in Skin Surgery (Basic and Clinical Dermatology)

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Innovative Techniques in Skin Surgery

edited by

Marwali Harahap University of North Sumatra Medan, Indonesia

Marcel Dekker, Inc.

New York • Basel

TM

Copyright © 2002 by Marcel Dekker, Inc. All Rights Reserved.

ISBN: 0-8247-0769-9 This book is printed on acid-free paper. Headquarters Marcel Dekker, Inc. 270 Madison Avenue, New York, NY 10016 tel: 212-696-9000; fax: 212-685-4540 Eastern Hemisphere Distribution Marcel Dekker AG Hutgasse 4, Postfach 812, CH-4001 Basel, Switzerland tel: 41-61-261-8482; fax: 41-61-261-8896 World Wide Web http://www.dekker.com The publisher offers discounts on this book when ordered in bulk quantities. For more information, write to Special Sales/Professional Marketing at the headquarters address above. Copyright # 2002 by Marcel Dekker, Inc. All Rights Reserved. Neither this book nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher. Current printing (last digit): 10 9 8 7 6 5 4 3 2 1 PRINTED IN THE UNITED STATES OF AMERICA

BASIC AND CLINICAL DERMATOLOGY Series Editors ALAN R. SHALITA, M.D. Distinguished Teaching Professor and Chairman Department of Dermatology State University of New York Health Science Center at Brooklyn Brooklyn, New York

DAVID A. NORRIS, M.D. Director of Research Professor of Dermatology The University of Colorado Health Sciences Center Denver, Colorado

1. Cutaneous Investigation in Health and Disease: Noninvasive Methods and Instrumentation, edited by Jean-Luc Lévêque 2. Irritant Contact Dermatitis, edited by Edward M. Jackson and Ronald Goldner 3. Fundamentals of Dermatology: A Study Guide, Franklin S. Glickman and Alan R. Shalita 4. Aging Skin: Properties and Functional Changes, edited by Jean-Luc Lévêque and Pierre G. Agache 5. Retinoids: Progress in Research and Clinical Applications, edited by Maria A. Livrea and Lester Packer 6. Clinical Photomedicine, edited by Henry W. Lim and Nicholas A. Soter 7. Cutaneous Antifungal Agents: Selected Compounds in Clinical Practice and Development, edited by John W. Rippon and Robert A. Fromtling 8. Oxidative Stress in Dermatology, edited by Jürgen Fuchs and Lester Packer 9. Connective Tissue Diseases of the Skin, edited by Charles M. Lapière and Thomas Krieg 10. Epidermal Growth Factors and Cytokines, edited by Thomas A. Luger and Thomas Schwarz 11. Skin Changes and Diseases in Pregnancy, edited by Marwali Harahap and Robert C. Wallach 12. Fungal Disease: Biology, Immunology, and Diagnosis, edited by Paul H. Jacobs and Lexie Nall 13. Immunomodulatory and Cytotoxic Agents in Dermatology, edited by Charles J. McDonald 14. Cutaneous Infection and Therapy, edited by Raza Aly, Karl R. Beutner, and Howard I. Maibach 15. Tissue Augmentation in Clinical Practice: Procedures and Techniques, edited by Arnold William Klein 16. Psoriasis: Third Edition, Revised and Expanded, edited by Henry H. Roenigk, Jr., and Howard I. Maibach 17. Surgical Techniques for Cutaneous Scar Revision, edited by Marwali Harahap 18. Drug Therapy in Dermatology, edited by Larry E. Millikan 19. Scarless Wound Healing, edited by Hari G. Garg and Michael T. Longaker 20. Cosmetic Surgery: An Interdisciplinary Approach, edited by Rhoda S. Narins 21. Topical Absorption of Dermatological Products, edited by Robert L. Bronaugh and Howard I. Maibach

22. Glycolic Acid Peels, edited by Ronald Moy, Debra Luftman, and Lenore S. Kakita 23. Innovative Techniques in Skin Surgery, edited by Marwali Harahap

ADDITIONAL VOLUMES IN PREPARATION

Safe Liposuction, edited by Rhoda S. Narins

Series Introduction

Over the past decade, there has been a vast explosion in new information relating to the art and science of dermatology as well as fundamental cutaneous biology. Furthermore, this information is no longer of interest only to the small but growing specialty of dermatology. Scientists from a wide variety of disciplines have come to recognize both the importance of skin in fundamental biological processes and the broad implications of understanding the pathogenesis of skin disease. As a result, there is now a multidisciplinary and worldwide interest in the progress of dermatology. With these factors in mind, we have undertaken to develop this series of books specifically oriented to dermatology. The scope of the series is purposely broad, with books ranging from pure basic science to practical, applied clinical dermatology. Thus, while there is something for everyone, all volumes in the series will ultimately prove to be valuable additions to the dermatologist’s library. The latest addition to the series by Marwali Harahap is both timely and pertinent. The author is a well-known authority in the field of skin surgery. We trust that this volume will be of broad interest to scientists and clinicians alike. Alan R. Shalita SUNY Health Science Center Brooklyn, New York

iii

Preface

The most novel surgical techniques are developed out of necessity or are created to simplify a surgical procedure. We often observe another surgeon’s work and recognize a technical innovation that makes the operation easier. There is more than one way to achieve excellent end-products by using sometimes different approaches and techniques. The purpose of Innovative Techniques in Skin Surgery is to offer the reader practical advice on how surgeons perform various procedures, based on new thoughts and ideas. The distinguished contributing authors possess special expertise in skin surgery and have contributed to the surgical literature. They explain each procedure in detail so that it can be confidently carried out by following the steps as outlined, bearing in mind the indications and potential complications. This book complements standard texts. Numerous textbooks and monographs are available to the student of skin surgery, but in the last decade there has been no useful treatise on how a specific individual performs a given procedure. Although such an endeavor cannot be entirely comprehensive, it is hoped that the procedures included herein prove useful as a ready reference of reliable information. Illustrations are used extensively to highlight and clarify the text. Selected references are listed at the end of each chapter for those desiring enhancement of their knowledge in skin surgery. This book should appeal not only to dermatological surgeons and doctors in training, but also to plastic surgeons, head and neck surgeons, ophthalmic surgeons, and other surgeons dealing with the wide range of skin problems. Marwali Harahap v

Contents

Series Introduction Preface Contributors Part I

iii v xvii

Basic Surgery

1.

Vermilionectomy Using the W-Plasty Technique J. M. Fernańdez-Vozmediano and J. C. Armario-Hita

1

2.

Running Vertical Mattress Suture Technique Stephen N. Snow and David Douglas Madjar, Jr.

11

3.

Dual Use of Monofilament Poliglecaprone in Layered Closure: Buried and Cuticular Paul J. Weber and Gale B. Oleson

15

4.

Short-Hand Vertical Mattress Stitch: A Rapid Skin-Everting Suture Technique Stephen N. Snow and David Douglas Madjar, Jr.

21

5.

Modified Buried Vertical Mattress Suture: A New Technique of Buried Absorbable Wound Closure Associated with Excellent Cosmesis for Wounds Under Tension Neil S. Sadick

25

vii

viii

Contents

6.

Modified Buried Dermal Suture James D. Whalen, Diana D. Antonovich, and Siobhan C. Collins

37

7.

Purse String Suture in the Management of Poorly Delineated Melanoma Charles B. Toner and Mary K. Mather

41

8.

Stitch Removal from Hair-Bearing Areas: A Simple Method A. Sagi and P. Benmeir

45

9.

Simple Securing of Subcuticular Running Suture and W-Plasty Domagoj Delimar, Zdenko Stanec, and Sanda Stanec

47

10.

A New Skin Suture Technique for Multiple Z-Plasty Noboru Ohsumi

51

11.

Double-Tipped Suture Needle for Dermostitches Akira Yanai, Yuzo Komuro, and Shinichi Hirabayashi

55

12.

Looped Square Knot: A Useful Suture Method that Allows Removal of Stitches Without Using Scissors Akira Yanai, Yuzo Komuro, and Shinichi Hirabayashi

57

13.

The Round Block Distorting Purse String Suture in the Treatment of Skin Cancer of the Face: An Aesthetic and Convenient Technique Carlo Tremolada and Francesca Carota

61

14.

Double- and Triple-Interlocking Suture Techniques Charles H. Hutchins

71

15.

Bury-and-Knot Suturing Method Akira Yanai, Yuzo Komuro, and Shinichi Hirabayashi

79

16.

Surgical Excision of Hemangioma with Minimal Blood Loss Marwali Harahap

87

17.

Intraoperative Nasal Ala Immobilization Using the Foley Catheter Joseph Alcalay

95

Contents

ix

18.

Tissue-Sparing Repair: A New Approach to Shorten Excisional Lines James B. Stewart, Jr., and Norman L. Levine

103

19.

Razor Blade Surgery Using the Castroviejo Blade Breaker and Holder Don Lum and Richard Lum

107

20.

Bolster Techniques in Cutaneous Surgery: The Red Rubber Robinson Effie Pappas, Kelsey Hamilton, and Robert A. Skidmore

107

21.

Creating a Curvilinear Scar Carl H. Manstein and Stacey Mandichak

117

Part II 22.

Nail Surgery

Nail Plate Excision Using the Hand-Held Thermocautery Unit Stephen N. Snow and David Douglas Madjar, Jr.

123

23.

Treatment of the Splitting Nail with Phenol Alcohol Partial Matricectomy Robert T. Brodell and Daniel M. Miller

129

24.

Nail Splinting for Ingrown Toenails: A New Noninvasive Treatment Modality Klaus W. Schulte and Norbert J. Neumann

135

25.

Treatment of Subungual Splinters Daniel M. Miller and Robert T. Brodell

139

Part III 26.

Mohs Micrographic Surgery

Excision of Exposed Cartilage for Management of Mohs Surgery Defects of the Ear Paul O. Larson and David Douglas Madjar, Jr.

135

x

27.

28.

Contents

Use of a Curved Blade to Harvest Mohs Micrographic Sections Ron M. Shelton Use of Multiple Different Tissue Specimens on the Same Glass Slide in Mohs Micrographic Surgery Hugh M. Gloster, Jr.

Part IV

149

159

Oral Surgery

29.

Simple Techniques for the Biopsy of Oral Lesions Marwali Harahap

165

30.

Transfixion Technique to Treat Oral Vascular Anomalies Javier Va´zquez-Doval

173

31.

Removal of a Large Labial Mucocele: A Cosmetic and Functional Approach Harry L. Parlette III and Eric C. Parlette

179

Part V

Anesthesia

32.

Bilevel Anesthesia and Blunt Dissection: A New Concept for the Millennium Lawrence M. Field

187

33.

Automated Subcutaneous Infusion Tumescent Anesthesia with Diluted Mixtures of Prilocain and Ropivacain Helmut Breuninger

193

Part VI

Instruments/Apparatus/Supply

34.

Use of a Combination Nail Elevator and Hemostat Clamp: Innovative Instruments for Nail Avulsion Joel K. Sears

201

35.

Acne Surgery Utilizing the Versatile Paper Clip Comedo Extractor Joseph L. Cvancara

207

Contents

xi

36.

Skin Hook Forceps Donald H. Lalonde

211

37.

The Ultrasonic Scalpel: Applications in the Treatment of Rhinophyma and Other Cutaneous Surgical Procedures Siobhan C. Collins, Raymond G. Dufresne, Jr., and James D. Whalen

217

38.

Clever Devices to Evaluate Vermilion-Skin Border in Lip Reconstruction Roberto Brusati and Federico Biglioli

223

39.

‘‘Tusked’’ Forceps for Rapid and Atraumatic Subcuticular Closure of the Skin Martin Hirigoyen Kelly

229

Part VII

Flaps

40.

Labial Muscle Z-Plasty to Reestablish the ‘‘Lip Seal’’ Mechanism Lawrence M. Field

233

41.

Total Upper Lip Reconstruction with Bilateral Fan Flaps Francisco M. Camacho

237

42.

Closure of Conchal Defects: The Hinged Retroconchal Island Flap with Overlying Transposition Flap Walter A. Schroeder, Jr.

243

43.

Burow’s Triangle Advancement Flaps for Excision of Two Closely Approximated Skin Lesions Paolo Boggio and Giorgio Leigheb

249

44.

Modified Bilateral Advancement Flap Marwali Harahap

261

45.

Trilobed Flaps for Simultaneous Repair of Multiple Defects of the Nose Paolo Boggio and Giorgio Leigheb

269

xii

Contents

46.

Bilobed Flap for Reconstruction After Simultaneous Removal of Three Lesions: Compound Bilobed Flap of the Nose Paolo Boggio and Giorgio Leigheb

277

47.

Rotation and Transposition Flaps for Reconstruction After Simultaneous Removals of Two Close Skin Lesions Paolo Boggio and Giorgio Leigheb

283

48.

Innovations in Island Pedicle Flaps David R. Byrd, Randall K. Roenigk, and Clark C. Otley

291

49.

Reconstruction of Umbilicus Using a Skin Flap Takatoshi Yotsuyanagi, Satoshi Urushidate, and Yukimasa Sawada

301

50.

Mini Z in Z to Relieve the Transverse Linear Tension After a Z-Plasty Transposition Ahmet Seyhan

309

51.

‘‘Iris’’ Technique for Immediate Umbilical Reconstruction Michael J. Miller

313

52.

Flap Defatting with an Ultrasonic Surgical Aspirator Kazuyoshi Yamanaka

319

Part VIII

Grafts

53.

Reusable Loop Suture Techniques to Secure and Allow Graft Reinspection Stephen N. Snow and David Douglas Madjar, Jr.

325

54.

Harvesting Auricular Cartilage Mitchell L. Levin

331

55.

Cartilage Removal Prior to Skin Grafting in the Triangular Fossa, Antihelix, and Concha of the Ear J. Ramsey Mellette, Jr., and James M. Swinehart

56.

Stents for Skin Grafts Paul O. Larson and David Douglas Madjar, Jr.

335

341

Contents

xiii

57.

Split-Skin Grafting on Severely Damaged Skin: A Technique Using Absorbable Tissue Adhesive Irshad Zaki and L. G. Millard

351

58.

Autologous Suction Blister-Induced Epidermal Grafts for Treating Localized Stable Vitiligo William Yuk Ming Tang

357

59.

First Dorsal Digital Web of the Hand as a Full-Thickness Skin Graft Donor Site for the Repair of Defects on the Hand and Digits After Mohs Micrographic Surgery Shih-Tsung Cheng, Hsin-Su Yu, and J. Ramsey Mellette, Jr.

365

60.

Delayed Intranasal Knot Placement in Alar Composite Grafts Tina M. Peloro and Michael L. Ramsey

373

61.

Clavicular Grafts Parwathi ‘‘Uma’’ Paniker and J. Ramsey Mellette, Jr.

379

62.

Disposable Suction Syringe for Epidermal Grafting Muhammed Mukhtar and Shyam Sunder Pandey

387

63.

Use of Free Cartilage Grafts in Nasal Alar Reconstruction De´sireé Ratner

393

64.

A Simple Preparation of Autologous Fibrin Glue for Skin Graft Fixation Mark A. Brzezienski and James L. Fowler III

399

65.

Stent Dressing Techniques in Skin Grafting Fernando Prune´s

405

66.

Rapid Stapler Tie-Over Fixation for Skin Grafts Haim Y. Kaplan and Josef Haik

411

67.

Nylon Threads Used as Drains in Free Skin Grafting Tomoharu Kiyosawa and Yoshio Nakayama

413

xiv

Contents

68.

Overgrafting for Leukoderma and Chronic Inflammatory Conditions of the Lower Lip: A New Application of an Already Established Method Vinayak Raghunath Chitale and Bindumadhav G. Galgali

419

69.

A Simple Method for the Classic Tie-Over Dressing Tamer Koldas

425

70.

Innovative Techniques in Skin Graft Fixation Alan T. Lewis and Ida Orengo

431

71.

Lubrication Jelly as a Dressing in Punch Grafts for Pitted Acne Scars Ada Regina Trindade de Almeida, Nalu Iglesias Martins de Oliveira, and Bogdana Victoria Kadunc

441

72.

Transparent Gasbag Tie-Over for Free Skin Grafting Jun Ren

445

73.

Primary Closure of Split-Thickness Skin Graft Donor Site Alfred Sofer and Richard C. Hagerty

457

74.

A New Method for the Dressing of Free Skin Grafts Tomoharu Kiyosawa and Yoshio Nakayama

461

75.

Improvised Method for Preparing Meshed Skin Grafts Akira Yanai, Yuzo Komuro, and Shinichi Hirabayashi

467

76.

External Use of a Wireframe for Sheet Skin Grafting Takashi Hirai

471

Part IX

Surgical Management of Alopecia

77.

Use of the Pulley Suture in Scalp Reduction Surgery Neil S. Sadick

483

78.

Automation of Hair Transplantation: Past, Present, and Future William R. Rassman and Robert M. Bernstein

489

Contents

Part X 79.

Liposuction

Highly Flexible, Reinforced Swan-Neck Liposuction Cannulae Paul J. Weber and Gale B. Oleson

Part XI 80.

xv

Autologous Fat Transplantation

Pinch Technique in Fat Transfer Mona Zaher, Michael Radonich, Dwight A. Scarborough, and Emil Bisaccia

Part XII

503

515

Dermabrasion and Chemical Peels

81.

A New Technique of Dermabrasion for Traumatic Tattoos Ernest D. Cronin, Payam Shayani, and Mark Jabor

521

82.

Sandpaper Mounted on a Safety Razor: A Simple Device for Dermabrasion Nitin J. Mokal and R. L. Thatte

527

Part XIII 83.

Ear Surgery

Repair of a Split or Deformed Ear Lobe with a Tongue Depressor Blade for Stabilization During Surgery Dee Anna Glaser and Christina Chia

Part XIV

531

Eye Surgery

84.

Traction-Modified Blepharoplasty Paul J. Weber and Gale B. Oleson

535

85.

Visible Incision Reduction in Cosmetic Oculoplastic Surgery Paul J. Weber and Gale B. Oleson

547

86.

Evaluation Documentation in Cosmetic Oculoplastic Surgery Paul J. Weber and Gale B. Oleson

573

xvi

Contents

Part XV

Additional Techniques

87.

Manual Punch for Tattooing Mohan B. Gharpuray and Sharad Mutalik

585

88.

A Simple Cryotechnique for the Treatment of Cutaneous Soft Fibromas Giuseppe Monfrecola

589

89.

Computer-Generated Operative Reports: How to Save up to 30 Minutes per Day James M. Swinehart

593

90.

Prevention of Hypertrophic Scars by Long-Term Paper Tape Application Robert S. Reiffel

601

Index

609

Contributors

Joseph Alcalay, M.D. Aviv, Israel

Mohs Surgery Unit, Assuta Medical Center, Tel

Diana D. Antonovich, M.D. Department of Otolaryngology, University of Connecticut Health Center, Farmington, Connecticut J. C. Armario-Hita, M.D. Department of Dermatology, University Hospital of Puerto Real, Cadiz University, Cadiz, Spain P. Benmeir, M.D. Department of Plastic Surgery, Soroka University Hosptial, Ben Gurion University of the Negev, Beer Sheva, Israel Robert M. Bernstein, M.D. New Hair Institute Medical Group, A Professional Corporation, Los Angeles, California Federico Biglioli, M.D. Department of Maxillofacial Surgery, San Paolo University Hospital, Milan, Italy Emil Bisaccia, M.D. College of Physicians & Surgeons, Columbia University, New York, New York Paolo Boggio, M.D. Division of Dermatology, School of Medicine, University of Piemonte Orientale, and Maggiore della Carita` Hospital, Novara, Italy Helmut Breuninger, M.D. Department of Dermatologic Surgery, University of Tu¨bingen, Tu¨bingen, Germany Robert T. Brodell, M.D. Dermatology Section, Northeastern Ohio Universities College of Medicine, Rootstown, and Case Western Reserve University School of Medicine, Cleveland, Ohio xvii

xviii

Contributors

Roberto Brusati, M.D. Department of Maxillofacial Surgery, San Paolo University Hospital, Milan, Italy Mark A. Brzezienski, M.D., M.S., F.A.C.S. Departments of Plastic and Orthopedic Surgery, University of Tennessee College of Medicine, Chattanooga, Tennessee David R. Byrd, M.D. Minnesota

Mayo Graduate School of Medicine, Rochester,

Francisco M. Camacho, M.D., Ph.D. Department of Dermatology, Hospital Virgen Macarena, University of Seville, Seville, Spain Francesca Carota, M.S. Department of Maxillofacial Surgery, San Paolo University Hospital, Milan, Italy Shih-Tsung Cheng, M.D. Department of Dermatology, Kaohsiung Medical University, Kaohsiung, Taiwan Christina Chia, B.A. Department of Dermatology, School of Medicine, Saint Louis University, St. Louis, Missouri Vinayak Raghunath Chitale, M.S., F.I.C.S. Maharashtra, India

Chitale Clinic, Solapur,

Siobhan C. Collins, M.D. Department of Dermatology, Brown University School of Medicine and Rhode Island Hospital, Providence, Rhode Island Ernest D. Cronin, M.D., F.A.C.S. Plastic Surgery Department and Residency Program, Christus St. Joseph Hospital, Houston, Texas Joseph L. Cvancara, M.D. Department of Dermatology, David Grant USAF Medical Center, Travis Air Force Base, California Domagoj Delimar, M.D., M.S. Department of Orthopaedic Surgery, Clinical Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia Raymond G. Dufresne, Jr., M.D. Mohs Micrographic Surgery, Department of Dermatology, Brown University School of Medicine, Providence, Rhode Island J. M. Fernańdez-Vozmediano, M.D. Department of Medical-Surgical Dermatology and Venereology, University Hospital of Puerto Real, Cadiz University, Cadiz, Spain Lawrence M. Field, M.D., F.I.A.C.S. International Society for Dermatologic Surgery, University of California at San Francisco, San Francisco, and Stanford University School of Medicine, Stanford, California

Contributors

xix

James L. Fowler III, M.D. Department of Plastic and Reconstructive Surgery, University of Tennessee College of Medicine, Chattanooga, Tennessee Bindumadhav G. Galgali, M.D. India

Chitale Clinic, Solapur, Maharashtra,

Mohan B. Gharpuray, M.D., F.R.C.P.(Edin), F.R.C.P.(Glas) Department of Dermatotherapy and Cosmetology, Maharashtra Medical Foundation, Pune, India Dee Anna Glaser, M.D. Department of Dermatology, School of Medicine, Saint Louis University, St. Louis, Missouri Hugh M. Gloster, Jr., M.D. Cincinnati, Cincinnati, Ohio

Department of Dermatology, University of

Richard C. Hagerty, M.D. Department of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina Joseph Haik, M.D. Department of Plastic and Reconstructive Surgery, The Sheba Medical Center, Ramat-Gan, Israel Kelsey Hamilton, B.S. Division of Dermatology and Cutaneous Surgery, Department of Medicine, University of Florida, Gainesville, Florida Marwali Harahap, M.D. Department of Dermatology, School of Medicine, University of North Sumatra, Medan, Indonesia Shinichi Hirabayashi, M.D. Department of Plastic and Reconstructive Surgery, Teikyo University School of Medicine, Tokyo, Japan Takashi Hirai, M.D. Department of Plastic and Reconstructive Surgery, Nippon Medical School, Kawasaki, Japan Charles H. Hutchins, M.D. Carolina

Gaston Memorial Hospital, Gastonia, North

Mark Jabor, M.D. Plastic Surgery Department and Residency Program, Christus St. Joseph Hospital, Houston, Texas Bogdana Victoria Kadunc, M.D. Dermatologic Clinic, Hospital do Servidor Pu´blico Municipal de S~ao Paulo, S~ao Paulo, Brazil Haim Y. Kaplan, M.D. Department of Plastic and Reconstructive Surgery, The Sheba Medical Center, Ramat-Gan, Israel Martin Hirigoyen Kelly, M.D., F.R.C.S.(Plas) Department of Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital, London, England

xx

Contributors

Tomoharu Kiyosawa, M.D., Ph.D. Department of Plastic Surgery, Institute of Clinical Medicine, Tsukuba University, Tsukuba City, Japan Tamer Koldas, M.D. Department of Reconstructive Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey Yuzo Komuro, M.D. Department of Plastic and Reconstructive Surgery, School of Medicine, Juntendo University, Tokyo, Japan Donald H. Lalonde, B.Sc., M.Sc., M.D., F.R.C.S.C. Plastic and Reconstructive Surgery, Dalhousie University, Saint John, Nova Scotia, Canada Paul O. Larson, M.D. Department of Surgery, University of Wisconsin, Madison, Wisconsin Giorgio Leigheb, M.D. Division of Dermatology, School of Medicine, University of Piemonte Orientale, and Maggiore della Carita´ Hospital, Novara, Italy Mitchell L. Levin, M.D., Sc.M. Department of Ophthalmology, School of Medicine, University of South Florida, Tampa, and Levin Eye Center, Kissimmee, Florida Norman L. Levine, M.D. Division of Plastic Surgery, Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma Alan T. Lewis, M.D. Department of Dermatology, Baylor College of Medicine, Houston, Texas Don Lum, M.D. Department of Dermatology, School for Medical Sciences, University of Arkansas, Little Rock, Arkansas Richard Lum, B.A. Department of Biology, Rhodes College, Memphis, Tennessee David Douglas Madjar, Jr., M.D. Department of Surgery, University of Wisconsin, Madison, Wisconsin Stacey Mandichak, P.A.-C. Department of Plastic Surgery, Jeanes Hospital, Philadelphia, Pennsylvania Carl H. Manstein, M.D., M.B.A. Department of Plastic Surgery, Jeanes Hospital, Philadelphia, Pennsylvania Nalu Iglesias Martins de Oliveira, M.D. Dermatologic Clinic, Hospital do Servidor Pu´blico Municipal de Saõ Paulo, Saõ Paulo, Brazil Mary K. Mather, M.D. Department of Dermatology, Walter Reed Army Medical Center, Washington, D.C. J. Ramsey Mellette, Jr., M.D. Department of Dermatology, University of Colorado Health Sciences Center, Denver, Colorado

Contributors

xxi

L. G. Millard, M.D. Consultant Dermatologist, Queen’s Medical Centre, Nottingham, England Daniel M. Miller, M.D., Ph.D. Ohio

Riverside Methodist Hospital, Columbus,

Michael J. Miller, M.D., F.A.C.S. Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas Nitin J. Mokal, M.S., M.Ch., D.N.B. Department of Plastic and Recostructive Surgery, Grant Medical College; B.J. Wadia Hospital for Children; Gokuldas Tejpal Hospital; and Shushrusha Citizen’s Co-operative Hospital, Mumbai, India Giuseppe Monfrecola, M.D. Department of Dermatology, University of Naples Federico II, Naples, Italy Muhammed Mukhtar, M.D.

Sofia Skin Center, Patna, India

Sharad Mutalik, M.B.B.S., D.V.&D., F.A.S.D.S. Department of Dermatotherapy and Cosmetology, Maharashtra Medical Foundation, Pune, India Yoshio Nakayama, M.D. Department of Plastic Surgery, Institute of Clinical Medicine, Tsukuba University, Tsukuba City, Japan Norbert J. Neumann, M.D. Department of Dermatology, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany Noboru Ohsumi, M.D. Division of Plastic and Reconstructive Surgery, Matsudo City Hospital, Matsudo, Japan Gale B. Oleson, M.D.

Private practice, Blue Springs, Missouri

Ida Orengo, M.D. Department of Dermatology, Baylor College of Medicine, Houston, Texas Clark C. Otley, M.D. Division of Surgical Dermatology, Mayo Clinic, Mayo Medical School, Rochester, Minnesota Shyam Sunder Pandey, M.D. Department of Dermatology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India Parwathi ‘‘Uma’’ Paniker, M.D. Department of Dermatology, University of Colorado Health Sciences Center, Denver, Colorado Effie Pappas, B.S. Division of Dermatology and Cutaneous Surgery, Department of Medicine, University of Florida, Gainesville, Florida Eric C. Parlette, M.D. Department of Dermatology, Naval Medical Center, San Diego, California

xxii

Contributors

Harry L. Parlette III, M.D. Departments of Dermatology, Plastic Surgery, and Otolaryngology–Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia Tina M. Peloro, M.D. Dermatologic Surgery Unit, Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania Fernando Prune´s, M.D. Bakersfield, California

Department of Surgery, Kern Medical Center,

Michael Radonich, M.D. College of Physicians & Surgeons, Columbia University, New York, New York Michael L. Ramsey, M.D. Dermatologic Surgery Unit, Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania William R. Rassman, M.D. New Hair Institute Medical Group, A Professional Corporation, Los Angeles, California De´sireé Ratner, M.D. Department of Dermatology, Columbia Presbyterian Medical Center of the New York Presbyterian Hospital, New York, New York Robert S. Reiffel, M.D. Plastic Surgery Section, Department of Surgery, White Plains Hospital, White Plains, New York Jun Ren, M.D. Department of Plastic Surgery, No. 3 Wuhan Municipal Hospital, Wuhan, People’s Republic of China Randall K. Roenigk, M.D. Department of Dermatology, Mayo Clinic, Mayo Medical School, Rochester, Minnesota Neil S. Sadick, M.D., F.A.C.P. Department of Dermatology, Weill Medical College of Cornell University, New York, New York A. Sagi, M.D. Department of Plastic Surgery, Soroka University Hospital, Ben Gurion University of the Negev, Beer Sheva, Israel Yukimasa Sawada, M.D., Ph.D. Department of Plastic and Reconstructive Surgery, Hirosaki University School of Medicine, Hirosaki, Japan Dwight A. Scarborough, M.D. College of Physicians & Surgeons, Columbia University, New York, New York Walter A. Schroeder, Jr., D.O., M.D., F.A.C.S. Head and Neck Surgery, Cape County Otolaryngology, Cape Girardeau, Missouri Klaus W. Schulte, M.D. Department of Dermatology, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany Joel K. Sears, M.D. Advanced Dermatology and Skin Surgery, Sacred Heart Medical Center, Spokane, Washington

Contributors

xxiii

Ahmet Seyhan, M.D. Department of Plastic and Reconstructive Surgery, Medical Faculty, Celal Bayar University, Manisa, Turkey Payam Shayani, M.D., J.D. Plastic Surgery Department and Residency Program, Christus St. Joseph Hospital, Houston, Texas Ron M. Shelton, M.D. Department of Dermatology, The Mount Sinai Medical Center, New York, New York Robert A. Skidmore, M.D. Division of Dermatology and Cutaneous Surgery, Department of Medicine, University of Florida, Gainesville, Florida Stephen N. Snow, M.D., M.B.A. Division of Plastic Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin Alfred Sofer, M.D. Department of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina Sanda Stanec, M.D., Ph.D. Department of Plastic Surgery, Dubrava Clinical Hospital, University of Zagreb, Zagreb, Croatia Zdenko Stanec, M.D., Ph.D. Department of Plastic Surgery, Dubrava Clinical Hospital, University of Zagreb, Zagreb, Croatia James B. Stewart, Jr., M.D. Division of Plastic Surgery, Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma James M. Swinehart, M.D. Department of Dermatology, Colorado Dermatology Center, Denver, Colorado William Yuk Ming Tang, M.R.C.P. Lek Yuen Social Hygiene Clinic, Lek Yuen Health Centre, Shatin, Hong Kong R. L. Thatte, M.D. Lokmanya Tilak Municipal Medical College & Hospital and Bhatia General Hospital, Mumbai, India Charles B. Toner, M.D. Maryland

National Naval Medical Center, Bethesda,

Carlo Tremolada, M.D. Plastic Surgery Service, Department of Maxillofacial Surgery, San Paolo University Hospital, Milan, Italy Ada Regina Trindade de Almeida, M.D. Hospital do Servidor Pu´blico Municipal de Saõ Paulo, Saõ Paulo, Brazil Satoshi Urushidate, M.D. Department of Plastic and Reconstructive Surgery, Hirosaki University School of Medicine, Hirosaki, Japan Javier Va´zquez-Doval, M.D., Ph.D. Dermacenter, Logron~ o, Spain Paul J. Weber, M.D.

Department of Dermatology,

Private practice, Fort Lauderdale, Florida

xxiv

Contributors

James D. Whalen, M.D. Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut Kazuyoshi Yamanaka, M.D. Department of Orthopaedic Surgery, Saiseikai Kanagawaken Hospital, Yokohama, Japan Akira Yanai, M.D., Ph.D. Department of Plastic Surgery, School of Medicine, Juntendo University, Tokyo, Japan Takatoshi Yotsuyanagi, M.D., Ph.D. Department of Plastic and Reconstructive Surgery, Hirosaki University School of Medicine, Hirosaki, Japan Hsin-Su Yu, M.D. Department of Dermatology, Kaohsiung Medical University, Kaohsiung, Taiwan Mona Zaher, M.D. College of Physicians & Surgeons, Columbia University, New York, New York Irshad Zaki, B.M., B.S, M.R.C.P. Consultant Dermatologist, Heartlands and Solihull NHS Teaching Hospital, Solihull, West Midlands, England

1 Vermilionectomy Using the W-Plasty Technique J. M. Fernańdez-Vozmediano and J. C. Armario-Hita University Hospital of Puerto Real, Cadiz University, Cadiz, Spain

I.

INTRODUCTION

The red mucosa of the lower lip is an anatomical area exposed to multiple irritating factors, including the continuous solar exposure and tobacco smoking. These irritants very frequently cause precancerous conditions such as leukoplasia of the lower lip or actinic cheilitis, which would need in some cases to be surgically removed in order to avoid the development of a spindle cell carcinoma. As in any surgical intervention carried out on the lips, when removing the red portion of the lips, there are some fundamental rules to be taken into account (1), such as: 1. 2.

3.

Avoiding nonesthetic scars and the distortion of the lip. Knowing the anatomy of the lip very well in order to cause as few lesions of the vascular-nervous structures as possible and to a correct suture in planes. The incisions should be made trying to maintain the natural folds in order to hide the scars within the anatomical structures such as the vermilion border or the nasolabial fold. Contrary to the usual recommended way of making lips incisions (i.e., vertical incisions), in the case of vermilionectomies, the incisions should always be horizontal and follow the vermilion border of the lip. 1

Fernańdez-Vozmediano and Armario-Hita

2

4.

5.

The most useful anesthesia in case of the lower lip is nerve blockade that is carried out by infiltrating the chin nerves with local anesthesia. It is appropriate to emphasize that the loss of a third or less of the lip can be directly sutured, whereas bigger defects would need the use of flaps for their surgical correction.

II. VERMILIONECTOMY The removal of the labial vermilion border, or vermilionectomy, is one of the most frequent surgical procedures in dermatological surgery. Among the techniques described for this procedure are conventional surgery, peeling with 5-fluorouracil, cryosurgery, electrosurgery, the radio frequency or laser abrasion with the CO2 laser. However, conventional surgery is the most frequently used, since it is a quite simple technique and with good functional and cosmetic results, whereas the other techniques would be indicated in more localized lesions or would require expensive and sophisticated devices (2). In 1845, Diffenbach was the first to describe vermilionectomy with conventional surgery or the cold scalpel procedure. Langenback modified the technique in 1885 (3). In Spain, one of the first descriptions of the technique was done by Dulanto (4) in 1958, and his indications have been clearly established by one of his best pupils, Serrano (5) (Table 1). The technique to carry out a vermilionectomy requires the usual surgical material for lip surgery and, in general, for any procedure in derma-

Table 1 Indications for Vermillionectomy Primary Precancerous mucocutaneous neoplasms of the lip Actinic cheilitis Leucoplakia of the lips Glandular cheilitis Spindle cell carcinoma in situ without deep infiltration Secondary Overgrowth of the lower lip Malformation of ‘‘double lip’’ Traumatic loss of vermilion Exfoliative cheilitis of Mickulicz-Ku¨mmel Persistent peeling of Brocq lip

Vermilionectomy Using the W-Plasty Technique

3

tological surgery. It is performed with local or regional anesthesia blocking the root of the chin nerves. It is recommended that gauze be placed under the intervened lip and that a suction pump be applied frequently to avoid blood entering the patient’s oral cavity. Next we make two reference stitches with silk at the commissure to diminish hemorrhage and to facilitate handling of the lip. Two elliptic incisions with concave borders and of different length are made on the internal and external borders of the red mucosa of the lip and the whole vermilion border is raised above the labial musculature (6). The lower lip is a very well-irrigated anatomical area; therefore special attention should be paid to hemostasis of the area, fastening if necessary the coronary vessels. Then we depilate the follicles of the anterior border of the lip before suturing, because once the wound is healed, the vertical growth of these hairs can provoke some discomfort in the patient. It is necessary to pull the mucosa forward to avoid the cutaneous hairy area getting inside to form the new lip, which could be quite unpleasant for the patient. Finally, suturing is carried out with thin silk of about 4/0 or 5/0 between the skin and mucosa. In most cases, it is not necessary to detach it, since this causes a slight retraction of the vermilion border which would protect it from future irritation by actinic radiation (7). It is advisable first to make three reference stitches, one central and two lateral, so that an assistant can pull on each hemi-lip and an incision line with the borders in contact is made (8). There is controversy regarding the best technique to close the defect—whether to use a short flap of advance of the mucosa (9) or a longer flap that extends until the gingivallabial wrinkle (10). The postoperative treatment after vermilionectomy is the common one for dermatological surgery, and the correct measures should be observed in order to avoid secondary infections and formation of crust. A good one is the use of local formulations with clorhexidine hydrochlorate at 0.2% and the use of a covering antibiotic. During the first days a liquid diet should be given for 48 h and brandish for 2 days before starting the patient’s usual diet. The secondary immediate complications of vermilionectomy, such as edema, inflammation, or ecchymosis, usually disappear the week after the operation. The advantages that have been described for this technique include a scar with good cosmetic and functional results without complications or collateral effects (11). However, a study to analyze the secondary effects and the complications observed in 52 patients after a year of follow up after vermilionectomy showed that in 15.4% of the cases a sensation of tension developed in the scar, mainly when smiling or when opening the mouth, and in some cases,

4


there was a painful sensation (7.6% of the patients). These sensations were more frequent in the first 3 months after the operation in 65.4% of the patients. Also, 25% of the patients presented persistent paresthesia, 7.7% presented pruritus, and 1.9% presented chronic pain. Regarding the functional alterations, it is appropriate to point out that 3.8% of the patients had permanent difficulties in opening the mouth 1 year after the vermilionectomy (12). When these alterations are associated with paresthesia due to breaking of the nervous fibers in this area, the patient could have real problems in achieving correct oral and facial expressions. Other postoperative effects have been described: scar retractions, usually more frequent at the commissures, a subjective unpleasant sensation, and a palpable scar in many patients. However, it has always been supposed that the scar palpable nodules usually disappear with time or have a very good reaction to infiltration with intralesional corticosteroids (13). Therefore, the complications associated with this technique can be summarized in a transversal and antitensional scar, which could difficult the distension in many cases (laugh or smile) or the contraction (suction) of the lip and it is frequent the appearance of local paresthesias. Due to all the exposed above, we describe a modification of the technique of vermilionectomy, with the performance of a W-plasty that would improve at least the functional results and would allow a better opening and closing of the red mucosa of the lip (14).

III.

VERMILIONECTOMY WITH W-PLASTY TECHNIQUE

Borges (15) described the W-plasty, or technique of excisions in a W pattern, for its application for the treatment of antitensional scars. It is based on the zig-zag technique for constrictive flanges of extremities and of Z-multiple of angles of 90 described by Ombredanne in 1937 (16). With this surgical technique we pretend to hide a scar dividing it into multiple short segments connected with sharp angles (Figures 1 and 2). Moreover, the pathological area is removed with the sacrifice of a minimum quantity of healthy skin, which should be the smallest to facilitate healing during the postoperative period (Figures 3 and 4). We carry out in each of the two incision lines a series of small flaps that are triangular or with sawtooth in form. The arms in angle of the W should have a minimum length of 5 mm. They are not equilateral triangles but have one arm shorter arm than the other to achieve good adjustment of the tensions and irregularities of the scar. On the other hand, it should be always taken into account that in front of a sharp or obtuse angle another of


5

Figure 1 Grazing cheilitis of the lower lip.

Figure 2 W-plasty.

Figure 3 Another case of grazing cheilitis of the lower lip.

Figure 4 Immediate result of the Wplasty.

Design of the technique in

the same angularity should coincide in order to close all the tips of the angle perfectly (Figures 5–8). One must be very careful when carrying out this kind of incision to get the most parallel possible segments, and, since it is a curved line, the line of incision of the external border should have the triangles with the sharpest angles with the purpose of correcting the different lengths of both lines of incision. Some surgeons recommend the use of a scalpel (17), since this way a more perpendicular cut will be achieved. It is indispensible to draw with gentian violet (dermographic pencil) the incision areas before beginning with the procedure (18). In fact, there are ‘‘patterns’’ where the unequal borders of the W are already marked and even blades in the shape of a W.


6

Figure 5 cheilitis.

Figure 7

Technique: chronic actinic

Immediate result.

Figure 6 Design of the W-plasty.

Figure 8 Results after 6 months.

A careful hemostasis should be performed. When suturing, the triangle of skin on one side is advanced until it interdigits with the whole of the opposed side in such a way that the sharp angle of the external line coincides with the internal line’s obtuse angle. A correct suture of the surgical wound can be so carried out. The suture could first require some subcutaneous stitches with reabsorbable suture of 5/0. Then suture each sharp angle with each obtuse angle with semiburied horizontal mattress stitches and finally suture the lateral sides of the triangles with a simple suture of loose stitches until the wound is perfectly closed. The apposition of the borders can be completed with approximation adhesive stitches (Steri-Strip), which should be changed daily for 6 weeks, to act as a support until the wound acquires enough resistance to traction. This


7

technique could be associated in some cases, and depending on the surgical incision made, to a flap in Z or even to other surgical techniques. This surgical technique does not determine the elongation of the cicatricial line, so its main indication is to break a lineal scar into another one with the formation of an accordion or zig-zag, which would provides more elasticity and therefore are more functional and acceptable from the esthetic and functional point of view (Figures 9 and 10). Regarding the main disadvantages of W-plasty, it is appropriate to emphasize its technical complexity, its higher laboriousness, and that incisions in W suppose a bigger sacrifice of tissue, therefore, patients should be carefully selected (Figures 11 and 12).

Figure 9 Actinic cheilitis with small spindle cell carcinoma.

Figure 10

Figure 11 Another case of chronic actinic cheilitis before the treatment.

Figure 12 Results of the W-plasty after 6 months.

Results after 6 months.


8

REFERENCES 1.

2. 3. 4. 5. 6.

7.

8.

9. 10. 11. 12.

13. 14.

15. 16.

17.

Greenway HT. The lips and oral cavity. In: Roenigk R, Roenigk HH, eds. Dermatologic Surgery. Principles and Practice. New York: Marcel Dekker, 1998:409–423. Fields LM. Macrocheiloplasty. Principles and techniques. J Dermatol Surg 1992; 18:503–507. Hernańdez Pe´rez E. Cirugı´ a de la queilitis. In: Cirugı´ a Dermatolo´gica Praćtica. San Salvador: UCA/ed, 1981:151–161. Dulanto F, Sańchez J, Jimenez A. La escisioń del borde rojo labial: tećnicas e indicaciones principales. Medicamenta 1958; 3:3–6. Serrano S. Vermillectomı´ a. Piel 1986; 1:79–80. Fewkes JL, Pollack SV, Cheney L. Lip reconstruction. In: Fewkes JL, Pollack SV, Cheney L, eds. Illustrated Atlas of Cutaneous Surgery. New York: GMP Ed, 1992:32.1–32.13 Katzenellenbogen I, Sandbank M. Cheillitis. In: Andrade R, Gumport SL, Popkin GL, Reeds TD, eds. Cancer of the Skin. Biology-DiagnosisManagement. Philadelphia: Saunders, 1976:607–634. Mazzocchi S, Buttafarro F, Mortera C. Lembi in regione labio-buccale. In: Leigheb G, Tulli A, eds. Manuale de Dermochirurgia. Milan: CILAG Spa Ed, 1990:211–237. Piscacia D, Robinson J. Actinic cheilitis: a review of the etiology, differential diagnosis and treatment. J Am Acad Dermatol 1987; 71:255–264. Field L. Prevention of the ‘prickling sensation’ following surgery for actinic cheilitis. J Am Acad Dermatol 1988; 18:1365. Trias A, Camps A, Semeraro C. Surgical treatment of carcinoma of the lip. J Dermatol Surg Oncol 1982; 8:367–374. Sanchez-Conejo-Mir J, Pe´rez-Bernal AM, Moreno-Gimenez JC, CamachoMartı´ nez F. Follow-up of vermilionectomies: evalutation of the technique. J Dermatol Surg Oncol 1986; 12:180–184. Field LM. An improved design for vermilionectomy with a mucous-membrane advancement flap. J Dermatol Surg Oncol 1991; 17:833–834. Fernańdez-Vozmediano JM, Romero-Cabrera MA, Carrascosa-Cerquero A. Vermilionectomy using the W-plasty technique. J Dermatol Surg Oncol 1989; 15:627–629. Borges AF. Bermellonectomı´ a. In: Borges AF, ed. Cicatrices ineste´ticas. Prevencioń y tratamiento. Barcelona: Labor, 1977:152. Dulanto F, Armijo M. Revisioń de cicatrices. Abrasioń rotatoria. Dermotomı´ a. In: Dulanto F, Armijo M, Camacho F, Naranjo R, eds. Dermatologı´ a Me´dico-Quiru´rgica. Granada: Anel Ed, 1992:1517–1536. Camacho F, Dulanto F. Normas para obtener una buena cicatriz y corregir las defectuosas. In: Camacho F, Dulanto F, eds. Cirugı´ a Dermatolo´gica. Madrid: Aula Me´dica, 1995:101–111.

Vermilionectomy Using the W-Plasty Technique 18.

19.

20. 21. 22. 23. 24.

25.

26.

27. 28. 29. 30.

31. 32

33. 34.

35.

9

Wolfe D, Davidson TM. Scar revision. In: Roenigk RK, Roenigk HH, eds. Dermatologic Surgery. Principles and Practice. New York: Marcel Dekker, 1988:935–958. Greenway HT. The lips and oral cavity. In: Roenigk R, Roenigk HH, eds. Dermatologic Surgery. Principles and Practice. New York: Marcel Dekker, 1998:409–423. Fields LM. Macrocheiloplasty. Principles and techniques. J Dermatol Surg 1992; 18:503–507. Hernańdez Pe´rez E. Cirugı´ a de la queilitis. In: Cirugı´ a Dermatolo´gica Praćtica. San Salvador: UCA/ed, 1981:151–161. Dulanto F, Sańchez J, Jimenez A. la escisioń del borde rojo labial: tećnicas e indicaciones principales. Medicamenta 1958; 3:3–6. Serrano S. Vermillectomı´ a. Piel 1986; 1:79–80. Fewkes JL, Pollack SV, Cheney L. Lip reconstruction. In: Fewkes JL, Pollack SV, Cheney L, eds. Illustrated atlas of cutaneous surgery. New York: GMP Ed, 1992:32.1–32.13 Katzenellenbogen I, Sandbank M. Cheillitis. In: Andrade R, Gumport SL, Popkin GL, Reeds TD, eds. Cancer of the Skin. Biology-DiagnosisManagement. Philadelphia: Saunders, 1976:607–634. Mazzocchi s, Buttafarro F, Mortera C. Lembi in regione labio-buccale. In: Leigheb G, Tulli A, eds. Manuale de Dermochirurgia. Milan: CILAG Spa Ed, 1990:211–237. Piscacia D, Robinson J. Actinic cheilitis: a review of the etiology, differential diagnosis and treatment. J Am Acad Dermatol 1987; 71:255–264. Field L. Prevention of the ‘‘prickling sensation’’ following surgery for actinic cheilitis. J Am Acad Dermatol 1988; 18:1365. Trias A, Camps A, Semeraro C. Surgical treatment of carcinoma of the lip. J Dermatol Surg Oncol 1982; 8:367–374. Sanchez-Conejo-Mir J, Pe´rez-Bernal AM, Moreno-Gimenez JC, CamachoMartı´ nez F. Follow-up of vermilionectomies: evalutation of the technique. J Dermatol Surg Oncol 1986; 12:180–184. Field LM. An improved design for vermilionectomy with a mucous-membrane advancement flap. J Dermatol Surg Oncol 1991; 17:833–834. Fernańdez-Vozmediano JM, Romero-Cabrera MA, Carrascosa-Cerquero A. Vermilionectomy using the W-plasty technique. J Dermatol Surg Oncol 1989; 15:627–629. Borges AF. Bermellonectomı´ a. In: Borges AF, ed. Cicatrices ineste´ticas. Prevencioń y tratamiento. Barcelona: Labor, 1977:152. Dulanto F, Armijo M. Revisioń de cicatrices. Abrasioń rotatoria. Dermotomı´ a. In: Dulanto F, Armijo M, Camacho F, Naranjo R, eds. Dermatologı´ a Me´dico-Quiru´rgica. Granada: Anel Ed, 1992:1517–1536. Camacho F, Dulanto F. Normas para obtener una buena cicatriz y corregir las defectuosas. In: Camacho F, Dulanto F, eds. Cirugı´ a Dermatolo´gica. Madrid: Aula Me´dica, 1995:101–111.

10


36.

Wolfe D, Davidson TM. Scar revision. In: Roenigk RK, Roenigk HH, eds. Dermatologic Surgery. Principles and Practice. New York: Marcel Dekker, 1988:935–958.

2 Running Vertical Mattress Suture Technique Stephen N. Snow and David Douglas Madjar, Jr. University of Wisconsin, Madison, Wisconsin

I.

INTRODUCTION

The running vertical mattress (RVM) suture technique is a quick method of closing defects while everting the skin for optimum epidermal apposition (1–3). The technique consists of two loops: a near-near skin loop that apposes the skin edges and a far-far loop that is tunneled under the skin to evert the skin edges. As viewed from above, the running VM suture has a running Z configuration.

II. SUTURE TECHNIQUE The RVM suture technique begins by tying a simple interrupted suture at one end of the defect. The suture knot is placed on the far side of the linear closure and distant to the operator. The far-far loop is placed first. The needle is offset from the knot (2–3 mm) and reinserted into the skin (about 4–5 mm) from the closure line at a 45-degree angle to the closure line. The diagonally angled needle is tunneled under the closure line and perforates the skin on the opposite side equidistant from the closure line. The needle is then reversed in the needle driver and perpendicular to the closure line a near-near (about 2 mm) loop is performed (sewing away from the operator). Our method of obliquely bury11

12

Snow and Madjar

Figure 1 The RVM suture is started with a simple interrupted suture tied at the apex of the wound to be closed. The free suture tail is cut but not the suture attached to the needle. The needle is then offset 3–4 mm and reinserted into the skin in an oblique direction. The needle is tunneled in the subcutaneous tissue (best sewn toward the surgeon) to the opposite side of the wound closure to exit the skin 5–8 mm from the closure axis. The near-near skin loop is then performed in line with the previously placed exit of the far loop.

Figure 2 The second row of the RVM sutures begins with the placement of the far loop. The needle is reinserted into the skin about 5–8 mm from the closure axis in line with the near-near loop. The needle is obliquely tunneled through the subcutaneous tissue (as performed in Fig. 1) to exit the skin on the opposite side of the closure axis.

Figure 3 The near-near loop is then performed. The completed first row is present showing the far-near-near-far suture sequence linear alignment.

Figure 4 Incomplete second row of RVM sutures. The far-near-near needle entrance and exits points are shown. To complete the second row, the final far suture needs to be placed.

Running Vertical Mattress Suture Technique

Figure 5 Completed third row is shown, and the exit point of the middle loop (average distance between far and near points) is shown. The middle loop is generated at the beginning and end of the RVM sutures. The distance from the closure axis, for the middle loop, is usually the average distance of the farnear needle puncture sites from the closure axis. This is done to equalize the tension vectors across the closure axis.

13

Figure 6 The near-far loop is lengthened by gathering an extra length of suture. The double loop of suture is tied to the free suture to complete the RVM suture.

ing the connecting suture link between consecutive VM sutures differs from the traditional running VM (4). A.

Distribution of Tension Across the Closure

In the classic VM suture, the tension is distributed directly across the closure line vertically aligned with the near-near and far-far suture loops. In the running VM suture, the far-far loop is used actually to begin and end each near-near loop cycle. The Z configuration thus formed changes the distribution of tension from directly across the wound edges (classic VM suture) to an oblique direction. Ideally, the tension across each far-far loop should be visibly equal; otherwise the unequal tensions would skew the alignment of the near-near loops. Redistribution of the tension across the entire length of the wound closure can be achieved by gently massaging the closure site with a wet gauze to press out the tight areas before the last stitch is securely tied. Unequal tensions across the closure line would affect the scar’s appearance and integrity. The VM suture technique has been shown to increase wound tensile strength in the early postoperative period (5). A variation of the VM suture can also be used as a buried VM suture to appose subcutaneous tissue (6).

14

Snow and Madjar

Figure 7

III.

RVM sutures completed in three rows.

CONCLUSION

The running vertical mattress suture technique is an excellent and rapid technique to evert skin edges for optimum wound healing.

ACKNOWLEDGMENT We thank Michael Hetzer, HS, ASAP, for his help in preparing the digital photographics.

REFERENCES 1. 2.

3. 4. 5. 6.

Stiff MA, Snow SN. Running vertical mattress suturing technique. J Dermatol Surg Oncol 1992; 18:916–917. Snow SN, Goodman MM, Lemke BN. The shorthand vertical mattress stitcha rapid skin everting suture technique. J Dermatol Surg Oncol 1989; 15:379– 381. Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol 1992; 18:785–795. Kolbusz RV, Bielinski KB. Running vertical mattress suture. J Dermatol Surg Oncol 1992; 18:500–502. Oki LN. Increased wound tensile strength with use of vertical mattress stitches (Abst). J Dermatol Surg Oncol 1990; 16:82–83. Sadick NS, D’Amelio DD, Weinstein C. The modified buried vertical mattress suture. J Dermatol Surg Oncol 1994; 20:735–739.

3 Dual Use of Monofilament Poliglecaprone in Layered Closure: Buried and Cuticular Paul J. Weber Private practice, Fort Lauderdale, Florida

Gale B. Oleson Private practice, Blue Springs, Missouri

I.

INTRODUCTION

Although the perfect suture material does not yet exist, the suture should have no tissue reactivity, tie reliably, and be applicable to a wide variety of uses. Unfortunately, such a material does not yet exist; the surgeon has to compromise by using the best available suture for the particular surgical requirement. Although not perfect, the monofilament poliglecaprone suture has been found to result in excellent scars when used combined buried and cuticular fashion.

II. DISCUSSION Braided polyglactin has been used simultaneously as both buried and surface suture material (1). We propose the use of monofilament poliglecaprone (Monocryl, Ethicon Inc., Somerville, NJ) as a preferred suture for the combination of simultaneous buried and surface suture. The use of poliglecaprone, an absorbable suture, can yield the same benefits and results 15

16

Weber and Oleson

as polypropylene (Prolene, Ethicon Inc.), a nonabsorbable suture. Polypropylene monofilament is an excellent cuticular suture. Multifilament or braided sutures (Vicryl-rapide) have been shown to result in an increased incidence of hypertrophic scar and keloid formation compared to Monocryl (2). There may be some concern that braided multifilament suture may interfere with the body’s healing by causing tearing and shearing bleeding as well as discomfort with suture removal. In the original report of the use of Vicryl, nearly 500 patients were studied and no untoward effects were observed (1). It is possible that different observers may vary in their threshold for observation of untoward effects. A study of intradermal Vicryl showed more early tissue reaction with the braided material than with monofilament Monocryl (3). This reaction was not noted at late evaluation. There do not appear to be any undesirable tissue effects with the use of poliglecaprone. The use of a single suture material for subcuticular and cuticular closure may have a financial advantage over the use of multiple different sutures, because less would be wasted. There are multiple applications for the use of poliglecaprone. Face-lift and elliptical defects of the face may be closed with subcuticular 4-0 or 5-0 poliglecaprone followed by a running subcuticular or cuticular poliglecaprone suture. Elliptical defects of the back can be closed with buried interrupted 1-0 or 0-0 poliglecaprone followed by a running cuticular closure with the same suture. Facial or appendigeal advancement rotation, unilateral advancement, transposition, rhombic, and subcutaneous island pedicle flaps are securely sutured by buried, interrupted poliglecaprone followed by a running subcuticular suture and occasional interrupted cuticular sutures. Usually three knots will secure a poliglecaprone suture whether buried or exposed. Sutures tie relatively well using an initial bubble knot if less tension is described; however, slippage may occur without the use of four knots. A running poliglecaprone subcuticular suture can be left untied at the ends. The suture maintains its placement well and may be removed by the patient by pulling on one end a week or two after surgery. A benefit of the clear poliglecaprone suture is that patients are socially presentable, with only a thin wound covering of antibiotic ointment without a bandage (Figures 1 and 2). This is especially true with blepharoplasty incisions approximated with buried interrupted and subcuticular or cuticular 7-0 poliglecaprone sutures.

III.

CONCLUSIONS

We have been using this technique with poliglecaprone for the past 5 years after attempting to use polydioxanone suture without success. No adverse

Monofilament Poliglecaprone Suture

17

(A)

(B)

(C)

Figure 1 (A) A 40-year-old woman preoperatively with malignant melanoma of the left inferior lateral-posterior neck. (B) Patient’s appearance immediately postoperatively. (C) Wound almost completely healed.

18

Weber and Oleson

(A)

(B)

Figure 2 (A) Lesion of right side of the face preoperatively. (B) Appearance immediately postoperatively.

effects have been observed when compared to polypropylene. Poliglecaprone can be used for both buried and surface closure.

REFERENCES 1. 2.

Fosko SW, Heap D. Surgical Pearl: An economical means of skin closure with absorbable suture. J Am Acad Dermatol 1998; 39:248–50. Niessen FB, Spauwen PHM, Kon M. The role of suture material in hypertrophic scar formation: Monocryl vs. Vicryl-rapide. Ann Plast Surg 1997; 39:254–260.

Monofilament Poliglecaprone Suture 3.

19

Kirpensteijn J, Maarschalkerweerd RJ, Koeman JP, Kooistra HS, van Sluis FJ. Comparison of two suture materials for intradermal skin closure in dogs. Vet Q 1997; 19:20–22.

4 Short-Hand Vertical Mattress Stitch: A Rapid Skin-Everting Suture Technique Stephen N. Snow and David Douglas Madjar, Jr. University of Wisconsin, Madison, Wisconsin

I.

INTRODUCTION

Whenever wounds need to be closed that require skin eversion, the shorthand vertical mattress (VM) suture technique deserves consideration (1). The technique produces the results of the classic VM suture with a shorter operative time (2). The classic VM suture consists of two loops. An inner loop called the near-near and the outer loop referred to as the far-far. In the classic VM suture, one starts with the far-far component and then the near-near loop is performed. In the far-far component, the needle is inserted through the skin at a distance (5–10 mm) from the line of closure. Then the needle is picked up, regrasped, and reinserted into the subcutaneous tissue to pierce the skin at an equidistant point from the line of closure and opposite the first insertion. The near-near component of the VM suture is similar to placing a simple interrupted suture 1–2 mm from the closure line.

II. SUTURE TECHNIQUE The short-hand VM suture technique is the reverse of the classic VM suture technique. In the short-hand VM suture technique the near-near loop is performed first and then the far-far loop. The near-near loop is performed 21

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Snow and Madjar

as if inserting a simple interrupted suture. Then about 3 in. of the suture tail and a proximal portion of the suture are grasped (with the thumb and index finger together) while gently pulling the skin edges upward. Lifting the skin causes the skin to tent, which brings both skin edges in closer approximation than if no tension was applied across the skin edges. Tenting allows the farfar loop to be placed in a single twist of the wrist. The stitch is then tied using the typical surgeon’s knot. Holding the skin edges in this suspended fashion allows the surgeon to see readily how the wound edges are going to come together. The placement of the deep far-far loop will set the skin edges in the position most desired by the surgeon. Both the classic and short-hand VM suture techniques use two loops, an inner and an outer, to complete the technique. The advantage of the short-hand VM suture is that, in experienced hands, it only requires two wrist motions to complete the technique, whereas in the classic VM suture there are four separate wrist motions. Inherent in both the classic and short-hand VM suture techniques is the need to reverse the needle. Whether one starts with the near-near or farfar insertion, suturing the second loop requires needle reversal in which the hand is pronated medially. With the short-hand VM suture technique, we

Figure 1 The shorthand VM suture technique is begun with placement of the near-near loop. The entry and exit points are equidistantly placed about 1–3 mm from the closure axis. The needle is pulled through until approximately 3–4 in. of suture tail remain. In anticipation of placing the next stitch, which is the far-far loop (not shown), the needle is grasped with the needle driver.

Figure 2 Before the far-far loop is placed, both the proximal portion of the suture (3–4 in.) and the distal end of the free suture are grasped together between the thumb and forefingers of the left hand (for right-handed surgeons). The skin is gently lifted superiorly, tenting the skin, which narrows the distance that the far-far loop has to travel.

Short-Hand Vertical Mattress Stitch 23

Figure 3 With the skin stabilized in the tented position, the far-far loop is placed with one sweeping rotation with the right wrist.

Figure 4 An attempt is made to place the entrance and exit points of the farfar loop equidistantly from the closure axis to balance out the closure tension across the wound.

Figure 5 Appearance of the shorthand VM suture after the near-near and farfar loops are placed.

Figure 6 The surgeon’s knot is then tied securing the VM suture. At completion, the far-near-near-far sequence of the shorthand VM suture should have a linear alignment perpendicular to the closure axis. For right-handed surgeons, the shorthand VM suture is best performed with the anticipated closure axis oriented in the 10 to 4 o’clock direction. The easier near-near suture is placed with a backhand pronation of the wrist. This allows the more difficult far-far loop to be placed with the dominant forehand wrist rotation, sewing toward the surgeon.

24

Snow and Madjar

have found that it is easier to sew first the near-near loop using reverse pronation. The near-near loop is usually so narrow that it does not require much special surgical skill to perform. Then the far-far loop, which is the stabilizing and more difficult to perform, is placed with the forehand in the supinated position, which is the dominant suturing position. Variations of the classic VM suture technique include the buried VM suture technique and the running VM suture techniques to increase epidermal-dermal wound apposition, decrease surgical time, and speed wound healing suture technique (3,4).

III.

CONCLUSIONS

Learning a new technique requires patience and practice. We have found the short-hand VM suture technique to be very fast, efficient, and equally effective in everting skin edges as the classic VM suture techniques. It is also one of the more enjoyable suture techniques to perform, because the sense of satisfaction is far greater than the effort to perform the procedure.

ACKNOWLEDGMENT We thank Michael Hetzer, HS, ASAP, for his help in preparing digital photographics.

REFERENCES 1. 2.

3. 4.

Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol 1992; 18:785–795. Snow SN, Goodman MM, Lemke BN. The shorthand vertical mattress stitcha rapid skin everting suture technique. J Dermatol Surg Oncol 1989; 15:379– 381. Sadick NS, D’Amelio DD, Weinstein C. The modified buried vertical mattress suture. J Dermatol Surg Oncol 1994; 20:735–739. Kolbusz RV, Bielinski KB. Running vertical mattress suture. J Dermatol Surg Oncol 1992; 18:500–502.

5 Modified Buried Vertical Mattress Suture: A New Technique of Buried Absorbable Wound Closure Associated with Excellent Cosmesis for Wounds Under Tension Neil S. Sadick Weill Medical College of Cornell University, New York, New York

I.

INTRODUCTION

Recent modifications of mattress suturing techniques have been reported producing rapid and effective skin eversion and excellent tensile strength while producing cosmetically esthetic results. Such closure should in addition minimize postoperative complications, whereas at the same time be performed easily and efficiently. A summary of optimal goals of elliptical wound closure is summarized in Table 1. A new variant of buried vertical mattress suturing techniques, the modified buried vertical mattress suture, presented here accomplishes many of the above aforementioned goals and is further evaluated in this chapter.

25

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Sadick

Table 1 Major Goals of Optimal Wound Closure Precise wound edge opposition Reduction of dermal tension Prevention of suture tracking Optimal cosmesis Minimal postoperative care, including dressing changes and suture removal Minimal postoperative complications, including wound infection, bleeding, dehiscence, and hypertrophic scarring

II. TECHNIQUE The modified buried vertical mattress suture is best accomplished utilizing 40-monocryler 5.0 monocryl suture (Ethicon Inc., Sommerville, NJ). Alternative 4-0 Vicryl, 5-0 Vicryl, or PDS-4-0 or PDS-5-0 may be employed. The advantage of monocryl is its long-lasting resiliency of approximately 3–4 weeks prior to its absorption, which is an advantage compared to the absorbable suture materials. This technique has its greatest practical usage when performed in areas of the body where there is uniform tension and thicker skin such as the trunk and proximal extremities. The precise steps for carrying out the modified buried mattress suture procedure are presently outlined as follows: Step 1: The needle is inserted in the near side of the wound deep through the reticular dermis depth of approximately 5–8 mm (Figures 1 and 2). Step 2: The needle is then brought out through the near side of the wound edge approximately 4–6 mm from the wound edge. Step 3: The needle is then passed obliquely into the same puncture site penetrated in Step 1; however, it is angulated so that it passes through the skin edge superficially and is brought back into the center of the wound (Figure 3; see Figure 1B). Step 4: The needle is then inserted into the far side of the wound at the same superficial level at an equidistant point as in Step 2 (Figure 4; see Figure 1C). Step 5: The needle is brought out from this point and then redirected to the same puncture site. Step 6: The needle is then reinserted into the same puncture site as Step 4 and then reangulated so that it exits from the site again into the center of the wound at a symmetrical reticular dermal level as in

Modified Buried Vertical Mattress Suture

27

Step 1 at a depth of approximately 5–8 mm (Figure 5; see Figure 1D). Step 7: The suture is then tied in a curved fashion utilizing a surgeon’s knot with an instrument to conclude the technique (Figure 6; see Figure 1E).

Figure 1 Schematic diagram demonstrating buried vertical mattress suturing technique. (A) Initial needle insertion. (B) Oblique superficial needle reinsertion. (C) Far side wound needle reinsertion. (D) Reinserted reangulated needle (same puncture site exiting center of wound). (E) Buried surgeon’s knot.

28

Figure 1

Sadick

(Continued)


Figure 2

29

Initial needle insertion through the reticular dermis.

Figure 3 Reinsertion of the needle obliquely through papillary dermis at the same puncture site.

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Sadick

Figure 4 Insertion of needle into far side of wound at papillary dermal symmetrical level.

Figure 5 Reinsertion of needle through same (Step 4) puncture site exiting center of wound at reticular dermal level.


Figure 6

III.

31

Completion of deep bilayered loop with buried tied surgical knot.

PREVIOUS STUDIES

In a previous double-blinded study, the author found that the modified buried vertical mattress suture technique produced less hypertrophic scar and keloid formation: 2 versus 16% for the conventional bilayered closure technique (1). It also was associated with less wound scar spread: 6 versus 24% for the conventional bilayered suturing technique. Infection rate, dehiscence, and suture reaction complications were comparable to conventional techniques. The modified buried vertical mattress surgical technique was also associated with a high degree of patient satisfaction (Table 2). Recent variations of the modified buried vertical mattress suturing technique include that reported by Zitelli et al. (2,3). This suture technique provides excellent wound edge eversion and prolonged support without permanent suture marks. However, running cutaneous or interrupted sutures may be necessary for exact wound edge approximation utilizing this technique. Snow et al. (4) described the short-hand vertical mattress suture as a means of providing rapid skin eversion. With this technique modification, blind placement of a deep loop is performed; a technical modification as well as post-operative follow-up for suture removal.

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Sadick

Table 2 A Comparison of Buried Vertical Mattress Suture vs Conventional Bilayered Closure Techniques (50 Patients) Buried vertical mattress suture technique

Standard bilayered closure

No. of patients

%

No. of patients

%

P

2 (50) 1 (50)

4 2

3 (50) 8(50)

6 16

NS 5 mg/kg) and sedation were supervised after the operation.

III.

PATIENTS AND INDICATIONS

Regardless of secondary disorders, all patients scheduled for surgery in local anesthesia underwent this kind of anesthesia. No suprarenin was added for

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Breuninger

Figure 1 SITA of a basal cell carcinoma. The anesthetic fluid spread beneath the tumor to all sides.

nerve blocks of the fingers and penis. We carried out a total of 5020 surgical procedures on 3270 patients (age 0.5 to 95 years; median 54 years). The 3935 minor procedures (78.4%, n ¼ 2257 patients) involved, for example, excisions of tumors, nevi or scars, defect reconstruction, and all kinds of flaps or transplantations in the head and neck area, including the nose and ear. The 573 medium procedures (11.4%, n ¼ 515 patients) involved, for example, giant nevi, large scar revisions, larger tumors, acne inversa of the trunk and proximal extremities, full-face anesthesia, and sentinel lymphnode biopsy. The 512 major procedures (10.2%, n ¼ 498 patients) involved, for example, stripping operations of the saphenous veins and lymph node dissection in the groin and axilla.

IV.

RESULTS

Ninety-six percent of 542 patients who had previously experienced other forms of anesthesia (general or regional anesthesia) for the same kind of operation preferred SITA, as did all 778 who had previously undergone conventional syringe injection. The duration of action of ropivacaine mixed with prilocaine in 3270 patients was significantly longer than that of prilocaine alone. Some patients

Automated Subcutaneous Infusion Tumescent Anesthesia

197

underwent surgery 4 h after SITA without any pain. Postoperative freedom from pain lasted 5 h on the average (minimum 1.3 h; maximum 23 h). Nineteen percent of the patients reported no noteworthy pain after the operation. Not a single minor or major incident involving local anesthesia occurred in any patient treated with the mixture of ropivacaine or with prilocaine or ropivacaine alone. Particularly noteworthy is the fact that not a single instance of clinically observable methemoglobinemia occurred in the mixture group. Intravascular injection occurred briefly in five patients during infiltration around the long saphenous vein. The epinephrine in these instances caused tachycardia of 150/min, which was seen immediately in the monitor; the pulse normalized again in all cases within a few minutes without the need of therapy.

V.

DISCUSSION

SITA proved to be effective for slow paravenous infusion into subcutaneous areas (2). Since no human hand can perform injection as slowly and steadily as a machine, this technique made local anesthesia painless and comfortable. The fluid permeated the subcutaneous layer slowly automated without assistance. The diluted anesthetic solution with the epinephrine additive persisted for a very long time in the subcutis, with consequent very low blood levels (3). The unit’s volume control prevented overinfusion. Since aspiration is impossible and there is no backflow in the infusion system, it was possible to use a 500-mL infusion bottle for more than one patient (maximum of 2 days), changing only the endpiece of the infusion tube. Use of a pulsoximeter is necessary to detect intravascular injection early by heart beat acceleration as an effect of the epinephrine. Moreover, after setting up the system during pulsoximetry and making sure that there was no intravascular infusion, the physician was able to perform anesthesia on another patient or to leave the room, leaving a nurse to monitor the patient. This proved to be calming, especially for children (we treated more than 300 children) and very anxious patients. SITA normally lasted from a few minutes to 20 min for minor operations and up to 55 min for major surgery. During this time, the patient reclined comfortably in bed or sat in a chair. The addition of long-acting ropivacaine to prilocaine (50% equivalent dose) prolonged the effectiveness of anesthesia considerably, so that it was not always necessary to carry out the surgical procedure immediately after the conclusion of local anesthesia.

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Breuninger

Figure 2 Two infusomats are used to perform SITA for wide excision of a melanoma of the forearm and for the sentinel lymph node biopsy of the axilla.

Ropivacaine has been shown by studies to be effective three times as long as lidocaine (4,5) and to have little toxicity and few side effects on the central nervous and cardiac systems (6,7). The combination of prilocaine and ropivacaine also reduced the specific side effects of the individual substances, in particular methemoglobinemia. A trial with test subjects showed that the mixture of local anesthetics described here widened the spectrum of their individual actions, since they differ in their individual effects (1). The use of different concentrations permitted better adaptation to the requirements of the operation. The concentration also determined the speed with which the anesthetic took effect. Postoperative pain returned notably later than with prilocaine alone, and was in fact either absent or only slight in 19% of the patients. All our

Automated Subcutaneous Infusion Tumescent Anesthesia

199

Figure 3 SITA is very helpful for local anesthesia in children without pain. It is used here to excise a nevus of the scalp.

patients took their meals with normal frequency preoperatively and postoperatively, and postoperative recovery was fast. Nearly all patients who had previously experienced general or regional anesthesia for the same kind of surgery and all who had had local syringe injection preferred SITA.

VI.

CONCLUSIONS

Automated SITA with mixed solutions of prilocaine and ropivacaine is an economical, safe, long-lasting, and comfortable technique for nearly all operations of the skin, even for children and very sensitive patients. However, selection of the most suitable concentrations, needles, needle positions, flow rates, and volumes requires some experience.

REFERENCES 1. 2.

Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987; 4:263–267. Breuninger H, Wehner-Caroli J. Slow infusion tumescent anesthesia (SITA). J Dermatol Surg 1998; 24:759–763.

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3.

Schimek F, Novgova L, Breuninger H. The effects and plasma levels of ropivacaine after the subcutaneous administration. Anesth Analg 1999; 88(suppl):279. Breuninger H, Hobbach PS, Schimek F. Ropivacaine, an important anesthetic agent for low infusion and other forms of tumescent anesthesia. J Dermatol Surg 1999; 25:799–802. Breuninger H, Schimek F, Heeg P. Subcutaneous infusion anesthesia with diluted mixtures of prilocain and ropvacain Langenbecks Arch Surg 2000; 385:284–289. Feldman HS, Arthur R, Covino BG. Comparative systemic toxicity of convulsant and supraconvulsant doses of intravenous ropivacaine, bupivacaine and lidocaine in conscious dog. Anesth Analg 1989; 69:794–801. Ruetsch YA, Fattinger KE, Borgeat A. Ropivacaine-induced convulsions and severe cardiac dysrhythmia after sciatic block. Anesth 1999; 90:1784–1786.

4.

5.

6.

7.

34 Use of a Combination Nail Elevator and Hemostat Clamp: Innovative Instruments for Nail Avulsion Joel K. Sears Sacred Heart Medical Center, Spokane, Washington

I.

INTRODUCTION

Nail avulsion is the most common nail operation. Multiple indications for removal of the nail plate include onychocryptosis, nail deformity, extensive nail infection, trauma, or evaluation of underlying neoplasm. Total nail avulsion refers to the removal of the entire nail plate from its two foci of adherence, the nail bed and the proximal nail fold. A variety of methods for total nail avulsion have been described, including chemical avulsion, distal approach and surgical avulsion, and proximal or anterior approach surgical avulsion. By far the most common technique for nail avulsion is the surgical distal approach. For this technique a blunt surgical instrument is introduced under the distal free edge of the nail plate and pushed proximally to the matrix. The instrument is then withdrawn and reinserted repeatedly in a linear longitudinal fashion over the entire nail bed to separate the nail plate from the underlying nail bed. The proximal nail fold can be loosened in a similar fashion by inserting the blunt instrument back and forth between the horny layer of the proximal nail fold and the nail plate. After

Adapted from Sears JK. The use of a combination nail elevator and hemostat clamp: new instruments for nail avulsion. J Dermatol Surg Oncol 1992; 18(3):223–225. Reprinted by permission of Blackwell Science, Inc.

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Sears

the nail is freed from the bed, the plate is grasped with a clamp and removed with pulling traction and rolling motion.

II. CURRENT INSTRUMENTATION A variety of instruments have been used to perform total nail avulsions. Some surgeons advocate using only a straight, blunt-ended hemostat (Figure 1A). With this technique, one blade of the hemostat is used to dissect free the nail plate. After the nail is freed from its nail bed attachment, the hemostat is clamped down and the nail lifted from the digit. Advantages of the hemostat clamp are the ratchet-action clamp for securing the plate and the finger loop handles for better maneuverability. Thus, nail avulsion may be performed with a single surgical instrument that is relatively inexpensive and readily available to the dermatological surgeon. Disadvantages of using the hemostat clamp exclusively for nail avulsions are that the hemostat blade is narrow and requires several passes back and forth to loosen the nail plate unevenly from the nail bed. The undersurface of the blade is not flat but rounded, and several passes between the adherent nail plate and the delicate nail bed may cause unnecessary trauma. Alternatively, a nail elevator or dental spatula may be inserted under the nail plate to free it from its points of adherence. The spatula is thin, flat, and operates on a wider surface area, thus allowing removal of the plate with fewer strokes and less potential for trauma to the nail bed and matrix. After the nail plate is freed, the spatula is set aside and the plate is then clamped with a hemostat and lifted from the digit. An alternative to the dental spatula is the Freer septum elevator (see Figure 1B). The convex and concave surfaces of this instrument closely match the curved surface of the nail plate and nail bed. It is also useful in defining the proximal nail groove and retracting the proximal nail fold. Although a spatula or elevator allows clean, efficient separation of tissue with less potential for trauma, this technique still requires the use of a second instrument, such as a hemostat clamp or its equivalent, to grasp and pull the nail, thereby requiring multiple instruments and increasing procedural steps. Another instrument used for nail avulsions is the platypus nail-pulling forceps (see Figure 1C). This instrument is sturdy, has a flat blade for clean, less traumatic undermining of the plate, and is designed to avulse without the need of a second instrument. However, the platypus lacks certain advantageous design characteristics found on the hemostat clamp; namely, finger loops on the handle, which provide better control and easier maneuverability, and the ratchet-action clamp, thereby preventing clamping and securing capability.

Use of a Combination Nail Elevator and Hemostat Clamp

203

Figure 1 Illustration comparing blunt-ended hemostat (A), Freer septum elevator (B), and the platypus nail-pulling forceps (C).

III.

COMBINATION INSTRUMENTS: DESIGN AND USE

Two instruments have been designed that combine the useful design specifications of a hemostat clamp with a nail elevator spatula or a Freer septum elevator. Specifically, one blade of a modified hemostat is replaced with a nail elevator device allowing nail elevation, clamping, and removal with a single instrument.

A.

Design

The first, called the Sears nail avulsion clamp (George Tiemann, New York), combines a modified hemostat with a rigid nail elevator spatula. A sturdy, straight 6-inch hemostat is modified by altering the grooved surface of the blades and by forming central bowing of the blades (Figure 2). The bowing of the blades provides space for the distal tip of the nail plate when the instrument is clamped down. Without this bowing, the nail plate would act as a fulcrum preventing effective grasping at the distal tip of the clamp forceps. One of the hemostat blades is replaced with a regular rigid nail elevator spatula with preservation of the grooved surface. No further alterations are made on the other blade. The nail elevator tip extends approximately 5 mm beyond the tip of the other blade so that the skin of the proximal nail fold will not be clamped when the elevator is passed over the proximal matrix.

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Sears

Figure 2 Sears nail avulsion clamp. One of the bowed hemostat blades is replaced with a nail elevator spatula with preservation of grooved surface.

The second instrument, called the Iowa-Freer avulsion clamp (George Tiemann, New York), combines the usefulness and practicality of a straight hemostat with the elegance of a Freer septum elevator (Figure 3). One of the hemostat blades is replaced with a blade in the shape of a Freer septum elevator. A grooved surface is made on the concave side. The remaining hemostat blade is curved to correspond with the curve of the Freer-shaped blade but is otherwise left unaltered.

Figure 3 Iowa-Freer avulsion clamp. One of the hemostat blades is replaced with a blade in the shape of a Freer elevator.

Use of a Combination Nail Elevator and Hemostat Clamp

B.

205

Technique

The Sears nail avulsion clamp and the Iowa-Freer avulsion clamp are both used in a similar, simple fashion. The avulsion clamp is held as you would normally hold a hemostat clamp. The elevator tip is inserted under the nail plate to dissect free the plate from the nail bed (Figure 4). With the elevator tip still in place under the nail plate, the instrument is then clamped down to grasp the nail plate. The nail plate is then removed intact with a rocking and pulling motion. The Sears nail avulsion clamp is best used for total nail avulsions of larger or thicker nails. The Iowa-Freer avulsion clamp can also be used for total nail avulsions, but because it is narrower than the common nail elevator spatula, it is better equipped to avulse fingernails, smaller toenails, or a portion of the nail during partial nail avulsion.

IV.

CONCLUSIONS

The useful design specification of a hemostat clamp for its use in nail avulsions is combined with the advantages of using a nail elevator for nail plate undermining to make a single instrument for nail avulsions. The Sears nail avulsion clamp and the Iowa-Freer avulsion clamp are easy to use, practical, and inexpensive instruments for more efficient and less traumatic nail avulsion.

Figure 4 Inserting the avulsion clamp. After elevating the nail, it is then clamped and removed intact all with the same instrument.

35 Acne Surgery Utilizing the Versatile Paper Clip Comedo Extractor Joseph L. Cvancara David Grant USAF Medical Center, Travis Air Force Base, California

I.

INTRODUCTION

Since the 1870s when Dr. Henry Piffard first devised an acne instrument, comedo extractors have been used in physicians’ offices. Contemporaries Jay Frank Schamberg and Paul Gerson Unna improved on Piffard’s instrument, modifications that are still used (1). Today, many designs and prices exist, ranging from disposable $3 to reusable $40 instruments (2). Cvancara and Meffert (3) reported an effective and simple comedo extractor design utilizing ordinary paper clips.

II. INSTRUMENT AND METHOD Several steel wire large (jumbo) and regular (#1) paper clips can be packaged and autoclaved for convenient use. Autoclaving does not rust or affect the ductile nature of the paper clip, but depending on the brand, may tarnish the wire. When a patient presents with a comedo or cyst that needs expression, a paper clip is easily bent and sized to be slightly larger than the lesion (Figures 1 and 2). Direct vertical pressure is exerted by this instrument circumferentially around the follicular opening or cystic lesion, increasing the forces within the dermis, resulting in extrusion of its contents onto the skin surface (Figure 3). For closed comedones and cysts, the top of the lesion is gently nicked with a #11 blade or 18-gauge needle prior to pressure 207

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Cvancara

Figure 1 Numerous configurations demonstrating the paper clip’s versatility. (Courtesy of JAAD, Mosby 1999.)

Figure 2 Cyst and paper clip comedo extractor prior to expression. (Courtesy of JAAD, Mosby 1999.)

The Versatile Paper Clip Comedo Extractor

209

Figure 3 Cyst and paper clip comedo extractor during expression. (Courtesy of JAAD, Mosby 1999.)

extraction. Since open comedones do not have an epidermal covering, no additional tissue manipulation is required.

III.

CONCLUSION

This versatile disposable instrument is economical and convenient, especially for those physicians who are involved in various satellite clinic visits, humanitarian work, or military deployments.

REFERENCES 1. 2. 3.

Parish LC. Historical Aspects of Cutaneous Surgery. In: Wheeland RG, editor. Cutaneous Surgery. Philadelphia (PA): W.B. Saunders Company; 1994. p. 4–5. Dermatologic Buying Guide. Council Bluffs (IA). Dermatologic Lab & Supply, Inc. (Delasco), 1998. p. 91, 117. Cvancara JL, Meffert JJ. Surgical Pearl: Versatile paper clip comedo extractor for acne surgery. J Am Acad Dermatol 1999; 40:477–478.

36 Skin Hook Forceps Donald H. Lalonde Dalhousie University, Saint John, Nova Scotia, Canada

I.

INTRODUCTION

The skin hook forceps was invented because it combined the advantages of: 1. 2. 3.

Double opposing skin hooks for skin manipulation. The jaws of a needle holder (driver) for needle manipulation. The frame of the Adson forceps.

The most commonly used forceps for skin manipulation in the later half of the twentieth century has been the Adson forceps. This is because the frame fits comfortably in the hand and the size of the forceps is just right. This is the reason that the skin hook forceps was originally built on to the Adson frame. Some surgeons do prefer Castravjego forceps or round-handled forceps, and therefore the skin hook forceps is also now available in Castravjego handle and round-handled models. One of the disadvantages of the Adson forceps is that it uses teeth for skin manipulation and the double opposing teeth are traumatic to the skin. For this reason, many surgeons have used skin hooks for manipulation and continue to do so. However, skin closure with skin hooks alone has been awkward until the advent of skin hooks on a forceps frame. Because there are actually two skin hooks on the forceps frame and they are double opposing, they act as a pincer which increases the value of the skin hook tremendously. It allows one to grasp the dermis with the skin hooks accurately and manipulate it in any direction is space, just as a forceps allows the human hand to do. A second disadvantage of Adson forceps is that it does not have needle holder (driver) pads like a needle driver does. The Adson forceps is therefore more awkward at suture/needle manipulation than a needle holder (driver). 211

212

Lalonde

There have been some Adson forceps developed with needle holder pads but without skin hooks. The skin hook forceps was the first instrument which included all three of the Adson frame, double opposing skin hooks, and needle holder pads to incorporate the advantages of all three of these technologies.

II. USE OF THE INSTRUMENT The skin hook forceps is used for skin and needle grasping. The double opposing skin hooks can be used to grasp the dermis only below the epidermis. It can also be used to grab the skin full thickness so that each portion of the epidermis and the dermis is pierced by one of the skin hooks of the forceps. By grasping the base of the dermis, the skin edge can be easily everted to facilitate intradermal suturing. This avoids piercing the epidermis, which can induce scarring. After the skin hook forceps has picked up the skin and the surgeon’s needle driver hand has been used to penetrate the skin with a needle, the needle is retrieved from the skin with the skin hook forceps by grasping it between the needle holder jaws of the instrument. The skin hooks are angled at 45 degrees to the instrument so that the skin hook forceps can retrieve the needle directly if there is a lot of needle tip showing after it has pierced the skin. If there is only a small amount of needle showing, the skin hook forceps can be flipped 180 degrees in the

Figure 1

Skin Hook Forceps

213

Figure 2

surgeon’s hand so that the skin hooks are facing upward, and the needle holder jaws can retrieve the needle even if only 1 mm of needle tip is showing through the skin edge. Because the suture needle is passed directly from the needle driver to the skin hook forceps, there is no need for the surgeon to retrieve the needle from the skin with the fingers. The risk of piercing a glove with a sharp needle tip is therefore decreased.

Figure 3

214

Lalonde

After the needle is retrieved from the skin with the skin hook forceps, the instrument passes the needle directly to the needle driver so the needle does not touch the surgeon’s fingers. With running sutures, the process of suturing a long length of skin can be very fast, because the needle is just passed from the needle driver to the skin hook forceps and back again without interruption.

III.

FLAP ELEVATION

For small delicate skin flaps such as the Limberg flap, the skin hook forceps can lift up the tip of the flat atraumatically to facilitate dissection without damaging any of the flap. When closing the skin with staples, the two skin edges can be grasped with the stapler and pulled up and away from the patient. This brings the skin together for 5 or 6 mm away from the stapler and the currently held staple in the skin. The stapler is then moved to just where the two skin hooks of the skin hook forceps are and a second staple is applied there to pick up the skin. The skin is held away from the patient with this second staple, just as it was for the first one, and the skin hook forceps is released from the skin and moved another 5–10 mm away from the currently held staple. By repeating the above procedures, an entire abdominal incision can be closed very quickly with the skin hook forceps and staples.

Figure 4

Skin Hook Forceps

Figure 5

Figure 6

215

216

Lalonde

Figure 7

IV.

DOUBLE INSTRUMENT TYING

When most of a suture has been used and there is only a short piece of thread left on the needle, the needle can be held with the skin hook forceps in one hand and the needle driver used in the other hand to perform a double instrument tie. This allows the surgeon to get an extra suture or two more easily than if the fingers were being used to hold the needle or thread. This has an economic impact, as it may prevent the opening of a second package of suture material for just one or two sutures.

V.

DISADVANTAGES OF THE SKIN HOOK FORCEPS

The first disadvantage is that the skin hooks have sharp tips which can pierce a glove, skin, or other material if they are not handled carefully. This is no different than the same disadvantage which is present with any regular skin hook. The second disadvantage of the skin hook forceps is that there is a short learning curve to using the instrument when it is compared to the Adson forceps, because the surgeon must learn to retrieve the needle with the skin hook forceps, which occasionally means that the instrument has to be flipped in the hand 180 degrees.

37 The Ultrasonic Scalpel: Applications in the Treatment of Rhinophyma and Other Cutaneous Surgical Procedures Siobhan C. Collins Brown University School of Medicine and Rhode Island Hospital, Providence, Rhode Island

Raymond G. Dufresne, Jr. Brown University School of Medicine, Providence, Rhode Island

James D. Whalen University of Connecticut Health Center, Farmington, Connecticut

I.

INTRODUCTION

The ultrasonic scalpel (US) is a unique surgical tool. Unlike other more commonly used instruments, it offers a smooth cutting, hemostatic scalpel with minimal tissue injury. This chapter will review the features of the ultrasonic scalpel and describe its use in the treatment of rhinophyma as well as other applications to cutaneous surgery.

II. THE ULTRASONIC SCALPEL The ultrasonic scalpel is a surgical instrument currently used primarily in endoscopic and laprascopic procedures (1), offering simultaneous cutting and coagulation properties. The US is composed of three parts: a generator, 217

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Ultrasonic scalpel: generator and handpiece.

a handpiece, and a blade applicator (Figure 1). The generator is a microprocessor-controlled high-freqency power supply that delivers an alternating current to the handpiece. The handpiece consists of an acoustic mount and an ultrasonic transducer. Current across the transducer results in vibrations which are transmitted longitudinally along the handpiece to the instrument tip. Several different types of tips are available, each designed for specific tasks. Cutting and coagulation occur through three main mechanisms: cavitation, heat generation, and protein denaturation. Cavitation occurs from the creation, expansion, and implosion of cavities of liquids. Heat generation is a result of internal tissue friction from high-frequency vibration and protein denaturation is caused by mechanical disruption of tertiary hydrogen bonds (2). In addition to hemostatic cutting with minimal tissue injury, the ultrasonic scalpel offers several other benefits to the surgeon. Unlike electrocautery or CO2 laser, the US generates no electrical current, sparks, or stray laser light; therefore, there is no nerve stimulation, electrical interference, or requirement for a grounding pad. Moreover, the US produces no smoking vapors or odor and less accumulation of debris in the wound, resulting in improved visualization of the surgical field. Cutting tissue does, however, produce a visible mist of cellular debris; however, morphological examination of this debris has revealed that it is composed largely of amorphous cellular fragments. Light microscopy shows a mixture of completely carbo-

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nized particles without the morphological characteristics of cells, charred cells, and coagulated tissue fragments. There has been no evidence demonstrating the release of viable airborne cells (2).

III.

RHINOPHYMA

In cutaneous surgery, the US has been best described for the treatment of rhinophyma. Rhinophyma results from chronic hyperplasia of sebaceous glands and connective tissue of the nose from long-standing rosacea, resulting in lobulated, often pendulous and deforming redundant nasal tissue (Figure 2). Several surgical modalities are employed to treat rhinophyma. Traditional methods include dermabrasions (3,4), and cold steel surgical excision with or without grafting (4,5). However, because of the vascularity of the tissues, these approaches are bloody and may require significant electrocautery, which often results in thermal injury and subsequent potential scarring (6). Electrosurgery (7) and the Shaw scalpel (8) provide hemostasis but produce significant adjacent tissue injury. More recently, the CO2 laser has been described in the treatment of rhinophyma (7–12). This modality, however, is costly and offers no tactile cutting sense for the surgeon. Moreover, when utilized in the vaporization mode for extensive rhinophymatous tissues, CO2 laser can often be a slower procedure.

Figure 2

Preoperative view of rhinophyma.

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The surgical treatment of rhinophyma with the US is simple and effective, producing an excellent cosmetic result with minimal intraoperative and postoperative complications. Patients generally require only local anesthesia in the tumescent manner using a mixture of Xylocaine (lidocaine) 0.1%, epinephrine 1:1,000,000, and saline. Others, however, may prefer sedation. The ultrasonic scalpel is used in the higher amplification range (setting at 7–8 out of 10), allowing for optimal excision and hemostasis of the highly vascularized tissues of the nose. Of the several types of titanium tips are available, we prefer a sharp blade similar in shape to a #15 blade (13). This tip allows the surgeon to cut tissues using a natural movement with excellent tactile feedback and simultaneous coagulation of small vessels with minimal adjacent tissue injury. Excision of tissue consists of smooth, sweeping movements with the blade tip (Figure 3). For larger vessels or areas not coagulated in the initial cut, slight pressure using the side of the blade is applied for tamponade and homeostasis. Care should be taken to remain within the pilosebaceous zone of the nasal tissues and to avoid exposure of cartilage. Generally, no other adjuncts to excision or shaping are required. Postoperatively, wounds are covered with nonadherent dressings like Xeroform or Omniderm dressings followed by an antibiotic ointment. Reepithelialization occurs quickly in approximately from 1–3 weeks. Cosmetic outcomes are generally excellent with no conspicuous scarring or dyschromia (Figure 4).

Figure 3

Intraoperative views of procedure.

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Figure 4

IV.

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Postoperative results.

OTHER USAGE OF THE ULTRASONIC SCALPEL

In addition to the surgical treatment of rhinophyma, the US has several other potential applications to skin surgery. For example, it has been used as a simultaneous cutting homeostatic tool for tumor excision in the Mohs fresh tissue technique in situations where hemostasis is a concern. This method causes minimal tissue injury and allows the surgeon to evaluate clearly the fresh-frozen slides for the presence or absence of tumor with little or no epidermal heat artifact (14). Similarly, the US can be used for standard excisions in areas such as the scalp where bleeding can be extensive. Epidermal injury, which is minimal using the US, can purposefully be magnified by increasing the pressure of the blade against the epidermis. In this manner, the US can be employed to separate easily epidermal lesions from the underlying normal tissue. This is particularly useful for the rapid removal of benign epidermal lesions such as seborrheic keratoses. Finally, it has been reported that the ultrasonic scalpel has been quite useful in the surgical debulking of extensive cutaneous mastocytomas (15). These tumors are extremely vascularized, and standard treatment with cautery or excision with fulguration have resulted in considerable hemorrhage. The US offers satisfactory separation of mastocytomas from the dermis with relatively minor bleeding and rapid reepithelialization.

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CONCLUSIONS

To date, the use of the US in cutaneous surgery has been limited. However, the potential of an instrument that can simultaneously cut and coagulate causing little adjacent tissue injury and providing good surgical tactile sense at a reasonable cost may have many applications for cutaneous surgery in the future. Special tips could be designed for potential use in areas such as hair transplantation, cosmetic endoscopic surgery, facelifts, blepheroplasties, and skin resurfacing.

REFERENCES 1. 2. 3. 4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14. 15.

Hodgson WJB. The ultrasonic scalpel. Bull NY Acad Med 1979; 10:908–915. Nduka CC et al. Does the ultrasonically activated scalpel release viable airborne cancer cells? Surg Endosc 1998; 12:1033. Elliot RA Jr et al. Rhinophyma: surgical refinements. Ann Plast Surg 1978; 1:298. Riefkohl R et al. Rhinophyma: a thirty-five year experience. Aesthetic Plast Surg 1983; 7:131. Har-El G et al. The treatment of rhinophyma: cold vs. laser techniques. Arch Otolaryngol Head Neck Surg 1993; 119:628. Hambley R et al. Wound healing of skin incisions produced by ultrasonically vibrating knife, scalpel, electrosurgery and carbon dioxide laser. J Dermatol Surg Oncol 1988; 14:1213. Greenbaum SS et al. Comparison of CO2 laser and electrosurgery in the treatment of rhinophyma. J Am Acad of Dermatol 1988; 18:363. Eisen RF et al. Surgical treatment of rhinophyma with the Shaw scalpel. Arch Dermatol 1986; 122:307. Wheeland RG et al. Combined carbon dioxide laser excision and vaporization in the treatment of rhinophyma. J Dermatol Surg Oncol 1987; 13:172. El-Azhary RA et al. Spectrum of results after treatment of rhinophyma with the carbon dioxide laser. Mayo Clin Proc 1991; 66:899. Lloyd KM. Surgical correction of rhinophyma. Arch Dermatol 1990; 126:721. Amadee RG, Routman MH. Methods and complications of rhinophyma excision. Laryngoscope 1987; 97:1316. Dufresne RG et al. An introduction to the ultrasonic scalpel: utility in the treatment of rhinophyma. Plast Reconstr Surg 1996; 98:160. Dufresne RG Jr, Whalen J. Preliminary experience with the ulrasonic scalpel in Mohs’ micrographic surgery. J Am Acad Dermatol 197; :471. McDermot WV, Topol BM. Systemic mastocytosis with extensive large cutaneous mastocytomas: surgical management. J Surg Oncol 1985; 30:222.

38 Clever Devices to Evaluate Vermilion-Skin Border in Lip Reconstruction Roberto Brusati and Federico Biglioli San Paolo University Hospital, Milan, Italy

Lip surgery is extremely challenging for the reconstructive surgeon, because the region is the center of the most watched part of the body: the face. As a consequence, the tolerance of mistakes is almost null and the precision has to be as high as possible. Any surgeon tries to reach the best result with some little tricks that may be useful. Before entering into those though, it must be remembered that lip reconstruction is based on few but fundamental principles. . . .

Precise and symmetrical reconstruction of the deep structures, the muscles, to sustain for a long time the results of surgery, avoiding later modifications of lip morphology Scrupulous alignment of the vermilion-skin margin Symmetry of Cupid’s bow morphology in upper lip surgery; reconstitution of lip height in lower lip surgery

In any field or situation in which reconstruction of the lip may be necessary (oncology, traumas, malformations), all these principles are mandatory, and forgetting even one of them may severely impair the final result. The precise reconstruction of the muscles (1) is fundamental not only for an immediate correct result as this may be reached, at least in part, by compensatory corrections in skin reconstruction, but especially for longstanding results. In fact, the skin may be stretched or expanded by forces applied to it and asymmetrical or the effects of incorrect tensions beneath 223

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the skin during postoperative weeks and months will surely distort the skin and change dramatically the result of surgery. Fine recognition of the vermilion-skin border is of absolute importance, as the exact match of the two sides of the lip in cases of cleft, trauma, or surgical wound is fundamental for lip reconstruction. This may be difficult in some cases such as in anemic patients, in very young patients (frequent in cleft surgery), or in whom the vermilion is particularly fair. Because of this problem, we devised a method to better visualize the skin vermilionskin border (2). Actually this method came out of an observation while preparing the surgical field. In fact, in those cases in which we were concerned about how difficult it would to identify this important landmark, the problem did not exist when we used iodate stain for disinfection (Figures 1 and 2), because the contrast between skin and vermilion becomes higher immediately after applying abundant iodated stain. As the stain dries, the effect disappeared, but it may be obtained again by repeating the step. Part of the reason for this effect may be that the stain attaches easily to the down that is already present on the skin, even if it is very thin, during the first months of life. Instead the vermilion is smooth and glossy without any down and the stain slides away. The obvious consequence is that the area between skin and vermilion is highly contrasted. The two teguments also have a different natural hue that enhances the brown color of the stain (the skin) or discolors it (the vermilion). Another explanation may be the different histology of the two tissues with different thicknesses of the keratinized epithelium. In fact, the thick keratinized epithelium of the skin may retain iodated stain better than vermilion, which is composed of a thin layer of keratinized epithelium. We believe that this is a simple and reliable method of locating the vermilion-skin border. When the contrast between the vermilion and the skin is not well differentiated after applying the stain the first time, a more abundant and fresh application easily points it out. A prospective study has not been carried out to evaluate if this method improves results in lip reconstruction, but it surely makes this type of surgery easier. So, taking into account the simplicity and quickness of the method, and considering that most surgeons already utilize iodated stain to disinfect the surgical field, we think that it should always be used, and not only when there is difficulty in locating the vermilion-skin border. Once the vermilion-skin border is truly visualized, it is better to mark it immediately, because as the operation proceeds, the swelling or ischemia due to injection of local anesthesia and the presence of blood may lead to difficulties in recognizing the border even by using iodated stain. That is why it is best to make a temporary tattoo by pricking the vermilion-skin border adjacent to the margins of the wound on both sides with a thin needle

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Figure 1

Figure 2 The smooth contrast between vermilion and skin (1) is highly enhanced by iodated stain (2) in a bilateral cleft lip repair.

dipped into Bonney’s Blu Solution. Doing so it is possible to concentrate on surgical steps of the deeper structure and later on coming back on skin without loosing the important landmarks previously. The last point is how to evaluate lip height while reconstructing the lip. This topic has challenged many surgeons, especially in cleft lip surgery. Many surgeons have tried to devise a method to understand better how to determine the length of the unoperated hemi-lip and that of the hemilip to be reconstructed. Some (3,4) use a caliper, whereas Dado (5) uses pieces of stainless steel wire, because a straight caliper cannot accurately follow the curvilinear profile of the vermilion-skin border and that of the wound. Another problem is shrinkage of the tissue, which are under tension

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in a normal lip but are retracted and appear shorter in cases of cleft or a wound, reducing their dimensions. Finally, even a highly experienced surgeon may have difficulty in evaluating the symmetry of a reconstructed Cupid’s bow. Most surgeons generally just rely on their eyes and their experience, avoiding any mechanical aid, as this may mislead the reconstruction or may be too difficult to be employed correctly. As these concepts are surely correct if we consider the situation before reconstruction (shrinkage of tissue, not plane tissues), there is actually an easy way to evaluate symmetry of the Cupid’s bow at the end of operation. Two lines parallel to each other are cut at variable distances on the back of a small mirror (12 20 cm) (depending on the age of the patient to be operated): 2.0 cm for infants a few months old and 3.5 cm for adults (Figure 3). After the reconstruction, the mirror is held over the patient’s face by the surgeon seated behind the patient (Figure 4). The mirror is held 30– 40 cm reflecting the patient’s face. Watching through the mirror the surgeon must superimpose one line to the inner canthi (reference line) while the other to the two high points of the Cupid’s bow (comparison line) (Figure 5). If one of the two points of the Cupid’s bow is higher or lower than the comparison line, it means that the hemi-lip is too short or too long and a correction of the procedure must be made (6).

Figure 3

The mirror devised to evaluate symmetry of the reconstructed lip.

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Figure 4 The mirror is held over the patient’s face to evaluate symmetry of the two high points of the Cupid’s bow at the end of the reconstruction.

Figure 5 The two parallel lines cut on the back of the mirror must be superimposed to the inner canthi and the two high points of the Cupid’s bow to evaluate their symmetry.

REFERENCES 1. 2.

Delaire J. Theoretical principles and technique of functional closure of the lip and nasal aperture. J Maxillofac Surg 1978; 6:109–116. Brusati R, Mannucci N, Biglioli F. The use of iodate stain to enhance contrast between vermillion and skin in lip reconstruction. Plast Reconstr Surg 1997; 100:124–125.

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3.

Clifford RH, Pool R. The analysis of the anatomy and geometry of the unilateral cleft lip. Plast Reconstr Surg 1959; 24:311–319. Saunders DE, Malek A, Karandy E. Growth of the cleft lip following a triangular flap repair. Plast Reconstr Surg 1986; 77:227–234. Dado DV. Analysis of the lengthening effect of the muscle repair in functional cleft lip repair. Plast Reconstr Surg 1988; 82:594–601. Analysis on photographs of the growths of the cleft lip following a rotation advancement flap repair: preliminary report. J Cran Max Fac Surg 1996; 24:140–144.

4. 5. 6.

39 ‘‘Tusked’’ Forceps for Rapid and Atraumatic Subcuticular Closure of the Skin Martin Hirigoyen Kelly Chelsea and Westminster Hospital, London, England

I.

INTRODUCTION

The desire for improved esthetics is at times the sole indication for plastic surgical procedures, and the utmost attention must be given to handling the skin atraumatically in order to optimize scar cosmesis. Continuous intradermal suturing is a useful method for the primary closure of long wounds (e.g., abdominoplasty, reduction mammaplasty), as it preserves the integrity of the epidermis at the wound edge and buries the suture material. Traditionally, toothed forceps are used to grasp the skin and steady it for passage of the needle through the dermis. However, excessive force applied through the teeth of Adson’s forceps devitalizes cutaneous tissues, which predisposes to wound infection and the formation of poor scars (1). Such indelicate handling occurs most often when the wound lies under tension, but may also occur during the placement of subcuticular sutures when toothed forceps are used to evert the skin edge. The skin hook is perhaps the least injurious instrument to the skin, as it elevates the dermal layer without breaching the epidermis (2). Its use is impractical for the suturing of long wounds, however, as it involves the repeated exchange of instruments. A modified skin forceps has been designed to allow for the rapid placement of subcuticular sutures without compromise of the wound margins.

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II. INSTRUMENT DESIGN A combination forceps and skin hook instrument, called ‘‘tusked’’ because of its appearance (Figure 1), was created by welding two metallic hooks onto the lateral aspect of the jaws of a dressing forceps. After modification, the length, angle, and distance from the tips of the hooked parts were found to be most practical at 4 mm, 120 degrees, and 5 mm (Figure 2). The forceps are readily autoclaved, and for storage purposes two rubber bungs may be used to protect the hooks from wear.

III.

DISCUSSION

Although the skin hook allows for retraction of the skin without trespass of the epidermis, its repeated use for the suturing of long wounds is inefficient. The hook must exchanged for forceps to grasp the needle and vice-versa. In addition, a better purchase of the needle is obtained using serrated, ‘‘dressing’’ forceps, than with Adson’s forceps, the teeth of which prevent the complete interlocking of the jaws. Although the tusked forceps combines these two instruments, the idea of joining together the respective advantages of a skin hook and a forceps is not new. Peled (3) first described the welding of hypodermic or suture needles along the axis of Adson’s forceps, whereas Frankel (4) reported good results by asymmetrically fixating one hook in the plane of the forceps handle. Lalonde (5) suggested placing two diametrically opposed hooks at the very tip of the forceps, which is well suited for the placement of vertical sutures as well as the handling of small skin flaps. Although these previous designs are undoubtedly effective, the present configuration combines a unique versatility for handling the skin edge during the placement of subcuticular sutures. A small pronatory movement of the wrist is required to steady the dermis during passage of the needle, and alternate wound margins may be sutured with similar ease. The tusked forceps is cheap to assemble, and it may be of use in the cosmetic closure of long elective skin wounds by the surgeon who is working unassisted.

Figure 1

Design of the forceps tip (lateral view).

‘‘Tusked’’ Forceps for Skin Closure

Figure 2

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Photograph of the tusked forceps.

ACKNOWLEDGMENTS The author would like to thank the engineering laboratory at A.P.S., Noisiel, France, for their assistance in the manufacturing of prototypes.

Figure 3 Wound closure using the tusked forceps. By gentle pronation of the wrist, the hook is used to anchor and elevate the dermis. Subcuticular passage of the needle is achieved without injuring the epidermis.

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Figure 4 Wound closure using the tusked forceps. The hook is released, and the serrated forceps tips achieve a firm grasp of the needle as it emerges from the wound edge.

REFERENCES 1. 2. 3. 4.

5.

Vistnes LM. Basic principles of skin surgery. In: Skin Surgery. Philadelphia: Saunders, 1987. McCarthy JG. Suturing. In: Plastic Surgery. Philadelphia: Saunders, 1990. Peled I. Hooked forceps. Ann Plast Surg 1984; 12:385–386. Frankel DH. The use of a combination skin hook and tissue forceps: a new instrument for dermatologic surgery. J Dermatol Surg Oncol 1988; 14:497– 499. Lalonde DH. Hook forceps. Ann Plast Surg 1991; 26:597.

40 Labial Muscle Z-Plasty to Reestablish the ‘‘Lip Seal’’ Mechanism Lawrence M. Field University of California at San Francisco, San Francisco, and Stanford University School of Medicine, Stanford, California

I.

INTRODUCTION

A 74-year-old male had undergone radiation therapy 8 years before for invasive squamous cell carcinoma of the right lateral lower lip. Bioatrophy of the mucosa and submucosal muscular layer had occurred, and a new locus of irregularity and slight induration was noted adjacent and medial to the previously irradiated area. Diffuse actinically induced premalignant cheilitis was obvious. The man had been complaining for several years of loss of fluids through the atrophic radiated area, and he requested an attempt at repair of his incompetent ‘‘lip seal’’ mechanism concomitant with the surgical reconstruction following removal of the newly malignant area (Figure 1).

II. SURGICAL TECHNIQUE The lower lip was initially marked and delineated into (a) the focal neoplastic region, (b) the atrophic area, (c) the actinic cheilitis limitations, and (d)

Presented at the Forum on Lip Surgery—Grafts, Flaps, and Combinations Thereof. American Academy of Dermatology, San Francisco, California, March 2000.

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Figure 1 Preoperative photograph showing (a) locus of radiation atrophy on the right lower lip with resulting loss of lip seal; (b) superficial squamous cell carcinoma just medial to that atrophic area; and (c) diffuse premalignant cheilitis.

Field

Figure 2 Inked delineation of these different involved areas (atrophic area solid, SCC adjacent to that region).

the juncture of mucosa and submucosal chin epidermis (Figure 2). Following bilateral mental regional blocks with 2% lidocaine, the lip was anesthetized with a standard solution of 1% lidocaine with 1 : 100,000 epinephrine. The entire actinically damaged lower lip mucosa anterior to the lip seal line (identified by closing the upper lip of the lower lip in closed, resting configuration) and the focal superficially invasive squamous cell carcinoma were sharply excised in continuity (1,2). The entire surgical specimen was submitted for intraoperative frozen section control (Figure 3) (3). A precise curved, horizontally directed dissection into the previously radiated area allowed maintenance of the intact specimen but left a definite deeper defect beneath the mucosa and the remnant radiated muscularis (Figure 3). In order to fill this depth of defect (as muscle had been previously utilized to fill deep contour defects [4]), and as had previously been documented with mucosal defects sparing the muscle (5), a full-thickness labial muscle Zplasty was conceived to bring additional muscle into the base. After dissecting the muscle segments free (Figure 4) and using only pinpoint bipolar coagulation for the minute bleeders, the two segments were brought into a central Z configuration across the defect, filling it (Figure 5). The two muscle flaps were sutured together and onto the subjacent tissue. A fullwidth vermilion advancement flap, freed to the base of the retrolabial space (Figure 5) (6), was brought anterosuperiorly and anastomosed with the subjacent chin epidermis using both interrupted 5-0 silk (Figure 6) and a running 6-0 nylon suture. Sutures were removed over the course of the

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Figure 3 Surgical specimen removed in continuity with residual deep concave defect in area of bioatrophy.

Figure 4 Labial muscle Z-plastic flaps raised prior to their transposition over the median point of the muscle atrophy and depression.

Figure 5 Muscle Z-plasty sutured in place with filling of muscle thickness deficiency. Vermilion flap mobilized and prepared for advancement.

Figure 6 Near finished postoperative result showing interrupted 5-0 silk sutures in place but prior to final approximation with running 6-0 nylon suture.

following week. One year later, the lip seal had been completely reestablished, with both cosmesis and function being excellent (Figure 7).

III.

CONCLUSIONS

A man developed a second squamous cell carcinoma adjacent an area of radiation atrophy with previous loss of the lip seal mechanism. This neo-

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Figure 7 Excellent late result with reconstitution of the lip seal, normal appearance, and no decrease in the oral aperture.

plasm and the entire actinically damaged premalignant lower lip mucosa were removed. Reconstruction was accomplished by combining a labial muscle Z-plasty to bring in additional tissue into the deeper atrophic radiation defect. This submucosal procedure was combined with a full lower lip vermilionectomy with advancement flap to recover the lower labia. Both appearance and function were essentially normal within 5 weeks of the procedure, with a full-width and completely competent oral stoma being present 1 year later.


5. 6.

Field L. On the appropriateness of vermilionectomy. J Dermatol Surg Oncol 1987; 13:466. Field L. An improved design for vermilionectomy with a mucous-membrane advancement flap. J Dermatol Surg Oncol 1991; 17:833–834. Gross D, Field L. Cooperative frozen section surgery. J Dermatol Surg Oncol 1987; 13:1085–1088. Field L. Two-stage correction of depressed glabella and nasal root scar contracture utilizing subcutaneous tissue advancement flaps and a layered soft tissue/procerus muscle transposition flap. J Dermatol Surg Oncol 1993; 19:962–966. Field L. Dual inner lip mucous membrane advancement-rotation flaps for lower lip surface defects. J Dermatol Surg Oncol 1983; 9:442–443. Field L. Prevention of the ‘‘prickling sensation’’ following surgery for actinic cheilitis. J Am Acad Dermatol 1988; 18:1365.

41 Total Upper Lip Reconstruction with Bilateral Fan Flaps Francisco M. Camacho Hospital Virgen Macarena, University of Seville, Seville, Spain

I.

ANATOMY OF THE UPPER LIP

The glabrous skin of the upper lip extends from the lower end of the nose to the vermilion zone that is the transitional zone between the skin and the mucous membrane. Under the skin of the external surface, which contains many pilosebaceous structures, there are bundles of striated muscle, particularly the orbicularis oris muscle, circumoral muscles intimately associated with the orbicularis oris, the submucosal layer, and on the inner surface the mucous membrane with many minor salivary glands. The upper lip includes the philtrum, a midline depression, also known as Cupid’s bow, extending from the columella of the nose to the superior edge of the vermilion zone, and laterally is bordered by the nasolabial fold. The commissures are the angles of the mouth where both lips, upper and lower, are jointed (1). The vermilion zone has a reddish pink color in Caucasians due to the rich capillary supply of the dermal papillae. The vascular supply is provided by the superior labial artery that is a branch of the facial artery and is found within the submucosa. Sensory innervation is a function of the infraorbital nerve (V2), and the motor innervation of the orbicularis oris is provided by the buccal branch of the facial nerve. The circumoral muscles are innervated by either the buccal or the marginal mandibular branches of the facial nerve. Lymphatic drainage flows to the submandibular lymph nodes.

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II. RECONSTRUCTIVE TECHNIQUE OF THE TOTAL UPPER LIP When the reconstruction of the total upper lip must be performed, bilateral fan flaps or Gillies’s flaps may be useful from the surgical point of view, but they are less adequate from the esthetic standpoint, since this technique does not permit the reconstruction of Cupid’s bow (2).

III.

SURGICAL TECHNIQUE

Bilateral fan flaps are full-thickness cheek flaps, and two details must be taken into consideration: (a) a wide pedicle in the commissural angle, including the facial artery, must be designed, and (b) the mucosal flap must be 8 mm longer, in the inner portions, than the skin flap used to reconstruct the lip semimucosa (3). A.

Obtention of the Fan Flaps

Before removal of the total surface of the upper lip, two bilateral full-thickness cheek fan flaps must be designed based on an inferior medial pedicle (Figures 1 and 2a). Then an amount of tissue 3 mm more than the middle of the defect must be excised on each nasolabial fold with a cutaneous width

Figure 1 On the left commissural angle, a large pedicle has been left including the facial artery. More mucosa than skin was excised, as can be observed. (Schedule published in the Journal of Dermatologic Surgery and Oncology 1992; 18:627–628; Reprinted by permission of Blackwell Science, Inc).

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similar to or 1–2 mm bigger, than the defect, but with a inner mucosa width more than approximately 8–10 mm in relation to the original width of the vermilion of the upper lip. The purpose of this is that this mucosa could be stitched on the cutaneous surface, and to reconstruct in this form the vermilion without tension when suturing avoiding lip entropy. The pedicle of the rotation flaps should be wide enough to include both the artery and the facial vein, inside the flap, allowing them to share the necessary vascularization when both flaps are displaced and sutured in the center. If possible, the marginal mandibular branch of the facial nerve might be included in the pedicle, just going through the commissural angle. Finally, a fusiform final excision must be performed to facilitate the direct close of the donor area (Figure 3).

B.

Suture of the Flaps

Once incised, the flaps are medially rotated to form the upper lip and the suture is started. First, the mucosal flaps must be sutured with nonabsorbable stitches to the cutaneous edge, reconstructing the vermilion (see Figure 2b). Then the mucosal surface must be sutured, also with absorbable stitches, to the oral mucosa, closing the inner defect. Finally, the submucosa and muscular and cutaneous layers must be stitched in both the donor area and in the receptor area (see Figure 2c). The mucosal inner stitches should be made with absorbable sutures and the cutaneous surface with nonabsorbable sutures (see Figure 2d). When tension is observed, traction sutures with stitches that pass through of a button or piece of rubber on each side of the central suture must be placed. Normally, one traction suture is enough. Two or three vertical mattress sutures can also be used to close the central suture.

C.

Postoperative Care

The stitches on the free edge of vermilion must be removed between 4 and 7 days. The central sutures between the two cutaneous surfaces must be removed between 4 and 7 days, but the vertical mattress sutures can be maintained for 10–14 days and the traction sutures at least 2 weeks in order to avoid dehiscence of the central wound. Nonsteroidal anti-inflammatory drugs must be used for 1 week, and a buccal antiseptic must be used before and after the operation. Smoking is forbidden at least 1 month before the operation, and, if possible, for some years afterward. Normally, the patient is functioning well 1 or 2 months postoperatively (Figure 4).

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Figure 2 (a) Extensive SCC occupying the total upper lip, including commissures. (b) The mucosal flaps are sutured in the middle. The lower part of the mucosa coming from the internal part is now much wider in order to be sutured afterward on the skin and to occupy the space of the lip. (c) The skin flap has been sutured directly in the middle and the donor region has also been directly closed. The internal lip mucosa sectioned from these flaps has been sutured on the free lip border, creating the semimucosa. (d) Two days after the operation, the functionality was acceptable.

Figure 3 The mucosa excised in excess permits it to be sutured on the skin flap, replacing the lip semimucosa. (From Ref. 3.)

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Figure 4 Two months after discharge from the hospital, the patient was functionally and esthetically pleased.

IV.

COMMENTARIES

Several authors who have studied the total upper lip reconstruction agree that for this extremely difficult situation, the most useful reconstructive flaps are the Gillies’ fan flaps (4,5). However, the same authors believe that this solution is not truly satisfactory, because the lack of a Cupid’s bow detracts from the esthetic result.

REFERENCES 1. 2.

3.

Scully C, Bagań J-V, Eisen D, Porter S, Rogers III RS. Dermatology of the Lips. Oxford, UK: Isis Medical Media, 2000. Camacho FM, Ortega RM. Surgical procedures for the lips and oral cavity. In: Lotti TM, Parish LC, Rogers III RS, eds. Oral Diseases. Textbook and Atlas. Berlin: Springer-Verlag, 1999; 251–283. Camacho F, Moreno JC, Conejo-Mir JS. Total upper lip reconstruction with bilateral fan flaps. J Dermatol Surg Oncol 1992; 18:627–628.

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4.

Rivlin D, Telfer NR, Moy RL. Flaps and grafts in the repair of facial defects. Curr Opin Dermatol 1993; 1:159–164. Moy RL, Rivlin D. Flaps and grafts in the repair of facial defects. Curr Opin Dermatol 1996; 3:158–162.

5.

42 Closure of Conchal Defects: The Hinged Retroconchal Island Flap with Overlying Transposition Flap Walter A. Schroeder, Jr. Cape County Otolaryngology, Cape Girardeau, Missouri

I.

INTRODUCTION

One principle of reconstruction is the restoration of anatomy after tissue has been altered or removed. Reconstruction of the auricle requires establishing contour and shape that will often be compared to the contralateral auricle. Although the tissue of the auricle is predominantly skin and cartilage, the development of the auricle results in an intricate pattern of concavities and convexities that give the ear its characteristic shape. These areas of concavity and convexity result in reconstructive challenges created by the relative inelastic properties of skin overlying cartilage. Preservation of tissue, maintenance of structural integrity, and establishment of tension-free closure are goals of surgery. Perforations of the auricle must be closed in a tension-free manner or recurrence of the perforation often results. Surgical incisions in the postauricular region must be closed in a manner that will not jeopardize the postauricular sulcus. The retroconchal island flap with overlying cutaneous transposition flap provides a technique for tension-free closure (1).

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II. TECHNIQUE A perforated concha (Figure 1) often requires tissue transfer for tension-free closure. A retroconchal island flap, slightly larger than the defect, is drawn with a surgical marking pen. The edges of the conchal perforation are freshened; the island flap is fashioned immediately posterior to the conchal defect. A rhomboid transposition flap is then drawn to facilitate closure of the donor site (Figure 2). After infiltration of 1% lidocaine with 1 : 100,000 epinephrine, a #15 Bard-Parker blade is used to incise the island flap (Figure 3A). The island flap is rotated into the surgical defect (Figure 3B). The rhomboid flap is harvested and the flap is transposed to cover the posterior portion of the island flap (Figure 4). The wound is closed with a combination of 4-0 chromic suture material for deep closure and interrupted 6-0 nylon for skin closure. The island flap is well healed 6 weeks following surgery (Figure 5).

Figure 1

Figure 2

Closure of Conchal Defects

Figure 3A

Figure 3B

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Figure 4

III.

Figure 5

DISCUSSION

Reconstructive closure of conchal perforations usually involve tissue transfer from the postauricular region. The rich blood supply provides viable tissue for such a transfer (2,3). When patients have had multiple prior surgeries, the postauricular sulcus can be made more shallow following closure. The shallow sulcus can result in asymmetry of the two auricles. Eyeglasses can be difficult to wear if the sulcus is too shallow. The described closure technique utilizing tissue immediately behind the perforation and a rhomboid local flap for donor site closure avoids a vertical closure within the sulcus. No tension is placed on this island flap.

IV.

CONCLUSIONS

The retroconchal island flap is a single-stage technique that provides a reliable closure with an excellent color match. The shallow postauricular sulcus is avoided. The technique has been used successfully in patients who have had prior surgical failures.

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REFERENCES 1.

2. 3.

Schroeder, WA Jr. Closure of conchal defects—the hinged retroconchal island flap with overlying cutaneous transposition flap. Dermatol Surg 1995; 21:560– 562. Chen C, Chen Z. Reconstruction of the concha of the ear using a postauricular island flap. Plast Surg 1990; 86:569–572. Kolhe PS, Leonard AG. The posterior auricular flap: anatomical studies. Br J Plast Surg 1987; 40:562–569.

43 Burow’s Triangle Advancement Flaps for Excision of Two Closely Approximated Skin Lesions Paolo Boggio and Giorgio Leigheb University of Piemonte Orientale and Maggiore della Carita` Hospital, Novara, Italy

I.

INTRODUCTION

The simplest way to remove a cutaneous lesion is with the elliptical excision, because it is quicker and easier and it leaves a smaller wound than any other technique. When two lesions are too near to one another to be excised with an elliptical incision because of the resulting excessive tension, it is possible to use two Burow’s triangle advancement flaps (1,2). This technique can be considered to be a variant of the single Burow’s triangle flap in which the secondary triangle (the so-called Burow’s wedge) contains one of the lesions (3–5). In the case of two closely approximated lesions, it is possible to draw two triangular flap variants, as two possible tangential incisions are available (Figure 1). The direction of the tangential incision may be chosen so that it fits well with the creases, folds, and skin tension lines.

Modified from Ref. 1. Reprinted by permission of Blackwell Science, Inc.

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The two variants of tangential incision allow two different final suture

II. TECHNIQUES This technique using Burow’s triangle advancement flaps is useful only if the distance between the lesions does not exceed 2 ‘‘diameters’’ (width of the hypothetical elliptical excision needed to resect a lesion). The resulting suture line is in this case longer than the sum of the two potential elliptical incisions (7 vs 6 diameters), but the more esthetic Z-shaped incision and the decreased tension on the suture line balance this apparent disadvantage. The different tension is shown in Figure 2, where the distance between the lesions is 1 diameter and the resulting suture line is as long as the sum of the two elliptical excisions. The width of the reconstruction is 1 diameter larger than that obtained with two elliptical excisions, so there is the same final tension as with a single elliptical excision. If the distance between the two skin lesions exceeds 2 diameters, the use of this technique is usually not advisable because of the need for extensive undermining and the length of the final closure.

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Figure 2 Case of two lesions with a distance between them of 1 diameter: The double elliptical excision gives a sum of suture lengths of 6 diameters and so does the triangular flap but with a distance between the vertical parts of 2 diameters instead of one, permitting closure under less tension.

Many different variants are possible according to the different anatomical regions. Four examples are shown for the frontal region (Figure 3), the superciliary and temporal regions (Figures 4 and 5), and the mandibular region (Figure 6).

III.

CONCLUSION

This technique is an excellent method for simultaneously removing two lesions that are closely approximated having the tension in comparison with excision by two elliptical incisions and giving acceptable esthetic results.

Figure 3 Double Burow’s triangle advancement flap. (A) Two lesions in the frontal region. (B) Final closure. (C) The result 2 months after the operation. (D) Diagram of the operation with the flaps drawn, the movement of flaps, and final suture lines.

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Figure 4 Double Burow’s triangle advancement flap. (A) Two basal cell carcinomas of the superciliary and temporal regions. (B) Drawing of incision lines. (C) Final closure. (D) Diagram of the operation.



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Figure 5 Double Burow’s triangle advancement flap. (A) Two basal cell carcinomas in the temporal region. (B) Final closure. (C) Diagram of the operation.



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Figure 6 Double Burow’s triangle advancement flap. (A) Two basal cell carcinomas in the mandibular region. (B) Final closure. (C) Diagram of the operation.



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REFERENCES 1.

2.

3. 4. 5.

Boggio P, Gattoni M, Zanetta R, Leigheb G. Burow’s triangle advancement flaps for excision of two closely approximated skin lesions. Dermatol Surg 1999; 25:622–625. Wheeland RG. Random pattern flaps: Burow’s triangle flap. In: Roenigk RK, Roenigk HH, eds. Dermatologic Surgery. New York: Marcel Dekker, 1989:283–284. Gormley DE. A brief analysis of the Burow’s wedge-triangle principle. J Dermatol Surg Oncol 1985; 11:121–123. Gormley DE. The N or reversed N closure of adjacent, parallel, elliptical excisions. J Dermatol Surg Oncol 1982; 8:240–242. Kaufmann R, Landes E. Simultaneous excision of two basal cell carcinomas. In: Kaufman R, ed. Interventi Dermochirurgici. Milan: Masson, 1994:133– 134.

44 Modified Bilateral Advancement Flap Marwali Harahap University of North Sumatra, Medan, Indonesia

I.

INTRODUCTION

The standard bilateral advancement flaps have had great popularity owing to their advantages in terms of reliability, ease of execution, and good results (1,2). However, the limited sliding capacity of these flaps has always been a problem. These flaps have a random vascularization through the subdermal vascular plexus. They are transferred with a forward movement. The flap can be mobilized up to the limits beyond which too much stretching causes failure of its vascularization (3). To improve this limit, a modification of the flap is described in this chapter. The flap extends the possibilities of coverage in the distal areas, reducing the tensile distress. The shape of the flap has been modified following a geometrical scheme that makes available a greater amount of tissue and reduces tension along the closure.

II. MATERIAL AND METHODS Over the past 5 years, I have performed 11 operations utilizing this technique to close facial defects due to excision of one squamous cell carcinoma,

From Harahap M. The Modified bilateral advancement flap. Dermatol Surg 27(5):463–466. Reprinted with permission from Blackwell Science, Malden, MA.

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one pyogenic granuloma, and nine basal cell carcinoma. The average patient was 52 years old, with a range in age of 26–65 years. Locations of the modified bilateral advancement flaps used are shown in Table 1. The limbs of the flap were not incised as straight lines but were curved outward slightly, making the flap broader than the standard bilateral advancement flap, thus minimizing risk of flap failure (4). A 30-degree wedge of tissue is removed from the distal end of one advancement flap (Figure 1). Then a bilateral transposition flap is created from tissue at both sides of the wound. The two triangular apical flaps properly detached are transposed medially and sutured together on the medial line to form a single, new tip (apex), which is then advanced and sutured into the concave base of the opposing advancement flap at its midpoint (5,6) (Figure 2). In this manner, we have more available tissue in the distal area and consequently less advancement of the flap is required. The remaining incision lines are sutured from the proximal end and toward the distal end (Figure 3). Two Burrow’s triangles may be placed as the need arises. Examples of the modified bilateral advancement flap are shown for reconstruction of facial defects in the forehead areas (Figures 4–9), in the temporal region (Figures 10–12), and in the cheek (Figures 13–15).

III.

RESULTS

Eleven modified bilateral advancement flaps have been successfully performed for facial defects over the past 5 years. Application of the modified bilateral advancement flap to facial defects achieve satisfactory esthetic results because of its good color and texture match and the ease of setting the suture line on the wrinkle line. It is a reconstruction without contour deficit. However, this is a technique that needs to be used judiciously, because it is a ‘‘flap on a flap’’(7). In the head and neck region, which has an excellent blood supply, it is a relatively safe procedure. Table 1

Location of the Modified Bilateral Advancement Flap

Site Forehead Nose Cheek Temple Lower eyelid Total

No. of patients 4 1 2 2 1 11

Modified Bilateral Advancement Flap

Figure 1 Design of the flap. The incision lines were curved outward slightly, making the flap broader. A 30-degree wedge of tissue is remove from one distal end of the flap.

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Figure 2 The two triangular apical flaps properly detached are transposed medially and sutured together on the medial line to form a new tip (apex), which is then advanced and sutured into the concave base of the opposing advancement flat at its midpoint.

Figure 3 The incision lines shown in Figure 2 are sutured.

IV.

DISCUSSION

Excision of facial lesions frequently leaves circular or near circular defects. If the adjacent skin is lax, the defect may be closed by resection of triangles of skin (dog ear) and direct approximation. In many areas of the face, the tension required for direct closure distorts the tissue or impairs the function (e.g., eyelids, lips). The modified bilateral advancement flap can be performed in one stage, because it does not require the division of the pedicle, the texture and color match is excellent, it can use the remaining tissue effectively for the reconstruction, and skin grafting is not required at the donor site. In addition, other advantages should be noted. It is also possible to make the reconstruction of defects without deviation of the landmarks

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Figure 4 A 56-year-old woman with a basal cell carcinoma on the left side of the forehead. Defect and outline of flap.

Figure 5 Closure following flap advancement and transposition shown in Figure 4.

Figure 6 Appearance of reconstruction shown in Figures 4 and 5 at 1 month postoperatively.

Figure 7 A 50-year-old white man with a basal cell carcinoma in the forehead. Skin defect following excision.


Figure 8 Closure of the wound immediately after surgery (see Figure 7).

Figure 10 Temporal defect following excision of a squamous cell carcinoma with flap design.

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Figure 9 Result of reconstruction shown in Figure 7 and 8 at 40 days.

Figure 11 Immediately after operation shown in Figure 10.

the

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Figure 12 Postoperative results of reconstruction shown in Figures 10 and 11 at 2 months.

Figure 14 Closure with flap advanced and transposed (see Figure 13).

Harahap

Figure 13 Skin defect after excision of a basal cell carcinoma in the cheek of a 60-year-old woman. The skin lesion on the left is a seborrheic keratosis.

Figure 15 Appearance 2 months after reconstruction shown in Figures 13 and 14.


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and can result in as natural a contour as possible and a more favorable setting of the scars. Complications are minimal when applied to the face. As in any use of this flap, edema secondary to a trapdoor phenomena is possible. The disadvantages of the modified technique is the requirement of excision of extra healthy tissue to convert bilateral transposition flaps into an apical flap; an increased vascular risk in the apical areas of the two distal flaps where the perfusion is more critical and include a slightly larger size of the final scar. However, the advantages of this technique’s shorter length and wider base for increased flap survival and the efficient distribution of available tissue by the combined use of transposition and advancement principles (8) outweigh the possible disadvantages. In conclusion, this method extends the capacity of the bilateral advancement flap for reconstruction and improves its applications and advantages.

REFERENCES 1. 2. 3.

4. 5. 6. 7. 8.

Jackson IT. Local flaps in head and neck reconstruction. St. Louis: Mosby, 1985:13. Larrabee WF Jr, Sherris DA, eds. Principles of Facial Reconstruction. Philadelphia: Lippincott-Raven, 1995:230. Jankauskas S, Cohen IK, Grabb WC. Basic Technique of Plastic Surgery. In: Smith JW, Aston SJ, eds. Grabb and Smith’s Plastic Surgery. 4th edn. Boston: Little Brown, 1991:63. Converse JM. Kazanijan & Converse’s Surgical Treatment of Facial Injuries. 3rd edn. Vol 1. Baltimore: Williams & Wilkins, 1974:492 Peng VT, Sturm RL, Marsh TW. ‘‘Pinch modification’’ of the linear advancement flap. J Dermatol Surg Oncol 1987; 11:251–253. Campus GV, Lissia M, Pancrazi E. The amplified sliding flap. Ann Plast Surg 1993; 31:318–321. Pribaz JJ, Chester CH, Barvall DT. The extended V-Y flap. Plast Reconstr Surg 1992; 90:275–280. Akan IM, Ulusory MG, Bilen BT, Kapucu MR. Modified bilateral advancement flap. The slide-in flap. Ann Plast Surg 1999; 42:545–548.

45 Trilobed Flaps for Simultaneous Repair of Multiple Defects of the Nose Paolo Boggio and Giorgio Leigheb University of Piemonte Orientale and Maggiore della Carita` Hospital, Novara, Italy

I.

INTRODUCTION

Many types of flap variants have been suggested for the repair of skin defects in the region of the nose, as it is often impossible to perform a direct excision and a skin graft may be unsatisfactory (1). The reconstruction becomes more difficult if there are many lesions to remove (2), so that successive excisions could be needed. When the lesions are relatively close to one another, it is sometimes possible to consider flap variants that exploit contiguous looser regions of the skin to prepare movable multilobed flaps, permitting simultaneous repairs (3). This technique gives satisfactory cosmetic results because of the similarity of the rotated skin.

II. TECHNIQUE The shape of a flap for the reconstruction after multiple excisions must be studied extemporaneously in order to adapt it to the different sites and size of lesions. No general rules are available, and the surgeon must evaluate the feasibility of the various techniques in each case. It is important to: 269

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. . . . . .

Use the smallest incisions possible. Remove the least amount of skin possible (compatible with complete removal of the tumor). Select the simplest technique with the least possible undermining. Prepare the flaps, when possible, along one side of the existing surgical incisions. Use the topographic subunits or wrinkles of the face for the final suture lines. Use the surgical wounds as Burow’s triangles to facilitate advancement or rotation of the flaps (4).

A useful type of flap for selected cases is the trilobed flap, which can be considered to be an extension of the bilobed flap principle with three serial transpositions flaps that reciprocally facilitate one another’s rotation. This type of technique can be used to remove multiple disseminated lesions localized along an ideal arcuate line and with a distance between each other of about 1 ‘‘diameter’’ (width of the hypothetical elliptical excision needed to resect a lesion). Figure 1 shows different types of trilobed flaps for the removal of two, three, or four lesions. The first diagram shows how the lateral movement of three flaps transplants the defect from an area of tissue scarcity to tissue abundance according to the classic transposition flap principle, but it must be noted that with multiple excisions, unlike the simple bilobed flap, the closure of donor areas between the gaps (designated A, B, and C in Figure 1) requires a partial direct closure sliding orthogonally to the direction of rotation. This is more evident if one of the flaps is shorter (see Case 2 below). Obviously the ideal condition is represented by lesions scattered along an arciform line with the axes of the lobes converging in a single point of rotation. The closure of the fourth wound in diagram 3 (Figure 1) exploits the Burow’s wedge principle. The mean rotation degree of flap axis does not usually exceed 30–60 degrees, but the arc that circumscribes lesions should not exceed 180 degrees to ensure a broad peduncle guaranteeing a satisfactory blood supply to the flap.

A.

Cases

The following two cases, in which trilobed flaps with opposite directions of rotation were used to excise multiple lesions of the nose, illustrate these principles.

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Figure 1 Types of trilobed flaps used to remove simultaneously two, three, or four lesions with respective final suture lines and direction of rotation. Partial orthogonal direct closure of donor areas between the wounds (A, B, C).

1.

Case 1

A 69-year-old woman with two basal cell carcinomas, one on the left side of the root of the nose and another just under the right medial commissure of the eye (Figure 2A). A large transposition flap was needed to cover the excision of the lesion on the right side, a second flap was used to cover the first donor area, whereas a third flap was needed for the other lesion. The resilience of the skin of the glabella assures both a good rotation of the trilobed flap and makes possible direct suture of the remaining donor areas. The suture line obtained is mostly disguised along glabellar, superciliary arch, and lower eyelid wrinkles (Figure 2B–C).

2.

Case 2

An 82-year-old woman with three epitheliomatous lesions; one on the glabella, a second at the beginning of the left superciliary arch, and a third at the medial commissure of the left eye (Figure 3A). After excision by Mohs surgery to minimize the wounds, the larger flap required for the glabellar region was taken laterally to the lesion with direct closure of the donor area because of the resilience of the skin. The closure of the two lower wounds, because of the rotation of the two shorter flaps, facilitates the movement of the first flap, which is also helped in this by the direct closure of the third donor area (Figure 3B–C). The suture

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Figure 2 (A) Two basal cell carcinomas of the nose and of paranasal region with the diagram before incision. (B) Final suture. (C) Diagram of the operating technique with the drawing of incision lines, the movement of flaps after removal of lesions, and final suture lines.

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obtained was well disguised both because of its sinuous line and its position along the regional subunits of the nose, the eye and superciliary arch, and the glabellar wrinkles (Figure 3D).

III.

CONCLUSIONS

We can conclude that plurilobed transposition flaps make it possible to excise multiple lesions simultaneously and that these techniques can give good cosmetic results also permitting maximum saving of time, complications, and, not least, of costs.

Figure 3 (A) Three lesions of the nose and of the glabella with the diagram before incision. (B) Final suture. (C) Diagram of the operating technique. (D) Result about 1 month following the operation.

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Figure 3C

Figure 3D

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Leigheb G. Lembi per sede topografica: naso. In: Leigheb G, Tulli A, eds. Manuale di dermochirurgia. Milan: Cilag spa, 1990:164. Sbano E, Della Corte G. Riparazione estetica dei difetti parziali del naso mediante lembi locali. G It Dermatol Chir Oncol 1993; 2:80–87. Salasche S. Nasal surgery. In: Roenigk RK, Roenigk HH, eds. Dermatologic Surgery. New York: Marcel Dekker, 1989:438–464. Boggio P, Gattoni M, Zanetta R, Leigheb G. Burow’s triangle advancement flaps for excision of two closely approximated skin lesions. Dermatol Surg 1999; 25:622–625.

46 Bilobed Flap for Reconstruction After Simultaneous Removal of Three Lesions: Compound Bilobed Flap of the Nose Paolo Boggio and Giorgio Leigheb University of Piemonte Orientale and Maggiore della Carita` Hospital, Novara, Italy

I.

INTRODUCTION

The bilobed transposition flap is usually used to fill losses of tissue by shifting a portion of the tissue from an elastic and mobile region of the skin to another relatively distant, more adherent and fixed area impossible to reach with a normal rotation or transposition flap. The distal flap is used to cover the excision while a second flap covers the donor area of the first flap. The donor area of the second flap is then closed by a direct suture (1,2).

II. TECHNIQUE The exeresis of multiple lesions when relatively close to one another can give reconstructive problems and the bilobed flap can be modified to fit many defects, including multiple lesions localized along an ideal arcuate line. This is possible by using the last excision area as a Burow’s triangle (as shown in diagrams 2 and 4 of Figure 1) that facilitates the flap rotation and by closing the donor areas directly (3,4). Different types of bilobed flaps used to remove one, two, or three lesions are shown in Figure 1. Note that when 277

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a gap is lying between the two lobes they can also be considered to be two seriated transposition flaps facilitating one another’s rotation (diagram 3 of Figure 1).

Figure 1 Different types of bilobed flaps used to remove one, two, and three lesions and respective final sutures. Note the direct closures of donor areas in diagram 2 (BCX) and 4 (ABY and CDZ) and the Burow’s triangle principle applied to the last gap in diagrams 2 (CD) and 4 (DE).

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Obviously anyone who does flaps knows that each situation is different and the adoption of these techniques must be evaluated in each individual case taking into account the size and spatial location of the lesions to be removed and the principles of tissue movement. When this technique is possible, it also gives very good cosmetic results because of the curved suture lines as well as the saving of a significant portion of skin and the reduction of the overall duration of the operation. Moreover, the simultaneous operation of three lesions is not only convenient in terms of patient discomfort and costs but also allows the patient to recuperate in the same time as after removal of an unique lesion. In the following case it was possible to excise simultaneously three lesions and reconstruct the nasal ala using a single bilobed flap that had a cutaneous-cartilaginous compound lobe.

A.

Case

An 82-year-old woman with three basal cell carcinomas (Figure 2), one on the nose apex, another on the left nasal ala, including the free margin (Figure 3), and a smaller one in the right paranasal region. The three lesions were localized along an arcuate line; the distance between the lesions was of

Figure 2 The three lesions of the nose to be excised: left alar, apical, and right paranasal.

Figure 3 Detail of the lesion of the left alar region.

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about 1 ‘‘diameter’’ (width of the hypothetical rhomboid exeresis needed to respect a lesion). The smallest lesion was localized in a relatively more elastic and extensible region of the skin. Exeresis were carried out under microscopic control of the margins, and the tumor of the left nasal ala implied the demolition of part of the alar edge, including the alar cartilage (Figure 4). By cutting a flap between the first two lesions and leaving a cartilaginous layer in its deeper portion, it was possible to reconstruct both the ala nasi and the free margin, the latter by tucking down the apex of the flap (Figure 5). Flap rotation was made easier by mobilization of a second lobe cut in the right ala with which the gap of the excision on the apex of the nose was also covered. Moreover, this rotation of the bilobed flap was made easier by the creation of a Burow triangle, the latter being represented by the operating gap of the third paranasal right-hand lesion. The two donor areas of the bilobed flap could be sutured directly (Figure 6). After 2 months, the cosmetic results were satisfactory considering the width of the operating wound (Figure 7).

Figure 4 Demolition of the alar edge and preparation of the compound flap with a cartilaginous layer in its deep portion.

Figure 5 Final suture and reconstruction of both the nasal ala and free margin by tucking down the apex of the flap.

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Figure 6 (A) Mobilization of the bilobed flap with the two gaps of the second donor area and of the paranasal lesion. (B) Final suture. (C) Diagram of the operating technique with the drawing of incision lines, the movement of flap, and the final suture lines.

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Figure 7

III.

Result of the operation about 2 months postoperatively.

CONCLUSIONS

Although the bilobed flap has always been considered in the reconstruction of unique operative gaps in which it has given good cosmetic results in certain regions, it can also have advantages in the exeresis of multiple lesions when these are relatively close to one another and localized along an arcuate line.


Wheeland RG. Bilobed flap. In: Roenigk RK, Roenigk HH, eds. Dermatologic Surgery. New York: Marcel Dekker, 1989:311–313. Leigheb G. Lembo bilobato di rotazione. In: Leigheb G, Tulli A, eds. Manuale di dermochirurgia. Milan: Cilag spa, 1990:123. Sbano E, Della Corte G. Riparazione estetica dei difetti parziali del naso mediante lembi locali. G It Dermatol Chir Oncol 1993; 2:80–87. Boggio P, Gattoni M, Zanetta R, Leigheb G. Burow’s triangle advancement flaps for excision of two closely approximated skin lesions. Dermatol Surg 1999; 25:1–5.

47 Rotation and Transposition Flaps for Reconstruction After Simultaneous Removals of Two Close Skin Lesions Paolo Boggio and Giorgio Leigheb University of Piemonte Orientale and Maggiore della Carita` Hospital, Novara, Italy

I.

INTRODUCTION

Rhomboid exeresis usually represents the easiest method for the removal of cutaneous lesions, but it is not always suitable either when best cosmetic results are desirable or when cutaneous resilience is lacking. In particular, in the case of two close lesions, a simultaneous double rhomboid excision often seems impossible to use. In such cases, an effective solution is offered by the Burow’s triangle advancement flap (1). However, in some regions, it is not always possible to find a triangular flap with a proper design either for the closeness to the natural orifices, or mismatching with wrinkle lines and cosmetic units, or for the irregular shape of emaculations. Thus, a good alternative solution can be the use of rotation or transposition flaps, which can be designed so as to obtain a single suture line, generally arcuate or curved.

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II. ROTATION FLAP A rotation flap is usually taken from more resilient skin regions to fill losses of tissue of adjacent less-resilient regions (2). It is usually fan-shaped (Imre flap) up to two to four times wider than the excision area, and a Burow’s triangle is cut out at its base to facilitate rotation (3). In the case of two close lesions, it is possible to obtain a simultaneous excision by circumscribing one of them with the Burow’s triangle with a technique that is similar to the one adopted for the Burow’s triangle flap (1). Four different variants are possible in this specific situation (Figure 1) allowing the choice of four corresponding types of final suture according to the cosmetic requirements. The distance between the lesions can reach a width of 3–4 ‘‘diameters’ (the width of the hypothetical rhomboid exeresis needed to resect a lesion). If the distance between the lesions is about 1 diameter, this rotation flap becomes a variant of the Dufourmentel transposition flap (a flap whose length is 1.5 times longer than the width of the lesion gap) (Figure 2) (5). It is possible, in fact, to cut out a flat between the lesions, whose length-width ratio is 1 : 1 and whose rotation is made easier by the direct suture of one of the two gaps (Figure 3). In this case, all of the four direction variants mentioned above are also possible. Because of the base width, the flap is very vital and, unlike a Dufourmentel flap, only a mild torsion of the ped-

Figure 1 Four different variants of the rotation flap when two lesions are removed simultaneously with the respective four final suture directions obtained.

Rotation and Transposition Flaps

Figure 2

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Dufourmentel’s transposition flap.

uncle can be expected, thus keeping better vascularization. It is noteworthy that this flap variant, although structurally and conceptually similar to the rotation flap, can be more appropriately considered to be a type of very simple transposition flap.

III.

TRANSPOSITION FLAP

A transposition flap is used when the operating gap is localized in lowresilient areas impossible to suture directly and is obtained by cutting out distant resilient donor areas that can easily be sutured (4). The rotation of this flap allows the surgeon to skip over sound skin, although its base corresponds to the gap (2). The rotation angle of the flap axis can reach an angle of up to 180 degrees (a limit to the peduncle torsion degree angle), but the rotation is usually not more than about 90 degrees (Figure 4). In the case of two close lesions, this type of plastic repair can be used especially if one of the two gaps is localized in a fairly resilient region. A flap is then cut

Figure 3 Transposition flap as a variant of Dufourmentel’s flap in the simultaneous excision of two lesions.

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Figure 4 Examples of three rotation angles (60, 90, and 180 degrees) in a transposition flap.

out in continuity with the gap localized in the more resilient are in order to create a unique gap that is directly suturable and making the flap rotation to the gap easier in the low resilient area (Figure 5). The adoption of this technique depends on the distance between the lesions, which should not exceed 1.0–1.5 diameters, because the length of the flap must be proportional to the receiving wound so as to avoid waste of reduntant skin. Even in this technique, two theoretical variants of the direction of the cut are possible in order to achieve the best cosmetic results (Figure 5). It is not possible to establish precise rules for these flaps owing to the extreme variability that two close lesions can display in regard to localization, shape, and distance. For this reason, the surgeon should evaluate the advantages of a simultaneous excision with simple and conservative techniques according to the conditions in each individual case. The basic principles of this type of surgery consider limited excision, minimal skin damage, and undermining, and minimal scarring in order to achieve the best results with the simplest methods. The following two cases best illustrate these principles.

A.

Cases

1.

Case 1

A 72-year-old woman with two evolving keratotic lesions on her left-hand cheek bone about 1 diameter apart. Because of the closeness of the lesions to the lower eyelid, made it impossible to achieve a satisfactory result with a variant of the triangular flap.


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Figure 5 Two possible variants of transposition flaps in the exeresis of two lesions and the respective final sutures (: gap in the less resilient area, þ: gap in the more resilient area).

However, a flap cut out between the two lesions with a peduncle at its inferior extremity made it possible to close the medial gap while rotating the flap laterally to obtain an arcuate suture line along the wrinkles of the lower eyelid (Figure 6 A–C). 2.

Case 2

A 71-year-old man with two large and irregular basal cell carcinomas localized on the left temporal region. The shape and size of the lesions made it impossible to use a simple elliptical excision or a triangular flap at the same time (Figure 7A). Having noted that the loosest skin, most suitable to provide a flap, was in the temporal region, a flap was sculptured to lengthen the lower gap; this

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Figure 6 (A) Drawing of the flap between the two gaps. (B) Result 1 month following the operation. (C) Diagram of operating technique with the drawing of incision lines, the movement of the flap, and the final suture line.

transposition flap was used to suture the upper gap localized in the lessresilient area. The donor area, extended into the lower gap, was easily sutured by sliding the lower border, thus aiding flap rotation. The obtained suture line was arcuate and broken and was well disguised along the borders of the frontal and temporal regional subunits (Figure 7 B–D).


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Figure 7 (A) Two large basal cell carcinomas of the temporal region with drawing before cut. (B) Final suture. (C) Result 2 months following the operation. (D) Diagram of operating technique.

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Figure 7D

IV.

CONCLUSIONS

Rotation and transposition flaps can be good alternatives for the simultaneous removal of close lesions when direct excision or triangular flaps are not feasible. Their direction should be carefully studied in terms of distance between lesions, localization, shape, cutaneous resilience, and possible cosmetic results according to the direction of the final suture. The simultaneous ablation of multiple lesions guarantees saving of time and costs and can give better cosmetic results than serial rhomboid excisions.

REFERENCES 1.

2. 3. 4. 5.

Boggio P, Gattoni M, Zanetta R, Leigheb G. Burow’s triangle advancement flaps for excision of two closely approximated skin lesions. Dermatol Surg 1999; 25:622–625. Wheeland RG. Rotation flap. In: Roenigk RK, Roenigk HH, eds. Dermatologic Surgery. New York: Marcel Dekker, 1989:291. Leigheb G. Lembi di rotazione e di trasposizione. In: Leigheb G, Tulli A, eds. Manuale di dermochirurgia. Milan: Cilag spa, 1990:117–123. Chernosky ME. Scalpel and scissors surgery as seen by the dermatologist. In: Epstein E, Epstein E Jr, eds. Skin Surgery. Philadelphia: Saunders, 1987:113. Dufourmentel C, Mouly R. Chirurgie plastique: Paris, Flammarion, 1959.

48

Innovations in Island Pedicle Flaps David R. Byrd Mayo Graduate School of Medicine, Rochester, Minnesota

Randall K. Roenigk and Clark C. Otley Mayo Medical School, Rochester, Minnesota

I.

INTRODUCTION

Island pedicle flaps (IPFs) (subcutaneous pedicle flap or kite flap) are random patterned flaps that gain their blood supply from subcutaneous tissue (1). These flaps are often useful in areas of high tension, areas adjacent or abutting cosmetically important structures, and areas requiring tissue sparing. IPFs are particularly useful in reconstructing defects in the perioral, perinasal, and periocular regions with minimal tension and little waste of tissue. Used in the proper setting, IPFs produce superior cosmetic results with minimal disruption of surrounding tissue. However, mobility can often be restricted by the secondary movement of surrounding tissue, immobility of the underlying fibromuscular pedicle, and anatomical barriers. Several modifications may be implemented to afford better movement and cosmetic results.

II. BIOMECHANICS An inverse relationship exists between subcutaneous or myocutaneous pedicle mobility and blood supply. Traditionally, IPFs are created by incising a

# Copyright 2001 the Mayo Foundation

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triangular wedge of tissue (Figure 1) adjacent to a surgical defect through the epidermis and dermis and severing the papillar dermal vasculature. Flap blood supply is derived from the subdermal random vascular plexus. This consists of a vascular network of unnamed blood vessels existing in the subcutaneous fat and muscle. If a flap is made too small, advanced too far (strangulating the blood supply), undermined too aggressively, or used in poorly vascularized regions, flap viability can be jeopardized.

III.

MODIFICATIONS TO THE IPF

The following modifications have been described. Changes to flap dynamics Laterally based pedicle flaps Bipedicle flaps Flip-flop flaps Tunneling flaps Defect preparation

Figure 1

Island pedicle flap. (By permission of the Mayo Foundation.)

Innovations in Island Pedicle Flaps

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Changes to Flap Dynamics

Once the initial incisions are made, the flap is advanced into the defect. To gain further mobility, the peripheral tissue surrounding the defect and flap can be undermined cautiously. Additional flap mobility can be attained by lengthening the subcutaneous or vascular pedicle of the flap or by incising deeper, which can potentially compromise blood supply. One of the primary advantages of IPFs is that once created they can move in virtually any direction. In our practice, the primary movement is advancement (Figure 2). Others (2) have modified flaps to be more rotational or transpositional. With this in mind, flap movement can be modified to meet restraints of anatomy, cosmesis, or vascular supply. In areas of contour, such as the nasal ala or nasolabial fold, flaps modified to move in a rotational manner complement the conformation of these areas (Figure 3).

B.

Laterally Based Pedicle Flaps

Similarly, the vascular pedicle can be based laterally (3,4) in areas where centrally based pedicles are frequently immobile or inadequate for flap viability (i.e., nasal dorsum) (Figure 4). Initial skin incisions are made in the

Figure 2 Design and advancement of an island pedicle flap. (From Ref. 8. By permission of the American Academy of Dermatology.)

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usual fashion. The underside of the flap is undermined to create a connection from the posterior aspect of the flap to the defect. The lateral subcutaneous and muscular pedicle is left intact, creating a flap, which glides along the base of the defect. This is particularly useful along the nasal dorsum where the fibrofatty tissue is adherent. Laterally based flaps on the nasal dorsum allow for greater mobility with less risk of strangulating the vascular pedicle.

C.

Bipedicle Flaps

Bipedicle flaps, where islands of tissue are mobilized from two sides of the defect (Figure 5), are a useful means of increasing flap mobility in areas where tissue mobility is limited, and they avoid excessive wound edge tension. This flap modification is of particular benefit in regions where tension makes primary closure an improbability, such as a large defect on extremities and the torso.

Figure 3

Rotating island pedicle flap.


D.

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Flip-Flop Flaps

Mobilized IPFs can be advanced through a full-thickness defect as in the conchal bowl of the ear (flip-flop or revolving-door flap) (Figure 6) (5,6). First, a template of the defect is made. The template is transposed onto the uninvolved tissue directly behind the through-and-through defect and marked with a marking pen. The skin is incised and the central pedicle is elevated. Additional mobility can be attained by carefully undermining the pedicle. As mobility is gained, vascularity can be compromised. The elevated flap is then passed through the defect and sutured into place.

Figure 4

Laterally based pedicle on nasal dorsum.

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Figure 5

E.

Bipedicle flap.

Tunneling Flaps

Tunneling of flaps can be used in areas of high vascularity where cosmesis is a significant concern (7). Flaps created adjacent to larger vessels (e.g., infraorbital [Figure 7] and supraorbital arteries) are better suited for tunneling. Creation of an incision from donor to recipient site may follow for easier tissue movement. This incision can be placed along skin tension lines for better cosmesis. Disruption of anatomical subunits and multiple-aged procedures is avoided. The advantages of a single-staged operation, added vascularity, and maintenance of cosmetic subunits make this modification

Figure 6

Flip-flop flap. (By permission of the Mayo Foundation.)


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Figure 7 Tunneling flap with incision from donor to recipient site. (By permission of the Mayo Foundation.)

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particularly attractive. Nevertheless, the need for a significantly vascularized subcutaneous pedicle may limit its use to areas adjacent to the cheek where there is an ample well-vascularized pedicle. Protuberance of the pedicle, trap-door defects, and compromised vascularity are hazards related to its use. Steroid injection or surgical revision or debulking of the pedicle after allowing time for adequate revascularization and healing may lead to resolution of excessively bulky pedicles. Undermining the tissue adjacent to the recipient site or making the defect and flap more square or angulated may prevent the development of trap-door defects. Careful planning to create pedicles that derive their blood supply from significant vessels may prevent flap necrosis related to poor vascularity. F.

Defect Preparation

Typically, IPFs are created by incising a triangular wedge of tissue (the flat end of the triangle abutting the defect) through the subcutaneous tissue. The flap gains its vascular supply from the underlying flat and muscle. Bevelededge defects after tangential incisions or excess fat after Mohs or simple excision often may impede the movement of the leading edge of the IPF. To obtain optimal IPF movement, the beveled edge of the Mohs defect, variable amounts of subcutaneous tissue at the base of the defect, and a triangular piece of subcutaneous tissue beneath the advancing edge of the flap (Figure 8A and B) (8) are excised. The removal of this tissue contours the flap to the defect, allowing better apposition of the advancing flap edge to the defect margin (Figure 8C). Careful dissection is essential, especially in areas adjacent to important neurovascular structures. Removal of tissue from the defect base allows for better tissue mobility with decreased wound tension.

IV.

CONCLUSIONS

IPFs are a useful tool for the reconstructive surgeon. Modifications to the flap itself and surrounding tissue allow for greater flap viability, versatility, and mobility. Derivation from a subcutaneous vascular pedicle allows for tissue mobility with minimal expenditure of tissue. Flap movement can subsequently be more advancement, rotational, or transpositional, depending on the demands the defect poses. Lengthening the flap, undermining, and removing the subcutaneous tissue in front of and beneath the advancing edge of the flap aid flap mobility. Bipedicle flaps are beneficial in closing defects in areas of high tension and limited tissue mobility. Flip-flop flats are useful closures for through-and-through defects of the ear. Proper prepara-


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Figure 8 (A) Excess tissue removed in preparing the defect for island pedicle flap. (B) Defect prepared with no impedance to advancement of island pedicle flap. (C) Island pedicle flap advanced into place. (From Ref. 8. By permission of the American Academy of Dermatology.)

tion of the defect is also a key to the IPFs’ versatility. When used in the proper setting, an IPF can lead to excellent functional and cosmetic results with minimal expenditure of tissue.

REFERENCES 1.

2. 3.

Wheeland RG. Random pattern flaps. In: Roenigk RK, Roenigk HH Jr, eds. Roenigk & Roenigk’s Dermatologic Surgery: Principles and Practice. 2nd ed. New York: Marcel Dekker, 1996:817. Dzubow LM. Facial Flaps: Biomechanics and Regional Application. Norwalk, CT: Appleton & Lange, 1990:57–65. Papadopoulos DJ, Trinei FA. Superiorly based nasalis myocutaneous island pedicle flap with bilevel undermining for nasal tip and supratip reconstruction. Dermatol Surg 1999; 25:530–536.

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4.

Ohsumi N, Ishikawa T, Shibata Y. Reconstruction of nasal tip defects by dorsonasal V-Y advancement island flap. Ann Plast Surg 1998; 40:18–22. Humphreys TR, Goldberg LH, Wiemer DR. The postauricular (revolving door) island pedicle flap revisited. Dermatol Surg 1996; 22:148–150. Fader DJ, Johnson TM. Ear reconstruction utilizing the subcutaneous island pedicle graft (flip-flop) flap. Dermatol Surg 1999; 25:94–96. Fosko SW, Dzubow LM. Nasal reconstruction with the cheek island pedicle flap. J Am Acad Dermatol 1996; 35:580–587. Otley CC, Roenigk RK. Surgical pearl: preparing the defect for an island pedicle flap. J Am Acad Dermatol 1997; 36:257–258.

5. 6. 7. 8.

49 Reconstruction of Umbilicus Using a Skin Flap Takatoshi Yotsuyanagi, Satoshi Urushidate, and Yukimasa Sawada Hirosaki University School of Medicine, Hirosaki, Japan

I.

INTRODUCTION

The umbilicus is located below the abdominal midpoint between the xiphoid process and the symphysis pubis. Situated over the disc between the third and fourth vertebrae, it is located approximately 2–4 cm above the line joining the crests of the ilia. Its position may vary considerably with the type of individual habitus (1). The umbilicus is the only important landmark on the abdominal wall. If the umbilicus is deformed or absent, it looks very strange. Many abnormalities easily occur in the umbilicus structurally and embryologically. Umbilical cord hernia and the defect accompanied by omphalocele or gastroschisis are the most common conditions for which umbilicoplasty is needed. We describe here the reconstructive techniques using a skin flap for these conditions.

II. UMBILICAL CORD HERNIA Umbilical cord hernia is one of the most commonly encountered abnormalities in the early months of infancy. Spontaneous resolution occurs within the first 3 years of life in almost all cases, but some of the children don’t heal. The incidence of functional complications is low. However, surgical repair may be necessary to acquire esthetic improvement (1). Although there 301

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have been reported many procedures using skin grafts or local flaps (2), we recommend the technique using a reverse V-shaped skin flap without skin grafts. It is the reason that this technique can create a natural umbilicus simply and with less scarring.

A.

Surgical Technique

An inferiorly based reverse V-shaped skin flap is designed over the bulging skin (Figure 1A). After skin incision and flap elevation, the area around the umbilical ring is widely undermined on the abdominal sheath, especially caudally (Figure 1B). The base of the hernia sac is transected carefully so as not to injure the omentum and the margins are firmly sutured to each other. Both edges of the sheath should also be sutured firmly in the midline to prevent recurrence (Figure 1C). The center of the flap is stuffed caudally into the subcutaneous space to make a deep sac. Some deep points in the sac are immobilized by anchor sutures to the abdominal sheath and bolster sutures to caudal skin. The cranial donor site of the flap is sutured in the midline. This procedure determines the size of the entrance of the created umbilicus. It is recom-

Figure 1 Schematic diagrams of the reconstructive technique for umbilical cord hernia. (A) A design of the V-shaped skin flap over the bulging skin. (B) The flap is elevated and the hernia sac transected. (C) Both edges of the sac and sheath are sutured in the midline. (D) Immediate postoperative view. (E) Longitudinal view. The sac is created caudally with bolster sutures.

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mended that the umbilicus should be slightly smaller than the natural size when the operation is finished (Figure 1D and E). An ointment gauze is packed into the umbilical fossa. All suture materials are removed within 7 days after the operation. A case report of a 3-year-old boy with an umbilical cord hernia is shown in Figure 2.

III.

ABSENCE OF THE UMBILICUS

The absence of the umbilicus is caused by surgery for various abnormalities such as omphalocele, gastroschisis, and tumors. As for umbilical cord hernia, the goal of satisfactory repair of an absent umbilicus is to crate a natural umbilicus simply and with less scarring. However, it is difficult to make a deep umbilicus, because almost all patients have a thin abdominal wall and a wide vertical scar. In addition, it is a serious complication when there is a loss of umbilical depth due to scar contracture, which easily occurs over time after umbilicoplasty (3). Many techniques for umbilical reconstruction, such as skin grafting, local flaps, a combination of local flap and skin grafting, and conchal cartilage composite grafting have been reported (3–6). Of these techniques, the one using flaps with sufficient length and width is the best to create a natural and deep umbilicus. The flaps should include a large volume of soft tissue in the flap and all the long unsightly scar should be removed simultaneously. We recommend our technique using two twisted flaps (6).

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Figure 2 (A) A preoperative view. (B) After the flap elevation, the hernia sac is pulled out and transected. (C) Appearance when operation is finished. (D) Appearance 1 year after the operation.


A.

305

Surgical Technique

Two skin flaps with the same pedicle are designed to include the vertical scar tissues. The position of the pedicle determines the newly created bottom for the umbilicus. The other scar with a suture mark can be removed simultaneously (Figure 3A). Two flaps are elevated from the rectus sheath so as not to injure the pedicle. The pedicle of these flaps is rigidly adherent to the rectus fascia. The flaps should include as large a volume of subcutaneous tissues as possible. This is the reason that the volume of soft tissues determines the depth of the umbilicus. The edges of the flaps are sutured to each other. A skin tube is formed by this procedure and is used as the lateral wall of the umbilicus (Figure 3B). The skin defect after the elevation of the flaps is closed primarily in the midline. In this procedure, parts of both margins, which are positioned at the entrance of the umbilicus, are undermined and turned down. This procedure can hide the circumferential scar within the umbilical cavity. The edge of the skin tube of the flaps is then twisted and sutured to this folded skin. This procedure creates normal-appearing wrinkles for the umbilicus (Figure 3C). It is better to create a slightly smaller size than normal, as with the technique for repair of umbilical cord hernia.

Figure 3 Schematic diagrams of the reconstructive technique for the absence of the umbilicus. (A) A design of the two skin flaps with the same pedicle on the vertical scar tissues. The other scar with suture mark can be removed simultaneously. (B) The edges of the elevated flaps are sutured to each other. The tube formed by the flaps is twisted. (C) The edges of the skin defect are sutured to each other and are sutured with the tube in the umbilicus.

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The newly formed umbilicus has a sufficient depression with a natural appearance. The suture materials are removed 7 days after the operation. Cleaning of the umbilical fossa is necessary once a week for the first few weeks after the operation. For the first few months, the prominence of the flap volume around the umbilicus feels strange. However, it gradually becomes inconspicuous. A case report of a 5-year-old boy with an absent umbilicus after the operation for gastroschisis is shown in Figure 4.

IV.

CONCLUSIONS

For success of umbilical reconstruction, a technique that results in a natural form and sufficient depth should be selected. In addition, scar contracture, which causes a loss of depth over time must be prevented. Therefore, we conclude that the above-described techniques are very good ones when used properly with flaps that have large size and volume.

Figure 4 (A) A preoperative view. (B) The design of the flaps. (C) The flaps are elevated with a large volume of subcutaneous tissues. (D) The flaps are sutured to each other to make a tube. (E) Appearance when operation is finished. (F) Appearance 1 year after the operation.


307


Bell MJ. Umbilical and other abdominal wall hernias. In: Holder TM, Ashcraft KW, eds. Pediatric Surgery. Philadelphia: Saunders, 1980:589–593. Park S, Hata Y, Ito O, Tokioka K, Kagawa K. Repair of mild umbilical hernia. Ann Plast Surg 1999; 42:634–637. Sawada Y. An umbilical reconstruction using subcutaneous pedicle flap. Eur J Plast Surg 1995; 18:185–187. Hatoko M, Harashina T. Reconstruction of the umbilicus using a full-thickness skin grafting. Jpn J Plast Reconstr Surg 1989; 32:357–360.

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5.

Matsuo K, Kondoh S, Hirose T. A simple technique for reconstruction of the umbilicus, using a conchal cartilage composite graft. Plast Reconstr Surg 1990; 86:149–152. Yotsuyanagi T, Nihei Y, Sawada Y. A simple technique for reconstruction of the umbilicus, using two twisted flaps. Plast Reconstr Surg 1998; 102:2444– 2446.

6.

50 Mini Z in Z to Relieve the Transverse Linear Tension After a Z-Plasty Transposition Ahmet Seyhan Celal Bayar University, Manisa, Turkey

I.

INTRODUCTION

One of the most common uses of the Z-plasty is the release of skin contractures. In clinical practice, one or a few large Z-plasties instead of many smaller ones are more effective for lengthening the skin in a desired direction (1). Therefore, in many situations, it is desirable to use as large as possible a Z-plasty. However, the larger the Z-plasty, the more the tension results in the transverse direction. A too large Z-plasty cannot be transposed because of excessive tension. Fortunately, planning of such a too large Z-plasty can usually be avoided by clinical examination; that is, pinching the skin adjacent to the contracture band or scar when flap planning. A special type of ruler can also be used during the clinical examination to determine the largest safely transposable Z-plasty (2). The clinical examination will help ensure that crucial mistakes will not be made; however, minor errors may occur in which a Z-plasty design, slightly larger than appropriate, may result in linear excess tension limited to the transversely oriented new central limb. This linear tension can interfere with the blood supply to the adjacent skin area, including distal points of the flaps, and the resulting furrow may have a constrictive effect on the extremity; at the very least, it looks unsightly. The problem caused by this linear tension and the resulting furrow can be overcome by using a supplementary mini Z-plasty in certain cases (3). 309

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II. OPERATIVE TECHNIQUE The technique is shown schematically in Figure 1 and presented intraoperatively in Figure 2 A–D. The configuration of the mini Z has to correspond with the transposed form of the large Z. The central member of the mini Z should lie within but not exceed the central one-third section of the central member of the large Z, preferably it should be smaller. The extent and the depth of the incisions for the mini Z limbs must not endanger the viability of the larger Z-plasty flaps (3).

Figure 1 (Top) Schematic drawing of a large Z-plasty that has been devised to lengthen a contracture line on an extremity. (Middle) After the transposition, the front (left) and lateral (right) views are shown. A mini Z-plasty has been devised to correct the constriction (arrow) resulting from tension just around the new center limb. (Bottom) After the transposition of the mini Z, the tension has been relieved and the constrictive effect (furrow) has disappeared. (From Ref. 3.)

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Figure 2 (A) The flaps of multiple Z-plasties for releasing the scar contracture on the right forearm of a 6-year-old boy have been transposed. A mini Z has been planned with a superficial scratch to release the tension on the central member of the proximally placed Z (on left). (B) Lateral view at the same stage. Note the constrictive effect (furrow) alongside the central member (arrow). (C) The spontaneous transposition is seen after the mini Z has been cut. (D) This view corresponds with Figure 2B; neither a wound healing problem nor a furrow is seen after just 3 weeks. (From Ref. 3.)

III.

INDICATIONS

After the transposition of a large Z-plasty on an extremity, the presence of a transverse linear tension associated with a furrow is the main indication for this mini Z-plasty application. The furrow indicates not only the linearity of the transverse tension but also the fact that too much skin has been oriented in the direction of the long diameter of the Z-plasty. In this case, the transposition of the mini Z results in making the furrow even without interfering with the existing functional elongation obtained by the large Z-plasty. This technique is not useful and should not be used when the tension affects a wider zone of skin beyond the proposed application area of the mini Zplasty.

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REFERENCES 1. 2. 3.

Furnas DW, Fisher GW. The Z-plasty: biomechanics and mathematics. Br J Plast Surg 1971; 24:144–160. Seyhan A. A ‘‘V’’ shaped ruler to detect the largest tranposable Z-plasty. Plast Reconstr Surg 1998; 101:870–872. Seyhan A. Mini Z in Z to relieve the tension on the transverse closure after Zplasty transposition. Plast Reconstr Surg 1998; 101:1635–1637.

51 ‘‘Iris’’ Technique for Immediate Umbilical Reconstruction Michael J. Miller The University of Texas M.D. Anderson Cancer Center, Houston, Texas

I.

INTRODUCTION

Loss of the umbilicus can result in an embarrassing deformity. Acquired loss can result from some older techniques of umbilical hernia repair (1) as well as from tissue necrosis complicating modern breast reconstruction based on the lower abdominal tissue. The umbilicus is the only structure normally found in the otherwise smooth and featureless skin of the mid abdomen. The ideal umbilical reconstruction creates a permanent, rounded depression in the mid abdomen with a minimum of scarring. The superior margin should form a slight hood of skin. Techniques described for umbilical reconstruction use various flaps (2–7) sometimes in combination with tissue grafts (8). Most of these are delayed reconstructions that are designed on an intact, smooth abdominal surface. Immediate reconstruction presents a slightly different problem in that more tissue is required which must be recruited from a greater distance. The ‘‘iris’’ technique described below satisfies this need by borrowing tissue from all directions.

II. TECHNIQUE Four local flaps of skin and subcutaneous fat are designed around the umbilical defect (Figure 1). Each flap is of equal size with a base of 1.5 313

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Figure 1 The ‘‘iris’’ technique. (A) Ablation of the umbilicus. (B) Design of the flaps. (C) Closure and revision of dog ears. (D) Final closure.

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Figure 2 Example of a young woman treated for melanoma on the lateral wall of the umbilicus by total resection of the umbilicus and adjacent abdominal wall. (A) Preoperative view. (B) Defect with four flaps raised. Anterior (C) and oblique (D) appearance after 6 months.

cm and length of 2.5 cm extending around one-fourth of the circumference of the defect. The individual flaps are short and well vascularized. After mobilization, the tips of each flap are sutured together and secured to the abdominal wall with nonabsorbable suture. They are positioned in a slightly cephalad location in order to recreate an upper skin fold characteristic of a normal umbilicus. Then proceeding from the center, the adjacent margins of the flaps are approximated resulting in a progressive rotation and advancement similar to the diaphragm, or ‘‘iris,’’ of a camera lens. As the flaps advance, the narrow distal portions begin to create a skin-lined tube pro-

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jecting inward simulating a natural umbilicus. The dog ears at the extremes of the incisions are immediately excised resulting in four radially oriented scars.

REFERENCES 1. 2. 3.

Iason AH. Umbilical hernia. In: Hernia. Philadelphia: Blakiston, 1941; 816– 858. Sugawara Y, Hirabayashi S, Asato H, Yoshimura K. Reconstruction of the umbilicus using a single triangular flap. Ann Plast Surg 1995; 34:78. Sawada Y. An umbilical reconstruction using subcutaneous pedicle flap. Eur J Plast Surg 1995; 18:185.

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4.

Jamra FA. Reconstruction of the umbilicus by a double V-Y procedure. Plast Reconstr Surg 1979; 64:107. Borges AF. Reconstruction of the umbilicus. Br J Plast Surg 1975; 28:75. Yotsuyanagi T, Nihei Y, Sawada Y. A simple technique for reconstruction of the umbilicus, using two twisted flaps. Plast Reconstr Surg 1998; 102:2444– 2446. Kirianoff TG. Making a new umbilicus when none exists. Plast Reconstr Surg 1978; 61:603. Matsuo K, Kondoh S, Hirose T. A simple technique for reconstruction of the umbilicus, using a conchal cartilage composite graft. Plast Reconstr Surg. 1990; 86:149.

5. 6.

7. 8.

52 Flap Defatting with an Ultrasonic Surgical Aspirator Kazuyoshi Yamanaka Saiseikai Kanagawaken Hospital, Yokohama, Japan

I.

INTRODUCTION

During flap surgery, some fat tissue must be retained with the donor skin to preserve vascularization. Defatting surgery may be later required if the flap is too bulky. Although primary defatting at the time of creating flap has been reported by some surgeons (1,2), these methods are technically difficult. Conventional defatting with scissors and forceps is meticulous and fatiguing work and sufficient defatting is difficult, because great care must be taken not to damage the flap circulation. Some new techniques have been introduced to facilitate flap defatting. Hallock (3) has applied suctionassisted lipectomy through a small incision and a blunt canula tunnel. Wu and Chan (4) have reported a technique using an arthroscopic shaver and a suction device. In this study, an ultrasonic surgical aspirator, which selectively fragments the fat tissue using ultrasound, was used for flap defatting, unlike the above-mentioned mechanical techniques (5).

II. PHYSICAL PRINCIPLE High-intensity ultrasound generates imploding microbubbles in fluids. This phenomenon is called cavitation. The implosion of endocellular or pericellular microbubbles causes an increase in molecular excitation up to a high energy level, causing cellular destruction. Cavitation is influenced by the 319

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density/viscosity of the medium (6). Fatty tissue is easier to cavitate than compact tissue like skin, blood vessels, and peripheral nerves. The features of ultrasound have been applied in the field of body contouring (6). The author has used an ultrasonic surgical aspirator mainly for the defatting in the hand, which contains different kinds of tissue close together in a small area.

III.

SURGICAL TECHNIQUE

An ultrasonic surgical aspirator (Sonotec Model MAA-2511, Mochida, Tokyo) was used for this surgical series (Figure 1). This instrument consists of a handpiece with an oscillating tip and an irrigation and suction system. The maximal ultrasonic power is 100 W, and the maximal oscillating width of the tip is 240 m at 24 kHz. The output power is controllable by the control console and foot pedal. We usually use this instrument at about half of the maximal power.

Figure 1 Ultrasonic surgical aspirator. The instrument consists of a handpiece with an oscillating tip and an irrigation and suction system. The output power is controllable by the control console and foot pedal.

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One side of the flap margin is opened and the flap is reversed. To make the operation safe and reliable, blunt defatting through a small incision is not performed. Since fibrous tissue is resistant to ultrasound, it is split bluntly with forceps to expose the fat. The oscillating tip is placed in direct contact with the fat, which is then emulsified and aspirated (Figure 2). This procedure is repeated until enough fat has been removed. Care should be taken not to keep the oscillating tip in contact with the skin for too long to prevent damage the arterial network of the skin. As nerves are resistant to ultrasound, this technique is useful in defatting flaps that contain nerves (Figure 3). However, the high power of high-frequency ultrasound has been reported to damage nerve function (7). Therefore, the ultrasonic tip should not be applied directly to the nerves and the device should not be used at maximal power. Redundant skin is excised and a compressive dressing is applied after skin closure over a drain. If the contact area with the marginal tissue of the flap is limited and fat removal from the entire flap in one session is considered to be hazardous for flap circulation, the defatting may need to be performed at intervals of several weeks (Figure 4).

Figure 2 Surgical procedure. (A) The fibrous septum of fat tissue is split bluntly to expose the fat. (B) The oscillating tip is placed in direct contact with the fat, which is then emulsified and aspirated. (From Ref. 5.)

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Figure 3 A 44-year-old man had his left hand injured during the explosion of an oxygen bomb. (A) The man was treated with a reversed radial forearm flap and a nerve graft using the lateral forearm cutaneous nerve in the flap. The first defatting procedure was performed mainly on the volar side of the flap using the ordinary technique 7 months after the flap operation. The second defatting procedure was performed on the dorsoradial side of the flap using the ultrasonic surgical aspirator 4 months after the first defatting procedure. (B) Two months after the second defatting procedure, the appearance of the finger has improved. The patient regained sensation in the injured finger. (From Ref. 5.)

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Figure 4 A 53-year-old man experienced a ring injury on his right ring finger. The entire skin from the base of the finger to the distal interphalangeal joint was necrotized. (A) The man was treated with a radial forearm flap. Because of the thick subcutaneous fat tissue in the flap, the index finger appeared to be very bulky. Three defatting procedures were performed using the ultrasonic surgical apsirator. (B) Five months after the last defatting surgery, the appearance of the finger seems to be acceptable. (From Ref. 5.)

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REFERENCES 1. 2. 3. 4. 5. 6. 7.

Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda N. Free thin paraumbilical perforator-based flap. Ann Plast Surg 1992; 29:12–17. Murakami R, Fuji T, Itoh T, Tsutsui K, Tanaka K, Iio Y, Yano H. Versatility of the thin groin flap. Microsurgery 1996; 17:41–47. Hallock GG. Defatting of flaps by means of suction-assisted lipectomy. Plast Reconstr Surg 1985; 76:948–952. Wu WC, Chan WF. Defatting of skin flaps using arthroscopic instrument—an effective alternative. J Hand Surg 2000; 25B:300–303. Yamanaka K, Ichikawa T, Horiuchi Y. Flap defatting with and ultrasonic surgical aspirator. Plast Reconstr Surg 1997; 99:888–891. Zocci ML. Ultrasonic assisted lipoplasty. Technical refinements and clinical evaluations. Clin Plast Surg 1996; 23:575–598. Fischer PD, Narayanan K, Liang MD. The use of high-frequency ultrasound for the dissection of small-diameter blood vessels and nerves. Ann Plast Surg 1992; 28:326-330.

53 Reusable Loop Suture Techniques to Secure and Allow Graft Reinspection Stephen N. Snow and David Douglas Madjar, Jr. University of Wisconsin, Madison, Wisconsin

I.

INTRODUCTION

In the typical skin graft, the graft bolster is tied down by placing simple interrupted sutures from the graft to the perigraft skin (1). In the classic example, the simple interrupted sutures are tied down firmly and typically have long suture tails (single or double threaded) with which to tie the bolster. If the graft needs to be inspected to remove a hematoma or seroma, the interrupted sutures are cut. Thereafter to ensure graft ‘‘take,’’ a new bolster is applied. In this situation, another round of local anesthetic is injected into the perigraft skin and more sutures are placed as described above. The reusable loop suture technique is a simple way of tying the bolster down over a skin graft that allows multiple viewings of the graft without the need of an additional anesthestic to rebolster the graft (2). There are two types of reusable loop suture techniques: loose loop and free loop.

II. LOOSE LOOP SUTURE TECHNIQUE The loose loop suture technique is actually a loose simple interrupted stitch in which one-half of the loop is buried in the skin. Instead of tying the suture firmly in a knot against the skin, the knot is deliberately tied loosely above 325

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the skin. In this technique, the needle is inserted through the skin in the usual manner. A second person holds a hemostat about 0.25 inch above the skin to serve as a platform on which the knot is to be tied. The first throw is then performed on top of the hemostat. The second throw squares the knot and secures the knot on the loose loop of suture. With practice, the loose loop suture can be generated without the help of a platform instrument.

III.

FREE LOOP SUTURE TECHNIQUE

The free loop suture technique consists of two steps: (1) tying a simple interrupted stitch and (2) creation of the free loop of suture. In the example provided, the skin is simple pierced leaving about 2 inches of suture tail exposed. the stitch it stabilized to the skin by the first throw of a simple interrupted stitch. The free loop is generated by grabbing the suture tail about 1 inch proximal to the free end of the suture tail. The suture loop is pulled partially through the first throw until at least a 0.25-inch loop has been created. The knot is squared in the usual manner. The process is repeated around the bolster to create four to six tied-loop sutures.

Figure 1 The loose loop suture technique actually represents a ‘‘loosely tied’’ simple interrupted stitch. The knot is intentionally tied loosely above the skin surface and not tightly against the skin. Here, the loose loop is threaded by the needed. The larger loop is the unthreaded free loop.

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Figure 2 The free loop suture technique begins with an intra- or subdermal skin stitch using 3-0 silk suture.

A.

Threading the Suture Loop

Both the loose loop and free loop are generally too short to use as ties to tie down the bolster. Threading additional suture through the loop will provide enough suture to tie the bolster down. Threading the loop can be single or

Figure 3 The needle is pulled through the skin leaving approximately a 1-inch suture tail exposed. In the first throw, the proximal third of the suture tail is grasped with the needle holder and pulled incompletely through to create the free loop of suture.

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The free loop is secured to itself with the second suture throw.

double stranded. In the single-strand bolster tie, the suture is threaded through the loop and the suture tail is tied at the loop. A double-stranded bolster tie is actually one suture pulled half way through the loop and the suture tails are then tied to each other. The double-stranded suture is easier to hand tie than the thinner single-stranded suture. When there is enough suture, we prefer to hand tie the bolster using double stranded 4-0 silk suture. It has excellent strength. Knots are easy to tie and are secure. The material is relatively inexpensive and widely available.

Figure 5

Free loop of suture being threaded by 3-0 silk suture.

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Figure 6 A 2 2 inch gauze bolster with four free-loop stitches placed on each side of the gauze square.

B.

Graft Inspection

Graft inspection is a simple matter of cutting the bolster ties and gently lifting the bolster off the graft to inspect it. Rethreading the loop with a new ligature allows the surgeon to tie down a new bolster without the need of injecting the perigraft skin with a local anesthetic in order to place new skin stitches. Other methods of bolster stabilization that permit multiple viewings of the graft include perigraft skin staples and surgical tape with special adhesive.

Figure 7 tie-over).

Free loops are threaded with a loop of 3-0 silk suture (double-stranded

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Figure 8 Appearance of bolster tied down with double-stranded 3-0 silk tie-over sutures.

IV.

CONCLUSIONS

Reusable suture techniques for securing bolsters for skin grafts do not take any extra time to perform. They offer the advantage of providing easy inspection of the graft site while minimizing the pain of injection of local anesthetic to resecure the bolster and the accompanying time for suture replacement.

ACKNOWLEDGMENT We thank Michael Hetzer, HS, ASAP, for his help with the digital photographs.

REFERENCES 1. 2.

Stegman SJ, Tromovitch TA, Glogau RG. Basics of Dermatologic Surgery. Chicago: Year Book, 1982:42–43. Snow SN, Larson P, Olansky D. Reusable loop stitches for inspection of grafts. J Dermatol Surg Oncol 1989; 15:799–801.

54 Harvesting Auricular Cartilage Mitchell L. Levin University of South Florida, Tampa, and Levin Eye Center, Kissimmee, Florida

I.

INTRODUCTION

Auricular cartilage has many uses in ophthalmic plastic and reconstructive surgery, including upper and lower eyelid reconstruction, orbital floor and medial wall repair, and scleral patching (1). Frequently, the ophthalmologist, dermatologist, or general plastic surgeon, unfamiliar with ear anatomy, will hesitate to harvest this valuable tissue. The following simple method to harvest auricular cartilage from an anterior or exposed surface minimizes complications (2).

II. TECHNIQUE After subcutaneous infiltration of local anesthetic, the ipsilateral ear is prepared for surgery. A 2.5-cm incision is made along the antihelical surface of the ear. Two perpendicular back cuts are extended 1 cm nasally along the superior and inferior extent of the wound (Figure 1). A Freer elevator is used bluntly to dissect skin from the perichondrial surface. The original incisions are deepened to include the full thickness of the cartilage, taking care not to incise the posterior skin surface. A fourth incision, completing the rectangle, is made through the cartilage. Again using blunt dissection, the rectangular piece of cartilage is gently harvested from the posterior skin surface of the ear. 331

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Figure 1 Raised skin flap with excised auricular cartilage retaining its toric shape.

This specimen retains its toric curvature and is placed in a sterile specimen cup with normal saline and antibiotic solution. The skin flap created is sutured back into place, using 6-0 plain gut, in either a running or interrupted fashion. Two simple mattress sutures of 5-0 plain gut are placed in the geometrical epicenters of the flap (with the knots on the posterior surface of the auricular skin) to eliminate the dead space (Figure 2). These mattress sutures eliminate the need for bulky and conspicuous pressure dressings. The skin wound is dressed with antibiotic ointment. The patient is reexamined in 48–96 h, after which the wound is gently cleansed. No suture removal is required. After 2 weeks, a good cosmetic result is obtained.

III.

CONCLUSIONS

A variety of methods to harvest auricular cartilage have been described in the literature, some as a composite graft with the auricular skin and some from the posterior surface of the ear (3–5). The technique described here has the advantage of good exposure combined with familiar anatomical landmarks. The mattress sutures prevent the complications of hematoma or

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Figure 2 Reposited skin flap with mattress sutures in place. The ear retains functional and there is a good cosmetic appearance.

seroma. Avoiding the bulky pressure dressing is both more comfortable for the patient and more esthetic. Moreover, it allows for adequate examination of the wound. The integrity of the donor ear is maintained and a good cosmetic result is obtained. This simple technique is easy to master.

REFERENCES 1. 2. 3.

4. 5.

Bayliss HI, Rosen N, Neuhaus RW. Obtaining auricular cartilage for reconstructive surgery. Am J Ophthalmol 1982; 93:709–712. Levin ML, Lober C, Levin RR. Harvesting auricular cartilage. J Dermatol Surg Oncol 1989; 15(7):712–713. Converse JM. Principals and procedures in correction, reconstruction and transplantation. In; Reconstructive Plastic Surgery. Vol 1. General Principles. 2nd ed. Philadelphia: Saunders, 1977:152–239. Guyuron B. Simplified harvesting of the ear cartilage graft. Aesthet Plast Surg 1986; (10):37–39. Smith B, Lisman RD. Preparation of split thickness auricular cartilage for use in ophthalmic plastic surgery. Ophthal Surg 1982; 13(112):1018–1021.

55 Cartilage Removal Prior to Skin Grafting in the Triangular Fossa, Antihelix, and Concha of the Ear J. Ramsey Mellette, Jr. University of Colorado Health Sciences Center, Denver, Colorado

James M. Swinehart Colorado Dermatology Center, Denver, Colorado

I.

INTRODUCTION

A skin graft needs a good vascular supply to survive and to thrive. During the first 24–48 h in the postoperative period, a graft survives by diffusion of oxygen and nutrients from the plasma. Neovascularization then occurs as early as 48–72 h, often initially by inosculation (attachment of capillaries in the recipient bed to the severed capillaries in the graft). Subsequently, granulation tissue forms under the graft, providing further nourishment and establishing the reattachment of the graft to the underlying tissue. With bare cartilage, following removal of the perichondrium (as well as with exposed tendon, bone, or nerve), the processes of inosculation and granulation tissue formation cannot occur. The only source of nourishment of a graft over these surfaces is from the ‘‘bridging’’ of its capillaries laterally to those in the surrounding tissues. However, this bridging phenomenon will generally only support a graft 1 cm or less in diameter1. In addition, a 1

From Mellette JR Jr, Swinehart JM. Cartilage removal prior to skin grafting in the triangular fossa, antihelix and concha of the ear. J Dermatil Surg Oncal 1990; 16:1102–1105 # 1990 by Elsevier Science Publishing Co., Inc.

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smooth cartilaginous surface offers less protection from shearing forces that might force separation of the graft. Mohs micrographic surgery (MMS) for larger basal cell carcinomas on the antihelix, the triangular fossa, and the concha of the ear may often produce relatively large defects with denuded cartilage, minus its overlying perichondrium, at the base. In some instances, owing to technical difficulties encountered in preparing frozen sections of cartilage, some doubt may remain concerning the presence of microscopic foci of tumor cells extending into this tissue layer. Accordingly, removal of cartilage in an area where it is not needed for structural support offers two advantages: (1) the changes of tumor recurrence are considerably decreased; and (2) split- or full-thickness skin grafting over a large, irregular area can now be achieved with a higher rate of survival. To date, over 15 surgical defects of the triangular fossa, antihelix, and concha of the ear have been repaired by removing the entire underlying cartilage and applying full-thickness grafts to the exposed subcutaneous tissue of the posterior aspect of the ear. We present one such case.

II. CASE REPORT A 58-year-old white male presented with a 15-mm 15-mm basal cell carcinoma inside the crura of the antihelix of the left ear. He was referred to the Mohs Surgery Unit of the Denver Dermatology Center in May of 1988. A tumor-free plane was reached after three stages of MMS. However, because of involvement of the perichondrium by tumor in several areas, the resulting 22mm 30-mm defect contained a base of exposed naked cartilage (Figure 1).

Figure 1 Exposed naked cartilage in 22-mm 30-mm defect after three stages of MMS.

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Figure 2

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Cartilage removed by sharp dissection.

The entirety of the cartilage was removed in two sections (Figure 2) by sharp dissection down to the subcutaneous tissue of the posterior aspect of the ear (Figure 3). A full-thickness skin graft was then taken from the left postauricular donor area, and was carefully prepared and trimmed to fit the recipient site. The graft was meshed in four sections with 4-mm incisions made with a #15 scalpel blade to decrease the chance of hematoma formation. The graft was then sutured in place with interrupted 5-0 prolene (including two basting sutures) (Figure 4) and dressed with a stent consisting of Melolite and sterile foam rubber secured by six tie-over sutures of 4-0 Supramid (Figure 5). Postoperative examination at a 6-week follow-up revealed an excellent cosmetic result (Figure 6).

Figure 3 Cartilage removed to expose the subcutaneous tissue of the posterior aspect of the ear.

Figure 4 Graft sutured with uninterrupted 5-0 prolene (including two basting sutures.

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Figure 5 Graft dressed with Melolite and foam rubber, using six tie-over sutures.

III.

Figure 6 Graft at 6-week follow-up.

DISCUSSION

Skin grafting onto cartilage devoid of perichondrium is rarely successful because of the lack of an adequate vascular bed, and it also would be technically difficult in the triangular fossa, antihelix, and concha owing to the undulations and convexities and concavities encountered. In addition, in the case described, and in most cases of basal cell carcinoma of the ear overlying cartilage it is difficult to know with certainty whether there is tumor extension into the cartilage. In addition, there is always a need to establish a good blood supply for the take of grafts. The lack of a good vascular supply for a graft placed over a cartilaginous surface can be solved by the use of multiple 2- to 4-mm windows in the cartilage using standard biopsy punches, allowing buds of granulation tissue to grow through, eventually nourishing the graft (2). However, this procedure alone would not have solved the other technical difficulties mentioned above. In some surgical situations, meshing of the graft or the use of a splitthickness skin grafts, can enhance survival in cases where the blood supply is tenuous (3). However, split-thickness grafts tend to show greater contraction, and have a poorer cosmetic appearance in an area as visible as the ear. The use of a stent, or bolus dressing, can solve some of the contour problems demonstrated in our cases, as can the use of basting sutures. However, respecting the deep (in some patients) concavity of the triangular fossa and the concha, complete contact of the graft with the underlying bed is an absolute necessity. Removal of cartilage underneath a defect resulting from MMS on the ear offers the following advantages:

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2.

3. 4.

5.

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The exposed underlying subcutaneous tissue on the other side of the ear provides an excellent bed to ensure graft survival. There have been no failures of any grafts in the 15 cases performed to date. A cosmetically superior full-thickness skin graft can be used for repair, whereas otherwise only a split-thickness skin graft might have survived. Cartilage that might contain any remaining traces of tumor is removed, providing an extremely high cure rate. Because the recipient bed in the triangular fossa, antihelix, and concha is much more accessible following cartilage removal, basting sutures are accomplished with greater ease. If necessary, a contour graft, as described by Hill (4), can be used for repair of the defect if one desires to restore the ‘‘relief’’ effect lost from cartilage removal.

One possible disadvantage of the procedure is the loss of structural support offered by the ear cartilage. The crura of the antihelix are deemed to be important for structural support of the ear. Therefore, for defects in this area, it is considered important to leave the crura intact whenever possible. In one case (not presented), the crus, although devoid of perichondrium, was not removed, and there was no compromise to the graft. However, it should be emphasized that this method should be employed only in locations where the surrounding support is to be deemed adequate, in contrast with the locations such as the rim of the helix. Removal of the ear cartilage underlying MMS defects in selected instances, can be a valuable adjunct to esthetic repair by full-thickness skin grafting in the triangular fossa, antihelix, and concha of the ear.

IV.

CONCLUSIONS

Skin grafting onto a large area of exposed ear cartilage with irregular contours poses an increased risk of inadequate re-establishment of circulation. Removal of cartilage not needed for structural support before grafting following Mohs surgery on the triangular fossa, antihelix, and concha of the ear decrease the risk of recurrence of the carcinoma, and increase the chances for survival of the graft.

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Trimble JR. Skin grafting as an office procedure. In: Epstein E, Epstein Ervin Jr, (eds). Skin Surgery. (4th ed). Springfield, IL: Thomas, 1977:219. Skouge JW. Techniques for split-thickness skin grafting. J Dermatol Surg Oncol 1987; 13:842. Glougau RG, Stegman SJ, Tromovitch TA. Refinements in split-thickness skin grafting technique. J Dermatol Surg Oncol 1987; 13:853–858. Hill TG. Contouring of donor skin in full-thickness skin grafting. J Dermatol Surg Oncol 1987; 13:883–888.

56

Stents for Skin Grafts Paul O. Larson and David Douglas Madjar, Jr. University of Wisconsin, Madison, Wisconsin

I.

INTRODUCTION

A variety of stents are used to immobilize skin grafts and to hold them firmly to the recipient site. Stents are thought to reduce shearing forces. The external pressure enhances cooaptation of the graft to the recipient bed and minimizes accumulation of blood or serum beneath the graft. Historically, grafts have been held in place with various dressings, including adhesive plasters (1), transparent isinglass (1), varnish plaster (1), tinfoil (1), greased lint (2), paraffin (3), damp marine sponges (4), inflated toy balloons (4), ‘‘pressure bags’’ (5), wax molds (4), and Silastic foam molds (6). The standard method of securing and immobilizing a graft is the tieover dressing. Tie-over stents are constructed from bulky, sterile dressing with sutures tied over the bulky dressing pressing the graft securely against the recipient bed. These stents are often cumbersome to apply. Variations of the tie-over dressings include the rubber band tie-over (7–8), the pressure button (9), the ring disc (10), and the plastic bead tie-over (11). As an alterative, stents that can be quickly and uniformly applied have been widely utilized. Probably most notable among these are foam rubber and thermoplastic stents. Other recent addition includes a Biobrane stent (12), Telfa strips and staples (13), a tie-over dressing using the base of a plastic IV bottle as a template (14), a hydrocolloid frame and staple tech-

Adapted from Ref. 30. # 1990 by Elsevier Publishing Co., Inc.

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nique (15), and, experimentally, securing a graft with 2-octylcyanoacrylate spray (16). Several investigators have even questioned the need for pressure dressings (17–21).

II. PROPERTIES OF AN IDEAL STENT/BOLSTER 1.

2.

3.

4. 5. 6.

7.

Immobilization: One of the major reasons for applying a stent or bolster is to prevent movement of the graft and subsequent shearing motion. Sheering motion may disrupt ingrowth of new vessels, and may result in bleeding underneath the graft. Pressure: For a skin graft to survive, it must be in contact with the recipient bed. Pressure to approximate the graft to the recipient bed, and thus reduce hematoma or seroma, has long been considered to be important for graft survival. Smith (22) suggested that the ideal pressure on a graft is 15–30 mm Hg. Barrier to infection: Application of a topical antibiotic and a sterile dressing over the graft serves as a barrier and helps prevent wound contamination and infections. Prevent dehydration: Delicate and vulnerable skin grafts should be humidified to prevent desiccation. Wicking/fluid adsorption: Absorptive dressings wick away blood serum, and exudate. Low profile: Low-provide bolsters/stents should be traumatized less frequently. This should reduce sheering injuries to the graft. Low-profile stents are also more cosmetically pleasing. Quick, easy to apply consistently: An ideal stent/bolster should be quickly and easily applied in a uniform, reliable, and reproducible fashion.

In my experience, both the foam rubber stent and the thermoplastic stent have been suitable. I formerly used the foam rubber stent, but now I use the thermoplastic stent almost exclusively because of the simplicity of application. The use of each is described as follows. A.

Foam Rubber Stent

The use of foam to apply even pressure is not new. Blair (4) called the sponge ‘‘the most practical distributor of pressure.’’ Rees (23) and Peled and Wexler (24) used a foam rubber tie-over dressing; Hill (25) used orthopedic east foam; and Harris (26), Weiner (27), and Kaplan (28) used stents made from microporous foam padding (Reston; 3-M

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Company, St. Paul, MN). Egan and Gerwels (29) used the foam from a standard detergent-free disposable surgical scrub brush that was cut to size and taped in place. We have modified the method of applying stents described by Weiner (27) and Harris (26) and used it when grafting selected defects created by Mohs surgery (Figure 1A–G) (30). This method was used for both splitthickness and full-thickness skin grafts. Wound beds are first prepared in a standard fashion by debriding them to an actively bleeding surface. The bleeding is stopped with pressure, topical epinephrine (1 : 100,000), thrombin solution, or electrocoagulation. The graft is harvested, draped into the wound, trimmed to proper size, and tacked into place with interrupted 6-0 nylon sutures (Figure 1C). Basting sutures are sometimes used to ensure the coaptation of the graft to the wound bed. ‘‘Pie-crusting’’ (fenestrating) incisions through the graft allowed egress of blood from under it. After examining the graft to make sure the bleeding has stopped, wound dressings are applied. The wound is first covered with polysporin ointment, then with N-terface gauze. A Reston foam pad (7/16 inch) with adhesive backing, precut to a 10-cm square and presterilized, is then used to prepare a stent. A Telfa nonstick gauze is applied to the adhesive side of the Reston pad, allowing the pad to be easily handled without sticking to the surgeon’s gloves. The Telfa pad also served as the inner absorbent layer for the stent. The Reston/Telfa pad is then cut with scissors to fit over the graft, with a 3to 4-mm overlap on all sides. Additional bulk is sometimes added to the stent by splitting it at the Telfa layer and stuffing it with sterile cotton. The Reston pad is stapled into place over the graft—one leg of the staple into the perigraft skin and the other leg into the Reston pad (Figure 1D–E). To avoid new bleeding under the graft, care is taken not to staple into the graft bed. An adhesive tape, for example, Hypafix, is applied over the stent to help keep the graft moist and to prevent the patient from disturbing it. The stent is generally left undisturbed for 1 week; then the staples and stent are removed, and the graft site is gently debrided. Polysporin ointment, N-terface dressing, and a Reston pad are taped into place for an additional week, after which time the sutures are removed. Steri-strips are then used to stabilize the graft for 1 additional week. The foam rubber stent fulfills many of the properties of an ideal stent/ bolster previously described. However, a note of caution with regard to use of a Reston pad must be remembered: If it is stretched too tightly, fairly high pressure can be generated on the graft. This might result in graft necrosis and loss of the graft. For this reason, I prefer the thermoplastic stent.

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Figure 1 (A) Basal cell carcinoma of the right distal bridge prior to treatment with Mohs surgery. (B) Surgical defect following Mohs surgery. (C) A full-thickness graft was used to repair the Mohs defect. (D) The graft has been covered with antibacterial ointment, nonstick gauze, additional cotton, or xeroform gauze to fill the concavity of the graft site and covered with a Reston foam rubber stent, which is being stapled into place. (E) The Reston stent has been securely stapled into place. Note that the stent has a very low profile and is unlikely to get bumped or traumatized. (F) Graft site 2 weeks after grafting. (G) Graft site 2 months after grafting.

B.

Thermoplastic Stent

Our preferred method of graft coverage is to use the Aquaplast stent (Figure 2A–I). The original thermoplastic materials used for skin grafts were developed in 1856 by an English dentist, Charles Stent (31). He developed a thermoplastic-like material for taking impressions of toothless mouths, and the materials were subsequently used for fixation of intraoral grafts. The word stent was adopted to describe a device used to hold a graft in place. Thermoplastic materials have been used most commonly for intraoral stent fabrication and graft placement (32–33). The thermoplastic material commonly available today comes in sheets (Aquaplast) and the precut OptiMold. Aquaplast was first marketed as a splinting material and used in splinting burns (34), orthopedic rehabilitation (35), and nasal splinting (36–38). Fish and Hilger reported on the use of Aquaplast as a moldable tie-down dressing for skin grafts (39).


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Aquaplast now comes in different thicknesses varying from 1/16 to 3/ 16 inches, with and without perforations, and in a variety of colors. It is also precut to various shapes and sizes (Opti-Mold). When warmed to 140 F, it softens and becomes transparent. In this state, it can be easily molded before it cools and hardens. The recipient bed is prepared in the same way as described previously for the foam rubber stent (see Figure 2A–B). After the final layers of top dressing are applied, an Aquaplast stent is cut to the approximate size with a bandage scissors (see Figure 2C). The Aquaplast is then immersed in water that has been heated to 140 F until the Aquaplast is transparent and pliable (see Figure 2D). The stent is then placed over the top dressing and molded to the contour of the graft site until it has hardened (see Figure 2E). Care should be taken to prevent any sharp edges from protruding into the surrounding skin. If the shape or size is not correct, the Aquaplast can be removed, trimmed to size, reheated, and again molded to the proper shape. The Aquaplast stent is stapled into place using a disposable stapler (Figure 2F–G). The stent is removed in 1 week, being careful not to pull off the graft with the stent. The graft is then covered with polysporin and clean dressings, and the patient is instructed to clean the graft daily. If additional protection is required, the Aquaplast can be cleaned with soap and water and/or alcohol and applied again over new sterile dressing and taped in place.

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Figure 2 (A) Mohs surgery defect 2 weeks after excision. (B) A full-thickness graft was used to repair the defect. (C) Aquaplast is cut to a size slightly overlapping the graft dressings. (D) The Aquaplast is immersed in hot water to soften the thermoplastic material. The Aquaplast becomes transparent when it is ready to be applied. (E) The pliable Aquaplast is molded over the graft dressing. As the Aquaplast cools, it becomes rigid. If additional molding is necessary, the Aquaplast can be removed and reheated. (F) The Aquaplast is stapled into place. (G) The final Aquaplast stent has been stapled into place. The stent is usually covered with an adhesive bandage to prevent drying of the underlying dressing. Note that this stent also has a very low profile. (H) Graft site 2 weeks after graft placement. (I) Graft site 18 months after graft placement. (Figure B–F from Ref. 30.)


III.

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CONCLUSION

Both the foam rubber (Reston) stent and the thermoplastic (Aquaplast) stent have been very useful in achieving the ideal properties of graft coverage.

REFERENCES 1. 2. 3. 4. 5.

Klasen HJ. Skin grafting by the Reverdin method and subsequent developments. In: History of Free skin Grafting. Berlin: Springer-Verlag, 1981:9–46. Klasen HJ. Skin grafting in eyelid surgery. In: History of Free Skin Grafting. Berlin: Springer-Verlag, 1981:45–60. Klasen HJ. Skin grafting during the first three decades of the 20th century. In: History of free Skin Grafting. Berlin: Springer-Verlag, 1981:103–147. Blair VP, Brown JB. The use and uses of large split skin grafts of intermediate thickness. Surg Gynecol Obstet 1929; 49:82–97. Smith F. Pressure bags for skin grafting. Surg Gynecol Obstet 1926; 43:99.

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6.

Groves AR, Lawrence JC. Silastic foam dressing: an appraisal. Ann R Coll Surg Engl 1985; 67:116–118. Rees TD. Use of rubber bands in tie-over dressings on the chest wall. Plast Reconstr Surg 1969; 43:635–636. Shively RE, Northington JW, Williamson GB, Gum RA. A simple skin graft dressing allowing early graft inspection. Ann Plast Surg 1981; 7:334–335. Burd DAR. The pressure button: a refinement of the traditional ‘‘tie-down’’ dressing. Br J Plast Surg 1984; 37:127–129. Silfverskiold KL. A new pressure device for securing skin grafts. Br J Plast Surg 1986; 39:567–569. Niranjan NS. A modified tie-over dressing for skin grafts. Br J Plast Surg 1985; 38:415–418. Jones LM. The Biobrane stent. J Burn Care Rehabil 1998; 19;352–353. Hoffman HT, La Rouere M. A simple bolster technique for skin grafting. Laryngoscope 1989; 99:558–559. Cheng LC, Lim TC, Tan WT. A simple tie-over dressing. Plast Reconstr Surg 1998; 101:246–248. Hochberg J, Ardenghy M, Paulk D. A new dressing for skin graft with hydrocolloid and staples [letter]. Plast Reconstr Surg 1996; 97:1089. Tamez OA, McGuff HS, Prihoda TJ, Otto RA. Securing meshed split-thickness skin grafts with 2-octylcyanoacrylate. Otolaryngol Head Neck Surg 1999; 121:562–566. Mehta JK. A new method of full-thickness skin graft fixation. Br J Plast Surg 1985; 38:125–128. Davenport J, Daus W, Harvey I, Griffiths RW. The bolus tie-over ‘‘pressure’’ dressing in the management of full-thickness skin grafts. Is it necessary? Br J Plast Surg 1988; 41:28–32. Dzubow LM. Skin grafts. Dermatol Surg 1995; 21:202. Orengo I, Lee MW. Surgical pearl: the ‘‘unsuture’’ technique for skin grafts. J Am Acad Dermatol 1998; 38:758–759. Langtry JA, Kirkham P, Martin IC, Fordyce A. Tie-over bolster dressing may not be necessary to secure small full thickness skin grafts. Dermatol Surg 1998; 24:1350–1353. Smith FA. A rational management of skin grafts. Surg Gynecol Obstet 1926; 42:556–562. Rees TD, Fleury AL. The use of foam rubber in pressure dressings. Plast Reconstr Surg 1956; 18:309–311. Peled IJ, Wexler MR. Designing and dressing of skin grafts by means of patterns on sponges of polyurethane. J Dermatol Surg Oncol 1981; 7:644–645. Hill TG. A simplified method for closure of full thickness skin grafts. J Dermatol Surg Oncol 1980; 6:892–893. Harris D. A new technique of skin grafting using Steri-Greffe and a selfadhering foam pad. Br J Plast Surg 1981; 34:181–185. Weiner LJ, Moberg AW. An ideal stent for reliable and efficient skin graft application. Ann Plast Surg 1984; 13:24–28.

7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

17. 18.

19. 20. 21.

22. 23. 24. 25. 26. 27.

Stents for Skin Grafts 28. 29.

30. 31. 32. 33. 34. 35. 36. 37. 38. 39.

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Kaplan HY. A quick stapler tie-over fixation for skin grafts. Ann Plast Surg 1989; 22:173–174. Egan CA, Gerwels JW. Surgical pearl: Use of a sponge bolster instead of a tieover bolster as a less invasive method of securing full-thickness skin grafts. J Am Acad Dermatol 1998; 39:1000–1001. Larson PO. Foam-rubber stents for skin grafts. J Dermatol Surg Oncol 1990; 16:851–854. Hedin M. The origin of the word stent. Acta Radiol 1997; 38:937–939. Martin JW, Jacob RF, Larson DL, King GE. Surgical stents for the head and neck cancer patient. Head Neck Surg 1984; 7:44–46. Eppley BL, Sclaroff A, Altshuler L. Thermoplastic material for intraoral stent fabrication. J Oral Maxillofac Surg 1985; 43:913–914. Fowler D, Pegg SP. Evaluation of Aquaplast splinting thermoplastic—use in a burns unit. Burns Incl Therm Inj 1983; 9:284–287. Kester DL. New product makes splinting easier. Am J Occup Ther 1966; 20:43–44. Kean H. A new material for nasal splints. Laryngoscope 1971; 81:1991–1992. Rettinger G, Masing H. Nasal splinting with thermoplastic material. HNO 1980; 28:320. Kalisman M. An easy method of nasal splinting. Plast Reconstr Surg 1981; 68:793. Fish FS, Hilger PA. Aquaplast thermoplastic (Opti-Mold). A unique moldable tie-down dressing for full-thickness skin grafts. J Dermatol Surg Oncol 1994; 20:239–244.

57 Split-Skin Grafting on Severely Damaged Skin: A Technique Using Absorbable Tissue Adhesive Irshad Zaki Heartlands and Solihull NHS Teaching Hospital, Solihull, West Midlands, England

L. G. Millard Queen’s Medical Centre, Nottingham, England

I.

INTRODUCTION

Patients with severe cutaneous damage either as a consequence of extensive cumulative ultraviolet exposure or following previous radiotherapy are at a relatively high risk of developing skin cancer. They present a difficult clinical problem, as their skin is often atrophic and therefore easily traumatized by suturing. This type of skin is also less mobile and local flaps are less likely to be successful. As a consequence, skin grafts are frequently required for wound closure, particularly after excision of lesions affecting the scalp. Tissue adhesives were first discovered in 1949, and although the initial compounds were found to be histotoxic, butyl cyanoacrylate is entirely safe and widely used in many medical specialities. This compound is liquid at room temperature but solidifies in approximately 20 s by an exothermic reaction catalyzed by small amounts of water on the wound surface. In particular, it has been of benefit in repairing lacerations in children in whom suturing may be emotionally traumatic (1). It is also preferable to sutures in some adult patients with lacerations (2). 351

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II. TECHNIQUE The method of using tissue adhesive to secure split-skin grafts is relatively straightforward. After excision of tumor, adequate hemostasis should be achieved at the recipient site. The split-skin graft is then harvested and the outer surface is placed on a nonadherent paraffin gauze dressing. This provides a degree of rigidity and hence easier control of the graft during the procedure. The graft should be placed at the recipient site in rough approximation and gently folded back along with the dressing (Figure 1). Small pellets of adhesive are applied to the edge and center of the wound as the graft is gradually replaced (Figure 2). Care should be taken to ensure that the graft lies in close approximation to the wound bed. Once the graft has been successfully applied, any excess tissue should be trimmed and a compression dressing applied if required. The dressing is removed 5 days later, and the patient is then requested to apply a topical antibiotic to the recipient site twice daily until the wound has healed completely. Any excess graft can be

Figure 1 The harvested split skin graft is placed on a nonadherent paraffin gauze dressing, which allows easier handling during the procedure. The skin graft is placed on the surgical wound.

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Figure 2 The skin graft along with the dressing is gently folded back. Small pellets of adhesive are applied to the wound as the graft is secured at the recipient site in exact approximation.

trimmed again at this stage if needed and the donor site is managed in the conventional manner. There is very little tissue reaction and biopsies taken 6 months after surgery in our series showed complete absorption of adhesive and no evidence of a foreign body reaction. There are several advantages of using tissue adhesive for securing skin grafts in severely damaged skin. It is less traumatic than suturing, considerably quicker, and therefore more cost effective (2). The cosmetic results are equally good compared with suturing in animal models (3) and our own series in humans (Figure 3). It is likely that butylcyanoacrylate will be superseded by newer compounds such as octylcyanoacrylate film adhesive (4,5), which may also reduce the risk of wound infection due to its antimicrobial effect (6).

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Figure 3 The cosmetic result and success rate of skin grafts secured with tissue adhesive is excellent despite extensive actinic damage to the surrounding skin.

III.

CONCLUSIONS

It is unlikely that tissue adhesives will replace sutures for all indications, as their use is confined to wounds with little or no tension, such as lacerations or split-skin grafts. They are, however, of enormous benefit in selected patients and should be considered the method of choice in securing splitskin grafts on severely damaged skin.

REFERENCES 1.

2.

Quinn JV, Drzewiecki A, Li MM, Stiell IG, Sutcliffe T, Elmslie TJ, Wood WE. A randomised, controlled trial comparing a tissue adhesive with suturing in the repair of paediatric facial lacerations. Ann Emerg Med 1993; 22(7):1130– 1135. Applebaum JS, Zalut T, Applebaum D. The use of tissue adhesion for traumatic laceration repair in the emergency department. Ann Emerg Med 1993; 22(7):1190–1192.

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4.

5.

6.

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Vanholder R, Misotten A, Roels H, Matton G. Cyanoacrylate tissue adhesive for closing skin wounds: a double blind randomised comparison with sutures. Biomaterials 1993; 14(10):737–742. Penoff J. Skin closures using cyanoacrylate tissue adhesives. Plastic Surgery Foundation DATA Committee. Device and technique assessment. Plast Reconstr Surg 1999; 103(2):730–731. Tamez OA, McGuff HS, Prihoda TJ, Otto RA. Securing meshed split skin grafts with 2-octylcyanoacrylate. Otolaryngol Head Neck Surg 1999; 121(5):562–566. Quinn J, Maw J, Ramotar K, Wenckebach G, Wells G. Octylcyanoacrylate tissue adhesive versus suture wound repair in a contaminated wound model. Surgery 1997; 122(1):69–72.

58 Autologous Suction Blister-Induced Epidermal Grafts for Treating Localized Stable Vitiligo William Yuk Ming Tang Lek Yuen Social Hygiene Clinic, Lek Yuen Health Center, Shatin, Hong Kong

I.

INTRODUCTION

Vitiligo, affecting about 1% of the general population worldwide, is an acquired disease of unknown etiology characterized by focal or widespread hypo- or depigmentation of skin, mucous membranes, and hair and is accompanied by loss of melanocytes. Vitiliginous patients generally have good general health, but its negative esthetic effects are detrimental to one’s self-esteem; in nonwhite races, loss of pigment can invite significant social stigma. Topical corticosteroids (1,2) and phototherapy (3,4) are established conventional treatments, but their success rates are variable. In patients who fail to repigment with these treatments and whose lesions are stable, autologous epidermal grafting using roofs of suction blisters can produce significant cosmetically acceptable improvement of repigmentation. The method of treating vitiliginous areas using autologous epidermal grafts obtained from the roofs of suction blisters is simple. It consists of three major steps: Production of bullae from donor site, preparation of the From Tang WY, Han JD, Lu NZ, Chan LY, Lo KK. Fine gauze is a useful carrier for epidermal graft in the treatment of vitiligo by means of the suction blister method. J Am Acad Dermatol 1999; 40:247–249. Reprinted with permission from Mosby, Inc., Harcourt Health Sciences Company.

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recipient site, and harvesting of donor epidermal grafts (roofs or bullae) and transferral to the recipient site.

II. STEPS IN TREATING VITILIGINOUS AREAS A.

Production of Blisters in Donor Site

Covered nonhairy areas of the skin are best for production of donor grafts. The nonhairy areas of the inner arms, abdomen, or inner thighs are commonly used for this purpose. Asepsis is carried out as in other surgical procedures, but anesthesia is not usually needed. Tailor-made suction cups of 1–2 cm orificial diameters or simple syringes with pistons removed, which are commonly available in clinics, are then applied. The number and size of the suction cups used will depend on the size of the recipient (vitiliginous) area. The ends of these suction cups are connected by flexible plastic tubes to an adapter and which in turn is connected to a suction machine. A negative pressure of 300 to 350 mm Hg is applied. To ensure a constant negative suction pressure within the system, all fittings should be checked and the suction tubes should not be too short or too long, and they should be checked to avoid kinking. After about 30–60 min, small vesicles start to appear which enlarge and gradually coalesce to form a large bulla after 1 h (Figure 1).

Figure 1

Two suction-induced bullae are well formed.

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B.

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Preparation of the Recipient (Vitiliginous) Area

This aims to remove the depigmented epidermis and can be done in several ways depending on the operator’s preference, availability of equipment, and individual patient’s situation. In the past, I treated the recipient site with suction cups in the same was as that for the donor site. However, if the recipient site is located at an undulated area (e.g., joints), a suction cup cannot be secure to facilitate suction. Similarly, suction at periorficial areas (e.g., lips) is hampered by herniation of the swollen soft tissue. Today, I remove depigmented epidermis with manual dermabrasion, but prior anesthesia is required. EMLA (eutectic mixture of local anesthetics) is applied on the recipient site under occlusion (e.g., Tegaderm) for about 1.5 h. A diamond fraise fitted to a handle is versatile and effective for this type of dermabrasion without resorting of refrigerant. For a small facial area, dermabrasion carried out gently for a few minutes will lead to erythema with pinpoint bleeding, and this signifies that the upper dermis is reached, which is the required endpoint for dermabrasion for epidermal grafting.

C.

Harvesting of Donor Epidermal Graft and Transferral to Recipient Site

The epidermal graft (roof of bulla) is harvested by cutting the suctioninduced bulla separate from the skin. This step should be done meticulously, because the epidermal sheet is flimsy and tends to curl, making subsequent identification of the epidermis from dermis difficult. This is crucial, because the melanocytes contained within the epidermal basal layer cannot be grafted if the wrong graft surface (epidermal surface) is applied onto the recipient vitiliginous dermis. After the graft is cut almost free from the bulla base, it can be harvested by applying on top of the bulla a moistened plain fine gauze (I find the one with a well-woven 0:7 1:0 mm lattice to be suitable). A pair of fine-tipped forceps is placed beneath the graft and the graft is lifted gently with the gauze on top being held steadily by the left hand so that the graft can be well attached to the gauze (Figure 2). At this moment, the whole epidermal sheet can be cut free and wholly collected on the gauze. This graft-gauze composite is then gently transferred onto a platform with the dermal surface of the graft facing upward. Now the graft can be spread and its curled rim uncurled with a pair of nontoothed forceps (Figure 3). Any fibrin clot attached to the dermal surface should be gently removed. After this maneuvre, the graft usually has spread well to its greatest size (Figure 4). The graft-gauze composite is then trimmed to the desired shape and size and the curled edge is removed if present. A small tail of the

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Figure 2 The epidermal graft represented by the roof of the bulla is dissected free from the underlying skin and overlaid by a piece of moistened plain fine gauze.

Figure 3

The graft is carefully uncurled and spread.


Figure 4

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The maximum dimension of graft is shown after uncurling and spreading.

Figure 5 The graft-gauze composite is trimmed to the appropriate size. Note the pair of forceps holds only the tail.

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gauze should be left at one end of the long axis of the composite (Figure 5) so that the composite can be forceped for accurate transferral onto the exact recipient surface without traumatizing the graft (Figure 6). Removal of the gauze is not essential, and I prefer to keep it intact. The grafting procedure is completed after dressing of the donor and recipient sites with paraffin gauze, plain dry gauze, and Tegaderm.

III.

FOLLOW-UP

In order to keep the grafts in direct intimate contact with the recipient dermis, the patient should be advised to refrain from excessive movement of the recipient site. The first few days are critical for a successful grafting. Dressings on the donor and recipient sites can be removed after about 7–14 days. For successful grafting, pigmentation should appear in the recipient site and gradually spread and intensify in the following weeks. However, even in areas where graft take is apparently not successful, pigmentation may sometimes occur, suggesting that some transplanted melanocytes might have landed on the recipient area early postoperatively. In patients whose vitiligo is stable with no signs of deterioration, pigmentation will gradually intensify and spread within the first 3–6 months (5); thereafter further

Figure 6

The graft-gauze composite is accurately placed on the recipient site.


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spread of pigmentation will cease but remain stable as long as the vitiligo is in quiescent state. In the donor areas, mild pigmentary changes can be expected but scars are notably absent. If fading of pigmentation occurs shortly after successful grafting, this would signify a poor prognosis for a successful surgical repigmentation.

IV.

DISCUSSION

Not until the exact etiology of vitiligo is known, treatment of this stigmatizing disease will be difficult. The aim of treatment is to stimulate melanocyte proliferation, prevent melanocyte damage, and replenish lost melanocytes. The conventional treatments using topical steroids and phototherapy can only produce variable success of repigmentation after a prolonged period. The use of autologous epidermal grafts obtained from the roofs of suction blisters was first introduced years ago (6), and it is a simple, effective, and safe surgical repigmenting method for localized and stable vitiligo. Koga classified vitiligo into two main groups: type A comprises the generalized type and type B comprises dermatomal, segmental, and localized forms. In type A, the lesions are usually progressive over time; in type B, the lesions can have an early explosive onset, but they are followed by a long period of quiescence of activity. Since stability of lesions (here it arbitrarily means no disease progression for 1–2 years and negative Kobner phenomenon) is a prerequisite for a successful surgical repigmentation, it would thus mean that most type B patients and some type A patients with stable lesions will benefit from surgical repigmentation should they fail to improve with nonsurgical therapies.

REFERENCES 1.

2. 3. 4.

Koopmans-van Dorp B, Goedhart-van Dijjk B, Neering H, van Dijk E. Treatment of vitiligo by local application of betamethasone 17-valerate in a dimethyl sulfoxide cream base. Dermatologica 1973; 146:310–314. Bleehen SS. The treatment of vitiligo with topical corticosteroids. Light and electronmicroscopic studies. Br J Dermatol 1976; 94(suppl 12):43–50. van Dijk E. Treatment of vitiligo with 8-methoxypsoralen. Dermatologica 1967; 134:345. Parrish JA, Fitzpatrick TB, Shea C, Pathak MA. Photochemotherapy of vitiligo. Use of orally administered psoralens and a high-intensity long-wave ultraviolet light system. Arch Dermatol 1976; 112:1531–1534.

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5.

Tang WY, Chan LY, Lo KK. Treatment of vitiligo with autologous epidermal transplantation using the roofs of suction blisters. HKMJ 1998; 4:219–224. Falabella R. Epidermal grafting. An original technique and its application in achromic and granulating areas. Arch Dermatol 1971; 104:592–600.

6.

59 First Dorsal Digital Web of the Hand as a Full-Thickness Skin Graft Donor Site for the Repair of Defects on the Hand and Digits After Mohs Micrographic Surgery Shih-Tsung Cheng and Hsin-Su Yu Kaohsiung Medical University, Kaohsiung, Taiwan

J. Ramsey Mellette, Jr. University of Colorado Health Sciences Center, Denver, Colorado

I.

INTRODUCTION

The hand is a unique, complex, and important structure of human anatomy. Delicate in design and function, it plays an important role in our everyday lives. It is thus critical to preserve maximal function and cosmesis when repairing surgical defects of the hand and the digits. The dorsal surface of the hand, which is exposed to a significant amount of ultraviolet light, is a common site for sun-induced malignancies to arise. In the southern part of Taiwan, where arsenic-induced multiple Bowen’s disease is endemic (1), the volar as well as the dorsal surfaces of the hand and digits are also frequently involved. Surgeons are challenged to excise the tumor totally while preserving the function and maintaining cosmesis. Since second-intention healing or primary closure is not feasible in the repair of sizable defects on the digits and hand after removal of a cutaneous 365

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malignancy because possible wound contraction or wound tension could limit mobility of the hand and thus compromise function, several modalities of repair have been advocated for wound closure, including several regional flaps and split-thickness skin graft (2,3). An excellent alternative for repairing large defects on the dorsal hand and digits is the full-thickness skin graft (FTSG), which is durable and cosmetically acceptable, and, most importantly, preserves function (4). Typical donor sites selected for a FTSG on the hand and digits include the inguinal fold, the anterior axillary fold, the antecubital fossa, and the volar wrist. However, the quality of grafts from those sites is often inadequate for the hand and digits (4,5). Replacing palmar skin of the hand and digits can be even more difficult owing to the specialized characteristics of the glabrous epithelium and high-density sensory receptors. The instep of the foot is an ideal donor site; however, a secondary surgical region is thus produced which might complicate walking (6). Skin on the first dorsal web of the hand usually exhibits abundant laxity in aging patients. The FTSG harvested from this area provides a superb match in color, texture, and thickness to the surrounding skin on the hand and digits and, most importantly, functional ability is reserved. We reported a patient with Bowen’s disease and a post–Mohs surgery defect on the side of the proximal finger and web who received FTSG from the first dorsal web and obtained an excellent result (7). In this study, we investigated the effectiveness of FTSGs from the first dorsal digital web of the hand in the repair of surgical defects on the other areas of the hand and digits in three more patients who had received Mohs micrographic surgery.

II. MATERIALS AND METHODS The records of four patients who underwent FTSG repair of defects on the dorsal and volar surfaces of the hand and digits after Mohs surgery were reviewed. Face-to-face interviews were conducted in the Department of Dermatology, Kaohsiung Medical University, Kaohsiung, Taiwan. Several outcome variables of function and cosmesis were evaluated. In our study group, the first patient (Figure 1) had a defect on a volar digit, the second patient on the palm (Figure 2), the third on the dorsal digit (Figure 3), and the fourth on the third proximal digit and the third web (reported elsewhere [7]). All patients were interviewed and examined to evaluate their grafts with regard to color match, texture match, graft sensa-

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Figure 1 (A) Squamous cell carcinoma of volar aspect of second digit of right hand. (B) Postoperative photograph of full-thickness skin graft harvested from the first dorsal digital web of the right hand with basting stitches on the graft. (C) Six months postoperatively there is mild hyperpigmentation.

tion, functional ability, and donor scar. The mean duration of follow-up for physician evaluation was 18 months (range 10–24 months). The study group included two women and two men with their ages ranging from 52–73 years (average 65 years). All the patients had Mohs micrographic surgery for cutaneous malignancy of the hand (one with basal cell carcinoma, two with squamous cell carcinoma, and one with Bowen’s disease). In contrast to the premise that the dorsal surface of the hand and digits is the most common sites for the cutaneous malignancy to arise, the diverse location of the tumors in our patients reflected the influence of endemic chronic arsenism on the skin malignancy in the patients of southern Taiwan. Operative techniques for harvesting and placing a FTSG on the hand and digits in our study do not differ from conventional methods reported

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Figure 2 (A) Basal cell carcinoma of left palm. (B) Defect after Mohs micrographic surgery. (C) Four months postoperatively.

elsewhere (8,9). The defect of the donor site was closed by either side-to-side closure or a rotation flap depending on the graft size and the laxity of the skin.

III.

RESULTS

All patients reported overall satisfaction with the results of their grafts (Figures 1–3). The color match, textural match, graft sensation, and functional ability were excellent. Donor scar was inconspicuous. The mobility of the thumb was not impaired. In the first patient with a defect on the volar surface of the digit (see Figure 1), graft hyperpigmentation was present during the first 3 months after the operation. The color mismatch improved thereafter. The second patient had a basal cell carcinoma and a post–Mohs surgery defect on the palm (see Figure 2). She cited hypoesthesia on the graft initially which improved gradually after 4 months. The two-point discrimination test did not reveal any difference between the graft and the surrounding skin. Graft durability was excellent without tears, dehiscence, or erosion


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Figure 3 (A) Defect on dorsum of the third digit of left hand. (B) Four months postoperatively there is mild erythema.

even when the patient resumed heavy manual labor as a farmer a few months after the surgery. The third patient had a defect on the dorsum of the digit (see Figure 3). Graft erythema was present. However, functional ability was not impaired. The fourth patient (reported elsewhere [7]) had Bowen’s disease and a post–Mohs surgery defect on the side of the proximal finger and web. She exhibited excellent results with no perceptible color and textural differences between the graft and the surrounding skin. The donor scar was indistinct. The mobility of the thumb was not limited by the scar. None of the patients in the study had postoperative complications such as graft failure, hematoma, infection, or nerve damage.

IV.

DISCUSSION

Repairing surgical defects on the hand and digits after Mohs micrographic surgery can be difficult for dermatological surgeons. Several modalities of repair have been suggested. Small defects on the volar and dorsal aspects of the hands can be closed by V-Y advancement, island pedicle flap, or other regional flap (2). However, because the adjacent donor skin is often tight, local flaps are often impractical in the repair of large defects. A split-thickness skin graft (STSG) can be used to cover large defects on the hand. However, the graft can contract significantly (10) and can produce significant tear and erosion during manual labor. The STSG also tends to produce hyperpigmentation resulting in color mismatch.

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The FTSG has been shown to be an excellent option for repair of defects larger than 1.0 cm on the dorsum of the hand and defects larger than 0.5 cm on the digits (11). According to Gloster et al., FTSG is durable, yields good cosmetic results, and maintains normal function of the hand (4). Typical donor sites for FTSGs include the inguinal fold, anterior fossa, and volar wrist. The instep of the sole to the medial malleolus of the foot was suggested to be a good donor site for defects on the palm and palmar aspect of the digits (6). Previously, the choice and the refinement of the donor site have been to some degree neglected, although up to 20% of all major complications arose from the donor sites in one series of local and free flap transfers (12). The incidence of complications on the FTSG donor sites is unknown. In many instances, the sites are only used for the convenience of the surgeon (13). Inguinal and axillary grafts are often dissimilar to the skin of the hand in pigmentation, texture, thickness, and hair-bearing qualities. They are apparent when used on the hand and digits. Harvesting graft from the volar wrist can produce a ‘‘suicide scar,’’ which may be unacceptable to the patients (4). Grafts from the antecubital fossa also result in unjustifiable disfigurement (5,13). Grafts from the instep of the foot can provide excellent replacement for the palmar skin. Both are glabrous skin with a thick epidermal layer and compact dermis (6). However, especially in the cases with large defects, the use of the instep of the foot as a donor site introduces a second surgical region and one that complicates walking (3). The skin of the dorsal surface of the hand and digits is thin, mobile, and supple. It allows individual movement of the osteoarticular portion of the hand. A satisfactory replacement must be thin with an undersurface that will permit tendon gliding (14). As we demonstrated in our cases, FTSG from the first dorsal web of the hand provides a superb match in color, texture, and thickness, because the graft is harvested from tissue immediately adjacent to the defect. The skin of the palmar surface of the hand and digits is thick, hairless, and cornified, providing protection and support and resisting tear damage. The high density of sensory mechanoreceptors in the tissue make it even more difficult to replace. The ideal substitute for palmar defects would be palmar skin from another digit, the hypothenar region, or the instep of the foot (14). Nevertheless, a second surgical region is thus produced, which usually defies simple closure. In our cases (see Figures 1 and 2), a FTSG from the first dorsal web of the hand can be a good alternative with durability and textural match, although color mismatch (see Figure 1) and hypoesthesia (see Figure 2) can be problems. With the abundant laxity of skin on the first dorsal web of the hand, which is common in aging patients, the donor site can usually be closed


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easily with primary closure or, in cases of larger defects, with a local flap, such as a rotation or transposition flap. The healing is rapid and the resulting scar is acceptable to the patient. None of our patients showed any limitation of the mobility of the thumb.

V.

CONCLUSION

The hand is a unique and complex structure of the human anatomy. Its function is vital in our daily lives. Our study showed that the FTSG from the first digital web of the hand is an excellent donor site for covering surgical defects on all the surface of hand and digits because of its durability, cosmetic appearance, and functional ability.

REFERENCES 1. 2.

3. 4.

5. 6. 7.

8.

9. 10. 11.

Yeh S, How SW, Lin LS. Arsenical cancer of skin: histologic study with special reference to Bowen’s disease. Cancer 1968; 21:312–339. Ratz JL, Kay JJ, Yetman RJ. The Hand. In: Roenigk RK, Roenigk HH Jr, eds. Roenigk & Roenigk’s Dermatologic Surgery: Principles and Practice. 2nd ed. New York: Marcel Dekker 1996:401–417. Robotti EB, Edstrom LE. Split-thickness plantar skin grafts for converage in the hand and digits. J Hand Surg [Am] 1991; 16A:143–146. Gloster HM, Jr, Daoud MS, Roenigk RK. The use of full-thickness skin grafts for the repair of defects on the dorsal hand and digits. Dermatol Surg 1995; 21:953–959. Hage JJ, Bloem JJAM. The forearm, no loner a suitable donor are in skin defects on the hand. Ned Tijdschr Geneeskd 1991; 135:174–177. Zoltie N, Verlende P, Logan A. Full thickness grafts taken from the plantar instep for syndactyly release. J Hand Surg [Br] 1989; 14B:201–203. Cheng ST, Wu CS, Yu HS. The first dorsal web of the hand as a graft donor site for the defects on the hand and digits. J Am Acad Dermatol 1999; 40:250– 251. Wheeland RG. Skin grafts. In: Roenigk RK, Roenigk HH, Jr, eds. Roenigk & Roenigk’s Dermatologic Surgery: Principles and Practice, 2nd ed. New York: Marcel Dekker 1996:323–345. Salasche SJ, Feldman BD. Skin grafting: perioperative technique and management. J Dermatol Surg Oncol 1987; 13:863–869. Ketchum LD. The use of the full thickness skin graft in Dupuytren’s contracture. Hand Clinics 1991; 7(4):731–741. Mack GR. Superficial anatomy and cutaneous surgery of the hand. Adv Dermatol 1992; 7:315–351.

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12.

Hallock GG. Relative donor-site morbidity of muscle and facial flaps. Plast Reconstr Surg 1993; 92:70. Beasley RW. Cosmetic considerations in surgery of the hand. In: Tubiana R, ed. The Hand. Vol. II. Philadelphia: Saunders 1985:96–103. Upton J, Havlik RJ, Khouri RK. Refinement in hand coverage with microvascular free flaps. Clin Plast Surg 1992; 19(4):841–857.

13. 14.

60 Delayed Intranasal Knot Placement in Alar Composite Grafts Tina M. Peloro and Michael L. Ramsey Geisinger Medical Center, Danville, Pennsylvania

I.

INTRODUCTION

Reconstruction of nasal passage defects creates unique challenges due to limited visualization and decreased working space. Additionally, the dermatologic surgeon is faced with repairing these defects not only for cosmetic reasons but also for functional restoration. Full-thickness defects of the ala can be repaired utilizing composite grafts containing both skin and cartilage (1–5). Such grafting requires external suturing of the skin as well as intranasal sutures in the mucosa. Placement of mucosal sutures within the small confines of the nostril can be facilitated by the use of delayed knot tying. The benefits of delayed knot tying have been recognized in the closure of small wounds (6,7). Placement of all subcutaneous sutures first followed by their respective knot tying allows precise suturing in confined spaces. The likelihood of appropriate eversion is thus improved owing to maximum visualization. This technique can be further applied in situations utilizing composite graft placements (8).

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II. TECHNIQUE The technique for nasal alar reconstruction published by Ratner, et al. described the use of a helical rim graft sutured in place by an interlocking method (9). The auricular graft consists of cartilage and its overlying epithelium. Skin is removed from each distal end of the graft producing lateral ‘‘pegs’’. These pegs are inserted into each side of the alar defect, thus producing an interlocking graft. Rather than the conventional method of placing sutures and knotting each one after it is placed, delayed knot tying and delayed insertion of the graft facilitates precise insertion of the composite auricular graft. After harvesting and preparing the helical rim donor, 6-0 mild chromic gut is used to begin suturing. The composite graft must be gently handled at all times to avoid tissue damage, thereby enhancing the likelihood of graft survival. The first needle insertion is made through the ‘‘mucosal’’ side of the graft followed by placement through the corresponding location on the nasal defect, with the suture exiting into the nostril. The two suture ends are then held by a hemostat and placed to the side. Additional interrupted sutures are placed between the nasal mucosa and the mucosal side of the graft (Figure 1).

Figure 1 Needle insertion through the planned mucosal side of the composite graft.

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By holding each pair of suture ends with hemostats, the graft can be gently held at a location distal to the defect, thereby enabling the entire alar defect and naris opening to be visible (Figure 2). This increased visibility and working space provides easier maneuverability to place precise corresponding sutures. Once all the intranasal sutures are placed, the graft can be carefully wedged into the alar defect by inserting the cartilaginous pegs (Figures 3 and 4) and tying the sutures proximally and then distally. After completion, all knots should be visible on the nasal mucosa. This secures the graft on the intranasal side, allowing for easy placement of cutaneous sutures on the alar surface.

Figure 2 Maintaining the graft distal to the recipient site and delaying knot placements of the intranasal sutures increases the working space.

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Use of hemostats prevents tangling of the sutures.

Figure 4 After placement of the composite graft in the recipient site, the intranasal sutures can be successively tied from the proximal to the distal end.

Delayed Intranasal Knot Placement

III.

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CONCLUSIONS

Several surgeons have described placement of all intranasal sutures before cutaneous sutures to properly secure composite grafts on the alar rim (5,8– 11). Delaying the intranasal knot tying is a simple variation that can benefit the surgeon. It is a technique that creates improved visibility by optimizing the working area of small defects in difficult to reach locations. Maintaining the graft distal to the defect allows the placement of sutures with maximum maneuverability, improving precision and minimizing graft trauma.


5. 6. 7. 8. 9. 10. 11.

Brown JB, Cannon B. Composite free grafts of skin and cartilage from the ear. Surg Gynecol Obstet 1946; 82:253–255. Symonds FC, Crikelair GF. Auricular composite grafts in nasal reconstruction: a report of 36 cases. Plast Reconstr Surg 1966; 37:433–437. Smith RO, Dickinson JT, Cipcic JA. Composite grafts in facial reconstructive surgery. Arch Otolaryngol Head Neck Surg 1972; 95:252–264. Field LM. Nasal alar rim construction utilizing the crus of the helix, with several alternatives for donor site closure. J Dermatol Surg Oncol 1986; 12:253–258. Maves MD, Yessenow RS. The use of composite auricular grafts in nasal reconstruction. J Dermatol Surg Oncol 1988; 14:994–999. Salasche SJ, Winton GB, Adnot J. Surgical pearls. Dermatol Clin. 1989; 7:75–100. Ramsey ML, Marks VJ, Neltner SA. Surgical pearl: delayed knot placement facilitates small wound closure. J Am Acad Dermatol 1996; 34:137–138. Albertini JG, Ramsey ML. Surgical pearl: delayed intranasal knot tying for composite grafts of the ala. J Am Acad Dermatol 1998; 39:787–788. Ratner D, Katz A, Grande DJ. An interlocking auricular composite graft. Dermatol Surg 1995; 21:789–792. Haas AF, Glogau RG. A variation of composite grafting for reconstruction of full-thickness nasal alar rim defects. Arch Dermatol 1994; 130:978–979. Skouge JW. Skin Grafting. New York: Churchill Livingston, 1991:65–67.

61 Clavicular Grafts Parwathi ‘‘Uma’’ Paniker and J. Ramsey Mellette, Jr. University of Colorado Health Sciences Center, Denver, Colorado

I.

INTRODUCTION

Among the most challenging issues in Mohs surgery is reconstruction of large cutaneous defects after tumor resection. Primary closure may not be possible secondary to distortion of facial features or sheer tension across wound edges. Second-intention healing is somewhat labor intensive for the patient and may take weeks to months for completion. In such instances, full-thickness skin grafts (FTSGs) are the ideal option. They may offer an advantage over split-thickness grafts in that they are less likely to contract (1). Also, they are more likely to match surrounding tissue with regard to texture and color.

II. HARVESTING OF DONOR SKIN Donor skin for FTSGs may be obtained from the preauricular or postauricular area, melolabial fold, upper eyelid, inner arm, supraclavicular fossa, or skin directly overlying the clavicle (1). Only three of these options yield sufficient coverage for large (> 3 cm) defects: the supraclavicular fossa, inner arm, and clavicle. Most cutaneous surgery texts outline a standard supraclavicular fossa harvest for large FTSGs (2–4). Our experience with over 100 supraclavicular grafts and now over 100 clavicular grafts indicates superiority of the clavicular donor site. Clavicular skin is the preferred reservoir for large FTSGs because of greater laxity permitting larger grafts 379

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with facility of closure (4). Furthermore, resulting scars in this area are less prominent. Harvesting clavicular skin for a FTSG is performed much as it would be at other donor sites (Figure 1A–E). An outline of the defect is made using a sterile marking pen. A template is then devised by pressing a nonadherent pad against the defect. This is cut to appropriate size and shape and placed over the clavicle. Again, using a sterile marking pen, the template is outlined on clavicular skin. The full-thickness graft is taken, trimmed of underlying

Figure 1 (A) Large Mohs defect. (B) Nonadherent pad (cut to appropriate size and shape) placed over clavicle. (C) Outline of clavicular graft. (D) Graft secured in recipient bed. (E) Primary closure at donor site.

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fat, and placed in the recipient bed. It may be secured with nonabsorbable (polypropylene or nylon) suture, staples, or fast-absorbing gut.

III.

REPAIR OF DONOR SITE

There are several considerations in the optimal repair of the clavicular donor site. It should be noted that relaxed skin tension lines (RSTLs) in the skin directly over the clavicle are highly variable. Our previous article indicated that closure of the clavicular donor site should always be done parallel to the long axis of the clavicle. After accruing much more experience with these grafts, it has been determined that closure must be tailored to the individual’s RSTLs. Therefore, vertical closure across the clavicle is perfectly acceptable in some cases. The donor site should be fashioned into the appropriate fusiform shape, undermined, and closed in two layers. Plication of the superficial muscular aponeurotic system (SMAS) assists in relieving tension on wound edges and, ultimately, achieving a thin surgical scar. This plication may be done by including fibers of the platysma when placing the deep/absorbable layer of sutures. Simple or running nonabsorbable sutures are used to approximate the skin edges. A patient underwent FTSG taken from the right supraclavicular fossa for coverage of a large forehead defect. Six years later, he underwent Mohs micrographic surgery for tumor recurrence. His second surgery produced a 3 5 cm defect, which required a large FTSG. This was taken from the left clavicular area. Long-term observation of both donor sites revealed widening (to 2 cm centrally) of the supraclavicular scar with less noticability (0.3 cm wide) of the clavicular scar (Figure 2). A recent patient underwent Mohs micrographic surgery for a recurrent basal cell carcinoma (BCC) at the right temple that had been present for 20 years. After four stages, the margins were clear of tumor, but the defect size was 6:0 5:4 cm. FTSG was the best reconstructive option. We do attempt to base repairs on the individual availability of skin in a given patient. On examination, it actually appeared that the better reservoir of skin lay in the superclavicular fossa rather than over the clavicle. So a right-sided supraclavicular graft was harvested and secured with staples. The patient experienced no complications with the graft itself and has a good result 3 months postoperatively. However, the right supraclavicular donor site underwent dehiscence 1 week postoperatively with subsequent second-intention healing and scar widening. For very large surgical defects, split-thickness grafts are used simply because they may offer a large surface area. However, split-thickness grafts are cosmetically inferior to FTSGs, and they require extended healing times

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Figure 2 Long-term healing of right supraclavicular donor site and left clavicular donor site (arrows).

at the donor site (1,5). The large defect in Figure 3A was the result of a neglected primary basal cell carcinoma that was treated with Mohs micrographic surgery. Its dimensions were 11 11 cm. Bilateral clavicular FTSGs were taken and stapled side by side to cover the defect. Figure 3E was taken 3 months postoperatively and demonstrates acceptable healing of the donor site. The patient in Figure 4A presented for Mohs surgical treatment of BCC on the right temple, which had recurred after excision, electrodessication, and curettage and 5-fluorouracil treatment. After Mohs excision in six stages, the defect measured 9 8 cm. Again, bilateral clavicular grafts were harvested (Figure 4B). They were trimmed, placed, and secured with staples. Figure 4D and E show outcomes at 6 and 13 months after surgery. The patient continues to find his FTSG and donor sites cosmetically acceptable 5 years after the procedure.

IV.

CONCLUSIONS

As previously mentioned, choice of a donor site for FTSGs must be performed on a case-by-case basis. Any potential donor site should be evaluated for thickness, actinic damage, and adnexal quality (2). Relative compatibility with skin surrounding the defect should be assessed.

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Figure 3 (A) Large Mohs defect. (B) Two full-thickness skin grafts (from clavicle bilaterally) secured side by side. (C) Right clavicular donor site. (D) Left clavicular donor site. (E) Clavicular donor site at 3 months postoperatively.

Supraclavicular or clavicular skin is rarely considered to be the first choice for FTSG in small facial defects. However, with large defects, options are limited. Considering the equal number of cases performed by the senior author (P.P.) employing supraclavicular FTSGs and clavicular FTSGs, the conclusions drawn here are certainly valid. When a large FTSG is required for reconstruction, the skin overlying the clavicle offers a more than adequate surface area and acceptable donor site scar.

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Figure 4 (A) Large Mohs defect right temple. (B) Clavicular donor site. (C) Two full-thickness skin grafts (from clavicles bilaterally) secured side by side. (D) FTSG at 6 months postoperatively. (E) FTSG at 13 months postoperatively.

REFERENCES 1.

2.

Kent DE. Full thickness skin grafts. In: Lask GP, Moy RL, eds. Roenigk & Roenigk’s Principles and Techniques of Cutaneous Surgery. New York: McGraw-Hill, 1996:298–308. Wheeland RG. Skin grafts. In: Roenigk RK, Roenigk HH, eds. Dermatologic Surgery. Philadelphia: Saunders, 1996:879–896.

Clavicular Grafts 3. 4. 5.

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Hill TG. Skin grafts. In: Wheeland RG, ed. Cutaneous Surgery. Philadelphia: Saunders, 1994:321. Matheson BK, Mellette JR. Clavicular grafts are ‘‘superior’’ to supraclavicular grafts. J Am Acad Dermatol 1997; 37:991–993. Tromovitch TA, Stegmans T, Glogau RG. Flaps and Grafts in Dermatologic Surgery. Chicago: Year Book, 1989.

62 Disposable Suction Syringe for Epidermal Grafting Muhammed Mukhtar Sofia Skin Center, Patna, India

Shyam Sunder Pandey Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

I.

INTRODUCTION

Epidermal grafting is a useful treatment for achromic and granulating lesions (1). To obtain the graft is a difficult task. PUVA (Psoralene + Ultraviolet light A) and thermally induced blisters cause necrosis of the epidermis (2,3). Even with a thin Thiersch’s graft, removal of only epidermis is incomplete (4). There are some suction machines available, but these are complex and time consuming to use (1,2,4–6). To combat these problems, we have developed a simple, readily available and inexpensive disposable suction syringe for obtaining an epidermal graft (7) (Figure 1).

II. INSTRUMENTATION A suction syringe can be made in different sizes such as 5, 10, 20, 50 mL, but a medium-sized syringe (20 mL) has been selected, because its diameter (20 mm) is quite large and the pulling force is not so high that it causes a problem at the time of application. To make a suction syringe, the distal end of the syringe (20 mL) is cut with a hot scalpel blade and the edges are smoothed. A hole is made in the piston approximately 1.5 cm proximal to the distal end. The piston is then inserted into the distal end of the syringe. 387

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Figure 1 An applied suction syringe in place (above) with bulbae/blisters (below).

The hole is used to pass a small (6–8 cm), hard metal rod to keep the piston in place during suction. The proximal end of the syringe with a fingerguard should be applied at the suction site. Now, we can make a suction syringe, from the syringe used for liver biopsy, only after cutting the distal part of barrel smoothly. There is no need to make a hole in the piston for inserting the metal rod.

III.

ULTRASTRUCTURE OF SKIN AND BASIS OF BLISTER FORMATION

The skin is made of two major layers: epidermis and dermis. But as shown by electron microscopy, there is a basement membrane zone (BMZ) between these two major layers. In the BMZ, the lamina lucida is a loose, less cohesive, and separable layer in the skin below the epidermis, which can be separated by suction as well as by thermal application (3).

Disposable Suction Syringe for Epidermal Grafting

IV.

389

MAGNITUDE OF SUCTION

When the piston is pulled after keeping the syringe in airtight contact with the skin, a vacuum (i.e., negative pressure) of 1 atm of pressure is created, which is equivalent to 760 mm Hg=cm2 at the site within the syringe. This negative pressure is equivalent to a force of 3:18 ð10Þ6 dynes, which is being applied by the piston to pull it during application ðF ¼ P A, where F ¼ force, P ¼ 1 atm pressure ¼ 1:012 ð10Þ6 dynes=cm2 , A ¼ area of suction ¼ +ðrÞ2 ¼ 3:14 sq cm where r ¼ 1 cm). The height of vacuum column has no effect on the magnitude of negative pressure as well as on the suction process, but it is better to pull the piston more so that a small metal rod can be easily passed into the hole during application.

IV.

PROCEDURE

The donor site is shaved aseptically, the syringe is directly applied over the flat and hard sites such as shin or back. If the site is soft, such as the abdomen, buttock or anterior surface of thigh, the skin has to be stretched

Figure 2

Disposable suction syringes.

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by an assistant before the application. After keeping the syringe in contact with the skin, the piston is then pulled and a rod is passed into the hole to sustain suction (Figure 2). The patient experiences pain which is subjective and subsides spontaneously in approximately within 5 mins in most of the cases. Sometimes, if the patient feels unbearable pain, a hard site can be selected or an injection of lignocaine (2%) with epinephrine (1/200000) can be infiltrated away from the suction over the soft site. After 30–60 min, coalescence of vesicles forms a single large unilocular bulla, and then the syringe is removed. Another benefit of the hard site is that one requires less time (about half that of soft sites) to get a suction blister. If the vesicles do not coalesce, injection of normal saline (1.0–1.5 mL) is given gently to induce a unilocular bulla. Multiple blisters can be produced at the same site and at the same time according to the size of grafting site. The spacing of the syringes should be 1.0–2.5 cm depending upon the hardness of the site. The blister roof is cut from the periphery with an iris scissors, and is kept it in a Petri dish containing normal saline. After giving an injection of lignocaine (2% with epinephrine 1/200000), the achromic site is dermabraded until the appearance of bleeding spots (i.e., up to papillary dermis). Hemostasis is achieved by applying pressure with a piece of gauze soaked in normal saline. After this the graft, preferably without removing the fibrinous material from its undersurface, is transferred to the transplant site after spreading the graft over a glass slide with the help of a disposable needle. The graft is secured in place with micropore adhesive tape and immobilized with a moderate, pressure bandage. Over a large treated area, the graft can be used as punch graft at a distance of 0.8–1.0 cm. The dressings are removed after 1 week, and patients are followed up monthly for at least 6–9 months. After 1 month, all patients are advised to expose the site to sunlight daily for 15–20 mins between 10.00 am and 2.00 pm for approximately 3–6 months.

V.

RESULTS

Normal color matching was achieved in 14 of 16 patients within 3–6 months. Donor sites healed with normal pigmentation. The persistence of pigmentation was observed during follow-up. In two patients, the pigment did not appear over four out of seven epidermally grafted sites without significant damage or infection of the graft. No patients complained of negative effects of the surgical procedure.

Disposable Suction Syringe for Epidermal Grafting

VI.

391

CONCLUSIONS

A suction syringe is an effective device for obtaining an epidermal graft faster than with other instruments. It is readily available and mechanically driven as well as manually devised, and it is inexpensive, which is especially important in developing countries. The time to obtain an epidermal graft using a suction syringe (30–60 min) is less than with other instruments, which could be due to the differences in the magnitude of applied negative pressure (760 vs 200 mm Hg). In two patients, the partial failure of the treatment may have been due to damage or detachment of melanocytes during removal of fibrin from the grafts. Also, the fibrinous material may be helpful in maintaining the hydration and basic structure of melanocytes and the graft. So, in the absence of fibrin, the epidermis containing melanocytes may become easily dried, resulting in failure of treatment. For this reason, a large scale comparative study needs to be carried out.

ACKNOWLEDGMENTS We are grateful to our colleagues Drs. Mir Fareed Uddin Ali Khan and Mohammed Abdul Baseer at Al-Quwaiyah General Hospital, Riyadh, Saudi Arabia, for their guidance and help in preparing the manuscript for this chapter.

REFERENCES 1. 2. 3.

4. 5. 6.

7.

Falabella R. Epidermal grafting: an original technique and its application in achromic and granulating areas. Arch Dermatol 1971; 104:592–600. Koga M. Epidermal grafting using the tops of suction blisters in the treatment of vitiligo. Arch Dermatol 1988; 124:1656–1658. Wilkinsons DS. Cutaneous reaction to mechanical and thermal injury. In: Rook A, Wilkinson DS, Ebling FJG et al., eds. Textbook of Dermatology. Oxford, UK: Blackwell, 1986:503. Kiistala V, Mustakallio KK. In vivo separation of epidermis by production of suction blisters. Lancet 1964; 112:1444–1445. Mutalik S. Transplantation of melanocytes by epidermal grafting: an Indian experience. J Dermatol Surg Oncol 1993; 19:231–234. Hann DK, Im S, Bong HW, Park Y-K. Treatment of stable vitiligo with autologous epidermal grafting and PUVA. J Am Acad Dermatol 1995; 32:943–948. Mukhtar M, Singh S, Shukla VK, Pandey SS. Surgical pearl: suction syringe for epidermal grafting. J Am Acad Dermatol 1997; 37:638–639.

63 Use of Free Cartilage Grafts in Nasal Alar Reconstruction De´sireé Ratner Columbia Presbyterian Medical Center of the New York Presbyterian Hospital, New York, New York

I.

INTRODUCTION

Reconstruction of defects of the nasal ala and soft triangle may pose unique challenges for the dermatological surgeon. Alar defects that extend into deep soft tissue and/or approach the free margin of the nasal ala after skin cancer resection may eventuate in a functional as well as a cosmetic deficit if not reconstructed with appropriate structural support (Figure 1A) (1). Not only is there a risk of alar retraction if the forces of wound contraction remain unopposed during healing, but, more importantly, the negative airway pressure created with inspiration may collapse the already weakened alar support structures, with resultant compromise of the nasal valve, leading to partial airway obstruction (Figure 1b–c) (1–6). Such alar collapse does not usually occur with expiration. Free cartilage grafts can be used to avert this potential problem by providing structural support for partial-thickness nasal alar rim defects (4,7–11). These grafts may be variously configured as columellar and tip struts, sidewall braces, dorsal buttresses, and alar battens to restore the natural form and appearance of the nose (4,7,8,10). Presented here is a simplified technique for the placement of free cartilage grafts as alar battens to replace the lost structural support of the nasal alar rim. These grafts may be used in conjunction with flaps or fullthickness skin grafts to maintain airway patency and to minimize the risk of alar retraction. 393

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Figure 1 (A) Partial-thickness nasal alar defect after Mohs micrographic surgery for a large basal cell carcinoma. The lower portion of the lateral nasal cartilage is visible. The defect extends to the deep soft tissue of the ala laterally and to within several millimeters of the alar rim inferiorly. (B) View of the same patient from below. The nasal ala collapses on inspiration due to weakening of the alar support structure. (C) Alar collapse is not apparent on expiration.

Alar batten grafts are curvilear grafts consisting of cartilage with its overlying perichondrium. These grafts are placed into soft tissue pockets situated at the points of maximum alar rim collapse to provide additional alar support (3,10,11). The intended position of alar batten grafts may be marked preoperatively on the medial and lateral aspects of the defect, and their convex surface is oriented laterally to provide lateral support for the collapsed region of the ala (3). Although these grafts may be harvested from the auricular, nasal septal, or costal cartilage, the auricular cartilage tends to be most accessible to the dermatological surgeon, and the conchal bowl and antihelix serve as the most common donor sites in the area (4,12). Although an anterior or posterior approach to the conchal bowl site may be used without alteration in the shape of the ear, the posterior approach results in a less conspicuous donor site scar (7,10,11,13).

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II. TECHNIQUE The length of the cartilage graft is determined by measuring the distance between the lateral and medial borders of the defect at the alar rim and adding to that measurement four or five additional millimeters. Alar batten grafts generally measure 10–20 mm in length and 3–8 mm in width. These grafts must be strong enough to resist the negative inspiratory forces that collapse the lateral nasal wall as well as the forces of wound contraction which could produce upward retraction of the alar rim over time (4,11). The posterior conchal bowl donor site is incised through the full thickness of the skin, and the skin is undermined anteriorly and posteriorly with blunt scissors dissection to expose the perichondrial surface of the conchal bowl. The desired length of cartilage is incised with a #15 blade scalpel, and a second incision is then made exactly parallel to the first incision to create a cartilaginous strip. The cartilaginous strip is easily separated from the anterior skin surface with gentle use of forceps and sharp scissors dissection and is placed in sterile saline while the donor site is reapproximated with running locked skin sutures. The alar batten graft is then secured into place. The soft tissue of the recipient bed is undermined medially and laterally at these points in the subcutaneous plane either with a hemostat or blunt scissors dissection. The ends of the graft are carefully inserted into these undermined pockets such that they interlock with their recipient bed and fit snugly, both to avoid movement and to provide maximal structural support (3,10,11,14). If the pockets are too big, the graft may shift, and if they are too small, the graft may bend on itself, resulting in a deformed alar contour. At times, it may be useful to secure the graft to the underlying dermis or to the lateral third of the lateral crus with a 5-0 absorbable or clear nonabsorbable suture both for increased apposition to the underlying tissue and to prevent graft migration medially (3,8–11). If the graft fits snugly into the undermined pockets, suture fixation may not be necessary. Care must be taken to avoid distorting the position of the lateral crus if a fixation suture is employed. After the graft has been securely anchored, a flap or full-thickness skin graft is sutured into place over the defect in a standard fashion to complete the closure (1,10,11,15). Sutures are removed after 1 week.

III.

DISCUSSION

When repairing partial-thickness defects of the nasal ala, it is important to preserve the nasal symmetry so as to achieve a cosmetically elegant result and to avoid the possible complication of nasal valve obstruction (1,2,10).

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Such an outcome may be prevented through the use of free cartilage grafts, which reposition the lateral nasal wall closer to its normal position, provide structural support to prevent nasal valve collapse on inspiration, brace the free margin of the alar rim against the forces of wound contraction, and maintain dynamic nasal airflow (Figures 2a–e) (1,4). Partial thickness defects of the alar rim and soft triangle may be unable to resist collapse if such grafts are not placed owing to weakening of the support structures of the nasal valve (1,2,10). This functional impairment may be all the more difficult for the patient to tolerate if wound contraction in this area produces any degree of alar retraction, resulting in impaired cosmesis as well (1).

Figure 2 (A) Partial-thickness defect of nasal sidewall and ala after Mohs micrographic surgery. An alar batten graft has been interlocked with the soft tissue of the recipient bed both medially and laterally and secured with a single 5-0 absorbable suture centrally. Two nasal sidewall battens have been placed superiorly for additional structural support. (B) A nasolabial flap has been sewn into place over the free cartilage grafts. (C–E) Views of the same patient from the front, the side, and below 1 month after free cartilage grafting and nasolabial flap placement. Note the excellent positioning of the nasal alar rim, the postoperative facial symmetry, and the lack of alar collapse on inspiration.

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Alar batten grafts replace the missing structural support elements of deep soft tissue defects of the nasal ala and soft triangle with a rigid but flexible cartilaginous framework, thereby bracing the free margin of the nostril and minimizing the risk of alar retraction (4,10). Although resorption of cartilage grafts may uncommonly occur, usually as a consequence of inadequate anchoring or contractural scarring, autologous free cartilage grafts normally maintain their shape and size for prolonged periods of time (4,16). It is essential to note, however, that crushed cartilage tends to have a decreased survival time compared to cut or uncrushed cartilage, making gentle handling of free cartilage grafts essential for reconstruction of the nasal support structure to be successful (17).

REFERENCES 1. 2. 3.

Robinson JK, Burget GC. Nasal valve malfunction resulting from resection of cancer. Arch Otolaryngol Head Neck Surg 1990; 116(12):1419–1424. Kasperbauer J, Kern E. Nasal valve physiology. Implications in nasal surgery. Otolaryngol Clin North Am 1987; 20(4):699–719. Toriumi D, Josen J, Weinberger M, Tardy MJ. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg 1997; 123(8):802–808.

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4.

Otley C, Sherris D. Spectrum of cartilage grafting in cutaneous reconstructive surgery. J Am Acad Dermatol 1998; 39(6):982–992. Troell R, Powell N, Riley R, Li K. Evaluation of a new procedure for nasal alar rim and valve collapse: nasal alar rim reconstruction. Otolaryngol Head Neck Surg 2000; 122(2):204–211. Teichgraeber J, Wainwright D. The treatment of nasal valve obstruction. Plast Reconstr Surg 1994; 93(6):1174–1182; discussion 1183–1184. Burget G, Menick F. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg 1986; 78(2):145–157. Burget G, Menick F. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989; 84(2):189–202. Burget G. Aesthetic reconstruction of the tip of the nose. Dermatol Surg 1995; 21(5):419–429. Ratner D, Skouge J. Surgical pearl: the use of free cartilage grafts in nasal alar reconstruction. J Am Acad Dermatol 1997; 36(4):622–624. Byrd D, Otley C, Nguyen T. Alar batten cartilage grafting in nasal reconstruction: Functional and cosmetic results. J Am Acad Dermatol 2000; 43(5):833– 836. Cardenas-Camarena L, Gomez R, Guerrero M, Solis M, Guerrerosantos J. Cartilaginous behavior in nasal surgery: a comparative observational study. Ann Plast Surg 1998; 40(1):34–38. Pereira M, Marques A, Ishida L, Smialowski E, Andrews J. Total reconstruction of the alar cartilage en bloc using the ear cartilage: a study in cadavers. Plast Reconstr Surg 1995; 96(5):1045–1052. Ratner D, Katz A, Grande D. An interlocking auricular composite graft. Dermatol Surg 1995; 21(9):789–792. Fader D, Baker S, Johnson T. The staged cheek-to-nose interpolation flap for reconstruction of the nasal alar rim/lobule. J Am Acad Dermatol 1997; 37(4):614–619. Collawn S, Fix R, Moore J, Vasconez L. Nasal cartilage grafts: more than a decade of experience. Plast Reconstr Surg 1997; 100(6):1547–1552. Bujia J. Determination of the viability of crushed cartilage grafts: clinical implications for wound healing in nasal surgery. Ann Plast Surg 1994; 32(3):261–265.

5.

6. 7. 8. 9. 10. 11.

12.

13.

14. 15.

16. 17.

64 A Simple Preparation of Autologous Fibrin Glue for Skin Graft Fixation Mark A. Brzezienski and James L. Fowler III University of Tennessee College of Medicine, Chattanooga, Tennessee

I.

INTRODUCTION

The use of surgical adhesives has gained considerable momentum over the last several decades. Biological adhesives rely upon fibrinogen and ultimately fibrin as their principle adhesive constituents. The fibrin adhesives, or ‘‘glues,’’ mimic the final common pathway of the coagulation cascade. These adhesives therefore consist of two solutions: a thrombin preparation and a fibrinogen preparation. When combined with appropriate cofactors, the mixture forms a fibrin clot which can be used to multiple advantages. Fibrin glue preparations have been commercially available for years in Europe and Canada. These preparations extracted fibrinogen from a pool of human plasma. Refined preparations have been approved by the U.S. Food and Drug Administration and are therefore available in the United States. However, the theoretical risk of viral or subviral particle transmission as well as anaphylactic reaction continues to be of concern (1). The heterologous products are also not without cost, which can be considerable depending on the volumes needed. The development of single-donor preparations were also initially costly and cumbersome to create. However, reports of operating table side preparation of autologous fibrin glue have made the technological advance of biological adhesives available to an ever-widening sector of surgeons. All this with minimal preparation time and cost (14). 399

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The literature is replete with applications for this technology. Fibrin glue has been used as a hemostat in vascular surgery, and it has decreased hemorrhage in trauma as well as in burn excision and grafting (2–3). It has been used as a sealant in the treatment of a number of fistulae in a variety of locations, including fistulae in ano (4). Pleural leaks and dural leaks have been effectively sealed (5–6). Fibrin glue has found its place in esthetic surgery by improving hemostasis and postoperative morbidity in face lift surgery. Suggestion has been made that growth factors in the autologous gel may promote more rapid healing (7). This finding has also been supported by a recent experiment conducted in our laboratory in which flap survival increased in an ischemic rat flap model with autologous fibrin glue treatment of the surgical site (8). The adhesive properties of this technology are perhaps no better employed than with its use in the fixation of split-thickness skin grafts. The first report of fibrin glue used as a skin graft fixative emerged in 1944 by Tidrick and Warner. Early recognized benefits of this technique were the elimination of sutures and staples, bulky bolster dressings, and multiple dressing changes (9). Since that time, fibrin glue has been reported to decrease the incidence of hematoma and seroma beneath the grafts and flaps (10–11). It is useful in grafting ‘‘difficult’’ wounds that are deep or involve invaginated soft tissue defects (9). Fibrin glue forms a strong matrix between the wound bed and the skin graft, accelerates the healing process, and may result in improved survival of the graft. The use of fibrin glue has been reported to improve graft survival in infected wounds and to decrease wound contraction (12–13). Decreased hospital stays and briefer periods of immobilization have also been reported as benefits (9). Finally, our experience has demonstrated improved cosmetic results using fibrin glue fixation.

II. PREPARATION AND APPLICATION Autologous fibrin glue preparation, as described by Hartman, is simple, time efficient, and cost effective (14). Autologous fibrin glue is prepared at the time of the skin graft procedure. The two solutions required are prepared separately. The first solution is mixed at the back table and consists of 2 mL of 10% calcium chloride solution, 2 mL bovine thrombin (1000 =mL), and 41 mL of normal saline solution. This 45-mL solution is kept in 60-cc syringe. The fibrinogen solution is derived from the patient’s venous blood. Approximately 10 cc of blood is aspirated per 100 cm2 area to be grafted. The blood is collected in a series of blue-topped tubes (sodiumcitrate Vacutainer, Franklin Lakes, NJ), and a centrifuged 3000 rpm for 10

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mins. The serum is then aspirated with an 18-gauge spinal needle and retained in an appropriately size syringe. The split-thickness skin graft is harvested in the usual fashion and meshed with the dermal side up. The recipient site is sprayed liberally with the calcium chloride/thrombin solution. The meshed skin graft is maintained on its mesher plate for ease of handling and sprayed with the fibrinogen solution. Enough solution is used to wet the graft thoroughly without runoff from the plastic mesher plate. The plate is then inverted and the graft is transferred to the wound bed. In the initial seconds after transfer, opportunity is taken to seat the graft digitally into all the undulations of the wound bed. The edges of the wound are not typically sutured down, because the graft will easily adhere to even vertical wound walls. Fixation occurs within 60 s. The graft is then dressed with a layer of Xeroform (Sherwood Medical) and covered in several layers of gauze which has been soaked in an antibiotic solution. Dry dressings and elastic bandages are then used to secure the dressing. Splints are used around mobile areas if needed; but it has been our experience that the use of fibrin glue permits early, safe mobilization. Take down of the dressing is performed in 3–5 days. Care is taken at the edges not to peal the graft from its bed. However, as the center of the graft is approached, firm adherence is characteristic. The graft is redressed with Xeroform and a dry sterile dressing for another 3 days after which nursing dressing changes can begin on a daily basis.

III.

DISCUSSION

Clinical studies have illustrated the effectiveness of autologous fibrin glue in the fixation of split-thickness skin grafts. Animal studies have demonstrated normal neovascularization with the use of fibrin adhesive. Shear strength or the ability of the graft to resist displacement has been shown to increase with the use of autologous fibrin glue (9). It is well known that the earliest constituents which bind a skin graft to its bed are fibrin and fibronectin, so it stands to reason that if we augment these elements, we can increase the graft’s ability to imbibe initially and revascularize later. This may lead to the recognized stability and improved survival of glue-treated grafts in problem wounds. Whereas commercial products have standardized fibrinogen concentrations, autologous glue does not. Fibrinogen concentration is linked to the tensile strength of the glue, but shear strength is more pertinent to the skin graft technique, and the presence of concentrated growth factors present in the autologous gel may also provide for a more receptive local healing milieu (7).

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Autologous fibrin glue has been successfully used for skin graft fixation in a variety of wound situations. These include traumatic wounds, free tissue transfers, burns, and chronic wounds. Our review of 56 patients treated with this technique indicated that 90% of patients had a 95% adherence of the skin graft. No patients had less than a 90% graft take. The mean area grafted was 237 cm2 (range 50–700 cm2 ). Those five cases with the poorest graft take were burn, venous stasis ulcer, and Fournier’s gangrene wounds. There were no adverse reactions or infections in the population, and no patients required repeat skin grafting (3).

IV.

CONCLUSIONS

Whereas staples and sutures have been the mainstay of skin graft fixation for decades, fibrin glue adherence of skin grafts is gaining a significant following. Autologous fibrin glue preparations, in particular, provide numerous advantages. Principally, using the suggested approach preparation of the required solutions is both easy and rapid. All components of the preparation area available in any approved operating suite. Blood may be drawn before surgery and processed in the main hospital laboratory. With increased use of the technique, and in suite centrifuge would decrease transport time and permit blood to be drawn just minutes before it is needed. In our opinion, the autologous fibrin glue method leads to a more esthetically pleasing result. It eliminates the need for bolus stent dressings and allows for improved graft take in cavernous, invaginated wounds. The subtraction of staples and sutures from graft fixation permits improved postoperative management and eliminates the discomfort and anxiety associated with their removal. Patient satisfaction is improved, and nursing time can be more effectively used. The hemostatic properties of fibrin adhesives have been well documented. The decrease in bleeding, seroma, and exudate associated with their use no doubt improves graft healing, increases take, and avoids follow-up surgery. Autologous fibrin glue is safe and cost effective. No heterologous blood products are used, so the risk of particle transmission is eliminated The cost of autologous fibrin glue is similar to traditional suture or stapling methods. However, as the number of stapling devises or sutures used increases, the cost effectiveness of the autologous adhesive, both intraoperatively and postoperatively, will be realized.

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REFERENCES 1.

2.

3.

4.

5.

6. 7.

8.

9.

10. 11.

12. 13. 14.

Mitsuhata H, Horiguchi Y, Saitoh J, Saitoh K, Fukada H, Hirabayashi Y, Togashi H, Shimizu R. An anaphylactic reaction to topical fibrin glue. Anes 1994; 81:1074–1077. Mcgill V, Kowal-Vern A, Lee M, Greenhalgh D, Gomperts E, Bray G, Gamelli R. Use of fibrin sealant in thermal injury. J Burn Care & Rehab 1997; 18:429–434. Buckly RC, Breazeale EE, Edmond JA, Brzezienski MA. A simple preparation of autologous fibrin glue for skin-graft fixation. Plast Reconstr Surg 1999; 103:202–206. Cintron JR, Park JJ, Orsay CP, Pearl RK, Nelson RL, Sone JH, Song R, Abcarian H. Repair of fistulas-en-ano using fibrin adhesive. Dis Colon Rectum 2000; 43:944–950. Mouritzen C, Dromer M, Keinecke HO. The effect of fibrin glueing to seal bronchial and alveolar leakages after pulmonary resections and decortications. Eur J Cardiothorac Surg 1993; 7:75–80. Toma AG, Fisher EW, Cheesman AD. Autologous fibrin glue in the repair of dural defects in crainiofacial resections. J Laryngol Otol 1992; 106:356–357. Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg 2001; 107:229–237. Albear P, Brzezienski M. Trophic Effects of Fibrin Glue on Ischemic Tissue. Presentation at the University of Tennessee College of Medicine, Chattanooga, TN, 1999. Saltz R, Sierra D, Feldman D, Saltz MB, Dimick A, Vasconez LO. Experimental and clinical applications of fibrin glue. Plast Reconstr Surg 1991; 88:1005–1015. Kulber DA, Bacilious N, Peters ED, Gayle LB, Hoffman L. The use of fibrin sealant in the prevention of seromas. Plast Reconstr Surg 1997; 99:842–849. Moore MM, Nguyen DHD, Spotnitz WD. Fibrin sealant reduces serious drainage and allows for earlier drain removal after axillary dissection: A randomized prospective trial. Am Surg 1997; 63:97–101. Jabs AD, Wider TM, DeBellis J, Hugo NE. The effect of fibrin glue on skin grafts in infected sites. Plast Reconstr Surg 1992; 89:268–271. Brown DM, Barton BR, Young L, Pruitt BA. Decreased wound contraction with fibrin glue-treated skin grafts. Arch Surg 1992; 127:404–406. Hartman AR, Galanakis DK, Honig MP, Seifert FC. Autologous whole plasma fibrin gel, intraoperative procurement. Arch Surg 1992; 127:357–359.

65 Stent Dressing Techniques in Skin Grafting Fernando Prune´s Kern Medical Center, Bakersfield, California

I.

INTRODUCTION

Successful skin grafting depends to a great extent upon the dressing technique used to immobilize the graft. The purpose of this chapter is to provide the reader with information about a variety of dressing techniques that have been effective in my hands.

II. METHODS AND MATERIAL It is assumed at the outset that the surface being grafted is a suitable one. Hemostasis is important, but excessive use of ligatures or electrocautery is discouraged. It is contingent upon the surgeon to provide good contact between the wound and the graft by eliminating shearing motion of the graft and preventing air, blood, or serum from collecting underneath the graft. Although many grafts are treated by the open technique, most grafts are best treated by a closed technique. Selection of the proper method of graft immobilization is, therefore, important. The oldest stent dressing, and still the most widely used, is the tie-over dressing (1). This dressing is most suitable for grafts of the face or for relatively small grafts (less than 3 cm in diameter) placed elsewhere. The graft is applied to the wound either as a sheet (intact of ‘‘pie-crusted’’) or as a mesh. The edges are sutured at 4–12 points using nonabsorbable sutures (my preference is silk). The sutures are 405

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left 15–20 cm long. I do not believe in exact approximation of the graft to the wound edges, so I allow some overlap. This overlap does not seem to affect the eventual cosmetic appearance of the graft, and it saves time. The stent dressing is made of simple fluffed, wet gauze over a nonadherent layer of fine gauze. The sutures are then tied over the gauze either individually or in batches of two or three with moderate tension (Figure 1A and 1B). I find it helpful to have the assistant grasp the knot with the tip of a needle holder as it is being tied. Immobilizing the knot as it is being tied prevents it from being tied too loose, or worse, being tied too tight. Alternatively, the sutures can be held together by a variety of devices (e.g., buttons, plastic or metal clips, lead shots). The dressing is removed in 3–5 days. When the wound to be grafted is larger than 3 cm in diameter and is located in an area that can not be easily immobilized, such as the groin, the axilla, or the neck, often the best technique is open grafting, using no dressings at all. Uncooperative patients, children, and outpatients, however, are poor candidates for open grafting. In these situations, for the last 15 years, my preference has been to use a modification of the tie-over stent dressing. This method is extremely versatile and much faster and effective than any other method that I know. The graft is applied to the wound with a small overlap, securing it to the wound edges with surgical skin staples. It is then

Figure 1 (A) Skin grafted defect of the medial canthal region of the eyelids. The tails of the sutures are left long. (B) Small, traditional tie-over stent dressing in place.

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covered with a layer of fine gauze and a wad of wet gauze. Sterile standard office rubber bands are lightly stretched over the dressing, securing them to the surrounding normal skin along multiple points in the immediate periphery of the graft, using surgical staples (Figure 2A and 2B). If the wound is very large, two or even three rubber bands may be looped together. If the graft is on the small side, a single rubber band is fixed at multiple points, crisscrossing over the dressing. Care must be taken not to apply undue tension to the rubber bands. This type of dressing will conform to any surface, no matter how irregular, and exerts gentle, firm pressure over the skin graft which is even superior to the standard tie-over. As long as the staples are removed in less than a week, I have not seen any visible scarring related to the staples. Patients have not complained about the staples, and many are amused at having rubber bands attached to them. When grafting defects in the limbs, I combine the rubber band method with a circular bandage. The stabilization provided by the stent dressing prevents the bandage from sliding off of the graft. Immobilizing the limb with a plaster splint or a cast adds security to the dressing. Other clever modifications of the dressing techniques described have appeared in the literature, and a few of them have merit. My favorite one is the substitution of the rubber bands for burn net. The application of the graft and the dressing material are the same as described previously. A piece of burn net is placed over the dressing, it is then gently stretched and secured to normal skin in the periphery of the wound with surgical staples (Figure 3A). The distinct advantage of this method is that at the time of the first dressing (or even the second), one can make a cut in the burn net, leaving the perimeter of the net undisturbed, change the dressing, and using additional surgical staples, the mesh is reapproximated over the new dressing. This additional stapling is done on the dressing only (Figure 3B). I tend to use

Figure 2 (A) Modified tie-over dressing over a grafted leg defect. Rubber bands and staples are used to secure the stent dressing. (B) Finished stent dressing.

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Figure 3 (A) Burn net and staples are used to secure a stent dressing over a grafted foot defect. (B) The dressing has been changed through an opening in the burn net. The burn net has been restapled, securing the new dressing.

this method whenever I anticipate that securing subsequent dressings with tape or bandages is going to be problematic. The scalp, the axilla, and the perineum come to mind. A second modification is to stent the graft using standard ‘‘egg crate’’ foam rubber instead of gauze (3,4). This material is cut to conform to the shape of the grafted wound and is applied over fine mesh gauze, flat side toward the wound. The foam rubber is then secured to the periphery of the wound with surgical staples. This dressing was aptly named ‘‘stegosaurus dressing’’ because of its appearance (4). The idea is good, but I believe that the rubber band method is more effective and certainly quicker. I have also found that the foam rubber tends to stick to the wound much more than wet gauze does, making subsequent dressing changes painful and difficult. I do like to use foam rubber instead of gauze when grafting penile shaft defects, a difficult area to graft.

III.

OTHER METHODS

I have little experience with the two following methods, which I mention for the sake of interest and completeness. Both of them involve the use of suction to secure the skin graft. I learned about the first one years ago from a presentation by Dr. Burt Brent in which he described placing a small suction catheter under a skin graft in a reconstructed ear, using negative pressure to hold the graft in place and to remove fluid. The catheter was the small plastic tubing of a butterfly needle, with the hub removed, and additional holes made into the tubing. The needle was then inserted into a standard vacuum tube (this suction device has been subsequently produced commercially). The idea is intriguing, but I have rarely used the method

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myself. A second method involving suction, has been described more recently. This one involves placing a suction catheter over the skin graft and then covering both, the graft and the catheter, with a thin plastic dressing to provide a vacuum seal (5). The only time I employed this method, I had some difficulty maintaining the vacuum seal intact.


5.

McGregor IG. Fundamental Techniques of Plastic Surgery. 5th ed. Baltimore: Williams & Wilkins, 1972. Prune´s F, Asbun H. A simplified stent dressing technique using elastic rubber bands. Ann Plast Surg 1989; 23:84–85. Balakrishnan C. Simple method of applying pressure to skin grafts of neck with foam dressing and staples. J Burn Care Rehabil. 1994; 15:432–433. Fullerton J, Smith CE, Milner SM. The ‘‘stegosaurus’’ dressing: a simple and effective method of securing skin grafts in the burn patient. Ann Plast Surg 2000; 45:462–464. Schneider AM, Morykwas MJ, Argenta LC. A new and reliable method of securing skin grafts to the difficult recipient bed. Ann Plast Surg 1998; 102:1195–1198.

66 Rapid Stapler Tie-Over Fixation for Skin Grafts Haim Y. Kaplan and Josef Haik The Sheba Medical Center, Ramat-Gan, Israel

I.

INTRODUCTION

Split-thickness skin graft is a basic procedure in reconstructive plastic and burn surgery. Immobilization and prevention of the movement of the graft over the recipient site in the first few days is essential to ensure graft take. The fixation secures the formation of the fibrin layer, with subsequent ingrowth of capillaries into the graft (1,2). Immobilization prevents hematoma formation, which is the most frequent cause of graft failure (3). A common practice to ensure immobilization is to use tie-over silk sutures. The technique uses cotton wool, rubber, latex, or silicon foam as a bolus substance and 2-0 or 3-0 silk sutures, which are tied over for fixation. The elasticity of foam substances has the advantages of maintaining the pressure applied for as long as the tie-over is kept in place. Care should be taken not to exceed the capillary perfusion pressure of 25–30 mm Hg.

II. TECHNIQUE Following a careful homeostasis of the recipient bed, an imprint of the wound is taken using a piece of the foam rubber. A split-thickness skin graft is applied to the wound using a staple gun for fixation at the periphery of the wound. A mesh gauze is then applied over the graft (4). In cases where the recipient site is a deep crater owing to the thickness of the skin layer resected, a double or triple foam rubber layer is used. The foam rubber is cut 411

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Figure 1 (A) Excision of basal cell carcinoma on the scalp with the foam is in place. (B) Skin take 5 days later.

to measure using the imprint. The thickness of the foam should be twice the depth of the wound; in a deep irregular wound, a smaller piece of foam rubber should be placed at the base. The foam is fixed under mild pressure to the margins of the wound with a staple gun (Figure 1A). In cases of a large grafted area or specific anatomic location where movement is expected, staples can be applied to the center of the foam to ensure additional fixation (Figure 1B). There is no need for another dressing. The procedure is quick, taking 1–2 mins to complete the pressure dressing. The staples should be removed 4–5 days later. The technique has been performed on patients since 1989 on limbs including the hand and foot, trunk, axilla, cubital fossa, scalp, and retroauricular region with no loss of the skin graft.

III.

CONCLUSIONS

A simple method to ensure split thickness skin graft immobilization is presented. The method uses foam rubber and staple gun. The method is safe and reliable and saves operating room time.


Samahel J. The healing of skin grafts. Clin Plast Surg 1977; 4:409. Vistnes LM. Grafting of skin. Surg Clin North Am 1977; 57:939. Flowers R. Unexpected problems in skin grafting. Surg Clin North Am 1970; 50:439. Kaplan HY. A quick stapler tie-over fixation for skin grafts. Ann Plast Surg 1989; 22:173.

67 Nylon Threads Used as Drains in Free Skin Grafting Tomoharu Kiyosawa and Yoshio Nakayama Institute of Clinical Medicine, Tsukuba University, Tsukuba City, Japan

I.

INTRODUCTION

Sheet skin grafting is one of the most fundamental and important techniques in plastic and dermatological surgery. In particular, a sheet graft is more appropriate than a mesh or stamp graft when a cosmetically pleasing result is required. However, hematomas often occur in sheet grafts, but not in mesh or stamp grafts. The prevention of hematomas in a free skin grafts is the first requirement for a successful cosmetic result (1), and meticulous hemostasis and appropriate pressure are therefore required. However, many points of tiny hemorrhage and the formation of a hematoma in a recipient bed are inevitable. Even if the area of hematoma are tiny, necroses may develop at several points in the areas of the skin graft overlying them. To prevent hematoma, small holes are often made on a graft with a sharppointed knife. However, these holes also cause unsightly scars that are inappropriate for plastic and cosmetic operations. As a method of minimizing hematoma in sheet skin grafting, applied nylon threads can be used as drains (2). Survival of a sheet graft using the nylon-drain method is excellent, with almost no necroses being found in the grafts. The results using this technique of the thread-drain method are thus cosmetically satisfactory.

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II. TECHNIQUE The method for inserting nylon-thread drains is straightforward (Figure 1). After several sutures of a split- or full-thickness skin graft are placed in the corners, 3-0, 2-0, or 1-0 monofilament nylon threads are distributed under the graft as drains. The nylon threads either lie under the graft throughout from one side to the other or reach up to the center of the graft. The suitable number of the drains has not been strictly settled upon, but they are maximally distributed at intervals of 0.5–1.0 cm. Subsequently, adhesive tape is optionally applied to fix the threads, as they could become obstacles in the subsequent suturing of the graft. Suturing threads at the margin are preferably used either with fine monofilament nylon in a pressure dressing or with braided nylon in a tie-over dressing. The following procedures are the

Figure 1 A plane illustrated view of the thread-drain method. 3-0, 2-0, or 1-0 Monofilament nylon threads are distributed under the skin graft as drains.

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same as in the usual method. Removal of the drains generally occurs from after a few days up to 1 week, according to the postoperative dressing condition. The drains are easily removed, and there are no accompanying complications. Usually, the effect of this drainage is sufficient, and nearly all of the sheet graft survives satisfactorily. III.

CASES

A.

Case 1

A 3-year-old boy had a hypertrophic scar on his right dorsal ankle region. The defect after resection of the scar was covered with a full-thickness skin graft from the groin. 2-0 Monofilament nylon threads were used as drains, and a pressure dressing was applied. The dressing was changed on postoperative day 7. The graft took very well, and no necroses were found. B.

Case 2

A 23-year-old woman had a burn scar on her forearm. The defect after resection of the scar was repaired with a split-thickness skin graft from the buttocks. 3-0 Monofilament nylon threads were used as drains, and a pressure dressing was applied. The dressing was changed on postoperative day 7. The bloodstain on the inside surface of the dressing showed the drainage effect. The marginal shape of the stain was reversible for the graft. The graft survived very well, and no necroses were induced. Hypertrophy of marginal scars was recognized transiently in a cubital area, but it subsided soon after. No residual effects from the use of drains were observed (Figure 2). IV.

DISCUSSION

The application of nylon drains seems to be a very advantageous method for achieving skin graft survival. The method is more favorable for reducing hematomas than other procedures such as making many small holes with a knife. Features of these drains include the following: (1) an ability to drain any collected blood, (2) no hindrance to acceptance of the graft, (3) a minimum tissue reaction, (4) easy availability in the operating room, (5) no adhesiveness and easy removability, and (6) no residual scar formation. These requirements for skin grafting are materially fulfilled by the use of 3-0, 2-0, or 1-0 monofilament nylon threads. Experience has shown that this method can be used with any size of skin graft, ranging from small grafts such as those used in separation of syndactylyl to large ones covering a 2

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Figure 2 A split-thickness skin graft on the forearm. (A) 3-0 Monofilament nylon threads were used. (B) Satisfactory results on the second postoperative month. (C) The bloodstain occurring on the inside of the dressing on the seventh postoperative day illustrates the drainage effect. The marginal shape of the stain is a mirror image of the graft itself.

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‘‘drum’’ area. The method is convenient, inexpensive, achieves a maximal effect in reducing hematomas, and has minimal complications. It can also be used together with the suction-drain method (3,4). When cosmetically and functionally excellent results are required for a free sheet skin graft, the thread-drain method is thus recommended.

REFERENCES 1.

2. 3. 4.

Converse JM, McCarthy JG, Brauer RO, Ballantyne DL. Transplantation of skin grafts and flaps. In: Converse JM, ed. Reconstructive Plastic Surgery. Vol 1. 2nd ed. Philadelphia: Saunders, 1977:152–239. Nakayama Y, Soeda S. Nylon threads used as drains in free skin grafting. Ann Plast Surg 1990; 24:91–95. Nakayama Y, Iino T, Soeda S. A new method for the dressing of free skin grafts. Plast Reconstr Surg 1990; 86:1216–1219. Nakayama Y, Soeda S. A new dressing method for free skin grafting in hands. Ann Plast Surg 1991; 6:499–502.

68 Overgrafting for Leukoderma and Chronic Inflammatory Conditions of the Lower Lip: A New Application of an Already Established Method Vinayak Raghunath Chitale and Bindumadhav G. Galgali Chitale Clinic, Solapur, Maharashtra, India

I.

INTRODUCTION

The terms vitiligo and leukoderma are used synonymously. However, there are some subtle differences in these conditions. Vitiligo is an acquired disfiguring pigmentary anomaly of the skin, manifested by depigmented white patches surrounded by a normal or hyperpigmented border. These white patches are devoid of melanocytes (1). Leukoderma, on the other hand, is defined as a type of acquired skin depigmentation produced by some specific substances or dermatosis (1). Both conditions are treated by excision or shaving off of the skin lesion and covering the defect by a split-thickness skin graft. Here, we have used the term overgrafting, which has been used to describe a technique in which multiple layers of skin grafts are used to build up thickness (2). We have never meant to use this aspect of the technique. Another aspect of overgrafting is when hypertrophic burns scar may be shaved down and then overgrafted with a split-skin graft. Shaving off of the original lesion and covering it with a split-skin graft is overgrafting. In vitiligo, overgrafting helps to camouflage the white patch. This involves active melanocyte transfer. This camouflaging offers enormous psychological support to the mentally depressed patient. 419

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In leukoderma with chronic inflammatory disease of the lower lip, thorough excision by shaving off of the original lesion and overgrafting offers a cure. Inflammatory disorders of the lips are as follows: 1. 2. 3. 4. 5. 6. 7. 8.

Contact cheilitis Actinic cheilitis Angular cheilitis Exfoliative cheilitis Plasma cell cheilitis Cheilitis glandularis Cheilitis granulomatosa Other forms of cheilitis

Many of these conditions are painful and can be premalignant. Surgical treatment has been advised as excisional treatment. In actinic cheilitis, vermilionectomy is advised. Surgical excision has been described as the best treatment in cheilitis glandularis. In cheilitis granulomatosa, palliative surgical repair has been recommended (3). In all these excisional procedures, repair by overgrafting has not been suggested, hence our performing overgrafting for vitiligo and chronic inflammatory diseases of the lips can be considered to be our original contribution based on the principles of plastic surgery.

II. OVERGRAFTING FOR VITILIGO OF LOWER LIP Overgrafting for vitiligo of the lower lip is a new application of an already established method (4). After initial infiltration of the lip lesion by 1% Xylocaine (lidocaine) with 1/200,000 epinephrine, a split-thickness skin layer of about 0.3 mm was shaved off. The resultant raw area was covered with split-skin graft obtained from the medial side of the left arm. Figure 1 shows the preoperative condition. Figure 2 shows the result on 23rd postoperative day. The take of the graft looks patchy. Figure 3 shows a uniformly dark color of the lip about 1.5 years later. Looking at the change in Figure 3 from Figure 2, this can be said to be a classic example of active melanocyte transfer to an area which was devoid of melanocytes.

Overgrafting for Leukoderma

Figure 1

Preoperative condition of patient with vitiligo of lower lip.

Figure 2 Postoperative day 23.

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OVERGRAFTING FOR CHRONIC INFLAMMATORY DISEASE OF THE LOWER LIP

A young man aged 20 years had a chronic inflammatory ulcer on the lower lip for the previous 7 months. After preliminary infiltration by 1% Xylocaine (lidocaine) with 1/200,000 epinephrine excision by shaving off of the lesion was performed. The resultant raw area was covered with split-thickness skin graft obtained from the medial side of the left arm. Figure 4 shows the preoperative condition. Figure 5 shows overgrafting on the day of operation. The biopsy of the ulcer showed chronic nonspecific inflammation with squamous epithelial hyperplasia, focally keratinizing. This is an example of chronic inflammatory dermatosis, which can be premalignant. Figure 6 shows the patient 3 months later having complete cure of his lesion with excellent cosmetic appearance. Figure 7 shows the same cured patient 3.5 years later.

Figure 3 One and a half years after the procedure.

Figure 4 Preoperative condition of patient with chronic inflammatory disease of the lower lip.

Overgrafting for Leukoderma

Figure 5 Overgrafting on the day of operation.

Figure 7 The same cured patient 3.5 years later.

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Figure 6 The patient 3 months later; there is complete cure of the disease with excellent cosmetic appearance.

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CONCLUSIONS

It can be said that thorough excision of vitiligo or chronic inflammatory disease of the lower lip followed by (1) overgrafting of vitiligo, which can produce excellent camouflage of the lesion; and (2) overgrafting of chronic inflammatory lesion of the lower lip can cure the condition, by providing normal, functional epidermis with an excellent cosmetic result. Overgrafting a lesion which has been surgically excised is an important contribution to the science of plastic surgery.

REFERENCES 1.

2. 3. 4.

Arnold HL, Odom RB, James WD. Disturbances of pigmentation in Andrews’ diseases of the skin. In: Clinical Dermatology. 8th ed. Philadelphia: Saunders, 1990:1000, 1004. Radolph R, Fisher JC, Ninnemann JL. Skin Grafting. Boston: Little Brown, 1979:148–149. Nair PR. Disorders of the Oral Cavity. Text Book and Atlas of Dermatology. Vol II. Bhalani, 1994:1014–1015. Chitale VR. Overgrafting for leukoderma of the lower lip: a new application of an already established method. Ann Plast Surg 1991; 26:289.

69 A Simple Method for the Classic Tie-Over Dressing Tamer Koldas Istanbul University, Istanbul, Turkey

I.

INTRODUCTION

Skin grafts are a valuable option for closing defects that cannot be closed primarily. Blair and Brown first reported their clinical use of split-skin grafting in 1929 (1). Many believe their work represents the landmark plastic surgery achievement. It is projected that skin grafting will stand as last century’s most important reconstructive surgical innovation (2). The success of skin grafting, or take, depends on the ability of the graft to receive nutrients and, subsequently, vascular ingrowth from the recipient bed. A graft that is not held immobile long enough to receive its new blood supply cannot succeed. The most common cause of graft failure is the development of hematomas or seromas beneath the graft, raising the graft from the bed and preventing adherence and revascularization. The failing graft is often the graft that was inadequately secured. Close contact between the skin graft and its recipient bed is essential. Hematomas and seromas under the skin graft will compromise its survival and immobilization of the graft is important. These are within the surgeon’s control. There are two phases of graft adherence. The first begins with placement of the graft on the recipient bed, to which the graft adheres because of fibrin deposition (3). Polk (4) has shown that the rate of skin graft adherence is greatest in the first 8 h, with a slower increase of adherence through the fourth day. The second phase involves ingrowth of fibrous tissue and vessels into the graft. Movement of the graft on the bed interrupts adherence and revascularization, and immobilization techniques include the use of tie-over 425

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dressing and its modifications on the face, neck, and thorax or splinting of the extremities (5–10). The classic tie-over dressing is commonly used in skin graft applications. The main object of the tie-over dressing is to ensure contact between the graft and the recipient bed. The significance of even pressure application against shearing forces using a tie-over dressing of skin grafts has been stressed previously (1). A tie-over dressing, inaccurately called a stent, is the best insurance for graft immobilization if done well.

II. CLASSIC TIE-OVER DRESSING In conventional grafting, the skin graft is laid over the bed but neither stretched excessively nor wrinkled. The graft is usually sutured using 4-0 or 5-0 silk or monofilament with sutures as close together as necessary depending on the location. Before the tie-over dressing is applied, the surgeon should ensure that there are no blood clots underneath the graft. These can be expressed by pressure, irrigated out with saline, or cleansed with small cotton-tipped applicators. This step before application of the dressing provides better adherence of the graft and improved survival rates. A layer of petrolatum gauze is applied and a bolus dressing is used to immobilize the skin graft. The sutures gently press the dressing down onto the skin graft, which in turn is pressed onto the wound bed. This maneuver immobilizes the graft on the wound and prevents hematoma collection. An outer dressing may be applied if desired. This procedure is usually tedious and time consuming, because all the sutures have to be tied over the bolster. The help of an assistant is necessary to tie the sutures. Moreover, the procedure is also not practical, because the threads tend to tangle and require the use of forceps to keep them straight. Once the dressing is tied, it is impossible to adjust, and should it be necessary to inspect the graft postoperatively, the tie-over dressing cannot be reconstituted. The dressing is left in place for approximately 4 or 5 days.

III.

MODIFIED CLASSIC TIE-OVER DRESSING

We have modified the classic tie-over dressing to a faster, more practible, effective, cheap, and reproducible procedure that requires a single stopper (9) (Figures 1 and 2). A simple tie-over dressing using a stopper, which has been used successfully in skin grafting on humans, gives firm fixation and allows inspection of the underlying grafted skin. If hematoma or any other complication is suspected, the graft needs to be examined after hours or days. The dressing can be easily removed and be reapplied after the hema-

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Figure 1 (A) The stopper. (B) Demonstration of the hole and squeeze mechanism when the button of the stopper is tightened.

toma is expressed or the complication is treated. This method has been used in many cases and has proven to be satisfactory. The ability to inspect the graft and reconstitute the pressure dressing has been proven. No grafts have failed. I have not experienced any problems due to this technique. In this modified tie-over dressing method, when absolute hemostasis of the recipient bed is obtained, the graft is applied and stitched in place in the same way as the conventional tie-over dressing. To facilitate the application of the stopper, the suture threads are left long. The graft is then dressed in the usual manner with a layer of paraffin gauze and a bolster made of serum or paraffin-impregnated gauze with a bolus of fluffy gauze. Application of the stopper requires little manual dexterity and can be done by one person alone. Figure 1a and b illustrates the stopper and its mechanism. The individual tie-over threads are picked up and held between the thumb and index finger of the left hand. The threads are arranged around the bolus dressing to provided adequate pressure. The stopper is applied by means of all sutures from the edge of the graft, which are brought in through the hole in the stopper. The stopper is threaded over its hole to pick up the bunch of threads. When sufficient pressure on the bolus dressing is achieved, the collar is applied to grip the tie-over sutures and maintain the pressure on the graft. The squeeze mechanism in the device will secure both monofilament and braided sutures. Figure 2 illustrates final result. Fixation of the threads through stopper is faster and enables subsequent application of the dressing. Extra fluffy gauze for equal pressure on the recipient area can be added if required.

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Figure 2 (A) The completed dressing and application of the device. (B) Viewing from the lateral side.

Advantages of a tie-over dressing using the stopper are: . . . .

Quick and easy to do without assistance. At any time necessary, adjustments and redressings can be carried out. Fixation of the dressing is always adequate, and patients are very satisfied with the comfort provided at the time of reapplying the dressing. There is the possibility to tighten and adjust the ties once in place.

Previously described modifications of the tie-over dressing, such as the pressure button by Burd (5) and the use of Denis Browne type of bead by Niranjian (6), simplify application of the pressure dressing and allow adjustments and inspection of the graft. But the stopper is still a simple, cheap, and more effective refinement of this technique.

REFERENCES 1. 2.

3. 4. 5.

Blair VP, Brown JP. The use and uses of large split skin grafts of intermediate thickness. Surg Gynecol Obstet 1929; 49:82–97. Fisher C. Skin Grafting. In: Georgiade NG, Georgiade GS, Riefkohl R, Barwick WJ, eds. Essentials of Plastic, Maxillofacial, and Reconstructive Surgery. Baltimore: Williams & Wilkins, 1987:23–32. Burleson R, Eiseman B. Nature of the bond between partial thickness skin and wound granulations. Surgery 1972; 72:315–322. Polk HC Jr. Adherence of thin skin grafts. Surg Forum 1966; 17:487–489. Burd DA. The pressure button: a refinement of the traditional ‘‘tie-over’’ dressing. Br J Plast Surg 1984; 37:127–129.

A Simple Method for the Classic Tie-Over Dressing 6. 7. 8.

9. 10.

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Niranjan NS. A modified tie-over dressing for skin grafts. Br J Plast Surg 1985; 38:415–418. Prune´s F, Asbun H. A simplified stent dressing technique using elastic rubber bands. Ann Plast Surg 1989; 23:84–85. Wolf Y, Kalish E, Badani E, Friedman N, Hauben DJ. Rubber foam and staples: Do they secure skin grafts? A model analysis and proposal of pressure enhancement techniques. Ann Plast Surg 1998; 40:149–155. Koldas T. A simple method for the classic tie-over dressing. Ann Plast Surg 1992; 28:386–387. Silfverskiold KL. A new pressure device for securing skin grafts. Br J Plast Surg 1986; 39:567–569.

70 Innovative Techniques in Skin Graft Fixation Alan T. Lewis and Ida Orengo Baylor College of Medicine, Houston, Texas

I.

INTRODUCTION

Skin grafts, full-thickness skin grafts or split-thickness grafts, are useful means to repair skin defects. When the immobility or unavailability of adjacent tissue makes a primary closure or a flap an impractical method of wound closure, a skin graft becomes a useful adjunct in wound closure. This situation is particularly evident when repairing defects of the nasal tip and anterior aspect of the auricle. Other anatomical sites that lend themselves to repair via full-thickness skin grafts are the nasal ala, upper lip, eyelid, forehead, and hand. When attaching skin grafts to the recipient bed, special steps should be taken to ensure that the graft is securely held in place over the recipient bed. This ensures immobilization of the graft, which protects it from external shearing trauma. This also ensures complete and uniform adherence of the graft to the wound bed, which facilitates vascularization and epithelialization, as well as preventing hematoma or seroma formation, which facilitates graft separation and infection. The traditional method of securing grafts to achieve immobilization and adherence has included tacking sutures and external bolsters.

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II. TRADITIONAL GRAFT BOLSTERING Bolstering of a skin graft has been in use for many years. Traditionally, the skin graft is harvested from a distant site and cut to fit over the defect, allowing a little bit of excess tissue to account for the contraction effect usually seen with skin grafts. The dermal side of the graft is defatted to maximize tissue perfusion and graft take. The graft is then placed over the wound bed and may be held in place via a tacking suture. A tacking suture is usually an absorbable stitch that is run through the center of the dermal side of the skin graft and then through the center of the subcutis of the wound bed. Care should be taken so that the graft is directly centered over the defect to ensure excellent graft apposition. Once the graft is tacked in place, the edges of the graft are sutured to approximate them with the skin edges of the wound bed. After the graft has been sutured in place, a set of bolstering sutures is then placed. These consist of sutures that are usually placed in line with the original graft-skin apposition sutures; however, they may be placed at a distant site if this better serves securing the graft. A suture is placed, tied, and cut leaving one tail of the suture long. Another suture is placed directly across from the original bolstering suture and cut leaving one tail long. This process of placing opposing sutures is repeated one to two more times. It may be done more than this if the size of the graft is large or the shape is asymmetrical. Once this is done, a stent should be fashioned to fit directly over the graft. This is usually constructed from gauze, foam or dental roll and may be wrapped in a nonadherent dressing such as Adaptic (Johnson & Johnson, NJ) or petrolatum gauze to prevent sticking of the bolster to the graft and subsequent damage to the graft when the bolster is removed. Wadding or rolling up a piece of nonadherent dressing may also be used to fabricate the stent. Once constructed, the stent is placed over the graft site and the long end of one opposing bolstering suture is tied to the long end of its counterpart, immobilizing the graft and placing pressure on the graft to facilitate adherence. This process is repeated with the other complementary sets of bolstering sutures until the graft is adequately immobilized. A pressure dressing may be placed over this. If a skin graft is used over the nasal ala, wadding can be constructed from gauze, dental roll, or petrolatum gauze, and this can be placed within the corresponding nare. In addition to the external bolster, this will apply pressure underneath the graft to increase adherence of the graft to the recipient bed. This traditional method of graft bolstering has been in use for many years and has a number of problems. First, this method is time consuming. Second, it is cumbersome; as the long ends of the bolstering sutures often get tangled with each other and with the stent. Third, the bolstering sutures may pull the edges of the skin with too much tension. This may cause elevation of

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the skin edges resulting in a crater-like deformity. This excess skin tension may also contribute to unnecessary suture marks. Finally, with the traditional tie-over bolster, the pressure applied to the graft is not predictable and is not uniform throughout the graft bed (1). Therefore, other methods of skin bolstering have been made to circumvent the problems of the traditional method.

III.

OTHER METHODS OF GRAFT BOLSTERING

A.

Unsuture Technique

The first of these has been referred to as the unsuture technique. It has been described elsewhere in the literature (2,3). The graft is harvested and trimmed to fit the primary defect. The edges are then sutured in place with a running 6-0 fast-acting absorbing gut suture (Ethicon, Johnson & Johnson, NJ). A stent of nonadherent gauze mesh is shaped into a ball to fit onto the graft. The skin surrounding the recipient bed is coated with tincture of benzoin or Mastisol (Ferndale Laboratories), and the stent is then placed over the graft site. The stent is held in place with 0.5-inch Steri-strips placed over the stent in a radial fashion. This arrangement holds pressure on the stent and secures it circumferentially around the edges of the graft (Figure 1). The bolster is removed in 1 week and the sutures are absorbed by this time (2). This technique takes advantage of the 6-0 fast-absorbing gut suture and its rapid absorption and minimal skin reaction. This manner of securing the graft with Steri-strips saves time by eliminating the need for the placement of interrupted suture, and it also eliminates the nuisance of having to deal with the long tails of the bolstering sutures (2). This method properly immobilizes the graft by applying a uniform amount of pressure without tenting up the graft edges with bolstering suture (2). It also eliminates unnecessary suture marks. B.

Reston Technique

Sponge bolsters has been used in a variety of ways to replace the traditional tie-over bolster technique. This technique has often been referred to as the Reston technique (1,4). This involves preoperatively preparing individual sheets of 8 10-inch Reston polyurethane foam (3M Company, St. Paul, MN) by placing them in standard paper–plastic peel packs. Reston polyurethane foam is used because one side of it is coated with an adhesive backing; the importance of this will be made evident as the description of the procedure unfolds. These packs are then sterilized with ethylene oxide gas at 135 F for 3 hs and are then allowed a period of aeration at 130 F. These

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Notice the radial placement of the Steri-strips over the stent.

foam packs are now ready for use. With the Reston technique, the graft is placed on the recipient bed and the sponge bolster is prepared in the following manner. A layer of antibiotic ointment may be applied over the graft site, if that is the preference of the surgeon. The graft is covered with a tailored piece of Xeroform gauze (Baxter Health Group, Deerfield, IL) or Adaptic nonadherent gauze. This is covered with a tailored piece of 4 4 gauze that is soaked in saline before placement. Once this is done, a piece of the prepped Reston foam is tailored, allowing a 2- to 3-mm overlap of the edge of the graft bed. A fine mesh gauze (1) or Telfa (Kendall Co., Mansfield, MA) (5) is cut to fit over the adherent side of the Reston foam. The adhesive backing of the Reston foam is removed and the tailored piece of fine mesh gauze is placed onto the adhesive surface. The addition of the fine mesh gauze serves to reinforce the foam stent when it is affixed to the graft site (1). This assembly is placed over the graft site with the fine mesh surface placed in apposition to the graft site. It is then stapled over the graft site with one leg of the staple being placed through the foam stent and the other leg of the staple being placed through the skin surrounding the graft site. The graft or graft bed is not incorporated into the stapling process. The bolster is removed at 5–7 days postoperatively. This method is mainly used over large defects of the trunk or extremities; however, it has been used to cover facial defects, including Mohs surgical defects, with good results (5,6).


1.

435

Advantages

The Reston technique has many advantages compared to the original tieover bolster method: (1) It applies a uniform amount of pressure over the entire wound bed, as opposed to tie-over bolster (1). (2) It is slightly easier and less time consuming than tie-over bolstering (1). (3) It has been shown to be reliable. The rate of successful graft take, independent of graft location or size, has been reported to be between 95 and 100% (1,4,6). (4) It is able to be used over any wound bed regardless of contour (4). (5) It has been shown to exert pressure to the graft side in a desired physiological range to maximize graft take. A pressure between 15 and 30 mm Hg has been hypothesized to maximize graft take. The pressure must be greater than 15 mm Hg to overcome interstitial pressure and ensure firm apposition to the graft bed (7). The pressure must also be less than 30 mm Hg, which avoids excess pressure to the capillaries and therefore allows for proper capillary perfusion (7). Weiner and Moberg (1) constructed a simulated Reston bolster, using a 7/16–inch foam stent, over a defect measuring 15 20 0:5 cm and determined the overall average pressure to be 16.8 mm Hg. 2.

Disadvantages

There are several disadvantages to the Reston technique: (1) One complaint with the Reston technique is that the staples often tear through the foam (4). (2) It requires the use of a special piece of foam that must be sterilized. To circumvent this, Egan and Gerwels (8) describe fashioning a foam bolster out of a foam pad of a presterilized, prepackaged scrub brush that contained no detergent. (3) It utilizes skin staples to affix the bolster to the graft site. Skin staples often leave permanent marks and are not always available. Egan and Gerwels (8) did not use staples to affix their foam bolster of a Mohs defect on the face. They described securing the bolster in place with an overlying elastic adhesive dressing, such as Mefix (SCA Molnlycke, Ltd.). This modification of the Reston technique is not supported by statistical evidence regarding the success of graft survival. C.

Fibrin Glue

One of the most innovative advances in skin graft fixation has been the advent of fibrin glue. Fibrin glue is a blood product made up of coagulation factors such as fibrinogen, factor XIII, thrombin, and the antifibrinolytic agent aprotinin. The formation of a fibrin mesh from fibrinogen is a vital aspect of coagulation and wound healing. Exogenous fibrin glue has been used for many years in Europe and Japan in a wide variety of surgical applications, including skin graft fixation. However, since it is a blood

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product and is subject to the inherent dangers of blood products (i.e., viral contamination with hepatitis or HIV), its use has been prohibited in many countries, including the United States. These contamination dangers have led to many practitioners producing autologous fibrin sealants from the patient’s own sera. There are many methods to produce autologous fibrin (9–11), all of which are beyond the scope of this chapter. There are many commercially available fibrin tissue adhesives such as Beriplast P (Aventis Pharmaceuticals, Bridgewater, NJ) and Hemaseel APR (Haemacure Corp., Montreal, Canada). These preparations come packaged in a number of separate vials, each containing one ingredient of the fibrin sealant. The contents of these vials are then mixed together to produce the active product. Beriplast P comes as four separate vials, which are mixed and then allowed to mature over 36 h before a final mixing step yields an active product. Hemaseel APR comes in two separate vials that are mixed and yield an active product immediately; however, a special mixing device is required. Hemaseel APR was approved by the U.S. Food and Drug Administration in 1998 for the indication of surgical hemostasis. It is the only such preparation presently available in the United States. In late 2001, Hemaseel APR Frozen Formulation is expected to become available for use in the United States. No reconstitution steps or any special mixing devices will be required for use. It will come prepackaged and ready to use. Fibrin tissue adhesives have been used in a wide variety of dermatological procedures with great success. Most reported applications of fibrin sealants have consisted of securing split-thickness skin grafts in the treatment of burns and stasis ulcers. These applications have been highly successful and have reported successful graft survival rates of 90–100% (11,12). Some work has been published regarding the use of fibrin sealants in fullthickness skin grafts. The success of full-thickness graft survival with fibrin sealants has been reported to be 100%. Staindil (13) reported at 100% success rate with 56 full-thickness skin grafts, and Chakavorty and Sosnowski (9) reported the same success rate with 40 patients who received full-thickness skin grafts after Mohs excision. Chakavorty and Sosnowski (9) detailed their use of autologous fibrin sealant with full-thickness skin grafts. Their process is as follows. The fibrin sealant is reconstituted and applied to the dermal side of the graft and the recipient bed. The graft is placed into the recipient bed and held in place for about 2 min. No sutures are placed and a protective dressing is applied. The graft site remains undisturbed for 5–6 days and the dressing is removed. The patient is instructed to leave the area exposed but to protect the area from injury. Of 40 patients grafted in this manner, all grafts were eventually successful. In three of these patients, the fibrin mixture did not seem to gel properly and the adherence of the grafts seemed in question. These grafts


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were secured with Steri-strips and all of these grafts survived without loss. In six patients, the grafts became dark and hardened at about 10 days postoperatively; however, at 2–3 weeks postoperatively, this layer fell off revealing perfectly healed skin underneath. The superficial layers of the graft seemed to perish, whereas the deeper layers took without incident. This latter complication occurred only in grafts greater than 5 cm2 . 1.

Advantages

The advantages of fibrin sealant are quite apparent: (1) The use of fibrin sealant is markedly faster than any other method described with an excellent success rates and (2) it has been shown to decrease skin graft contraction (14). Two equivalent full-thickness skin defects were created in 15 rats. The defects were repaired with partial-thickness grafts. One defect was repaired with fibrin sealant and the other utilized conventional sutures. The wounds treated with fibrin glue contracted 14–15% less than did the control wounds at 21 days postoperatively. 2.

Disadvantages

The disadvantages of fibrin sealant include cost, safety, and unpredictability: (1) The cost of commercially available fibrin sealant is greater than traditional techniques. (2) Fibrin sealants are blood products and therefore carry the risk of viral contamination. However, these risks are minimized in commercial available products through viral screening and sterilization processes. Haemocure Corp. states that Hemaseel APR has been applied over 5 million times in over 10 years of use internationally and not one case of viral transmission has been reported. (3) Sometimes the fibrin glue does not reconstitute properly, leading to a sealant of questionable quality. This was much more of a problem with the ‘‘homemade’’ fibrin sealants. The newer, commercially available fibrin sealants have largely overcome this problem through standardized preparation methods.

IV.

DISCUSSION

The practice of bolstering skin grafts has been in use since the turn of the 20th century. Conventional teaching states that bolsters are necessary for ensuring graft survival. However, many surgeons have questioned the need for bolstering. Some feel that bolsters subject the graft to undue trauma and may impede the perfusion of the graft. Daly et al. (15) performed 40 fullthickness grafts, of unspecified size, on the head and neck area. Twenty grafts were secured via traditional tie-over bolsters and 20 were secured

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via quilting sutures (multiple interrupted sutures were placed full thickness through the body of the graft to tack it to the tissue of the recipient bed). They found no difference in graft success between the two methods. Langtry et al. (16) performed 30 full-thickness skin grafts of the head and neck area. The sizes ranged from 8–45 mm (mean 20 mm) in diameter. The grafts were secured with conventional running sutures to fasten the graft edges to the wound bed edges and were dressed with pressure dressing when possible. The dressings, when applied, were removed in 5–7 days. At 2 weeks postoperatively, 28 grafts showed good take, 1 patient exhibited some duskiness of the graft, and 1 showed graft necrosis. The patient with graft necrosis was on warfarin and exhibited profuse postoperative bleeding requiring fresh frozen plasma for control. At the 2- to 3-month review, all patients exhibited excellent graft healing.

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8.

9. 10. 11.

12.

Weiner LJ, Moberg AW. An ideal stent for reliable and efficient skin graft application. Ann Plast Surg 1984; 13(1):24–28. Thomas JR, Mechlin DC, Templer J. Skin grafts: the ‘‘unsuture’’ technique. Arch Otolaryngol 1982; 108(7):437–438. Orengo I, Lee MW. Surgical pearl: the ‘‘unsuture’’ technique for skin grafts. J Am Acad Dermatol 1998; 38(5 Pt 1):758–759. Wells MD, Kirn DS. A new method of skin-graft stabilization: the Reston technique. Ann Plast Surg 1995; 34(5):554–556. Larson PO. Foam-rubber stents for skin grafts. J Dermatol Surg Oncol 1990; 16(9):851–854. Caldwell RK, Giles WC, Davis PT. Use of foam bolsters for securing facial skin grafts. Ear Nose Throat J 1998; 77(6):490–492. Smith F. A rational management of skin grafts. Surg Gynecol Obstet 1998; 42:556–562. Egan CA, Gerwels JW. Surgical pearl: Use of a sponge bolster instead of a tieover bolster as a less invasive method of securing full-thickness skin grafts. J Am Acad Dermatol 1998; 39(6):1000–1001. Chakravorty RC, Sosnowski KM. Autologous fibrin glue in full-thickness skin grafting. Ann Plast Surg 1989; 23(6):488–491. Siedentop KH, Harris DM, Sanchez B. Autologous fibrin tissue adhesive: factors influencing bonding power. Laryngoscope. 1988; 98(7):731–733. Dahlstrom KK, Weis-Fogh US, Medgyesi S, Rostgaard J, Sorensen H. The use of autologous fibrin adhesive in skin transplantation. Plast Reconstr Surg 1992; 89(5):968–972. Lilius P. Fibrin adhesive: its use in selected skin grafting. Practical note. Scand J Plast Reconstr Surg Hand Surg 1987; 21(3):245–248.

Innovative Techniques in Skin Graft Fixation 13. 14. 15.

16.

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Staindl O. Tissue adhesion with highly concentrated human fibrinogen in otolaryngology. Ann Otol Rhinol Laryngol 1979; 88(3 Pt 1):413–418. Brown DM, Barton BR, Young VL, Pruitt BA. Decreased wound contraction with fibrin glue-treated skin grafts. Arch Surg 1992; 127(4):404–406. Davenport M, Daly J, Harvey I, Griffiths RW. The bolus tie-over ‘‘pressure’’ dressing in the management of full thickness skin grafts. Is it necessary? Br J Plast Surg 1988; 41(1):28–32. Langtry JA, Kirkham P, Martin IC, Fordyce A. Tie-over bolster dressings may not be necessary to secure small full thickness skin grafts. Dermatol Surg 1998; 24(12):1350–1353.

71 Lubrication Jelly as a Dressing in Punch Grafts for Pitted Acne Scars Ada Regina Trindade de Almeida, Nalu Iglesias Martins de Oliveira, and Bogdana Victoria Kadunc Hospital do Servidor Pu´blico Municipal de Saõ Paulo, Saõ Paulo, Brazil

I.

INTRODUCTION

The ‘‘ice pick’’ types of acne scars are fibrotic and not distensible but are small depressions with sharp margins. The fibrotic process may extend through the dermis to the fatty layer (1–2). They are not suitable for filling techniques, and their response to dermabrasion is only partial (2–4). The best therapeutic option for them is punch grafting. In this technique, for these types scars, the entire scar is removed by punch and replaced by graft from the retroauricular region (3–6). The ways used to hold grafts in place may be suture, tissue glue, or adhesive strips in each graft (3–4). The last option is the most common, with the strips being changed every 48 h. It has to be done in a careful and timeconsuming manner in order to avoid loss of the grafts. Johnson suggested the insertion of a pin under the adhesive strip, before its removal, to keep the graft in place (3).

II. MATERIAL To eliminate graft fixation problems, we suggest the lubrication jelly (K-Y) as a postoperative dressing (7). This jelly is water soluble, transparent, not greasy, readily available, and easy to apply. It has been used in the post441

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operative care of hair transplantation and by Tromovitch et al. in harvesting split-thickness grafts with a dermatome (8).

III.

TECHNIQUE

The surgery is performed as usual: ice pick scar removal, harvesting grafts from the retroauricular area, and their placement at the recipient region. With the grafts in place and the area cleaned and dried, a thin layer of jelly is applied and allowed to dry (Figure 1). A fan or hair dryer can be used to speed up the drying process. The jelly will become a transparent film that will hold the grafts in place (Figure 2). A compression dressing is applied for the first 24 h. It is easily removed in the following day, because it almost does not attach to the transparent film and allows good visibility of the grafts during the postoperative period (Figure 3). In the 5 following days, new coats of jelly are applied once or twice daily, by the patient, without any other dressing. On the sixth day, the area can finally be washed and the water-soluble jelly is easily removed. The patient is instructed to continue the application until the tenth day. The use of lubricating jelly as a dressing has the advantages of maintaining grafts in place, allowing good inspection, and making the postoperative care easier.

Figure 1

With the grafts in place, the jelly is applied and allowed to dry.

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Figure 2

The jelly has become a transparent film that holds the grafts in place.

Figure 3

The water-soluble jelly is easily removed and reapplied when necessary.

REFERENCES 1. 2. 3.

4.

Fulton JE. Dermabrasion, chemabrasion and laserabrasion. Dermatol Surg 1996; 22:619–628. Varnavides CV, Forester RA, Cunliffe WJ. The role of bovine collagen in the treatment of acne scars. Br J Dermatol 1987; 116–206. Johnson WC. Facial scarring: punch grafting and dermabrasion. In: Parish LC, Lask G, eds. Aesthetic Dermatology. New York: McGraw-Hill, 1991:117–127. Alt TH, Coleman III WP, Hanke CW, Yarborough JM. Dermabrasion. In: Coleman III WP, Hanke CW, Alt TH, Asken S., eds. Cosmetic Surgery of the Skin: Principles and Techniques. Philadelphia: BC Decker, 1991:147–195.

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5.

Orentreich N, Durr NP. Rehabilitation in acne scarring. Dermatol Clin 1983; 1:4005–4013. Orentreich DS, Orentreich N. Facial scar revision with full thickness autologous punch grafting from posterior ear lobe. In: Robins P, ed. Surgical Gems in Dermatology. New York: Journal Publishing Group 1998:54–59. Trindade de Almeida AR, Oliveira NIM, Kadunc BV, Sampaio SAP. Surgical Pearl: Lubricating jelly as a dressing in punch grafting for pitted acne scars. J Am Acad Dermatol 1998; 38:613–615. Tromovich TA, Stegman SJ, Glogau RG. Split-thickness grafts. In: Tromovich TA, Stegman SJ, Glogau RG, eds. Flaps and Grafts in Dermatological Surgery. Chicago: Year Book, 1989:55–67, 57.

6.

7.

8.

72 Transparent Gasbag Tie-Over for Free Skin Grafting Jun Ren No. 3 Wuhan Municipal Hospital, Wuhan, People’s Republic of China

I.

INTRODUCTION

Free skin grafting has a very long history. In 3000 bc, there was free skin grafting being performed in Egypt and India in almost the same manner as today. However, lacking anesthesia and aseptic technique made it an unpleasant process, which was apt to lead to infection and necrosis. It is only in the last 100 years that the process has been regarded as a formal and safe surgical technique. Yet it was still not widely grasped by surgeons, because of its difficult and immature maneuver. After World War I, several important innovations were achieved for this technique, mainly in three respects: 1. 2. 3.

Split-skin graft of intermediated thickness (1) Dermatome and calibrated intermediate skin graft (2) Pressure dressing (3)

Since then free skin grafting has shown its unique and irreplaceable effectiveness in traumatic and plastic surgery. This ‘‘traditional’’ method continues to be used even today. In recent decades, many modifications have been made. They can be classified into two groups: 1.

Improvement of the inner structure of the skin graft: a. Consecutive or bare whole-piece skin graft 445

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b.

2.

Free skin graft with a preserved subcutaneous vascular network c. Nonvascular anastomosed free deep fascia flaps d. Full-thickness graft with subdermal fat tissue Modifications in dressing a. Securing dressing with plastic disc pressure b. Silicone gel sheet tie-over for skin graft c. Gasbag pressure with inspection d. Use of a wire frame to fix skin grafts externally e. Transparent gasbag pressure with inspection

II. IMPROVEMENT OF THE INNER STRUCTURE OF THE SKIN GRAFT The improvement of the inner structure of the skin graft is mainly for a bigger area, better appearance, and various thicknesses. On the basis of fullthickness graft, free skin grafts with a preserved subcutaneous vascular network, subdermal fat tissue, or/and deep fascia were designed. Their application expands the indications for free skin grafting, gives the graft a better appearance, and improved local fullness after the graft takes. There has been a lot of basic research and clinical reports on free skin grafts with a preserved subcutaneous vascular network and full-thickness skin graft with subdermal fat tissue. But there are less reports on nonvascular anastomosed free deep fascia flaps. A.

Consecutive, or Large Whole-Piece Skin Graft

Song and Lin (4,5) reported the application of large whole-piece skin grafts to large skin defects resulting from trauma or burns, Their main modification is that, when using a drum dermatome to harvest skin graft bigger than the size of the limitation of the dermatome, they reset the dome to gain a consecutive larger whole piece of skin graft. Thus, there would be no rig-up of skin on the recipient bed, the correspondent scar would be reduced, and a better result would be achieved. B.

Free Skin Graft with a Preserved Subcutaneous Vascular Network

Since Tsukada first reported it in 1979 (7), many experiments and clinical trials have been performed in China. The theoretical base of this procedure is that, without vessel anastomosis, newly grafted skin forms new connec-

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tions with the vessels of the recipient bed through the subdermal vascular plexus. Because it has a subdermal vascular plexus and is thicker than a split-thickness graft (usually 0.10–0.65 cm), it has been supposed to have a higher rate of taking and better quality. I have used this method in 302 cases; 315 location, only 26 locations were partly necrotic. The overall taking rate was over 91%. C.

Nonvascular Anastomosis Free Full-Thickness Skin Graft with Deep Fascia

Wang first reported successful survival of this kind of deep fascia flap in animals (rabbits, dogs, and pigs) from 3–100 cm2 in size; most of them were 5–50 cm2 in size. Except for 1 case with 50% necrosis, all the other grafts survived. The survival rate reached or approximated 100%. Although this method is only limitedly adopted in smaller defects, with few clinical reports, the mechanism of its taking is still unknown, its unique thick subdermal fat tissue and rampant vascular network ensured its potential usage to cover exposed nerves, vessels, tendons, and small area of bone. D.

Full-Thickness Skin Graft with Subdermal Fat Tissue

In 1989, Wu first reported using this method. On the basis of free skin graft with a preserved subcutaneous vascular network, subdermal fat as thick as 0.3–0.5 cm was attached to the skin graft. The mechanisms of its taking and its indications are the same as that of free skin graft with a preserved subcutaneous vascular network. Because some cases would be pigmented after taking, their application is limited. In 1995, Wang reported 30 clinical cases in which this method was used: 20 of them totally survived, 4 cases 90% survived, 6 cases 70% survived. Eighteen patients had normal skin color, 10 patients had different degree of pigmentation, and scars recurred in two patients. The pigmentation rate reached 33.3%.

III.

MODIFICATIONS IN DRESSING

A bolus or some other type of dressing and the pressure it provides are the important elements for free skin grafts to take. Pressure not only helps coagulation, but it also secures the skin graft and keeps it in close contact with the recipient bed, thus ensuring the revascularization of the graft. The shortcomings of traditional tie-over method include immeasurable intrabolus pressure and an inability to inspect the taking process, which result in the untimely treatment of possible complications. In this respect, modifications

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mainly focus on how to secure the skin graft and how to monitor the pressure and the skin taking process and try to make free skin grafting easier, more objective, and scientific. A.

Plastic Disc Pressure for Securing Skin Grafts

Silfverskiold (18) introduced a new method for pressuring and securing skin grafts. He made some plastic discs with peripheral inlets which mounted on a cross. For more even pressure, additional spokes can be added to the cross. The left a few short ends of the sutures of skin graft wedged into the cleavages. The frictional force was strong enough to hold even one single thread. The disc made free skin grafting less time consuming than before, but they still had the shortcomings of the traditional method, that is unable to monitor and modulate the pressure and viability of the skin graft. Author has used this disc method in 15 cases with satisfactory result, with no failure. B.

Silicone Gel Sheet Tie-Over for Skin Grafts

In 1988, Swanda (19) reported the use of a silicone gel sheet tie-over for a skin graft of the eyelids. After the free skin graft sutured to the recipient bed by 4-0 or 5-0 nylon, a silicone gel sheet, 0.5 mm in thickness, cut to the same shape and size as the recipient bed and put over the skin graft. If necessary, several layers can be used. They are secured by Sasaki’s knot of the sutures. Because the silicone gel sheet is semitransparent, the color of the skin graft is visible. However, this method can only be applied in the case of a small, smooth and superficial recipient bed, and the pressure over the graft is also undetectable. I have not seen any accumulation of fluid or blood in between the skin graft and the silicone gel sheet, nor have I seen infection. Moreover, a silicone gel sheet has some effect in the prevention of postoperative excessive scar formation. C.

Gasbag Pressure with Inspection

Pressure is one of the important elements in the process of the taking of skin grafts. However, different investigators have reported different optimal pressure values. Ren (20) reported the application of gasbag pressure and pressure inspection in free shin grafts. He used a gasbag bigger than the recipient bed to cover the dressing over the skin graft. Bandages were loosely fixed outside the gasbag, only to limit its outward expansion. By measuring the gas pressure inside the gasbag, the actual direct pressure over the skin graft can be grossly deduced. The shortcomings of this method include indirect, thus inaccurate, measurement of the pressure and an inability to


449

observe the viability of the underlying skin graft. Jie (21) reported experimental research on the effects of pressure on the skin graft. Instead of using a common dressing and a bolus, a soft rubber balloon was used. The balloon was placed directly over the free skin graft and was externally fixed by a hard plastic box or bandages. The balloon was filled with enough gas to keep a constant pressure. I have concluded that the optimal pressure of skin graft taking in small pigs and rabbits is 40 mm Hg (5.33 kpa). However, the viability of the skin graft cannot be inspected either, and it is still in the stage of animal experiments. D.

Use of a Wire Frame to Fix Skin Grafts Externally

Hirai (22) reported this method in 1991. Because the outgoing strength passed through the threads, the traditional tie-over dressing often causes lifting of the circumference of the skin graft. This can cause ectropion of the graft edges and excessive scar formation. Besides fixation of the graft in the usual way, Hirai et al. employed a wire frame, made of Kirschner wire 1 mm in diameter, the same shape as the recipient bed but a little bigger than the graft. The wire frame was knotted and fixed in between the two long ends of each suture stitch, thus the frame was close to but a little outside the configuration of the suture line. Then tie-over fixation was done in the traditional method. The tension produced by the bolus was evenly distributed on the wire frame. Thus, the edges of the graft would not lift and the tension along the suture line was reduced, which was beneficial in preventing excessive scar formation. I have used this method to 22 patients: 26 location, of sheet skin graft with good results. No local infection or ischemia have been found. E.

Transparent Gasbag Tie-Over for Persistent Pressure and Inspection

Because the traditional tie-over method does not allow direct inspection of the free skin graft, Ren et al. (23–25) reported transparent gasbag tie-over for persistent pressure and inspection in free skin grafting. An elastic gasbag made of silicone gel or rubber and linked with an airball and barometer by a three-limb tube and rubber tubes is applied according to the size of the raw surface (Figure 1). The tie-over technique is similar to the traditional one. The gasbag, instead of the absorbent cotton, is put and limited in a space that is formed by sutures, a plastic cap (Figure 2), or elastic net (Figure 3). Since the bolus is replaced by a transparent gasbag, the color change of the skin graft can be observed at any time postoperatively (Figure 4). Pressure on the skin graft can be controlled and adjusted in order to maintain it in the

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Figure 1

The method for connecting the gasbag with the barometer and air-ball.

Figure 2

The method for using the gasbag tie-over in skin grafting.


Figure 3

Elastic net and transparent gasbag tie-over in free skin grafting.

Figure 4

Observing color change in the grafted skin.

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range of the best pressure (Figure 5), and complications can be timely treated. I have successfully used the transparent gasbag tie-over dressing in skin grafting on 15 rabbits. Both sides of their backs were divided into two groups—experimental group (gasbag method) and control group (traditional method). The two groups had no significant difference in survival rate and bacterial contamination rate (P < :01) (Table 1). The pressure of the gasbag was maintained at approximately 20 mm Hg (mean SD ¼ 21:33 1:22 mm Hg). The whole taking process was successfully monitored. In addition, the method was used on 48 patients whose results were compared with those of other patients who used the traditional bolus method. The size of skin grafts was 22–108 cm2 , and the pressure inside the gasbag was more than 30 mm Hg (mean SD ¼ 32:54 1:87 mm Hg). Ninety-five percent of the grafts survived, and there was an excellent result in 85%. The graft survival rate was statistically significant in comparison with the traditional method for the corresponding period (P > :05) (Table 2). The result suggests that this new method is superior to the traditional one. The disadvantages of this method include the necessity of regular postoperative airing and that it is not suitable for an irregular or uneven raw surface.

Figure 5

Monitoring pressure and observing color change postoperatively.


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Table 1 Survival Condition of Skin Grafts in Animal Experiment Result Group

Excellent

Good

Mediocre

Bad

Remarks

Experimental

6 (42.86%) 5 (35.72%

4 (28.57%) 6 (42.86%)

3 (21.43%) 2 (14.28%)

1 (7.14%) 1 (7.14%)

14 Rabbits 14 Grafts (100%) 14 Rabbits 14 Grafts (100%)

Control

2 ¼ 2:494 < 2 0:05ð3Þ ¼ 7:815; P > :05, the difference was not significant. A rabbit died by biting on the second postoperative day.

IV.

CONCLUSIONS

The progress of free skin grafting in the field of skin surgery mainly took place in two areas: (1) modification of the inner structure of free skin grafts and (2) modification of the dressing method of free skin grafts. In the first area, free skin grafts with a preserved subcutaneous vascular network is so far relatively mature, with many basic research and clinical application. Much remains to be clarified for nonvascular anastomosed free deep fascia flaps and full-thickness grafts with subdermal fat tissue, and further research is needed. In the second area, objective pressure survey and direct inspection of the underlying graft skin are two main goals. How to make the transparent gasbag tie-over technique more simple, practical (e.g., spontaneous pressure regulation), and versatile are the problems that need to be further explored. Once these problems are solved, free skin grafting can enter a more scientific and even perfect stage.

Table 2

Survival Condition of Skin Grafts in Clinical Applications Result

Group

Excellent

Good

Mediocre

Bad

Remarks

Experimental

23 (47.92%) 20 (32.79%)

18 (37.5%) 17 (27.87%)

5 (10.42%) 17 (27.87%)

2 (4.18%) 7 (11.4%)

48 Cases 48 Grafts (100%) 48 Cases 61 Grafts (100%)

Control

2 ¼ 8:126 > 2 0:5ð3Þ ¼ 7:815: P < :05, the difference was significant.

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REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11.

12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Blair VP, Brown JB. Use and uses of large split skin grafts of intermediate thickness. Surg Gynecol Obstet 1929; 49:82. Padgett EC. Calibrated intermediate skin grafts. Surg Gynecol Obstet 1939; 69:799. Nelaton C, Ombredanne L. Les autoplasties. Paris: G. Steinheil, 1907. Song RY. Two modifications on free skin graft and grafting with pedicle. Chin J Surg 1953; 1:21. Song RY, Lin ZH. Application of ‘‘continuous’’ free skin graft in hand-dorsum grafting. Acta Beijing Plast Surg Hosp 1981; 1(1):3. Tsukada S. Transfer of free skin grafts with a preserved subcutaneous vascular network. Ann Plast Surg 1980; 4:500. Chen ZJ, Wang XL, et al. Free skin grafting with a preserved subcutaneous vascular network 1981; 1(1):28–38. Shi PT, Chen J. Free skin grafting with a preserved subcutaneous vascular network. Chin J Stomatol 1983; 18:225. Chen YS, Ma ZL. Repairing facial skin trauma by retransfer of skin grafts with a preserved subcutaneous vascular network. Chin J Plast Surg Burns 1988; 4(3):190. Wang XL, Chen ZJ, et al. Clinic application of non-vascular-anastomosis free full thickness skin grafting with deep fascia. Beijing Med 1985; 7(6):336. Wu BG. Superthickness free skin grafting with subdermal fat tissue. Second Annual Special Subject Meeting of Chinese Plastic Surgery and Burns. Yang Zhou, China, April 18–20, 1991. Wang ZP, Chang K, Liu TF. 30 cases report on free skin grafting with subdermal fat tissue. Chin J Repar Reconstr Surg 1955; 9(2):126. Davenport M. The bolus tie-over ‘‘pressure’’ dressing in the management of full thickness skin grafts. Is it necessary? Br J Plast Surg 1988; 41:28–32. May N. Reconstructive and Reparative Surgery. Philadelphia: Davis, 1958:34. Stark RB. Plastic Surgery. New York: Hoeber, 1962:75 Wpeet E, Patterson TJS. The Essentials of Plastic Surgery. Oxford, UK: Blackwell, 1963:39. Maneksha. RJ. Plastic Surgery in the Tropics. Bombay: Pobular Prakashan, 1965:15. Silfverskiold KL. A new pressure device for securing skin grafts. Br J Plast Surg 1986; 39:567. Sawada Y. Silicone gel sheet tie-over for skin graft on the eyelid following release of scar contracture. Br J Plast Surg 1988; 41(3):325. Ren J, Ni SX, Liu YN, et al. Application of gasbag pressuring and pressure inspection in free skin grafting. Chin J Plast Surg Burns 1990; 6(2):145. Jie B, Qi KM, Nu W, et al. An experimental research on the effects of pressure on the skin grafting. Chin J Plast Surg Burns 1990; 6(3):221. Hirai T, et al. The use of a wire frame to fix grafts externally. Br J Plast Surg 1991; 44(1):69.

Transparent Gasbag Tie-Over for Free Skin Grafting 23.

24.

25.

455

Ren J, Yang JJ, Deng B, et al. Transparent gasbag tie-over for the persistent pressure and inspection in free skin grafting. Plast Reconstr Surg 1995; 95(20):126. Ren J, Yang JJ, Deng B, et al. An experimental research on transparent gasbag tie-over for the pressure and colour inspection in free skin grafting. Chin J Med Aesthet Cosmetol 1997; 6(2):65. Ren J, Yang JJ, Deng B, et al. Clinic application on transparent gasbag tieover for the pressure and colour inspection in free skin grafting. Chin J Med Aesthet Cosmetol 1997; 6(2):71.

73 Primary Closure of Split-Thickness Skin Graft Donor Site Alfred Sofer and Richard C. Hagerty Medical University of South Carolina, Charleston, South Carolina

I.

INTRODUCTION

Split-thickness skin grafts are the most used grafts in the practice of plastic surgery and dermatology. Their thickness ranges from 0.010 to 0.016 inches. Since dermis is left behind, however, the donor site usually heals through epithilialization (1). There are multiple acceptable methods for donor site dressings, but management of the split-thickness donor site usually involves intense would care and pain control (2–6). Donor sites are areas of significant morbidity in patients with atrophic skin, particularly in the elderly, immunocompromised patients, diabetics, and patients who are steroid dependant. Therefore, they may require a prolonged healing time. Donor sites can be associated with long-term sequelae such as hypopigmentation, hypertrophic scarring, and keloids (7,8). In this chapter, a simple method of improving the donor site of splitthickness skin graft is presented. Elimination of the split-thickness donor site results in decreased pain, less local wound care, and a more esthetic pleasing result (9). One acceptable method of eliminating the split-thickness donor site is the use of exogenous sources such as synthetic skin substitutes or cultured epithelial autografts (10,11). Another method of eliminating the split-thickness donor site is to convert the split-thickness skin graft donor site to a full-thickness defect and subsequently close the wound primarily. We have employed this technique on 31 patients involving 38 grafts (7). The donor site healing was rapid. Complaints of donor site pain were decreased 457

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both in severity and duration. Since this study primary closure in small- to moderate-size donor sites has been standard procedure within the past 10 years. This technique is useful not only in patients with high risk to morbidity to the split-thickness donor site but also in pediatric populations and young adults, since its management requires less patient compliance. Primary closure of the split-thickness donor site should be considered in all patients requiring skin grafts of moderate size or less. Large grafts of up to 20 10 cm can be harvested and still closed primarily (7).

II. SELECTION OF DONOR SITE Selection of a proper split-thickness skin graft donor site is necessary to ensure compatibility with the recipient site. This includes appropriate color match and minimum scarring at the site of the harvest (12). The incision has to be strategically placed, allowing for shorts and swimwear to be worn. When color match is not a significant concern, the groin can be an ideal split-thickness skin graft donor site, because the resultant scar will be hidden within the groin crease. The adjacent bony prominences in this area, however, make use of instrumentation for skin harvest more difficult. The use of tumescent creates a plateau between the pubis and anterior superior iliac spine (13). In addition, it minimizes bleeding and diminishes later discomfort. Alternate donor sites include the inferior gluteal fold, the suprapubic area, the scalp where hair provides camouflage, and the posterior auricular area (7,13) (Figure 1). The groin, however, is probably the most inconspicuous donor area for this technique. The left side is preferred to avoid future confusion of a right lower quadrant scar used for appendectomy (7). The width of the grafts in this area, however, may be limited if primary closure is considered. Bauer et al. have reported preexpansion of the donor site with tissue expander (14). In their study, expanded full-thickness grafts maintained all of the characteristics of nonexpanded full-thickness skin grafts including durability and graft contracture. A possible disadvantage to this technique, however, is its cumbersome multistage maneuver.

III.

TECHNIQUE

The graft can be harvested using any technique. The graft may be taken full thickness and converted to a split thickness, or it can be harvested from the donor site as split thickness. The donor site is then converted into an ellipse and excised down to the subcutaneous and fatty tissue. The wound is pri-

Primary Closure of Split-Thickness Skin Graft Donor Site

459

Figure 1

marily closed and the scar hidden. Meticulous attention to donor site closure is essential for minimizing morbidity. We recommend closing in two layers with the use of absorbable suture in the subcutaneous layer and nonabsorbable suture in the subcuticular layer. Application of paper tape for 3 months and massaging the site every day minimize scarring. Disadvantages to this technique include increased operating time and expense, which are well compensated for by the advantages of decreased pain, fewer wound care problems, and a more esthetic donor site (7).

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REFERENCES 1. 2.

3. 4. 5.

6.

7. 8. 9. 10.

11.

12. 13. 14.

Marx MW, Marx C. Skin Grafts. In: Fundamentals of Plastic Surgery. Marx, ed. Philadelphia: Saunders 1997. Breach NM, Davies DM, Yiacoumettis A. Study of effects of porcine and bovine dermis on the healing of split-thickness donor sites in humans. Plast Reconstr Surg 1979; 63:546. Morris DM, Hall GM, Elias EG. Porcine hetero-graft dressing for split-thickness graft donor sites. Surg Gyneol Obstet 1979; 149:893. Brady SC, Snelling CF, Chow G. Comparison of donor site dressings. Ann Plast Surg 1980; 5:238. Barnett A, Berkowitz RL, Mills R, Vistens LM, et al. Comparison of synthetic adhesive moisture vapor permeable and fine mesh gauze dressings for splitthickness skin graft donor sites. Am J Surg 1983; 145:379. Zapata-Sirvant R, Hansbrough JF, Carroll W, et al. Comparison of Biobrane and Scarlet dressing for treatment of donor site wounds. Arch Surg 1985; 120:743. Hagerty RC, Warm H. Primary closure of the split-thickness donor site. Plast Reconstr Surg 1990; 85:293. Schmidt GH. Primary closure of split-thickness donor site. Plast Reconstr Surg 1990; 86:604. Ward H, Ahrenholz DH, Crandall H, et al. Primary closure of wounds in burned tissue: experimental and clinical study. J Trauma 1985; 25:125. Place MJ, Herber SC, Hardesty RA. Basic techniques and principles in plastic surgery. In: Grabb and Smith’s Plastic Surgery, 5th ed. Aston SJ, Beasley RW, Thorne CHM, eds. Philadelphia: Lippincott-Raven, 1997. Putland M, Snelling CFT, Macdonald I, Tron VA. Histologic comparison of cultured epithilial autografts and mesh expanded split-thickness skin graft. J Burn Care Rehabil 1995; 16:627. Randolph R, Ballantyne DL Jr. Skin Grafts. In: McCarthy JG, ed. Plastic Surgery. Vol I Philadelphia: Saunders, 1990. Hallock GG. The cosmetic split-thickness skin graft. Plast Reconstr Surg 1999; Bauer BS, Vicari EA, Richard ME, Schwed R. Expanded full-thickness skin grafts in children: case selection, planning, and management. Plast Reconstr Surg 1993; 92:59.

74 A New Method for the Dressing of Free Skin Grafts Tomoharu Kiyosawa and Yoshio Nakayama Institute of Clinical Medicine, Tsukuba University, Tsukuba City, Japan

I.

INTRODUCTION

In most cases of sheet skin grafting, epithelialization is finally completed even if small necrotic skin areas occur. In such cases, the cosmetic appearance of the skin is not optimal because of unsightly scar formation accompanying the reepithelialization during wound healing in necrotic areas. However, when cosmetic improvement is the purpose in skin grafting on the face or hands, almost complete survival is demanded. Even a tiny hematoma the size of a grain of rice can cause a small amount of necrosis. Pressure irregularities routinely occur in conventional pressure dressing, with hematomas occurring in the weak locus of pressure inducing partial necroses. To solve this problem, we have devised a new pressure method (1,2) for skin grafting to produce the least amount of hematoma possible. Transparent and adhesive drapes and a disposable suction drain are used in this method, which we refer to as the suction-drain method. This method contributes not only to maximal graft survival due to uniform and constant pressure but also to overall excellent cosmetic results.

II. TECHNIQUE In the suction-drain method, after a skin graft is fixed as usual with fine monofilament nylon threads, it is covered with a fine meshed silicone gauze 461

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impregnated with ointment. A suction drain tube is placed on the grafted area, and circumferential areas are wiped and dried. A transparent surgical drape, which must be thin, adhesive, transparent, and wider than the grafted area, is loosely affixed (Figure 1). A tincture of benzoin is applied optionally

Figure 1 (a) A plane illustrated view of the suction-drain method. (b) An oblique view of the illustration shows the order of dressing: (1) transparent and adhesive surgical drape(s), (2) drain tubes connected to a disposable suction bag, (3) silicone gauze impregnated with ointment, (4) skin graft, (5) skin defect.

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463

around the graft to increase the adhesiveness. Sometimes furrows occur in the area where the suction tube passes under the drape; ointment is therefore applied there to stop air leakage. Furthermore, small-sized drapes are often added to maintain airtightness. After a plastic bag is connected to the suction tubes, the suction apparatus is set so that work can begin. The graft is uniformly compressed throughout the area even on an irregular surface by pressure that is equivalent to the negative pressure of the suction drain. Any air leakage that occurs must be stopped. If there is no leakage, the technique will be a success. The existence of hematomas can be easily detected, because the graft is observable at all times. Dressing changes carried out only to check for hematomas are unnecessary. Minimum packing is employed in concave areas such as the axilla, genitalia, and interdigital space, as the tightened drape cannot enter completely into these concavities. However, cotton packing is not necessary on the limbs and trunk areas such as the thorax, abdomen, or back. In addition, immobilization of the joints around the graft is not necessary. When the conventional method is used, the pressure of the dressing alters owing to movement around the graft. However, the uniform pressure continues in the suction-drain method if the joints around the graft range in motion. Additionally, pain-free postural changes of a patient can be adopted.

III.

CASES

1.

Case 1

A 60-year-old woman suffered from right breast cancer. After mastectomy, the defect (10 15 cm) was covered with a split-thickness skin graft. The graft was perforated in many sites to create drainage pores using a #11 knife blade and then sutured. The suction-drain method was then utilized. The graft had been adhered to the defect despite respiratory movement at the thorax. Since no hematoma was observed, the first dressing change was carried out on the seventh postoperative day. The graft survived well without any necrotic areas. 2.

Case 2

A 20-year-old woman who had an unsightly scar contracture on the right dorsal hand, including five fingers, underwent reconstruction with a sheet skin graft. Dressing with the suction-drain method was applied for 1 week. As a substitute for creating drainage pores in the graft, the thread-drain method was also applied. Neither hematomas no partial necroses were

464


found, and the skin graft completely survived, with the final result being cosmetically satisfactory (Figure 2).

IV.

DISCUSSION

A free skin graft applied by means of the dressing method requires appropriate pressure for it to take successfully (3). To apply pressure to grafted skin, either a tie-over dressing or a pressure bandage can be used. A tieover dressing is often used for grafts on the hand, face, trunk, or genitalia, whereas a pressure bandage such as a roll bandage is used for grafts on the upper and lower extremities. There are several advantages and disadvantages to both methods. The tie-over dressing is superior to the pressure bandage in its rigidity, but hematomas cannot be detected at an early stage. Furthermore, a marginal hypertrophic scars tend to be generated, especially in Orientals. The pressure bandage is superior to the tie-over dressing in its exchangeability, but its pressure is sometimes uneven so that hematomas do sometimes occur. But methods are usually successful when carried out by experts, but appropriate adjustment or tying or bandages is very difficult to master. There are no objective criteria, so dressing adjustment depends on the individual surgeon. The pressure bandage is better than the tie-over dressing in the early detection of hematomas, but it is not sufficiently effective. If hematomas exist on the first operative day, they must ideally be removed to salvage the grafts placed over them. Indeed, it is difficult for the surgeon to determine whether or not hematomas are actually present. Using the suction-drain method, it is very easy to detect hematomas during the crucial period even if they are very tiny. This method is superior to conventional dressings in some respects. The advantages of the suctiondrain method are (1) the early detection of hematomas, (2) eliminates unnecessary dressing changes to check for hematomas, (3) decreases the need for meticulous packing, (4) somewhat allows movements without the necessity for immobilization, and (5) application of uniform, objective, and adjustable pressure. Conversely, the disadvantages are (1) expense, (2) the possibility of contact dermatitis due to adhesive drapes, and (3) inapplicability in some areas such as nasal and oral regions. The advantages generally appear to outweigh the disadvantages. This method can also be used together with the thread-drain method (4). When a successful result is needed either in complicated areas such as concavities or undulations or in a place where a graft is difficult to immobilize, the suction-drain method is available for use by any surgeon and is recommended as an excellent technique.

Figure 2 A skin graft on the dorsal hand. (A) The suction-drain method was applied with minimum gauze packing. (B) Immediately postoperative view. (C) No necrotic areas were seen on the seventh postoperative day. (D) Cosmetically excellent results were observed in the fourth postoperative month.

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REFERENCES 1. 2. 3.

4.

Nakayama Y, Iino T, Soeda S. A new method for the dressing of free skin grafts. Plast Reconstr Surg 1990; 86:1216–1219. Nakayama Y, Soeda S. A new dressing method for free skin grafting in hands. Ann Plast Surg 1991; 6:499–502. Converse JM, McCarthy JG, Brauer RO, Ballantyne DL. Transplantation of skin grafts and flaps. In: Converse JM, ed. Reconstructive Plastic Surgery. Vol 1. 2nd ed. Philadelphia: Saunders, 1977: 152–239. Nakayama Y, Soeda S. Nylon threads used as drains in free skin grafting. Ann Plast Surg 1990; 24:91–95.

75 Improvised Method for Preparing Meshed Skin Grafts Akira Yanai and Yuzo Komuro Juntendo University, Tokyo, Japan

Shinichi Hirabayashi Teikyo University School of Medicine, Tokyo, Japan

I.

INTRODUCTION

Meshed skin grafts are indicated for coverage of burns and other such wounds. Certain instruments are available for performing these grafts (1,2). During operations, there sometimes arises a situation requiring a meshed skin graft even if such instruments have not been readied. Ordinarily, in these situations, we are forced to wait while the instruments are prepared and sterilized. We have developed a method of preparing such skin grafts without the use of these special instruments.

II. TECHNIQUE The principle of the technique for the creation of meshed skin grafts is shown in Figure 1. First, a split-thickness skin graft is folded so that the width of the fold is less than 2 cm (Figure 1, top). In the next stage, the skin is alternately incised on one side and then on the other at regular intervals (Figure 1, middle). All that is left to be done is to unfold the skin (Figure 1, bottom). It is helpful to use a sheet of thin paper as a support for the splitthickness skin graft before carrying out this procedure. Skin with a paper 467

468

Figure 1 mesh.

Yanai et al.

(Top) Folding the skin. (Middle) Incising the skin. (Bottom) Completed

Improvised Method for Preparing Skin Grafts

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support is more easily incised with scissors or a scalpel than skin without such support.

REFERENCES 1. 2.

Tanner JC, Vandeput J, Olley JF. The meshed skin graft. Plast Reconstr Surg 1964; 34:287. Haeseker B. Forerunners of mesh grafting machines: From cupping glasses and scarificators to modern mesh graft instruments. Br J Plast Surg 1988; 41:209.

76 External Use of a Wireframe for Sheet Skin Grafting Takashi Hirai Nippon Medical School, Kawasaki, Japan

I.

INTRODUCTION

A clean and well-vascularized bed, meticulous hemostasis, and accurate approximation and postoperative immobilization of the graft are essential for a successful skin graft. Graft failure is inevitable with the lack of any one of these. The author has employed a simple technique to get better graft fixation for sheet skin grafts. With the use of an externally attached Kirschner wire, grafts were protected against shear force and were able to get tie-over pressure evenly on the entire surface. The technique has brought about better results in sheet skin grafting.

II. MATERIALS AND METHODS The operative procedure follows the conventional sheet skin grafting technique until the adequate approximation and ligature of the graft are accomplished. After finishing the circumscribing sutures, a wireframe is made from a Kirschner wire and according to the outline of the graft. The diameter varies depending on the lesion. For instance, a 1.0 mm diameter is appropriate for eyelids, 1.2-mm for lips, and 1.5 mm for limbs. The wire is bent to fit the outline of the graft three dimensionally and is made slightly wider than the graft itself. Both ends of the wire are cut with nippers and joined end-to-end with adhesive tape. The wireframe is then attached by the sutures 471

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with which the graft is stitched. After all the surrounding sutures are ligated, tie-over fixation is performed in the usual manner utilizing these same sutures (Figure 1). It is feasible to let the wireframe to stay for few more days after the tie-over removal.

III.

CASES

1.

Case 1

A 7-year-old boy presented a deep dermal burn on his right anterior ankle joint. Split-thickness skin, 16/1000 inch in thickness, was grafted onto the lesion. Figure 2A demonstrates an attached wireframe. No lifting was observed at the edge of the graft after the tie-over fixation was completed

Figure 1 (A) A wireframe is laid over the graft. (B) The wireframe is attached with the sutures stitching the graft. Note that the wireframe is made wider than the outline of the graft. (C) The tie-over fixing is completed.

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(Figure 2B). The tie-over gauze was secured with the framework of a 1.5mm Kirschner wire. The graft showed its complete take (Figure 2C). 2.

Case 2

A 26-year-old man had suffered from facial scar contracture due to a windshield injury. He underwent scar revision and full-thickness skin grafting (Figure 3A). An external wireframe was made a little wider than the graft

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Figure 2 (A) A wireframe is attached after a split-thickness sheet skin is grafted on the recipient site. (B) The wireframe secures the graft during the period of the tie-over fixation. (C) The graft showed total survival 7 days postoperatively.


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and bent three dimensionally to trace the outline of the graft (Figure 3B). The wide frame made it possible to distribute appropriate tie-over pressure over the entire graft. Thus, a favorable result was identifiable even at the very peripheral edge of the graft (Figure 3C and D). 3.

Case 3

A 32-year-old woman with a facial burn injury underwent full-thickness sheet skin grafting on her right lower and left upper eyelid. As the wireframe prevented the graft edge from lifting, any palpebral ectropion that could cause corneal ulceration was not identifiable during the whole course of the tie-over fixation. Figure 4 indicates the total graft take after the tie-over removal. 4.

Case 4

A 32-year-old man underwent full-thickness skin grafting on his lacerated left upper eyelid. Figure 5 reveals the total take of the graft after the tie-over removal. A three-dimensional framework can be appreciated from the oblique view. Stable fixation was available against his blinks without any palpebral ectropion. He was also able to close his left eye during the tie-over fixing.

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Figure 3 (A) A case of a scar contracture after a windshield injury. (B) A wireframe slightly wider than the graft is attached. (C) The graft shows complete take after the tie-over removal. (D) 3 months postoperatively.


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Figure 4 A burn case with the use of external wireframes shows total graft take of a right lower and a left upper eyelid. The patient was able to blink even with wireframes in place.

5.

Case 5

A 32-year-old man with a deep facial burn underwent split-thickness sheet skin grafting on both sides of his lower eyelids and upper and lower lips. The lips as well as eyelids were applicable areas for the external wireframe fixing. The wireframes secured the grafts against oral movements and prevented graft contamination with saliva by avoiding ectropion of his lower lip. The grafts showed favorable results (Figure 6).

IV.

DISCUSSION

Skin graft take can be accomplished with paying particular attention to: 1. 2. 3.

Pre-operatively: a well-vascularized bed Intraoperatively: meticulous hemostasis Postoperatively: immobilization of the graft

Even if these factors are present, other factors, such as infection, can still cause graft failure. Excessive tie-over pressure may also bring graft loss. The


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Figure 5 A full-thickness skin graft on the left upper eyelid reveals total take including its peripheral edge. The oblique view reveals that the wireframe traces the outlines of the graft three dimensionally.

Figure 6 Split-thickness skin grafts on bilateral lower eyelids and lips showed complete survival in an extensive burn case.

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external wireframe technique reduces these postoperative risks owing to the following reasons. First, a wireframe secures a graft against shear force stretching the graft, externally especially at the movable areas such as the face and extremities. Second, a wireframe prevents a graft from being contaminated by lacrimation or salivation, as it does not permit elevation at the graft edge. This may serve to reduce the risk of infection. Finally, tie-over pressure is distributed equally over an entire graft. Tie-over pressure can be concentrated at the center of a graft when the graft bed is soft (Figure 7A). A wireframe, which is made slightly wider than the graft, makes it possible to apply appropriate tie-over pressure both at the center and the very peripheral portion of the graft (Figure 7B). Planas (1) first reported the use of a buried wireframe to reduce contraction of grafts. We have confirmed the utility of a buried wireframe to fix grafts in place. And a nonburied, external wireframe seemed to be sufficient for the purpose of stabilizing a graft (2). Because external wireframes should be removed about 8–10 days after the skin grafting, the anticontraction

Figure 7 Transectional schematics of two types of tie-over fixing with and without a wireframe. Arrows indicate the direction and degree of the tie-over pressure which these grafts sustain.


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effect of the external wireframe method in split-thickness skin grafting is less conspicuous than that of the buried method. However, the external wireframe technique has shown better viability and good results in sheet skin grafting on movable areas.

REFERENCES 1. 2.

Planas J. The use of a buried wire frame to reduce contracture of grafts. Plast Reconstr Surg 1984; 74:798–808. Hirai T, Hyakusoku H, Fumiiri M. The use of a wire frame to fix grafts externally. Br J Plast Surg 1991; 44:69–70.

77 Use of the Pulley Suture in Scalp Reduction Surgery Neil S. Sadick Weill Medical College of Cornell University, New York, New York

I.

INTRODUCTION

One of the most common adjuvant procedures in male pattern alopecia surgery is scalp reduction (1). The most common techniques include (1) median reduction, (2) paramedian reduction, (3) Y-plasty and its modifications (2,3), (4) ellipse with M-plasty (4), (5) bilateral occipitoparietal flap advancement technique (5,6), and (6) scalp reduction utilizing tissue expanders (7– 12). No matter which technique is employed, the objective is the same: to approximate two wound edges that are under tension. The most common technique to relieve this tension and allow the wound edges to be approximated precisely has been undermining. Occasionally, even with extensive undermining, the wound edges will not approximate. It is in this situation that the pulley suture becomes a valuable tool (13). Other mechanisms which may be utilized to increase intraoperative scalp mobility include mechanisms which increase mechanical creep (stretching response created by tension applied to skin for short periods of minutes to hours) intraoperatively. These include: . .

Volumetric expansion: PATE procedure—intraoperative balloon expansion. Nonvolumetric tissue expansion: Where the scalp is extended by means other than a balloon-filled device. Examples include suture tension adjustment reel (Miami Star) towel clips. SURE closure (Life Science Inc., Princeton, NJ), (14–18). 483

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The pulley suture falls into the latter category of nonvolumetric intraoperative scalp expansion. The amount of stretching is due to collagen fiber realignment. No tissue growth occurs. Delayed expansion is based upon the concept of biological creep where a stretching response is incited by tension applied to the skin for periods of weeks to months. Stretching may be maximal as a result of tissue growth (14).

II. TECHNIQUE The pulley suture generally involves the use of 0 or 2-0 Ethilon suture material and acts as a retention suture without buckling opposing skin wound edges. The suture is applied first in the center of the wound as follows: 1. 2.

The needle is inserted far from the wound edge and brought out on the opposite side close to the contralateral edge (Figure 1). The suture is then inserted near the original side wound edge and subsequently brought out far from the contralateral edge (Figure 2). This establishes a pulley system that will approximate wound edges similar to a vertical mattress suture but with far greater leverage (Figure 3).

Figure 1 Insertion of suture far on the left side and coming out near the right edge.

Figure 2 Insertion of the same suture near on the left side and coming out far on the right edge.

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Figure 3 system.

Pulling both ends of the suture in opposite directions creates a pulley

3.

Additional sutures may be applied symmetrically along the wound from the central suture (Figure 4). Vertical mattress sutures may be applied in between the pulley sutures to approximate wound edges without tension. (The tension has been absorbed by the pulley sutures.) Alternating sutures may be removed in 6–8 days with the remaining sutures removed 1–2 days later (Figure 5).

4.

5.

III.

DISCUSSION

The pulley suture, commonly employed in general surgery, has rarely been described in the dermatological surgical literature It may be an extremely valuable tool during scalp reduction surgery. The advantages of this technique are: 1. 2. 3.

Decreased tension along the suture line, allowing close approximation of wound edges with subsequent excellent healing. Diminished suture line spread, resulting in rapid healing and improved cosmetic scar Excellent hemostasis during the operative procedure

Other adjuvant techniques in scalp reduction surgery described by Alt (19) include accessory supra-auricular incisions, transverse scale incisions, relax-

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Figure 4 Additional pulley sutures along the wound can supplement the main pulley suture.

Figure 5 Clinical, intraoperative pulley suture placement.

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ing galeotomies, and running buried absorbable sutures. Utilization of the pulley suture technique should be added to the list of valuable surgical techniques in this clinical setting.

IV.

CONCLUSION

The pulley suture is a valuable adjuvant tool in all excisional surgery, but it has found special efficacy in scalp reduction surgery.

REFERENCES 1. 2. 3.

4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14. 15.

McGregor IA. Fundamental Techniques of Plastic Surgery and Their Surgical Applications. 7th ed. New York: Churchill Livingstone, 1980. Schultz BC, Roenigk HH. Scalp reduction for alopecia. J Dermatol Surg Oncol 1979; 5:808–811. Alt TH. Scalp reduction as an adjunct to hair transplantation: review of relevant literature and presentation of an improved technique. J Dermatol Surg Oncol 1980; 6:1011–1018. Unger MG, Unger WP. Alopecia reduction. In: Unger WP, ed. Hair Transplantation. New York: Marcel Dekker, 1979:102–108. Marzola M. An alternative hair replacement method. In: Norwood OT, ed. Hair Transplant Surgery. 2nd ed. Springfield, IL: Thomas, 1984:318–328. Brandy DA. The Brandy bitemporal flap. Cosm Surg 1986; 3:11–15. Manders CP, Graham WP III. Alopecia reduction by scalp expansion. J Dermatol Surg Oncol 1984; 10:967–977. Pierce HE. Possible use of the radovan tissue expander in hair replacement surgery. J Dermatol Surg Oncol 1985; 11:413–417. Bosley LL, Hope CR, Montroy RE, Staub LS. Reduction of male pattern baldness in multiple stages: a retrospective study. J Dermatol Surg Oncol 1980; 6:498–503. Unger MG, Unger WD. Management of alopecia of the scalp by a combination of excision and transplantation. J Dermatol Surg Oncol 1978; 4:670–672. Stegman SJ, Tromovitch TA. Scalp reduction for alopecia. In: Cosmetol Dermatologic Surgery. Chicago: Yearbook, 1980. Bell MN. The role of scalp reduction in the treatment of male pattern alopecia. Plast Reconstr Surg 1982; 69:272–277. Hitzig GS, Sadick NS. The pulley suture. Utilization in scalp reduction surgery. Dermatol Surg Oncol 1991; 18:220–222. Cohen BH. Navigating through tissue expansion terminology. J Dermatol Surg Oncol 1993; 19:614–615. Cohen BH, Cosmetto AJ. The suture tension adjustment reel: a new device for the management of skin closure. J Dermatol Surg Oncol 1992; 18:112–123.

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16. 17.

Frechet P. Scalp extension. J Dermatol Surg Oncol 1993; 612–622. Lam AC and others. Decrease in skin-closing tension intra-operatively with suture tension adjustment reel, balloon expansion, and undermining. J Dermatol Surg Oncol 1994; 20:368–371. Gibson T. The physical properties of the skin. In: Converse JM, ed. Reconstructive Plastic Surgery. Philadelphia: Saunders, 1977. Alt TH. Aids to scalp reduction surgery. J Dermatol Surg Oncol 1988; 14:309– 315.

18. 19.

78 Automation of Hair Transplantation: Past, Present, and Future William R. Rassman and Robert M. Bernstein New Hair Institute Medical Group, A Professional Corporation, Los Angeles, California

I.

INTRODUCTION

Once a fantasy, the automation of hair transplantation is becoming both a reality and a necessity. With the emergence of the transplantation of individual follicular units (1–3), the transplantation of these small grafts in large quantities in a single session has become the standard for hair transplant procedures performed all over the world. This process has made the modern hair transplant procedure dependent upon large numbers of highly skilled staff members working within tight quality controls. The omission of small details in the process often leads to a significant reduction of survivable grafts. The skills required of staff members may take months or even years to develop and, as a result, hair transplant surgery has too often been customized around the limitations of staffing logistics.

II. NEED FOR AUTOMATION An interesting tug-of-war has developed between an increasing demand for quality hair transplants and the ability of the surgical community to successfully deliver the modern Follicular Unit Transplantation procedure. As a result, overenthusiastic hair transplant surgeons attempt, and often fail, to deliver the high standard that they represent. The solution to this problem 489

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will emerge as better instruments are developed which automate the various components of the hair transplant process and thereby decrease the impact of human skill and human error. Consistency in technique is essential for the best results. The number of automation tools available today is limited, but as ‘‘necessity is the mother of invention,’’ automated solutions will inevitably develop over time. The authors believe that state-of-the-art technique of the Follicular Unit Transportation would be peformed as the procedure of choice, if it could be delivered efficiently and in a cost-effective manner. Automation of hair transplantation is necessary because it provides the best solution to a number of problems inherent to the modern hair restoration procedure. The most common problems of modern Follicular Unit Transplantation that may be solved by automation include the following (4): A.

Graft Harvesting

The objective of graft harvesting is to remove grafts (ideally follicular units) from the strip of donor skin without injuring the follicles or breaking up the naturally occurring follicular groups. The goals are to preserve the critical follicular anatomy during dissection and, when handling the grafts, to minimize trauma and desiccation. Training of the staff to produce quality grafts during dissection can be accomplished in 2–3 weeks, but efficient, costeffective harvesting skills may take months or years to achieve. Quality control systems are critical to successful graft preparation. Labor and/or time-saving devices that automate graft dissection with cutting grids and specialized knives abound, but these shortcuts have significantly sacrificed hair yield. The loss of as much as 50% of the harvested hair may be the cost of blind cutting tools, making such approaches far from ideal. B.

Graft Placement

Traditionally, graft placement has been a two-step process. First, sites (wounds) are created in the recipient area, often with a small scalpel or needle. Once the sites are made, the follicular units are placed with forceps or other similar instruments. During placement, as in the dissection phase, graft damage and desiccation must be minimized. Grafts that are allowed to dry will be damaged or killed in just a few minutes. Grafts are often grasped and squeezed repeatedly as staff members position each graft optimally in the sites. Squeezing the growth centers of the follicular unit can negatively impact hair growth. Learning how to place the grafts with a minimum of trauma and in a competent and efficient manner using manual techniques requires experience that may take many months or years to

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acquire. Furthermore, graft placement requires the surgeon to have not only a keen knowledge and mastery of the specific techniques involved in the procedure but also organizational and management skills in order to control the large number of staff members required to perform the defined tasks. As it takes at least a year for the doctor to see the results of the procedures he/ she has performed, any adjustments to one’s technique is, therefore, delayed. As a consequence, the learning curve can be very long. C.

X-Factor

In 1984, Dr. Richard Shiell (Australia) and Dr. O’Tar Norwood (United States) (5) first described the existence of the X-factor as something which produces unexpected and unexplained poor results in 4-mm grafts that occurred in less than 1% of the cases. It was conjectured that some sort of antibody reaction rejection process produced localized graft ischema. The emergence of the megasession in the early 1990s brought new concerns of poor or no growth in large micrografting sessions. D.

H-Factor

In 1994, Greco postulated the existence of the ‘‘human factor’’ (H-factor) (6) as the primary cause of decreased micrograft survival. The H-factor is any ‘‘subtle or invisible iatrogenic trauma to the follicular growth center’’ that occurs during the operative process, resulting in decreased growth or no growth (7). The H-factor can occur in any phase of the transplant procedure. The effects may be categorized as either primary or secondary Hfactor. In primary H-factor, the insult is directly caused by the surgeon or the assistant. Seager (Toronto, Canada) nicely demonstrated this with his ‘‘skinny’’ and ‘‘chubby’’ micrograft study, which demonstrated decreased growth in the over aggressively dissected follicular units. Seager postulated that poor growth also results from the ‘‘disruption of the physiological and anatomical bond between the hairs of naturally existing follicular clumps’’ (8). H-factor can be decreased through several different means. First, the industry can develop better instrumentation which shortens the harvesting time and makes the dissection easier and more accurate. Second, placement techniques may be improved by enhancing the skills of technicians or by using automated instruments which would enable the technicians to be more gentle, more proficient, and increase their placing speed. Also, attention to the negative effects of rough handling and/or exposure to air and temperature can decrease the H-factor. Finally, the use of microscopes for identifying the important elements of follicular unit anatomy in the dissection phase

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can decrease the effect of the H-factor. The use of automated graft placement instruments will speed up the graft placement phase and reduce follicular trauma. Regardless of technology, the most important and effective measure in controlling the H-factor is attention to detail throughout every phase of the hair transplant procedure.

III.

AUTOMATING GRAFT HARVESTING AND GRAFT PLACEMENT

A.

The Need

Most surgical procedures involve a surgeon and one or two assistants. In hair restoration, the number of staff required for the surgical procedure increases with the number of grafts transplanted. For follicular unit dissection, the cutting speed for high quality, microscopically viewed grafts range from 100–300 grafts per hour per worker. For immigrants cut to size without a microscope, the speed can double or triple. The graft placing speed of small grafts does not vary between mini- or micrografts cut to size when compared to follicular units. Placing speed can vary widely depending upon experience, with ranges from 50 grafts per hour for the inexperienced technician, to as high as 500 grafts per hour for the highly experienced person. As graft harvesting and placement are tedious, time consuming, monotonous tasks, adequate relief workers must be available. Surgeons often abdicate quality control to the technical staff doing the work. Results vary with the expertise of the staff, and consistency becomes hit-or-miss if tight quality control mechanisms are not in place. If a surgeon is fortunate to have good management skills and a dedicated, loyal and stable staff, results will be predictable. Unfortunately, this concept is often foreign to the way surgery is performed today, often using the one surgeon/one assistant principle derived from more conventional surgical models.

B.

The Goal

Automation can solve the labor and quality control problems for today’s Follicular Unit Transplantation. It would also allow the surgeon more easily to regain control over the surgical process. The automated solution should accomplish the following goals: 1. 2.

Reduce surgical time Reduce labor requirements to one surgeon and one or two assistants


3. 4. 5. 6. 7.

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Reduce or eliminate many of the human variables intrinsic to the surgical procedure Reduce the stress of the procedure on the surgeon and staff Reduce the training and skill requirements for the surgical staff Reduce graft damage from manipulation and/or drying by eliminating much graft handling Reduce the need for staff quality control processes other than elements involving the surgeon’s direct medical involvement and judgment

Automated devices should also create less trauma in the hair transplant surgery by reducing medication, time under anesthesia, wounding, bleeding, and tissue exposure to hostile environmental factors. To accomplish these goals with automation, the various procedures involved in hair transplantation must be reevaluated and reengineered. For simplicity, the process can be divided into two phases: graft harvesting and graft placement. The automated tools should ideally be able to integrate and simplify both phases of the surgery. C.

Donor Strip Harvesting

Today’s automated tools for graft harvesting are limited to multibladed knives and a variety of graft cutting devices. Multibladed knives have been shown to be traumatic to the grafts by transecting hair follicles as the knife is drawn across the donor area. It is literally impossible to hold the angle of the knife blade such that it remains parallel to the angle of the follicular shaft. A miss of a few degrees will transect valuable hair follicles. Although the use of tumescence helps stabilize the donor area for several minutes before it is absorbed, the smallest differential between the angle of the blade and the angle of the emerging hair shaft causes follicular transection. The amount of transection is directly proportional to the number of blades used by the surgeon. Transected follicles usually cannot be salvaged and successfully transplanted. Even if transplanted, their chances for producing a normal terminal hair is significantly decreased. D.

Graft Cutting

There are several automated graft-cutting devices on the market, specifically the Graft-tome and the Mangubat Graft Cutter (9). Such graft-cutting devices require that the surgeon place a 1.0–1.5-mm cut strip of scalp on its side across a series of razor blades. Most strips are harvested with multibladed knives with spacing of about 1.0–1.5 mm. Alignment of the strip

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across the razor blades makes the erroneous assumption that the hair follicles are all parallel to each other and that the strip can be stabilized as it is cut. Although this technique offers speed and is proported to require much less surgical skill, the human variables can be quite significant. Damage to hair follicles due to the multibladed knives may be as high as 35% even in the best of hands. When the blind technique from graft cutting is added to the multibladed knife, extensive follicular damage is to be expected.

E.

Graft Placement

Traditionally, sites are first created in the recipient area and then grafts are placed into these preformed sites. Today, most of the sites are created as slits with a fine knife or needle, although some surgeons use small punches. In the traditional manual process, the grafts are grasped with forceps and manipulated into the premade sites. Graft placement is a very delicate process and learning how manually to place grafts in a competent and efficient manner, with minimal trauma, often requires months or even years of experience. Preventing graft drying is also very important; delays caused by reduced skills may kill the graft or negatively impact graft growth. Simultaneous site creation and graft placement offers the following benefits: 1.

2.

3. 4.

5.

Single action for graft placement: As each recipient site is created, the graft is placed directly into the recipient site with a single mechanical action. In the majority of cases, the grafts will remain in place with no additional manipulation. In certain situations, the grafts may need a fine adjustment to keep them from lifting after insertion. Less bleeding: Bleeding is reduced in the majority of sites, as immediate graft placement compresses many of the smaller blood vessels in the recipient site. The immediate insertion of the graft creates a tamponading effect on small open blood vessels. Less anesthesia administered: The total anesthesia dosage is reduced owing to shorter surgical time. Less graft manipulation: Manipulation of the grafts during the placement process is virtually eliminated. The compression of the graft with forceps is no longer necessary for the placement process. This reduces the possibility of damage to the graft. Less emphasis for quality control monitoring during placing: Quality control emphasis involved with human variables is reduced.


6.

7.

8.

9.

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Less staff stress: The time-consuming and laborious process of graft placement is reduced. Staff fatigue and eyestrain are minimized. Appropriate physician focus: By reducing the tediousness of hair transplantation, the surgeon may focus on the excision of the donor site, the design of the hairline, and the placement of the grafts. Shorter staff training: The protracted training period required to teach graft placement is reduced. However, at least one member of the surgical team must be skilled in manual graft placement techniques in the event that the automated technique is ineffective in a particular patient. Reduced procedure costs: An expedited surgical procedure frees facility capacity and the surgeon’s time to a significant degree. Because costs are a critical factor in the decision to elect transplantation as a solution to hair loss, decreased costs to the patient should reduce the threshold for the decision to have surgery.

There are several tools that specialize in the automation of the placement of hair grafts. Such automated devices include the Choi Hair Transplanter (10), the Hair Implanter Pen (11), and Calvitron and the Rapid Fire Hair Inserter (in final development stage in our office).

1.

Choi Hair Transplanter

The Choi Hair Transplanter (Figure 1) was, until recently, the only available device which both creates the recipient sites and places the grafts. The loading process is laborious and time-consuming, and it requires reasonable skills for efficient use. Grafts for this device must be very thin and stripped of much of the fat that offers some protection against desiccation. For this reason, a highly efficient experienced staff is required. It also works best with rigid, coarse hair, as it pushes (rather than pulls) the hair into the recipient site. For this reason, the Choi implanter is particularly suited for Asian hair. Its advantage over the manual technique is that the manual skills needed for placing grafts are reduced, refocusing the skills of the technicians to the unique characteristics of the Choi Hair Transplanter. In inexperienced hands, it can take longer to load the Choi Hair transplanter than it takes to place grafts by hand.

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Figure 1

2.

The Choi Hair Transplanter, invented by Dr. Yung Chul Choi.

Rapid Fire Hair Inserter (in final commercial development)

Like the Choi Hair Transplanter, the Rapid Fire Hair Inserter (and its predecessor device the Rapid Fire Hair Implanter Carousel) combines what was a two-step process into a one-step process. The Choi Hair Transplanter employs a piston and ‘‘pushes’’ the grafts into the hole, whereas the Rapid Fire Hair Inserter gently ‘‘pulls’’ the graft into the hole. The authors believe that this later mechanism is superior to the Choi Hair Transplanter, as it protects the grafts from compression, or folding, during the placement process, thereby minimizing trauma. It is also more versatile, working well with fine, caucasian hair, and easily accommodating different shaft diameters up to 1 mm (Figure 2). The device loads similarly to the Hair Implanted Pen (shown below). 3.

Hair Implanter Pen

The Hair Implanter Pen (Figure 3) was developed by Dr. Pascal Boudjema. The Hair Implanter Pen utilizes a suction tip to grasp the end of a hair graft of any small size. The surgeon then drags the graft into the preformed site.


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Figure 2 A schematic of the Rapid Fire Hair Inserter as used in limited clinical trials at the time of this writing.

Figure 3

The Hair Implanter Pen.

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When the suction is released, the needle tip quickly retracts, leaving the graft in place. As the suction mechanism does not grasp or squeeze the graft, there is little or no trauma to the graft. The Hair Implanter Pen can increase the placing speed and thereby reduce the surgical time. 4.

Calvitron

The Calvitron is the oldest and conceptually the most elegant and on-target automation device. The Calvitron, also invented by Dr. Pascal Boudjema, was designed to remove grafts from the donor area and place them directly into the recipient area in a single motion, without touching the human hand and without being stored. By harvesting and placing the grafts in one continuous step, most or all of the problems associated with the automated tools prior to or since the Calvitron was invented theoretically would disappear. The problem with the Calvitron lies in the difference between theory and practice. The Calvitron was designed to work with the older techniques (i.e., the large grafts) and, as such, is not able to handle the small follicular unit grafts efficiently. The unit is clumsy, temperamental, requires high maintenance, and does not work smoothly. Although various versions have been introduced over the past decade, it has not been widely accepted by the hair transplant community. The Follicular Unit ExtractionTM technique uses special 1-mm punches to extract individual follicular units directly from the donor area. This is a tedious procedure used in special situations where a limited number of follicular units (generally under 500) are transplanted in a single session. Automation is the key to mass implementation of this exciting new technique, but as of the time of this writing, automated devices have not been fully perfected.

IV.

CONCLUSIONS

With balding present in 50% of the male population above the age of 40 years, the demand for hair restoration surgery will inevitably increase as the ‘‘baby boomers’’ age into their later years. Since a good hair transplant is not detectable, the public still sees people with the classic ‘‘doll’s hair’’ appearance of the older style hair transplants and believes that this is the best the field has to offer. It is only a matter of time that an awareness of today’s techniques will reach the average consumer experiencing hair loss. The need to develop enabling tools that allow surgeons to perform predictably high-quality follicular unit transplants will serve to accelerate


Figure 4

Figures 4 and 5 Patient before and after one surgery of 1,981 grafts.

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500


Figure 6

Figures 6 and 7 Patient before and after one surgery of 1,800 grafts.


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the acceptance of hair restoration by the general public. The old adage that necessity is the mother of invention will work to the benefit of both surgeon and patient. Newer automated tools will inevitably develop to solve the problems surgeons are confronting in delivering today’s labor-intensive procedures. We will eventually move to an integrated, technically based surgical procedure that is less dependent upon a large supportive staff and therefore is less costly to deliver. The model that Dr. Boudjema invented with the Calvitron may, in fact, be the correct model for a further hair transplant system. The technical limitations of the existing Calvitron, however, must be overcome, and the scale for grafting must be at the follicular unit level. The final automation product will extract follicular units directly from the donor area and pass them to an inserting instrument without touching human hands. The grafts will come out of the donor area and within seconds be placed into the recipient site. The final technology will function similarly to the way the Calvitron functions now but without its awkward size and cumbersome complexity. The ideal instrument will most likely appear in steps that have been developed through two separate paths: the harvesting process and the inserting process. Although successful in controlled trials, the Rapid Fire Hair Implanter Carousel never made it to market. Its follow-up product, the Rapid Fire Hair Inserter, should satisfactorily solve the graft insertion problem, but it will still require graft handling. We anxiously await what the future in automated hair restoration will bring for it should change the entire field with regard to market penetration and the physicians who supply the services.


5. 6.

Bernstein RM, Rassman WR, Szaniawski W, Halperin A. Follicular transplantation. Int J of Aesthetic and Restorative Surg 1995; 3:119–132. Bernstein RM, Rassman WR. Follicular transplantation: patient evaluation and surgical planning. Dermatol Surg 1997; 23:771–784. Bernstein RM, Rassman WR. The aesthetics of follicular transplantation. Dermatol Surg 1997; 23:785–799. Rassman WR, Bernstein RM. Rapid Fire Hair Implanter Carousel: a new surgical instrument of the automation of hair transplantation. Dermatol Surg 1998; 24:623–627. Shiell RC. Whither the x-factor? Hair Transplant Forum Int 1996; 6(4):13. Greco J. The h-factor in micrografting procedures. Hair Transplant Forum Int 1996; 6(4):8–9.

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7.

Bernstein RM, Rassman WR. What is delayed growth? Hair Transplant Forum Int 1997; 7(2):22. Seager D. Binocular stereoscopic dissecting microscopes: should we use them? Hair Transplant Forum Int 1996; 6(4):2–5. Mangubat EA. Impulsive force: a new method to cut grafts. Int J of Cosmetic Surg 1998; 6(1):19–23. Choi YC, Kim JC. Single hair transplantation suing Choi hair transplanter. J Dermatol Surg Oncol 1992; 18:945–948. Boudjema P. A new hair graft implanter: the hair implanter pen. Hair Transplant Forum Int 1988; 8(4):1–4.

8. 9. 10. 11.

79 Highly Flexible, Reinforced SwanNeck Liposuction Cannulae Paul J. Weber Private Practice, Fort Lauderdale, Florida

Gale B. Oleson Private Practice, Blue Springs, Missouri

I.

INTRODUCTION

Traditional and ultrasonic liposuction cannulae usually are relatively rigid, (1,2), which has advantages and disadvantages. Advantages include control, ease of manufacture, and propagation of ultrasonic energy. Disadvantages include the fact that most areas of the human body are curviform and that the combination of straightness and rigidity places undesirable forces on the tissues adjacent to the cannula’s tip and the tissues of the entrance wounds while the cannula is inserted in the patient. In this chapter, we describe new designs for a system of cannulae of 2.5–6.0 mm in shaft diameter. A previous publication described only the use of the stainless steel shaft system for shaft diameters between 2.0 and 3.5 mm and drew comparisons with previously available equipment (3). Since that time, development and testing of practical cannulae exceeding 3.5 mm in shaft diameter have been successfully completed.

II. CANNULAE SYSTEMS AVAILABLE Both systems, manufactured by KMI (Anaheim, CA), allow the cannula’s point of entry to act as a fulcrum (with an optional interposed insert) in 503

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concert with the surgeon’s guiding hand to deflect cannulae with long flexible shafts and highly reinforced swan necks. The cannula’s tip is preferably highly beveled with an adjacent set of three openings. The novel system easily penetrates fibrous fat and may reach fat deposits relatively distant from the entrance wounds. The highly flexible, reinforced swan-neck cannula shafts are intended to move in an easily controllable manner within the subcutaneous tissue below the dermal envelope in an arciform fashion. Benefits include a reduced need to move a patient’s body position intraoperatively. A novel Teflon entrance wound insert (or antifriction means), also manufactured by KMI, provides for reduced friction and tissue trauma at the dermal-epidermal level. The surgeon may require time to become proficient at maximizing the usage of novel cannula motions that occur as a result of using the cannula’s entrance point as a fulcrum and redirecting the distal shaft and tip of the cannula with an opposing hand. The novel motions arise from the minimally to highly arced possible cannula paths. Many innovative cannula types and designs have been described and manufactured. Over time, the most commonly used variations have become the basis of traditional liposuction cannula design. Cannula designs may be categorized according to tip, aperture, shaft, handle, alloy, and customization features (3,4). The novel cannula system described herein contains a unique combination of modifications and innovations not previously seen in the literature or for manufacture. The new system was originally conceived to address the needs and concerns of ballerinas, fashion models, professional cheerleaders, and similar patients about delicate fat removal with a minimum of cannula entrance wounds. Other issues that fostered a need for the cannula system included body curvature considerations and the need for intraoperative patient movement and positioning on the table. Previous attempts to address similar needs included the use of various long, rigid, permanently but slightly curved cannulae (5). Many cannula tip designs are currently available. Each design has its positive and negative dynamics or attributes under varying conditions of usage. Liposuction cannula design dynamics have been summarized elsewhere (3). The triport bevel tip has been found to penetrate the fibrous fat with relative ease in combination with the systems described here. Cannula passage in even the fibrous environment of previously suctioned patients appears to be facilitated. The triport bevel tip combination, although a very aggressive fat-removing design, has yielded as little bleeding as we have seen with any other cannula tip design. Precise control over the aggressive action of multiple tip opening cannulae is recommended and

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may be gained by reducing the suction pump vacuum level to a suggested level of 12 torr. It is recommended that the novel cannula be moved slowly, at first, through the patient’s tissues until the surgeon develops the necessary skills to guide the cannula consistently to the appropriate target. Slow passage of these cannulae will usually provide aggressive liposuction and should be continuously monitored visually through the clear suction tubing and by palpation of the target site. Potential considerations in cannula shaft modifications include lengthening, resiliency, diameter minimization, curvature, reinforcement, alloy composition, and the use of combinations of dissimilar materials.

III.

SWAN-NECK MODIFICATIONS

Swan-neck modifications have been used in the past to aid the surgeon in directing the movement and placement of the cannula in close areas. Nonetheless, the forces customarily generated by the surgeon’s arm during the course of surgery have been known to cause premature breakage in previous swan-neck design junctions. Problems with earlier swan-neck cannulae have included localized metal weakness, fracture, failure, undesired ‘‘bendability,’’ and awkwardness. Among its positive features, the novel design provides a previously unattainable example that can now more fully demonstrate the many benefits of swan-neck systems. Swan-neck formations are especially helpful in combination with longer cannula shafts, since traditional cannula linearity, length, and rigidity may increase the probability that the surgeon’s hand or cannula handle will bump or strike a patient’s protuberance or convexity. Without swan-neck modifications, the cumbersome length and rigidity of designs of previous cannulae caused surgeons to place additional stress on their own arms and the patient’s tissues to guide the cannula shaft and handle in a workable fashion (Figure 1). In the novel cannula system, the swan-neck cannula has been specially and grossly reinforced (Figures 1 and 2). This reinforcement provides the needed additional stability at the handle-shaft junction to help a surgeon increase leverage on the cannula’s shaft and thus make use of the cannula’s entrance point as a fulcrum. Increased shaft leverage, in turn, allows the tip of the cannula to move in both traditionally expected and novel directions. To the surgeon who is not accustomed to using the new cannulae, this change and apparent unpredictability of tip movement may be alarming. With practice, tip motion can be perfected and the benefits of the new design will become apparent.

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Figure 1 Highly flexible metal shaft, reinforced swan-neck, triport bevel cannula in its entirety connected by the Quick-Connect system.

IV.

SHAFT MODIFICATIONS

Factors affecting a surgeon’s selection of shaft length and character may be numerous. They may include ease of tip location detection with shorter cannulae, concerns of increased handle-shaft junction breakage with increased length secondary to length-induced leverage, the secondary need for increased shaft diameter to increase strength (durability) when a longer cannula is desired, and/or the advantage of minimizing the number of

Figure 2 Highly flexible metal shaft, reinforced swan-neck, triport bevel cannula system broken down into its two metal component pieces, handle and shaft, at the Quick-Connect junction.


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entrance wounds by using longer cannulae. The reinforced swan-neck cannula allows for an increased range of workable cannula lengths for a variety of metal shaft diameters (Figures 3 and 4). These attributes, together with the special tip bevel, allow controllable tissue penetration with novel motions that should reduce the number of entrance incisions, hasten the procedure, and reduce the need for patient repositioning. In our practice, these benefits have been attained without an apparent increase in bleeding or complications. The use of high-memory extended-length cannulae allows for movements and attributes heretofore considered problematic. For example, unique approaches to hard to reach areas as well as decreasing the number of entry point openings may modify a surgeon’s repertoire. Along with the tip modification and swan-neck modification changes, the shaft specifications have been altered. The longer stainless steel shafts have been successfully used numerous times in all of our liposuctions performed over the last 2 years. Stainless steel shafts in the new cannula system are 2.0, 2.5, 3.0 and 3.5 mm in diameter. Currently available stainless steel tubing does not provide the flexibility or memory needed for proper function for shaft diameters exceeding 3.5 mm. Although shaft diameters between 2.0 and 3.5 mm provide surprisingly efficient and aggressive liposuction, many surgeons require cannula shaft diameters exceeding 4 mm to address obese patients and larger liposuction cases. Now, with the addition of autoclavable plastic shafts in combination with central metal ‘‘memory’’ reinforcing wires, shaft lengths greater than 4 mm are available to suit those surgeons’ needs. One limiting factor for each surgeon to consider now regarding shaft length is the interior dimensions of

Figure 3 Highly flexible metal shaft, reinforced swan-neck, triport bevel cannula system shows degree of bending allowed with the 3-mm model.

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Figure 4 Highly flexible 3.5-mm metal shaft, reinforced swan-neck, triport bevel cannula showing utility of bending within a human body at the hip.

a standard outpatient surgical autoclave. Use of the Quick-Connect system allows for longer functional total shaft length while minimizing individual device dimensions (see Figure 2). This system aids in fitting the disconnected device into an autoclave. Metal cannulae with long shafts exceeding 3.5 mm in diameter were found, on extensive testing, not to possess the desirable qualities of a wide range of flexibility in combination with proper memory. Therefore, a new system of plastic cannula shafts with internal metal support wires was developed and tested successfully (Figure 5). This system allows controlled rigidity of the plastic shafts; the cannulae can be bent into a semicircle without breaking and yet still return to the original shape (Figure 6). The plastic shafts must withstand repeated autoclaving without being deformed or losing their desirable properties. They needed to be reinforced, since extensive testing in vivo without reinforcement demonstrated a need for a graded strength along the shaft in more fibrous liposuction patients and locations. The reinforcing memory wires in the most recent models are specially made to be slightly less flexible in the proximal portions of the shaft and more flexible toward the distal tip, thus allowing a convenient gradation of shaft flexibility (Figure 7). A single new reinforced swan-neck disconnect system was designed to be used with and lock in any number of different plastic shaft diameters, thus significantly lowering the cost per diameter unit (Figure 8). The wide range of modified plastic shaft performance makes it possible to suction predictably the mid lower back from an incision in the umbilicus without rotating the patient, as was previously necessary.


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Figure 5 Highly flexible 6-mm plastic shaft, reinforced swan-neck, triport bevel cannula in resting conformation.

Predictable flexibility and excellent memory are imperatives for the novel metal and plastic shafts. In this system, it is not preferred that the surgeon be able to bend a cannula prior to placement into the patient and have the cannula maintain the bent shape. Surgeons who desire the quality may find it available in preexisting systems that eventually weaken and require replacement of the cannulae secondary to stress fractures.

Figure 6 Highly flexible 6-mm plastic shaft (with memory wire), reinforced swanneck, triport bevel cannula showing degree of bending allowed that will still permit return to resting conformation without deformity.

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Figure 7 Highly flexible 6-mm plastic shaft with central memory wire visible through most proximal shaft opening. The white irregular coloration of the beveled tip is deliberate; the white plastic is sonic welded into the open plastic shaft and corrugation increases the effective surface area of the weld. All surfaces are sanded smooth.

Figure 8 Disconnect system that can lock in and accommodate any number of different plastic shaft diameters. Highly flexible 6-mm plastic shaft (with memory wire), reinforced swan-neck, and triport bevel cannula is shown.


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The benefits of increased flexibility and memory can be demonstrated in at least two noteworthy behaviors of the new cannula system. The first, called ‘‘opposing motion,’’ occurs if less than one-half of the cannula shaft length has been introduced into the patient. Forcing or pointing the cannula handle to the right will move the cannula tip to the left in the patient and vice versa. Lifting the handle will usually direct the tip downward deeper into the patient’s subcutaneous tissue. Second, the cannula tip and distal shaft can be made to ricochet (in conjunction with the aforementioned opposing motion action exerted by the cannula handle) within the patient’s subcutaneous fat. Many liposuction texts and authorities continue to advocate the spokewheel technique of cannula passage. This technique may be considered as a series of 90-degree (or any other number of degrees) intersecting lines (6). Another potential benefit of the novel cannula system is that by using the principle of opposing motion action, a surgeon can approximate desirable criss-cross tunneling via increasingly distant entrance wounds.

V.

BENEFITS

An apparent benefit of the use of the new cannulae system is the ability to perform liposuction at a relatively great distance from the cannula entrance wounds. With the use of these cannulae, one surgeon has reduced the number of entrance wounds. In patients with a hereditary predisposition to pigment at entrance wounds, this benefit may be significant. For example, undesirable pink marks can be reduced in fashion models. Typical cannula entrance wound-suction site pairs include the following: posterior flank suctioned from anterolateral abdominal entrance wounds, knees suctioned from superiormost thigh wounds, inner crural thighs suctioned from medial knee wounds, and ankles suctioned from knee wounds. The use of steel 2.5– 3.5 mm diameter cannulae appear to be most helpful in approaching the excess fibrofatty material in the infragluteal area from a medial knee incision in patients who are not over 25% in excess of ideal body weight. For patients in excess of this ideal weight, the plastic shaft with reinforcing wire is of benefit. The relatively vertical criss-crossing effect has allowed for ridge-free protuberance reduction with no notable buttock ptosis.

VI.

DISADVANTAGES

There may be disadvantages to this new cannula system. A significant learning curve is required. The use of fewer holes to approach more sites will, by

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necessity, increase the duration of friction and leverage pressure applied to each entrance wound. Longer cannulae, dry operating room air, and accumulation of proteinaceous material on the outside of the cannulae can also increase entrance wound friction. The friction may be further increased if a surgeon attempts to use the entrance wound as a fulcrum or use the opposing motion action technique. Although all entrance wounds will naturally scar, those that are traumatized the most will remain pigmented the longest, especially in pigment-prone patients. Aside from coating and external portion of cannula shafts with nonstick polymers (which eventually wear off) and applying lubricating gels to the entrance wounds, another solution to the entrance wound friction problem is the use of temporary intraoperative plastic stents or antifriction means (7). Currently available screw-in devices are made of thicker materials and damage skin entrance wounds via pressure more than the antifriction means presented here. The preferred antifriction means is a conical Teflon insert, as we have previously described (3). The insert is of low friction inside (to aid in cannula passage) and higher friction outside (to reduce the tendency to extrude on cannula backstroke). It can be easily and quickly applied to or removed from an appropriately sized liposuction entrance wound (Figure 9). Outside friction is increased predictably as a result of projections, which are unidirectional notches or slits in the insertional exterior portion of the antifriction means. The noninsertional portion of the antifriction means may have a single row of oppositely directed notches or slits to prevent overinsertion of the device.

Figure 9 Various prototypes of antifriction inserts measuring between 3 and 6 mm (smallest conical opening).


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In addition to the use of an antifriction means, lightly cross suturing the entrance wounds with 6-0 polypropylene (with stitch removal at the 7day follow-up visit) minimizes entrance wound healing times. Sutures on the most inferior anatomical sites should be much more loosely coapted. With cannula entrance wounds exceeding 2.5 mm, sewing appears to improve the healing and outcome of traumatized entrance wounds. We disagree with Klein’s statement that cannula entrance wounds should not be sewn. The reader should take into consideration the following observations. Klein is most accustomed to very small-diameter microcannulae and their ramifications, including longer surgical time and the requirement for smaller, more numerous entrance wound incisions. The doublethrow 6-0 polypropylene cross suture recommended herein is not placed tightly and fluid leaks quite obviously and vigorously from the author’s stitched cannula entrance wounds. Photographs of Klein’s suture technique appear to reveal Klein making a single tight throw that could impede fluid egress in Klein’s own study of stitched wounds. Multiple variables affect wound outcome and wounded tissue beds. How much tension were Klein’s entrance wound sutures under? Were the tied suture tensions objectively measured by a device? If nylon suture material was used to close the entrance wounds, it would be more irritating to tissue than polypropylene; 5-0 sutures would usually cause more wound trauma and point stress than 6-0 sutures. It should be clear that many variables should be considered before generalizations can be accepted. Another concern is that the novel suction tip is very aggressive. It is therefore recommended that the novice initially choose as small a diameter cannula relative to the size of the case to avoid oversuctioning. The special tip, especially in small diameters, in the hands of a novice could puncture a vital structure if placed under undue force and if not directed properly. To minimize these potential problems, the cannula may be moved slowly (fat is still removed efficiently at slow speeds) and held delicately like a violin bow (with two fingers only when not working around dramatic curves) until the surgeon becomes proficient with the new cannula system. Even after the surgeon gains adequate proficiency, cannulae with diameters less than 3.5 mm may best be held at the handle like a violin bow because of the efficiency of movement within tissue and suction in areas such as the inner thighs.

VII.

CONCLUSIONS

New designs for a system of cannulae of 2.5–6.0 mm of shaft diameter have been described. The designs, manufactured by KMI (Anaheim, CA) allow a

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patient’s cannula entrance wound to act as a fulcrum in concert with the surgeon’s guiding hand to deflect cannulae with long flexible shafts and highly reinforced swan necks. The novel system easily penetrates fibrous fat and may reach fat deposits relatively distant from the entrance wounds. The highly flexible, reinforced swan-neck cannula shafts are intended to move in an easily controllable manner. Benefits include a reduced need to move a patient’s body position intraoperatively, fewer entrance wound incisions, and the ability to approach areas of lipodystrophy from a variety of directions.

REFERENCES 1.

2.

3. 4. 5. 6. 7.

Rohrich RJ, Beran SJ, Kenkel JM, Adams WP Jr, DiSpaltro F. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg. Thornton LK, Hahai F. Equipment and instrumentation for ultrasoundassisted lipoplasty. 1998; 101(4):1090–1091. Clin Plast Surg 1999; 26(3):299– 304. Reinforced swan-neck, flexible shaft, beveled liposuction cannulae. Am J Cosm Surg 1999; 16(1):41–47. Collins PS. Selection and utilization of liposuction cannulae. J Dermatol Surg Oncol 1988; 14:1139–1143. Elam MV. Knee, calf, ankle lipo-suction. Am J Cosm Surg 1986; 1:10–11. Dolsky RL. Spoke wheel lipo-suction technique. Am J Cosm Surg 1986; 1:33– 35. Abramo AC. A device to protect the incision in performing liposuction [letter]. Plastic Reconstr Surg 1994; 94:743–744.

80 Pinch Technique in Fat Transfer Mona Zaher, Michael Radonich, Dwight A. Scarborough, and Emil Bisaccia Columbia University, New York, New York

I.

INTRODUCTION

Autologous fat has been used as a filler for soft tissue defects for the past two centuries (1). As early as 1893, Neuber reconstructed a facial defect with fat. He felt that the fat survives as tiny parcels of tissue (1). Erich Lexer, in 1910, described repairing depressions status postfacial fractures with autologous fat; he performed studies that showed that the fat grafts were fragile and minimal trauma would jeopardize graft survival (1). Peer, in the 1950s, emphasized that the fat cells survived on diffusion for the first few days and by the fourth day neovascularization occurs (1). Injection volumes less than 3 mm in diameter were suggested by Carpaneta in 1994, since tissue nutrients only diffuse 1.5 mm (2). Cosmetic surgeons had renewed verve for the fat transfer technique during the 1980s when tumescent liposuction became an accepted technique. Viable adipose tissue had become readily available. The literature contains many reports of variable techniques in harvesting, preparing, and injecting fat grafts. The pinch technique aids in accurate placement of the graft (3). It has been used to correct facial defects involving the nasolabial fold, buccal cheeks, and lips.

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II. MATERIALS AND METHODS The procedure used in the pinch technique is divided into harvesting, preparing, and injecting the fat grafts. Two weeks before the procedure, all nonsteroidal anti-inflammatory drugs, blood thinners, and vitamin E are stopped to decrease chances of bruising. One day before the procedure, the patient is started on a course of oral antibiotics. The donor site is carefully chosen; preferably the outer thigh or the abdomen. Both the donor and recipient sites are scrubbed with Betadine swabs. Then 1% lidocaine with 1 : 100,000 of epinephrine is injected to form intradermal wheals at the donor and recipient ports. At the donor site, approximately 80 mL of Klein’s solution (0.25% lidocaine with 1 : 400,000 epinephrine) is administered with a small Zaki infusor until the donor site is adequately tumesced and firm to palpation (Figure 1). A 2.5-mm neck harvester with a two-holed or a Mercedes blunt cannula tip is attached to a 10-mL Luer-Lock syringe is used to harvest the fat. To minimize the vacuum created by the suction, the plunger of the 10-mL syringe is withdrawn slowly and stabilized with the first three digits of the ‘‘working’’ hand. The fat is harvested in a spokewheel pattern. The ‘‘nonworking’’ hand is used to stabilize the overlying, donor site skin and enhance the curetting-like action with counter palm pressure.

Figure 1

Infiltration with the Zaki infusor.

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Upon filling the adequate number of syringes, the filled syringes are each capped with an 18-gauge needle and stood upright for approximately 10 min. The tumescent and serosanguineous fluids settle to the bottom of the syringes and are discarded. The donor site is iced after the harvest is made. When the fat transfers have been completed, a Steri-strip is applied to the donor port and a gauze pad pressure bandage is applied. Fingertip digital pressure is placed on either side of the recipient defect while the fat grafts are injected into the mid dermis with needle withdrawal (Figure 2). This ‘‘pinching’’ action allows for accurate placement preventing the grafts from ‘‘wandering’’ and ‘‘going out of bounds’’ during fat injection. Initially, the patient is supine during harvesting and grafting and, subsequently, the patient is sat upright for further grafting if necessary. The fat grafts may be molded and kneaded after placement to get rid of any lumps or bumps. Avoiding excessive physical activity and wearing a compression girdle at the harvest site for several days is recommended.

III.

DISCUSSION

Fat transfer is indicated for correcting areas with subcutaneous loss or atrophy and improving facial contours. Common areas treated include the nasolabial fold, lips, buccal cheeks, glabellar and marionette lines, crow’s feet, and earlobes. Atrophic insults such as morphea, Romberg’s syndrome, burned-out panniculitis, insulin injections, liposuction divots, and scars respond well. Also, allografts may be enhanced with fat transfer. Being autologous, readily available, and cost effective, makes fat a favorable graft. Several theories exist as to the fate of the transplanted adipocyte (4). It has been proposed that the autologous fat graft promotes fibrosis in the traumatized recipient area and may be responsible for the contour enhancements (5). Fat donor sites include the inner and outer thigh, abdomen, submental region, jowls, and any other site that has adequate reserves. When choosing the donor site it is important to note any asymmetries. The preferred donor site is the outer thigh for several reasons. First, the outer thigh is resistant to weight loss, especially in women (6), and second, the fat harvested is less fibrous (7). Also, approaching through the outer thigh through the buttock crease leaves a hidden, minimal scar (8). Application of the pinch technique allows for total control of fat deposition. It prevents deposition from passing outside the curvilinear boundaries of the pinched skin. If additional pressure is needed to inject

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Figure 2

Manual bilateral palpation is used in the pinch technique.

the fat, the bilateral finger placement and pressure prevents extension beyond the created boundaries. The fat transfer procedure limitations must be fully understood by the patient beforehand. Results show moderate augmentation. Several sessions may be necessary to achieve the desired correction, since 30–80% survival rates have been reported for transplanted fat (5); 3 months should pass to allow for neovascularization before performing any touch-ups. A 20–30% overcorrection is necessary to get the desired result with each grafting session. Bruising, edema, necrosis, and secondary infections can occur postoperatively at both the donor and recipient sites. Serious but rare complications have been reported including middle cerebral artery occlusion and ocular fat embolism (9).

REFERENCES 1. 2.

Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997; 24(2):347–367. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose autotransplants. Aesth Plast Surg 1994; 18:17–19.

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4. 5. 6. 7. 8. 9.

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Bisaccia E, Scarborough DA, Swensen RD. Fat transfer—a ‘‘pinch’’ technique for accurate placement of donor tissue. J Dermatol Surg Oncol 1989; 15:1072– 1073. Horn DB. The wound healing response to grafted tissues. Otol Clin North Am 1994; 27(1):13–24. Perez MI. Autologous fat transplantation: past and current practice. Cosm Dermatol 1999; 12(6):7–13. Asken S. Autologous fat transplantation: micro and macro techniques. Am J Cosm Surg 1987; 4:111. Hudson DA, Lambert EV, Bloch CE. Site selection for autotransplantation: some observations. Aesth Plast Surg 1990; 14:195–197. Fulton JE, Suarez M, Silverton K, Barnes T. Small volume fat transfer. Dermatol Surg 1998; 24:857–865. Feinendegen DL, Baumgartner RW, Schroth G, Mattle P, Tschopp H. Middle cerebral artery occlusion and ocular fat embolism after autologous fat injection in the face [letter]. J Neurol 1998; 245:53–54.

81 A New Technique of Dermabrasion for Traumatic Tattoos Ernest D. Cronin, Payam Shayani, and Mark Jabor Christus St. Joseph Hospital, Houston, Texas

I.

INTRODUCTION

Traumatic tattoos result from the accidental deposition of pigmented particles within the dermis. Dirt, carbon, asphalt, and other substances are deposited in the dermis and result in black or blue pigmentation of the skin depending upon the depth of embedment. The mechanism of entry for the foreign particles is abrasive or explosive trauma. The abrasive tattoos are more common and occur secondary to friction with a road surface such as a fall from motorcycle or bicycle and automobile accidents. The most frequent sites of particulate deposition in abrasive trauma include face, forehead, chin, hands, and knees. The explosive type of traumatic tattoos involve blast injury with firecrackers, firearms, dynamite, and bombs as the source. The explosive deposits are commonly found on the face, around the neck, and hands (Figure 1). The explosive force typically results in a deeper deposition of particles at the foci of the explosion with more superficial particles being embedded circumferentially (1,2).

II. IMMEDIATE TREATMENT Regardless of the mode of injury, the best cosmetic result is obtained by early treatment before the wounds have epithelialized over the foreign particles. This is especially important in facial injuries where after 72 h a complete closure of the wound is expected. Furthermore, during the first few 521

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Figure 1

Patient with traumatic tattooing of face after gunpowder explosion.

hours after the injury the inflammation, edema, and exudation facilitate the mechanical removal of the pigments and result in less residual pigmentation (3). As part of the initial management the pigmented area is cleansed with saline and soap followed by application of Neosporin or petroleum-based antibiotic ointment to improve the miscibility of the pigment (4). This is followed by a trial of conventional dermabrasion with a pear-shaped diamond bur. For many traumatic tattoo injuries this conventional approach is successful and sufficient. For a patient presenting at a later time, after epithelialization of the wound, the treatment may include excision of the largest carbon deposits with a #11 scalpel followed by primary closure with 8-0 or 9-0 monofilament nylon. However, tissue that is deeply stained in small concentrated areas is extremely problematic and several techniques have been described for its treatment (5,6). We describe a new technique for removal of these deeply stained traumatic tattoos.

III.

METHOD

Perioperative administration of antibiotics such as a first-generation cephalosporin is advisable. Pain relief during the procedure is obtained by either general anesthesia or local anesthesia and intravenous sedation. Local anesthesia is administered by injection of 1% lidocaine (Xylocaine) with

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1 : 100,000 epinephrine into and around the involved area by using a 25gauge, 3-inch spinal needle and a 10-mL syringe (1). Perioperative analgesia includes 100 mg meperidine (Demerol) intramuscularly and 20 mg prochlorperazine (Compazine) intramuscularly in combination with 10 mg diazepam (Valium) orally. Refractory pigments that are deposited into the deepest layer of the dermis can be successfully removed by an innovative technique that utilizes a 1-mm otological cutting bur and a Stryker drill (Figure 2). The process is begun by abrading the skin at each site of the resistant pigmentation at a progressively deeper level. The tip of the bur is placed directly perpendicular to the pigmented area and the abrasion is continued until the deep pigment is removed. Often, the bur penetrates deeply resulting in a small full-thickness defect. This process is repeated as many times as necessary until all the resistant pigments are removed. The small defect that results is left open to heal by secondary intention and generally results in minimal to no scar (Figure 3). This technique is easily reproducible, requires a minimal number of instruments, and completely removes the pigment with little trauma to the surrounding unaffected tissue (Figure 4). In contrast, conventional dermabrasion requires considerable more damage to surrounding tissue when the pigment is embedded deeper in the dermis, often resulting in significant scarring.

Figure 2

A Stryker drill and a 1-mm cutting bur used for dermabrading.

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Figure 3 Depiction of the line of sharp debridement and the consequent small fullthickness defect that is left open to heal by secondary intention.

The postoperative treatment includes washing the treated area three times a day with soap and water and application of antibiotic ointment to the affected area two times a day until epithelialization is complete. During this healing process, which may take up to 3 weeks, the patient is instructed to avoid exposure to sunlight in order to minimize the possibility of excessive melanization. The wounds must remain open and the erythema present postoperatively should resolve over the next 4–6 months.

Figure 4

Patient 9 months after the procedure.

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REFERENCES 1. 2. 3.

4.

5. 6.

Agris J. Traumatic tattooing. J Trauma 1976; 16:798–802. Agris J. Adventitious tattooing. J Dermatol Surg Oncol 1976; 2:72–74. Bohler K, Muller E, Huber Spitzy V, Schuller-Petrovic S, Knobler R, Neumann R, Seidl K. Treatment of traumatic tattoos with various sterile brushes. J Am Acad Dermatol 1992; 26:749–753. Edlich RF, Rodeheaver GT, Stevenson TR, Magee CM, Thacker JG, Edgerton MT. Management of the contaminated wound; Compr Ther 1977; 3:67–74. Horowitz J, Nichter L, Stark D. Dermabrasion of traumatic tattoos: simple, inexpensive, effective. Ann Plast Surg 1988; 21:257–259. Kurodawa M, Isshiki N, Taira T, Matsumoto A. The use of microsurgical planning to treat traumatic tattoos. Plast Reconstr Surg 1994; 1069–1072.

82 Sandpaper Mounted on a Safety Razor: A Simple Device for Dermabrasion Nitin J. Mokal Grant Medical College, B.J. Wadia Hospital for Children, Gokuldas Tejpal Hospital, and Shushrusha Citizen’s Co-operative Hospital, Mumbai, India

R.L. Thatte Lokmanya Tilak Municipal Medical College & Hospital and Bhatia General Hospital, Mumbai, India

I.

INTRODUCTION

Dermabrasion is a technique in which the epidermis and parts of the dermis are removed from affected areas to correct skin irregularities. Despite the availability of power-driven instruments, hand-held sandpaper continues to be used for the procedure.

II. METHODS AND MATERIALS Because of the difficulty in handling the relatively rigid sandpaper, we have devised a simple method to achieve a smooth, convex abrading surface. Small sheets of sandpaper are wrapped tautly around the head of an old fashioned safety razor and held in place by transfixing perforation at either end with a screw onto which the razor handle is fixed (Figures 1 and 2). The handle of the razor can be held according to the surgeon’s convenience and 527

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Figure 1

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Method of preparing and attaching sandpaper to razor.

the dermabrasion is performed using either a rotator or a to-and-fro movement. We have so far used only a plastic razor, which is sterilized by standard chemicals used in operating theaters. We have used this technique commonly in patients with postacne scarring (Figure 3), postinfective scarring after smallpox and chickenpox, and posttraumatic depressed scars and as trial dermabrasion prior to complete dermabrasion of epidermal pigmented lesions (Figure 4). Our experience with 25 different types of cases has been encouraging.

Figure 2

Method of using prepared instrument.

Sandpaper Mounted on a Safety Razor for Dermabrasion

Figure 3

Result of dermabrasion using this technique.

Figure 4

Trial dermabrasion of an epidermal pigmented lesion.

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83 Repair of a Split or Deformed Ear Lobe with a Tongue Depressor Blade for Stabilization During Surgery Dee Anna Glaser and Christina Chia Saint Louis University, St. Louis, Missouri

I.

INTRODUCTION

Ear piercing and wearing is associated with many adverse sequelae. The need for repair of the split ear lobe (also known as the cleft ear lobe) dates back to ancient Indian writing (1). Although related to few serious risks, ear piercing has a high complication rate (2). Haughie and Biggar (3) reported a 2% incidence of ear lobe tears in a questionnaire study of nearly 500 women. Cleft ear lobes are commonly acquired from prolonged traction of heavy earrings. Through decades of wear and tear the ear lobes of older women often present as incomplete clefts of elongated or deformed ear lobe canals (1,4,5). Split ear is less commonly due to pressure necrosis from clipon earrings (5) and acute and chronic trauma (1,25). Boo-Chai (1) and Niamtu (6) mention a congenital anomaly, known as coloboma lobuli, consisting of clefting of the ear lobe at birth.

II. TECHNIQUE Upon initial assessment of the split ear lobe, it is important to evaluate the length of the cleft. If the deformity extends to the lower third of the ear lobe, 531

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Niamtu (6) recommends total excision through the inferior portion of the lobe. When doing so, he experienced fewer incidence of bunching and ensured satisfactory results. In our experience, this is not usually necessary. Local anesthesia is obtained with an injection of 1% lidocaine with epinephrine to the anterior and posterior surfaces of the ear lobes. The ear is then prepared with povidone (Betadine). The basic technique involves removing the epidermis and reapproximating the refreshed edges. Then a repair and closure is performed. Usually split ear can be repaired by simple closure, although multiple techniques have been described. It is often difficult to excise precisely the scar tissue to create fresh wound edges. Because of the mobility of the lobe, it is helpful to support the lobe, and we prefer the use of a tongue depressor. The surgeon stabilizes the ear lobe with the nondominant hand by placing a sterile tongue depressor blade posterior to the ear lobe. The tongue depressor provides a simple, inexpensive and practical solution to the dilemma. Chalazion forceps can be used to stabilize the ear lobe as well, but these are not always available.

Figure 1 A sterile tongue blade offers the surgeon a clean and stable background to remove the epidermis of the ear defect.

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Excision of the epidermis is performed. A #11 blade scalpel works well and precisely. Many surgeons describe repair with preservation of the earring canal with such things as sterile toothpicks, transpositional flaps, or 2-0 sutures (1–8). The floor of the canal carrying the weight of the earring is a scar, so other surgeons prefer secondary replacement of a canal after repair and healing (9,10). Z-plasty and L-plasty were presented, respectively, by Hamilton and La Rossa (8) in 1975 and Fearonand Cuadros (10) in 1990 to prevent notching of the healed ear lobe. However, Gajiwala (11) found that Z-plasty gave rise to more pointed rather than rounded ear lobes owing to lengthening. It also increased the possibility of an oblique tear. Any of the techniques listed above can be used to close the wound.

III.

REPIERCING

The conventional approach to repiercing suggests a minimum of 6 weeks after repair; we recommend repiercing 3 months after the repair (4). If

Figure 2

A chalzion clamp can be used to stabilize the ear during surgery.

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immediate repiercing is performed, place a stainless steel ear post through the sutured wound. Gold or other types of ear posts should be avoided in open wounds because of the predisposition to develop allergic contact dermatitis from contact with tissue fluids (12). The suture lines are cleansed twice daily with peroxide and antibiotic ointment. Nylon sutures are removed 7 days after the repair. If earrings were placed at time of the repair, rotate them twice a day to encourage fistulization, which may take 3–6 months to complete.

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Boo-Chai K. The cleft ear lobe. Plas Reconstr Surg 1961; 28:681–688. Hendricks WM. Complications of ear piercing: treatment and prevention. Cutis 1991; 48:386–394. Haughie GE, Biggar RJ. Medical problems with ear piercing. NY State J Med 1971; 71:460–462. Tan EC. Punch technique: an alternative approach to the repair of pierced ear lobe deformities. J Dermatol Surg Oncol 1989; 15:270–272. Pardue AM. Repair of torn earlobe with preservation of the perforation for an earring. Plas Reconstr Surg 1973; 51:472–473. Niamtu J. Surgical repair of the cleft earlobe. J Oral Maxillofac Surg 1997; 55:886–890. Elejabertia J, Lasso JM. Elliptical punch to repair incomplete cleft earlobe. Ann Plast Surg 1998; 41:569–570 Hamilton R, LaRossa D. Method of repair of cleft earlobes Plas Reconstr Surg 1975; 55:99–101. Apesos J, Kane M. Treatment of traumatic earlobe clefts. Aesthetic Plast Surg 1993; 17:253–255. Fearon J, Cuardos CL. Cleft earlobe repair Ann Plast Surg 1990; 24:252–257. Gajiwala K. Repair of the split earlobe using a half Z-plasty. Plas Reconstr Surg 1998; 101:855–856. Chernosky ME. One step procedure for earlobe surgical repair and ear post replacement J Am Acad Dermatol 1985; 12:721–723

84 Traction-Modified Blepharoplasty Paul J. Weber Private Practice, Fort Lauderdale, Florida


I.

INTRODUCTION

Although increasing mechanization, tools, and surgical fields are the recent general trend in surgery, in selected procedures it may be that simplification may actually enhance performance, shorten overall procedure times, and moderate costs. Potential complications in blepharoplasty surgery have been summarized elsewhere (1). In this chapter, we will discuss blepharoplasty techniques that require less surgical instrumentation and time; many are based upon the application of traction. Normally, only one ‘‘scrubbed’’ surgical assistant in association with an experienced surgeon is necessary to perform the techniques described here. However, the use of a second assistant during orbital fat removal may facilitate the performance of these procedures. Assistants are trained and directed not to place pressure on the globe for > 40 s without an intermission, so as not to compromise retinal blood flow. The technique is facilitated by the use of 2 2 (and occasionally 4 4) gauze in positioning of, and applying pressure to, the eyelids. Periorbital and orbital tissue manipulation is best performed using gauze that is opened into one- or two-ply leaflets. Thicker stacks of gauze may cause lack of control and sliding and are not recommended. It is noteworthy that the use of a real cotton gauze is preferred, not the artificial organic polymer substitutes like Nu-gauze. Real cotton absorbs blood, oil, and serum better and there is a higher coefficient of friction between a moist, dry, or oily 535

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cotton gauze and the underlying dermis, fat, or overlying epidermis. The only apparent disadvantage of real cotton is that improper assistant manipulation in distracting or supporting a lid could result in a more severe corneal abrasion versus than what might have resulted from a synthetic cotton-like substitute. With appropriate use of the technique described here, this does not happen. The technique is also facilitated by the elimination of any facial draping. Sterile boundaries (drapes) are placed and meticulously maintained under the head and around the upper neck. The ability to view the entire face during the blepharoplasty aids in achieving a more integrated or natural looking result than can be obtained if the surgeon sees the patient’s eyes as isolated from the rest of the face. Facial symmetries and asymmetries extending well beyond the orbit thus may be taken into account to improve or modify appropriately the blepharoplasty and therefore to achieve a better balance. Gas-sterilized surgeon’s bonnets or sterile tapes are used beyond the hairline to keep the patient’s hair in place following a double prep—first with alcohol as a degreaser and then with a 5% povidone-iodine (Betadine solution). The authors have a combined total of over 2000 eyelid surgeries with this technique and have had no infections. The use of the methods described here has virtually eliminated the use of the cotton-tipped swabs, hemostatic clamps, or skin hooks during blepharoplasty. A notable exception is ptosis surgery where levator aponeurosis localization and dissection via a moistened cotton-tipped swab are preferred. The use of this technique and various associated ‘‘pearls’’ vary depending on the location and type of blepharoplasty surgery.

II. UPPER BLEPHAROPLASTY The upper lid is marked with minute dots spaced 0.5 mm apart. The most minute dots are best achieved by sharpening the tip of a sterile surgical marking pen using the proximal portion of a #15 scalpel blade. Two percent lidocaine with 1 : 100,000 epinephrine is administered via a 3-mL syringe and 30-gauge needle and allowed to permeate the local tissues of 10 min to provide maximal operative hemostasis. A single leaf of cotton gauze is advanced just over the upper lid lash line and is used to distract caudally the upper lid. The epidermis, dermis, and orbicularis then are incised with a #15 scalpel blade at a 30-degree bevel angle by cutting through the exact center of the lower curve of dots (Figure 1A and B). A spread of 2–3 mm is desired on a single scalpel pass so as not to serrate a wound edge. Next, a gauze ply is advanced over the lower (crease) incision, which effectively controls and absorbs bleeding. Stretch then is applied to the proposed

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upper incision area that is now about to be incised. If any bleeding from the crease incision starts to leak laterally, a sterile 2 2 gauze is placed over the temple extending laterally from the canthus. The forces of adsorption and capillary action initiate and make the gauze stick easily. The lack of a cumbersome surgical facial drape allows for complete observation of the temple area for sanguinous leakage. If the temporal 2 2 gauze becomes saturated, it may be replaced easily. The advanced gauze is now drawn caudally along with the underlying lid. A #15 scalpel blade is then passed to bevel the upper lid superior incision at a 30-degree angle from medial to lateral. Depending upon how much skin should be removed, the scalpel may pass through the exact center of the surgical marker dots or below them. In patients with a preoperative ‘‘flat’’ orbit, less skin is taken so that if these techniques are aggressively employed and desirable sulci are created about the eyes, sufficient skin will be available to cover the invaginations and avoid lagophthalmos. As before, a wound spread of 2–3 mm is desired via a single scalpel incisional pass so as not to cause serration. A bulb- or blunt-tipped curved, preferably serrated, scissors is used to undermine, in the orbicularis plane, the tissues demarcated by the incisions. Electrocoagulation is usually still not used even to this point. Careful strip thinning of the dermal and muscular and fatty tissues superior to the uppermost upper lid incision aids in bringing about the most desirable tissue match postoperatively. Even with current resurfacing procedures, a postoperative upper eyelid tissue mismatch is usually quite evident to both surgeons and patients. Upon strip thinning these tissues, mostly orbicularis and dermis, with an iris scissors (see Figure 1C), significant bleeding may occur. At this point, a 4 4 gauze is sometimes substituted for the temple 2 2 gauze. Usually, it is preferred not to coagulate any vessels until all of the excess tissues have been removed. Thus, a root or ‘‘feeder’’ vessel may be identified and can usually be more efficiently coagulated; thereby saving time and reducing overall bleeding. A 4 4 gauze is then used to roll back-up the strip-thinned tissues superior to and hidden beyond the upper incision; thus, exposing all vessels, including those on periosteum and those on the underside of the dermis. The use of quality electrosurgical generator with a Colorado needle for accurate application of energy is preferred (see Figure 1D). Some surgeons advocate the use of the carbon dioxide laser for virtually all aspects of blepharoplasty (2). However, the severed vessel trunks generated by the strip-thinning process described here may be larger than the vessels encountered by those who advocate total laser usage. Failure to coagulate all significant vessels could result in a tracking or expanding hematoma. Current lasers do not provide equivalent retrograde coagulation down target vessels in the strip-thinned tissues and may be less efficient at providing hemostasis for the larger, most significant

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Figure 1 (A) Upper blepharoplasty: The inferior (crease) upper eyelid incision is made using a #15 blade scalpel with a 30-degree inferiorly angled bevel. (B) Upper blepharoplasty: The superior upper eyelid incision is made using a #15 blade scalpel with a 30-degree inferiorly angled bevel. (C) Upper blepharoplasty: Removal of redundant orbicularis and dermis strip thinning using iris scissors. (D) Upper blepharoplasty: Electrocautery of bleeding vessels using a bent, disposable, sharp-tipped needle.

vessels encountered in this technique. Once all identified bleeding vessels are coagulated, the surgeon moves on to discover the fatty compartments working from the midpupillary line medially. Fatty pockets are carefully identified, incised, and teased with forceps and bulb-tipped scissors while the primary assistant applies pressure via a 2 2 gauze placed over the lower eyelid and globe as well. Ocular fat is removed via forceps with delicate manipulation using the needle of an electrosurgical device as a probe with which to tease the periorbital fatty deposits. The surgeon injects local anesthesia into the encased emerging fat, sometimes causing a small canthal ‘‘puddle’’ of local anesthesia. The puddle is efficiently and quickly controlled and removed using gentle gauze blotting by the secondary assistant. Fat is removed as a continuous strand by pulling, electrifying, and teasing gently. Depending upon the case, sometimes a 2- to 3-cm–long strand is generated. Further traction on the strand aids in the presentation of yet further orbital fat to become a proximal portion of


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the ever-developing strand. The second assistant, preferably standing behind the head of the patient, is instructed to blot intermittently and appropriately using a tightly rolled 2 2 gauze, which can be secured into the jaws of a hemostat if desired. A moistened gauze is placed over the incision to monitor sanguinity and protect the site from drying until the completion of the contralateral lid. Before 7-0 polypropylene running cuticular epidermal closure, three or four 6-0 polyglactin sutures are placed in a lateral to medial order, and in a buried interrupted fashion, to unite the upper eyelid incisions. The remainder of the upper lid procedure may be performed by any number of previously described methods (3–5).

III.

SKIN OR MUSCLE FLAP LOWER BLEPHAROPLASTY

No gauze, assistant, or pressure on the globe is necessary until after the subciliary incision is completed. The lower lid procedure begins by incising the lateral canthal dermis at an angle to < 1 cm. The canthal incision allows an undermining scissors to gain access to either the high orbicularis plane (for a skin flap) or the lower orbicularis-septal plane (for a skin-muscle flap). Upon detecting a septal plane of free and easy, nonresistant undermining extending to the lid margin and the orbital rim, scissors undermining is complete. A sharp, curved iris scissors is then used to incise carefully and smoothly the dermis and orbicularis from the lateral canthus medially. The subcilliary incision is located no closer than 2 mm to the lashes; a slight bevel may be desirable depending upon tissue quality. The subciliary incision may initially be separate from the initial lower lid undermining plane. Therefore, a scissors, preferably serrated, may be necessary to connect the subciliary incision and the previous scissors-undermined plane. Once the desired flap is united and formed, a 2 2 gauze is used to roll down the lower lid flap, hold it in place, and allow the second assistant to gauze blot for easier electrocoagulation of bleeders (on both the inner flap side and exposed deeper tissues). This obviates the need for skin hooks in traditional lower subcilliary blepharoplasty. We remind the readers that exact pinpoint and delicate coagulation of both sides of all generated eyelid flaps is necessary to avoid hematoma formation, because the two sides of vessels both capable of active bleeding owing to networking may be separated by the undermining process. Gauze and pressure are placed as shown to isolate fat, pronounce the fat, and remove fat electrosurgically. Electrocoagulation without clamping is preferred with the techniques described here. Lower lid blepharoplasty techniques and variations thereof have been described in the literature and may be applied or intermixed with the aforementioned methods (6–9).

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TRANSCONJUNCTIVAL LOWER BLEPHAROPLASTY

Transconjunctival blepharoplasty, especially in a ‘‘tight’’ lower lid, requires the most harmony between surgeon and assistant with the technique at hand. Gauze and a Jaeger lid plate are placed as shown in Figure 2A. The lower lid is pulled and gently pressed while a bent electrosurgical apparatus incises the conjunctiva linearly 5–7 mm from the eyelid margin on forceps stretching (Figure 2A). The gauze leaflet never crosses the lid margin when this maneuver is performed properly. Paradoxically, we have found our greatest display of fat for removal with proper pulling and pressure directed caudally via the gauze placed on the lower eyelid. It is possible the rolling torque applied to the tissues in this fashion also aids pressuring the fat to protrude (Figure 2B and C). Fat is removed, preferably as a strand, as previously described (Figure 2D) and temporarily placed on the

Figure 2 (A) Transconjunctival lower blepharoplasty: the conjuntiva is incised 3– 5 mm below the lower lid margin using cutting current and a bent, disposable, sharptipped needle. (B) Transconjuntival lower blepharoplasty: The lower eyelid is pulled inferiorly, thus protruding the lower eyelid fat pads. (C) Tansconjuntival lower blepharoplasty: Maximal exposure of lower fat pads can be easily accomplished, although rarely necessary, via the traction-assisted technique. (D) Transconjuntival lower blepharoplasty: Fat is removed as a strand by pulling, electrifying, and gently teasing.


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primary assistant’s sterile glove (dorsal hand) to save time intraoperatively. Usually, the eyelid fat pads most commonly missed by surgeons are the lateral lower pads; a key to removing these pads is to perform the left lateral lower fat pad removal from the patient’s right side and vice versa. Contralateral visualization down into lateral deep pockets is helpful and fat removal is made much easier. A young man’s transconjunctival blepharoplasty was performed in this fashion (Figure 3). A final noteworthy comment regarding transconjunctival blepharoplasty performed using this method is that traction on the lower lid causes a ‘‘reversible stretching’’ of the lateral tendon and of the lower lid in general, probably including some lid margin elements as well. This reversible lid stretching usually begins with the first several minutes of proper pressure and pull. In many cases, this temporary ‘‘disconnect’’ allows for increased visualization, a better ability to remove fat from even the tightest lids, and obviates the need for a combination lateral canthoplasty. It is important for the surgeon and patient to appreciate that it may take 24–48 h after transconjunctival blepharoplasty for the stretched sutures to retract. Sometimes retraction takes longer if there is conjunctival swelling and inflammation induced by the blepharoplasty. A downside to performing blepharoplasty in the aforementioned fashion is that an untrained or inattentive primary assistant may significantly scratch the cornea using the cotton gauze; however, this has never happened in our practice. Repositioning or positioning of the initial gauze movements by the surgeon is important. Slightly saline- or anesthesia-moistened gauze may decrease friction and the possibility of a corneal abrasion. As the surgeon and assistants become more adept at this technique, drier gauze can be used. Minor abrasions are rare even when training new personnel in this technique. Postoperative ophthalmic ointment may remedy this problem. Transconjunctival techniques previously discussed in the literature may be performed in conjunction with the methods described here (10,11).

V.

PLANNING AND PERFORMING MULTIPLE EYE PLASTIC PROCEDURES

Depending upon the lower eyelid procedure to be performed, whether alone or in combination with an upper eyelid procedure, the following is the recommended order of events. If a transconjunctival lower lid blepharoplasty and an upper lid blepharoplasty are to be performed on the same patient, it is suggested to score the upper lid incisions first, then perform the transconjunctival procedure, and then return to complete the upper lids. By performing the procedures in this order, less tension and trauma are

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Figure 3 (A) Lower eyelids—preoperative: 42-year-old male. (B) Lower eyelids— 20-min postoperative result after transconjunctival lower blepharoplasty. Note: the asymmetry seen on forward gaze lasted 30 min postoperatively because of unopposed ocular muscle function caused by local anesthetic injections into the fat. (C) Lower eyelids—2-month postoperative result of transconjuntival lower blepharoplasty; laser resurfacing was performed 1 month postblepharoplasty.


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incurred by the upper lid 7-0 polypropylene (Prolene) suture line. When performed in combination with a skin or skin-muscle lower eyelid flap, we suggest performing the upper blepharoplasty first, because there is usually less undermined and altered upper eyelid tissue to press on when a surgeon attempts to display, protrude, and excise the lower (opposite) eyelid fat. If a ptosis procedure and an upper and a lower blepharoplasty are to be combined, it is recommended to perform the ptosis procedure last, as swelling and patient cooperation may change depending upon the duration of the procedure.

VI.

LASER RESURFACING

‘‘Laser finishing’’ is an integral part of the aforementioned procedure. If only a lower lid transconjunctival blepharoplasty is performed or an upper lid nasal pad transconjunctival blepharoplasty is performed, then the resurfacing laser is used at the close of these procedures. However, all areas of epidermal stitching are to be avoided with the resurfacing laser, which is usually used 2–5 weeks following suture removal. A Sharplan Silk Touch CO2 laser is used at settings of 13–17 W, 0.5 s on time and 0.4 s off time, using a 10-mm square scan shape. All periorbital and glabellar rhytids are highlighted by dotting with a marker. One resurfacing laser pass is made to the entire area with the outermost areas receiving irregular projecting scans that cover the linked areas. Occasionally, a second laser pass is made to the thicker outermost-lying rhytids depending on the character of the skin and nature of the rhytid. If an upper lid blepharoplasty was performed, the CO2 resurfacing laser should overlap the upper lid incision by only 2 mm. This helps to minimize laser exposure to the upper lid pretarsal tissues. The laser finishing procedure has several benefits, including allowing greater patient latitude/ selection in the usage of the transconjunctival approach (less need for scalpel reduction of wrinkles), tightening of the medial upper lid redundancy that is preferably left (not excised) over a reduced medial fat pad, and improving the matching of lateral upper lid tissues (Figure 4). Again, if only a transconjunctival upper or lower blepharoplasty is performed, then it is recommended to first perform the blepharoplasty followed immediately by laser finishing while the patient is still anesthesitized. If any upper lid or a traditional lower lid epidermal or dermal incisional procedure is performed, then laser finishing over the upper lid incision 1 month postoperatively is suggested. This appears to be the optimal time delay interval allowing proper wound healing.

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Figure 4 (A) Upper and lower eyelids—preoperative: 47-year-old female. (B) Upper and lower eyelids—2-month postoperative upper and lower transconjunctival blepharoplasty; CO2 laser resurfacing was performed 1 month postblepharoplasty.

VII.

CONCLUSIONS

The use of these techniques produces cosmetic results that are at least equivalent if not superior to and more natural than blepharoplasty performed in the traditionally described manner. The minimization of instrumentation and surgical draping reduces overall operative time and offers improved visualization. The use of hooks, forceps, and cotton-tipped applicators has been eliminated or greatly reduced, as well as their attendant possible concerns, including hook sticks, operating room personnel, forceps wound trauma, and the limited availability of sanguinous or other fluid absorption of applicators. Thus, the proficient surgeon can focus more on the performance of blepharoplasty techniques critical for optimal cosmetic outcome and patient satisfaction.


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6. 7. 8. 9. 10. 11.

Dortzbach RK. Ophthalmic Plastic Surgery: Prevention and Management of Complications. New York: Raven Press, 1994. David LM, Sanders G. Carbon dioxide laser blepharoplasty: a comparison to cold steel and electrocautery. J Dermatol Surg Oncol 1987; 13:110–114. Seigel RJ. Advanced upper lid blepharoplasty. Clin Plast Surg 1992; 19:319– 327. Gradinger GP. Cosmetic upper blepharoplasty. Clin Plast Surg 1988; 15:289– 296. Scaccia FJ, Hoffman JA, Stepnick DW. Upper eyelid blepharoplasty. A technical comparative analysis. Arch Otolaryngol Head Neck Surg 1994; 120:827– 830. Aston SJ. Orbicularis oculi muscle flaps: a technique to reduce crow’s feet and lateral canthal skin folds. Plast Reconstr Surg 1980; 64:206–216. Hamra ST. Repositioning the orbicularis oculi muscle in composite rhytidectomy. Plast Reconstr Surg 1992; 90:14–22. McCord CD, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Reconst Surg 1998; 102:2471–2479. Rees TD, Tabbal N. Lower blepharoplasty with emphasis on the orbicularis muscle. Clin Plast Surg 1981; 8:643. Zarem HA, Resnick JI. Expanded applications for transconjunctival lower eyelid blepharoplasty. Plast Reconstr Surg 1991; 88:215–220. Baylis HI, Long JA, Groth MG. Transconjunctival lower eyelid blepharoplasty. Ophthalmology 1989; 96:1027.

85 Visible Incision Reduction in Cosmetic Oculoplastic Surgery Paul J. Weber Private Practice, Fort Lauderdale, Florida


I.

INTRODUCTION

Visible scarification following cosmetic eyelid surgery that is readily detectable is generally considered undesirable or unnatural. In addition to a negative impact on appearance, surface scarification may have the adverse consequences of anatomical distortion, ectropion, lid retraction, exacerbation of rosacea, and dry eye syndrome (1). Visible scarification and persistent wrinkling following blepharoplasty surgery have been reduced by the transconjunctival approach and laser resurfacing (2,3). Various techniques in blepharoplasty surgery are described in this chapter that may be used singularly or in combination to facilitate the procedure or minimize visible scarification and tissue trauma: (1) a diminished, laterally positioned upper lid incision with a tunneled approach or a transconjunctival approach to the medial upper fat pocket, (2) nonexcisional removal of hypertrophic orbicularis of the lower eyelid via two electrosurgical methods, (3) limited and irregularly patterned laser resurfacing with altered time sequence of delivery, (4) contralateral approach to the temporal lower lid fat pads, and (5) use of electrosurgically excised orbital fat for placement into distant facial rhytids or folds. The typical patient profile benefiting from such procedures includes men and women with steatoblepharon and mild to moderate skin excess of 547

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the lower and upper eyelids. However, patients with conditions beyond this spectrum may respond well to the techniques described here. Proper execution of these techniques may yield a more natural look with similar operative times.

II. UPPER LID BLEPHAROPLASTY TECHNIQUE AND MODIFICATIONS Traditional methods of upper lid blepharoplasty have been well documented in the literature (4–8). The techniques described here may be used in combination with previously cited techniques except where a directive to the contrary exists. Patients not allergic to iodine are prepped with alcohol as a degreaser followed by iodine and pat dried. Before sedation, the natural upper eyelid creases are demarcated with a sharpened sterile marker with 0.5-mm dots placed 1 mm apart. Natural lid creases may not be incised in cases of asymmetry or at a patient’s request. The scrotal (highly wrinkled) skin initially is superiorly demarcated with a marker to within 10 mm of the eyebrow hairs by 0.5-mm dots. This line marks the least amount of skin that must remain between the brow and the superior margin of the upper skin incision. The lines of demarcation are tested with smooth forceps to predict the potential for lagophthalmos. However, depending upon gender and the shape of the protruding ocular adnexa, less skin will be removed to allow for the epidermis to redrape and cover the potential concavities created as a result of the surgical removal of underlying obtital fat, orbicularis muscle, and dermis. Skin excision is typically less aggressive in men than in women. After marking, 2% lidocaine with 1:100,000 epinephrine is injected followed by injections of a 50/50 mixture of 2% lidocaine and 0.5% bupivicaine with epinephrine. A #15 scalpel blade is passed with a 30-degree bevel across the dots marking the lid crease to the level of the mid orbicularis. Again, the superior markings of patients displaying prominent fat are rarely incised. For patients presenting with an already concave orbit, a 2mm ‘‘cushion’’ of excess upper lid skin is maintained between the superior markings and the true superior incision if a laser resurfacing is planned to allow for potential or resultant skin contraction. For patients presenting with a flat orbit, a cushion exceeding 2–4 mm is desirable, especially medially. The cushion of apparent excess superficial skin can be modified or reduced by laser resurfacing several weeks following suture removal. Superior and inferior incisions are scalpel beveled in opposite directions, yielding a wound spread of 2–3 mm to the orbicularis. A single scalpel

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pass is made so as not to cause edge serration. The upper incision should join or intersect the lower incision at a hypothetical vertical line tangential to the medial portion of the iris. Limited incisions should rarely extend lateral to this landmark if a laser resurfacing is planned (Figure 1).

Figure 1 Diagrammatic representation of the laterally based upper lid excision shows medial limit of upper lid beveled incisions. Broken lines depict areas where limited conjunctival incisions permit fat removal. (A) Elongate lateral lower transconjunctival incision for greater surgical exposure. (B) Three separate minute lower transconjunctival incisions for minimization of conjunctival and retractor trauma.

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The incised upper eyelid tissue is excised with an electrosurgical needle or scissors to a depth approaching the mid thickness of the orbicularis muscle. Any pretarsal, preseptal, or preorbital orbicularis remaining caudal to the superior incisions is not removed. The presence of some undisturbed orbicularis appears to reduce postsurgical edema as seen in contralateral comparisons with aggressive contralateral orbicularis removal. After the upper lid skin and muscle excision, cautious and uniform yet relatively aggressive sharp scissors removal of dermis and orbicularis superior is performed medial to the excision. Depending on the case, this superior orbicularis and dermal excision may be aggressive and is extended 0.5– 1.0 cm under the dermis and epidermis beneath the eyebrow. Continued thinning of tissues in strips (including orbicularis, dermis, and brow fat) via sharp iris scissors excision superior to the uppermost upper lid incision is performed to bring about the most desirable incisional tissue match postoperatively. Lack of or inappropriate tissue thinning may yield a postoperative upper eyelid tissue mismatch that both surgeons and patients may dislike. During strip thinning of these tissues, mostly orbicularis and dermis, with an iris scissors significant bleeding occurs which is best positioned and rectified using cotton gauze. Preferably vessels are not coagulated until all of the excess tissues have been removed. A bent Colorado needle attached to a high-quality electrosurgical device is favored for pinpoint coagulation. It is more expedient to excise tissues and vessels distal to vascular bifurcations rather than electrocoagulating or lasing them, because further excision may be required beneath the coagulated surface to reach an optimal level of removal and a desirable final result. A 4 4 gauze is favored to roll backup the tissues superior to the excision with slight traction, thus exposing all potential bleeding vessels, including those on periosteum and on the underside of the dermis. Again, singular root vessels can usually be more efficiently coagulated, saving time and often reducing overall bleeding. Inadequate coagulation may result in a significant postoperative hematoma. Laser for coagulation is not advocated at this phase of a blepharoplasty, because laser-induced vascular sealing appears to be less efficient for significantly sized vessels. To reach middle upper fatty pockets, incisions are made through the orbital septum and fat pad capsules via a 3- to 4-mm ‘‘window,’’ as shown in Figure 1. After removal of the middle fat pad, the levator aponeurosis and muscle are inspected. Next, the nasal fat pad is approached. Smooth small blunt scissors will effect the dissection, so it should be approached with caution to avoid perforating the levator complex. The dissection is facilitated by the previously described ‘‘tunneling’’ removal of orbicularis muscle directed toward the medial canthus (hidden beneath the intact epidermis just medial to the superior incision). Because of the limited exposure effected by


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a restricted incision, a > 1-cm tunnel must frequently be developed before the nasal fat pad or its fibrous encasement is reached. The orbital fat pads, encased by their capsules, are identified carefully with forceps and incised < 3 mm while the primary assistant applies pressure through a 2 2 gauze placed on the opposing side of the globe. Additional local anesthetic may be injected at this time. The contents of the capsule are dissected further under delicate forceps, stretching and teasing with the sharp-tipped electrosurgical needle, while fibrous encasing septa are ruptured. The electrosurgical needle efficiently delivers the orbital fat in long strands via forceps (electrical energy not being applied during portions of the manipulation phase). Depending on the patient, a continuous strand of fat is formed often measuring over 2 cm in length per fat pad. In 90% of cases, the limited upper eyelid incision is performed extending medially no more than the medial limbus, thus requiring the removal of the upper nasal fat pad via a 1.0- to 1.5-cm tunnel pointing inferomedially. No currently available skin laser appears to be superior to electrosurgical methods regarding the removal of the medial fat pad in a tunnel of the length and depth rendered by such a limited upper lid incision. Aggressive removal of the nasal fat pad is advocated, especially in women. It appears that weak septal and fibrous capsular encasements as well as excessive fat are responsible for protruding orbital fat pads. Therefore, simply ‘‘tightening’’ weakened septa to hold back nasal fat pads, particularly very prominent pads, does not seem to halt their eventual protrusion. An alternative upper lid blepharoplasty technique using a transconjunctival approach is convenient when only the nasal fat pads need to be addressed (9). A decade of experience with this technique has yielded the following observations: Transconjunctival upper lid nasal fat pad removal is facilitated by placing a temporary 5-0 retraction suture superior to the lashes along the lid margin 1 cm from the medial canthus. Preferably, a hemostat is used to retract the 5-0 suture. A Jaeger lid plate is then placed over the medial superior globe and pressed slightly to force the medial fat pad into prominence beneath the intact conjunctiva. A 2- to 3-mm incision in the nasal upper lid conjunctiva is made with a sharp scissors. Careful probing of the scissors while minimally opening and closing the scissors tips will allow the eventual encounter of an edge of the nasal pad capsule. This pad is then teased and pulled through the incision aided by the forces placed on the lid pate and along the retraction suture. Care and caution should be exercised during the transconjunctival delivery of the upper eyelid nasal fat pad because of the relative tenuousness of the medial horn of the levator aponeurosis at its medial attachment (along with the medial check ligament) into the medial orbital wall. A relatively large incision in the transconjunctival space could injure the dia-

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phanous connective tissue of the medial horn. Incisions in this location may be used to correct eyelid retraction and can result in profound medial ptosis; this may cause a flattening of the eyelid contour. The transconjunctival technique to approach the medial fat pad should be done meticulously and only via an extremely small conjunctival incision. If one is not performing procedures such as suborbicularis oculi fat modification, Hamra’s composite rhytidectomy repositioning the orbicularis oculi muscle (10), canthopexy, or an open technique for the electrosurgical removal of hypertrophic orbicularis in conjunction with upper or lower blepharoplasty, pinpoint delivery of the fat for identification and removal may be preferred. Pinpoint or minimal incision delivery of fat is performed in an effort to minimize lid structure trauma and maintain as much of the natural ocular anatomy as possible (Figure 1). Fat delivery through 3-mm incisions into the septum or fibrous encasements reduces overall tissue injury, reduces inadvertent tissue injury risk, appears to reduce healing time, and preserves anatomy for future eyelid surgeries. Laser resurfacing is almost routinely used at some time following upper lid blepharoplasty to enhance results and will be discussed in a later section. Results of incision reduction upper lid blepharoplasty techniques may be seen in Figures 5–10 and 18–21.

III.

LOWER LID BLEPHAROPLASTY TECHNIQUES AND MODIFICATIONS

Various techniques to simplify and improve lower eyelid blepharoplasty will be described. However, some patients with severe lower lid skin excess, ‘‘bags on bags,’’ or a history of blepharochalasis may not be good candidates for these procedures. Such conditions may best lend themselves to a subcilliary incision that will allow greater direct excision of the hypertrophic orbicularis and space for imbricating or plicating remaining orbicularis (7,8,11). Midface periosteal suspension of lax tissues and other techniques may be more easily approached and best executed with the greater exposure (10,12,13). For patients with little steatoblepharon of the lower lids and prominent hypertrophic orbicularis, the ‘‘closed approach’’ of electrosurgery may be used as described later. The lack of steatoblepharon may reduce the need for transconjunctival surgery. However, a transconjunctival fat removal is performed if the patient, on superior gaze, shows bulging lower eyelid fat pads; this finding on examination or when tested may indicate a propensity


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for noticeable steatoblepharon in the future. If epidermal and dermal wrinkling is present as well, then laser resurfacing may be considered. A.

Transconjunctival Lower Blepharoplasty

Transconjunctival techniques previously discussed in the literature may be performed in conjunction with, or substitute for, some of the methods described here (2,14). Following conjunctival anesthetic eyedrop application, 2% lidocaine with 1 : 100,000 epinephrine is injected transconjunctivally followed by injections of a 50/50 mixture of 2% lidocaine and 0.5% bupivicaine with ephinephrine. The lower lid is caudally retracted with cotton gauze leaves; simultaneously, a Jaeger lid plate is pressed gently against the globe. The Colorado needle linearly incises the conjunctival surface caudal to the tarsus (5–7 mm from the eyelid margin) from lateral to medial, with cutting current applied, while a forceps stretches a conjunctival wound edge to minimize thermal damage by reducing contact. Pressure directed caudally through the gauze placed on the lower eyelid appears to provide the greatest display of fat and to facilitate removal. Rolling torque applied to the lid in this fashion may pressure the fat to protrude. The fat is then pulled, electrified, and teased gently into a strand. Again, a continuous strand of fat is desired, often measuring over 2 cm in length per pad. Surgeons frequently fail to remove the lateral lower fat pads sufficiently, possibly because of technical difficulties in visualization or fat presentation. A potential aid to removing these pads is for the surgeon to perform the left lateral lower fat pad removal while positioned on the patient’s right side and vice versa. Contralateral visualization deep into lateral fat pockets is helpful and facilitates fat removal. Occasionally, adequate exposure of the lower eyelid anatomy for fat removal is still difficult. In that case, slightly greater subcilliary lower lid gauze caudal traction administered by an assistant may reversibly stretch the lower lid supporting structures. This additional traction on the lower lid usually yields a ‘‘reversible stretching’’ of the lateral tendon and other posterior lamellar elements as well within several minutes. This stretching may allow for increased visualization to aid in removing fat from even the tightest lids, and may obviate the need for a combination lateral canthoplasty or disinsertion. However, stretching the supporting tissues of the lower lid can modify the efficiency and accuracy of the placement of the positioning needle in the ‘‘open approach’’ to hypertrophic orbicularis described later. Both surgeons and patients should appreciate that it may take 24–48 h posttransconjunctival blepharoplasty for the stretched structure to normalize. Normalization may take longer if there is conjunctival swelling and inflammation induced by the blepharoplasty. Care should be taken to advise, counsel, and counter

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the effects of tissue stretching should it not be reversible within 1–2 days. This has not occurred in over 300 cases of relatively tight lower eyelids and transconjunctival blepharoplasty. After the transconjunctival removal of the fat, a suborbicularis oculi fat (SOOF) procedure and arcus marginalis release may be performed. Additionally, at this time, any hypertrophic orbicularis tissues may be managed. This management may be effected simultaneously by the open technique or a month later by the closed technique to be described. As an aside, the unwashed eyelid fat harvested during blepharoplasty may be placed in sterile saline cooled in an ice bath for later use for facial injection via 3-mL syringe and 14-gauge needle. Typical areas of successful placement include the subvermillion lips, nasolabial folds, facial depressions, and chin. Completeness and duration of correction appear to be better than or similar to fat harvested from donor sites outside of the ophthalmic region. However, it should be noted that piecemeal removal of the fat with electrosurgical energy could damage the harvested fat to varying degrees. Extensive electrical damage to fat may reduce the final yield of correction.

IV.

TECHNIQUES FOR TREATING HYPERTROPHIC ORBICULARIS

Hypertrophic orbicularis may be appreciably altered via two electrosurgical techniques: an open method, usually performed in conjunction with a transconjunctival blepharoplasty, and a closed method whereby a specially formed and insulated electrosurgical needle is arced through the target tissue and energized upon withdrawal. Destructive heat is created, because target tissues resist the passage of current. Controversy regarding proper nomenclature for electrosurgery exists. There is consensus that the terms monopolar and bipolar are not technically correct. They do not apply to alternating current, because the direction of current changes millions of times per second and therefore positive and negative poles do not exist. Various workers disagree on the use of the terms monoterminal and biterminal. However, most agree that the use of a return electrode/dispersion plate qualifies for biterminal surgery. Traditionally, electrodessication and electrofulguration are monoterminal-based and electrocoagulation is biterminal. The various tissue effects of applied current are not mutually exclusive. Frequently, electrocoagulation and electrodessication are achieved in a simultaneous or sequential manner (15). Electrocoagulation, or high-frequency, highamperage, low-voltage, damped surgery with the use of a dispersion plate


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is the form of electrosurgery recommended for use in the open and closed methods of hypertrophic orbicularis modification. A.

Open Technique of Hypertrophic Orbicularis Modification

The open approach is performed at the conclusion of lower transconjunctival blepharoplasty. Before any anesthetic injection, prominent orbicularis is marked and the approximate vertical and horizontal dimensions are noted. Once the transconjunctival fat has been removed, a plastic-hubbed, 1-inch, 22-gauge positioning needle is passed from temporal to medial in an arc along the curve of the marked orbicularis immediately beneath the epidermis, as demonstrated in Figure 2. A small hemostat or the barrel of a 1-mL tuberculin syringe may be attached to this 22-gauge positioning needle to allow for better leverage and control. To position the tissue for treatment, a forceps is used to hook and roll the superior aspect of the transconjunctival incision anteriorly with one tooth. Across the incision, the 22-gauge positioning needle itself should not be visualized and it should be hidden by the target orbicularis. If seen, the 22-gauge needle should be repositioned. The 22-gauge needle is a positioning needle only and is not to be energized or electrified. Electrification by fulgurating spread is performed using a ‘‘COAG’’ mode; this is shown diagrammatically in Figure 3 and photographically in Figure 4. The settings are idiosyncratic for each electrosurgical

Figure 2 A 22-gauge positioning needle entering at lateral canthus just subdermally after performance of an otherwise typical transconjunctival blepharoplasty.

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Figure 3 Diagrammatic representation of lower lid forceps eversion causing the orbicularis to be tented over the positioning needle. The electrosurgical unit is activated using COAG setting seeking visible tissue shrinkage.

Figure 4 Photographic representation of lower lid forceps eversion causing the orbicularis to be tented over the positioning needle. The electrosurgical unit is activated using COAG setting seeking visible tissue shrinkage.


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generator, so the surgeon should initially start on a low setting and gradually increase the power if deemed necessary. A fulgurating dispersion of coagulation energy is applied correctly when a visible spark alters and shrinks the protruding orbicularis. The orbicularis muscle should respond by drying, shrinking, and changing to a depth between 0.5 and 1.0 mm. Figures 5–10 document the open technique photographically preoperatively and postoperatively.

B.

Closed Technique of Hypertrophic Orbicularis Modification

A closed approach can be performed through a < 1- to 2-mm incision made 2–3 mm inferior to the lateral canthus or in the area of the bulge of the superior lower eyelid fold. Usually, the closed technique is used when a patient has orbicularis hypertrophy out of proportion to other factors that ‘‘age’’ the lower eyelid or in unhappy postblepharoplasty patients who have had transconjunctival or traditional subciliary blepharoplasty without attention to the orbicularis. Please note that the closed technique was not designed to be used in conjunction with a transconjunctival blepharoplasty unless performed as shown in Figure 1 where fat is removed through several small discontinuous incisions. However, the closed techni-

Figure 5 A 45-year-old woman before incision-reduction upper blepharoplasty, lower transconjunctival blepharoplasty with open method, and CO2 laser resurfacing.

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Figure 6 A 45-year-old woman after upper blepharoplasty, lower transconjunctival blepharoplasty with open method, and CO2 laser resurfacing.

Figure 7 A 40-year-old woman before incision-reduction upper blepharoplasty, lower transconjunctival blepharoplasty with open method, and CO2 laser resurfacing.


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Figure 8 A 40-year-old woman after incision-reduction upper blepharoplasty, lower transconjunctival blepharoplasty with open method, and CO2 laser resurfacing.

Figure 9 A 65-year-old woman before incision-reduction upper blepharoplasty, lower transconjunctival blepharoplasty, arcus marginalis release, the open method, and CO2 laser resurfacing.

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Figure 10 A 65-year-old woman after incision-reduction upper blepharoplasty, lower transconjunctival blepharoplasty, arcus marginalis release, the open method, and CO2 laser resurfacing.

que may be used at least 1 month postoperatively following any transconjunctival blepharoplasty. The prominent orbicularis is marked and anesthetized with < 1 mL of 2% lidocaine (Xylocaine) with 1 : 50,000 epinephrine. Digital pressure is applied for approximately 10 min to decrease injection edema and enhance hemostasis, thus reducing the chance of blood or fluid collections on probe/ needle insertion. Blood and other ionic fluid collections may disperse or cause an irregular application of electrosurgical energy to the target tissues. Specifically insulated and tipped electrosurgical needles/probes are a necessity (Colorado Biomedical, Boulder, CO) and are bent to approximate the curvature of the lower eyelid margin. The needles/probes are also specially insulated to reduce friction and conduction. Two varieties of the Colorado needle may be used: sharp-tipped needle or bullet-tipped probe, as seen in Figures 11 and 12. The closed technique and an external depiction of the internal placement of the Colorado bullet probe are shown in Figures 13–15. An 18-gauge needle, #11 scalpel blade, iris scissors, or Gradle scissors may be used to make a 2-mm perforation or puncture at the lateral marked edge of the hypertrophic orbicularis. The 2-mm long perforation or puncture should penetrate through the dermis into the orbicularis muscle. The insulated bullet-tipped probe is introduced through the lateral incision, tunneling and arcing through the targeted hypertrophic obicularis in a medial direction to a point inferior and lateral to the punctum. If there is resistance


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Figure 11 Specially insulated and tipped Colorado electrosurgical sharp-tipped needles or bullet-tipped probes.

on passage because of tissues ‘‘catching’’ or ‘‘hanging-up’’ on the beveled insulation near the tip of the needle or probe, the needle/probe should be pulled back slightly and advanced farther with a gentle twisting. The Colorado needle/probe is in place when the electrosurgical tip reaches a

Figure 12 Close view of specially insulated and tipped Colorado electrosurgical sharp-tipped needles or bullet-tipped probes.

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point about 3 mm inferior and 2–3 mm lateral to the punctum. For the closed approach, the depth of the path of the needle placement should be at about one-half to two-thirds the depth of the demarcated hypertrophied orbicularis. A single central tunnel should be sufficient in folds of hypertrophic orbicularis < 4 mm in vertical dimension. If the vertical height of the hypertrophic orbicularis exceeds 4 mm, two separate tunnels may be necessary. Figure 13 shows the lateral entrance wound and the orientation of the attached electrosurgical handpiece, while the internal positioning of the full advanced insulated Colorado electrosurgical needle/probe remains hidden from this view. Once the probe is in position, electrical energy is applied with brief, less than 0.5-s, pulses of COAG electrosurgical energy. The pulses are made as the Colorado needle/probe is withdrawn laterally in a stepwise fashion of 2-mm units. With each 2 mm of needle/probe withdrawal, coagulation is reapplied. The technique is repeated until the noninsulated tip reaches the

Figure 13 Diagrammatic view of positioning and curvature desired for closed method showing the location and path of the bullet-tipped Colorado probe in the targeted hypertrophic orbicularis oculi.


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Figure 14 Photograph of external representation of approximate positioning and desired curved path for closed method shows the reach of the Colorado needle/probe from the anticipated entrance incision site.

Figure 15 Photograph of interoperative view of desired positioning of Colorado needle for closed method demonstrates instrument orientation and skin position.

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insertion wound. An initial low COAG setting is recommended. Higher settings may be necessary with the bullet-tip probe, depending upon insulation and length of metal exposure beyond the insulation. Energy is applied only when the needle probe is not moving in the target issue. Visible endpoints to the closed method include a fine wrinkling or alteration of the epidermis or change in shape of the overlying or target tissue. A crackling sound may also be heard arising form the area of electrosurgical tip activity. Currently, work is in progress to determine if an acoustic sensor with feedback capabilities may be used to control energy application end points and levels. Such acoustic methods have been previously used to control laser surgery (16). The open and closed techniques may be used in combination with lateral canthoplasty or other blepharoplasty technique modifications including the simultaneous lateral, anterior, and posterior lower lid blepharoplasty (SLAP) technique for patients with ectropion or lower lid laxity (17). The nonexcisional techniques of hypertrophic orbicularis modification as well as laser resurfacing described in this article may cause contraction of tissue layers. This may predictably result in scleral show, or ectropion, or destabilization of the lower eyelid dynamics. Cautious preoperative physical examination identifying the need for simultaneous horizontal resuspension of the lid or postoperative maneuvers, for example massage or digital traction, to improve lower eyelid position may be necessary for optimal and natural results. If a laser resurfacing is performed following the electrosurgical reduction of the hypertrophic orbicularis with the open or closed techniques, then the resurfacing laser energy should be reduced adjacent to the orbicularis treatment sites. The open and closed techniques have been employed successfully in combination with carbon dioxide laser resurfacing. Figures 16 and 17 illustrate the results of the closed technique with concomitant laser resurfacing in a 50-year-old woman who had undergone lower lid subciliary blepharoplasty elsewhere 5 years earlier. Figures 18 and 19 are of a 45-yearold woman after upper lid blepharoplasty, lower transconjunctival blepharoplasty, followed 1 month later by laser resurfacing and the closed technique. Figure 20 shows a 66-year-old man before a lower transconjunctival blepharoplasty that occurred several years after a lower subciliary blepharoplasty performed elsewhere. Figure 21 shows the 1-year postoperative result. Figures 22–24 illustrates and may help to dichotomize the effects of initial transconjunctival blepharoplasty with concomitant carbon dioxide laser resurfacing, both separated by 3 months, from a closed technique electrosurgical orbicularis hypertrophy modification. The patient in Figures 22–24 is a young man who desired further reduction in lower eyelid


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Figure 16 A 50-year-old woman with previous subciliary lower blepharoplasty performed 5 years earlier elsewhere immediately before closed method followed immediately by CO2 laser resurfacing.

Figure 17 cing.

A 50-year-old woman following closed method and CO2 laser resurfa-

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Figure 18 A 45-year-old woman before incision-reduction upper lid blepharoplasty, lower transconjunctival blepharoplasty, laser resurfacing, and the closed technique.

Figure 19 A 45-year-old woman after incision-reduced upper lid blepharoplasty, lower transconjunctival blepharoplasty, followed 1 month later by laser resurfacing and the closed technique.


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Figure 20 A 66-year-old man shown before a lower transconjunctival blepharoplasty, closed technique, and laser resurfacing all of which occurred after a lower subciliary blepharoplasty performed elsewhere 5 years before.

Figure 21 A 66-year-old man 1 year after lower transconjunctival blepharoplasty followed 1 month later by a closed technique and laser resurfacing.

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prominences, especially those worsened by smiling, 3 months after combination transconjunctival blepharoplasty and laser resurfacing. Figure 22 of the patient preoperatively. Figure 23 shows him with slight smiling accentuation 3 months following transconjunctival blepharoplasty with concomitant laser resurfacing and immediately prior to the closed technique. Figure 24 was taken 1 month after the closed technique in the same patient. Note the slight right lower lateral lid retraction that resolved after 1 month of superiorly and temporally directed massage of 5 min twice daily.

C.

Laser Finishing

Laser resurfacing may play an integral role in optimizing the aforementioned procedures. A Sharplan Silk Touch Laser is preferred with controls set to 13–17 W, 0.45 s on time, 0.4 s off time, and a square scan shape of 10 min size. All periorbital and glabellar wrinkles are irregularly outlined in ink. One pass is made to the entire area, creating a wound in the form of an irregular shaped mask. If only a transconjunctival blepharoplasty is planned, it may be followed immediately by laser resurfacing. If any sutured upper lid or a subciliary incision lower lid procedure is performed, then laser resurfacing is executed over the incisions 1 month postoperatively. The presence of a full-thickness cutaneous incision and/or sutures precludes

Figure 22 A 40-year-old man before a simultaneous transconjunctival blepharoplasty and CO2 laser resurfacing with the expectation and delivery of a hypertrophic orbicularis deformity, especially on the right.


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Figure 23 A 40-year-old man after a simultaneous transconjunctival blepharoplasty and CO2 laser resurfacing with the expectation and delivery of a hypertrophic orbicularis deformity, especially on the right.

Figure 24 A 40-year-old man 3 months posttreatment with the closed technique for hypertrophic orbicularis deformity.

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the simultaneous use of a resurfacing laser. The optimal time delay interval allowing proper incision scar maturation appears to be 2–6 weeks after suture removal. If an upper lid blepharoplasty was performed, the upper eyelid lasing should extend only 1–2 mm over the eyelid crease so as not to disturb the remainder of the pretarsal skin, with the exception of the skin overlying the previous location of the nasal fat pads. Prominent wrinkles may receive an additional irregular single pass of 13–16 W, depending on the skin type and character. Laser exposure to the upper pretarsal tissues is to be minimized. The laser finishing procedure has several benefits that include expanding applications of the transconjunctival approach (less need for subciliary scalpel excision of redundant lower lid wrinkled tissues), tightening of medial upper lid tissue redundancy after removal of a protruding medial fat pad, and softening almost all types of upper lid superior and inferior tissue mismatches. Electrical resurfacing and chemical resurfacing maneuvers may also be useful.

V.

RESULTS

Results for the most recent 200 patients undergoing any of the above techniques either individually or in combination were graded using the available rating categories of poor, fair, good, or excellent. The procedures recorded did not include those in which laser resurfacing was the sole procedure performed. Six months was the minimum follow-up criterion. A total of 150 patients had upper lid blepharoplasty and 110 had lower lid blepharoplasty. Women outnumbered men 7 : 3. Ages ranged from 25 to 68 years. Primary subcilary lower lid blepharoplasty patients were excluded from the study. Seventy percent of patients rated the results as excellent, 20% good, and 10% fair. Ninety-five percent of patients underwent either carbon dioxide or erbium: YAG laser resurfacing of the eyelid and periorbital skin in combination with the blepharoplasty. One patient reported a 1- to 2-mm nonhealing area that arose 4 days after the closed technique and healed at 1 week. The area was examined 3 weeks later and a 1-mm hypopigmented macule existed, possibly indicating a previous ulcer. It is suspected that the lesion in question was a thermally induced ulcer secondary to excessive local electrosurgical energy application. Three upper eyelid incisions resulted in remaining excess medial canthal tissues that were reduced by the bullet-tipped Colorado needle or scalpel/scissors excision. Although the use of these techniques may appear to be relatively simple, the learning curve can be steep. Caution must be exercised so that the dermis is not placed in direct contact with the electrosurgical needle and


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thereby injured or scarred. Although no ectropion has been seen with either technique, a degree of scleral show was experienced in several cases. The scleral show was easily ameliorated with upward massage of the eyelid over the course of 1 month. No clinical signs of orbicularis paralysis have been seen with these techniques. The follow-up in some of these cases is relatively short, and caution should be extended to verify that these patients do not progress, regress, or show signs of eyelid flaccidity or paralysis in the future. The mere concept of minimization begets obvious questions such as: How much minimization yields an improved result before compromising that very result? What determines desirable endpoints of minimization? What is an acceptable result? Were the white scars from previous upper lid incisions of decades past, extended near to the caruncle or tented across the medial canthus, unsightly? Almost anything can be minimized. How much minimization is excessive as opposed to sufficient?

VI.

CONCLUSIONS

The techniques described herein can be used to modify blepharoplasty surgery to an appreciable degree. Drawbacks include a significant learning curve regarding patient selection and surgical execution, potential cutaneous ulceration, and occasional temporary anatomical distortion as manifested by scleral show. Complications were minimal and the technique is safe in all patients studied. As our understanding of the esthetic morphology of aging increases, blepharoplasty may no longer be used to remove skin and fat but rather as a lifting and a repositioning procedure. Many effective new techniques have been described to recreate the smooth lower eyelid arc seen in the youthful face, including arcus marginalis release, subperiosteal and SOOF lifting, and mid face lifting. The techniques described here may be used in conjunction with other procedures to rejuvenate and restore the eyelid contour further.

REFERENCES 1. 2. 3.

Dortzbach RK. Ophthalmic Plastic Surgery: Prevention and Management of Complications. New York: Raven Press, 1994. Baylis HI, Long JA, Groth MJ. Transconjunctival lower eyelid blepharoplasty. Ophthalmology 1989; 96:1027–1032. Manuskiatti W, Fitzpatrick RE. Goldman MP. Long term effectiveness and side effects of carbon dioxide laser resurfacing on photoaged facial skin. J Am Acad Dermatol 1999; 40:401–411.

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4.

Gradinger GP. Cosmetic upper blepharoplasty. Clin Plast Surg 1988; 15:289– 296. Scaccia FJ, Hoffman JA, Stepnick DW. Upper eyelid blepharoplasty. A technical comparative analysis. Arch Otolaryngol Head Neck Surg 1994; 120:827– 830. Seigel RJ. Advanced upper lid blepharoplasty. Clin Plast Surg 1992; 19:319– 327. Tardy ME, Thomas JR, Brown RJ. Facial Aesthetic Surgery. St. Louis: Mosby, 1995. Rees TD. Aesthetic Plastic Surgery. Philadelphia: Saunders, 1980. Januszkiewicz JS, Nahai F. Transconjunctival upper blepharoplasty. Plast Reconstr Surg 1999; 3:1015-1018. Hamra ST. Repositioning the orbicularis oculi muscle in composite rhytidectomy. Plast Reconst Surg 1992; 90:14–22. Aston SJ. Orbicularis oculi muscle flaps: a technique to reduce crows feet and lateral canthal skin folds. Plast Reconst Surg. 1980; 65:206–216. Hamra ST. Composite Rhytidectomy. St. Louis: Quality Medical, 1993. McCord CD, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Reconst Surg 1998; 102:2471–2479. Zarem HA, Resnick JI. Expanded applications for transconjunctival lower eyelid blepharoplasty. Plast Reconstr Surg 1991; 88:215–220. Sebben JE. Cutaneous Electrosurgery. Chicago: Year Book, 1989. Nahen K, Vogel A. Investigations on acoustic on-line monitoring of IR laser ablation of burned skin. Lasers Surg Med 1999; 25:69–78. Weber PJ, Popp J, Wulc AE. Simultaneous, anterior, lateral and posterior blepharoplasty. Ophthal Surg 1992; 23:259–264.

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6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

86 Evaluation Documentation in Cosmetic Oculoplastic Surgery Paul J. Weber Private Practice, Fort Lauderdale, Florida

Gale B. Olsen Private Practice, Blue Springs, Missouri

I.

INTRODUCTION

Cosmetic surgeons frequently spend much time dictating and formulating a surgical plan. Unfortunately, time constraints can limit the amount of information transferred to the actual medical record. This can have medical and medical-legal implications. Accurate documentation may also aid in cases of medical insurability. The evaluation of the ophthalmic surgical patient and the relationship to planned cosmetic surgery has been previously described (1,2). This chapter facilitates transcription or notation in ophthalmic plastic surgery. The use of a form to record physical and historical findings for eye plastic surgery is nothing novel; however, we believe that the forms at the end of this chapter are among the most complete, concise, and efficient in the medical literature presented to date. Although the questionnaire is straightforward and is to be completed by the patients to gather their impressions and desires, the evaluation record or document should be completed by the surgeon or surgeon’s assistant. The following is an explanation of the individual elements of the evaluation document and its use with respect to each item.

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II. EYEBROW There is a surgical as well as an anatomical relationship between the eyebrow and the upper eyelid (3). Several factors relate to the interplay of these two structures. Record the hair density. Is it symmetrical? If not, which side is higher? Palpate the orbital rim to detect the brown insertion. Record by circling whether it is at or above the orbital rim. Is there segmental brow ptosis? If yes, fill in the estimated lift, in millimeters, that is necessary by pulling up on the forehead and brow tissue and measuring the brow movement necessary to improve vision or ideally place the brow (as if a properly performed blepharoplasty were used in addition). The symbol ~ is used to signify the nose, and separate the right side notations from the left eye notations. Circle the appropriate symbol within the parenthesis (þ or ) to describe the hairline: (þ=) High forehead; (þ=) receding hairline; (þ=) sparse scalp hair.

III.

LACRIMAL GLAND

On which eye is there visible temporal fullness? When the eyelid is turned (everted), is it visible on either side? Is the gland visible on digital pressure applied against the globe of the eye? The manipulation procedure may aid in determining the potential for glandular movement over time, whereas the observation of temporal fullness provides an obvious assessment of the current state. Recording the function of the lacrimal and other tear glands will be discussed later. Nonetheless, this section of the evaluation record may present the surgeon with documentation to justify corrective procedures for prolapse of the gland (4). The value of the Schirmer test as well as its predictive value in disease compared with maxillary anatomical variation has been reviewed and in the subject of debate (5–8).

IV.

VISUAL ACUITY

Visual acuity may be crudely tested with a vision card with contact lenses or glasses being used by the patient. Is there 20/20 vision in both eyes corrected? However, for medicolegal reasons, it may be best to have a preoperative examination performed and documented by an ophthalmologist or optometrist. If this is done, record that specialist’s most recent findings on the line provided and attach the documentation to the chart. The patients may also provide evidence of their refraction. Record the eye examination date.

Evaluation Documentation in Oculoplastic Surgery

V.

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OTHER

It is important to record Bell’s phenomenon, especially in patients with a possibility for dry eyes. Bell’s phenomenon is the natural tendency for the cornea to rotate upward during sleep or eye closing, thus protecting it from dehydration. Are the pupils, equal, round, and reactive? This is helpful to note preoperatively, because a long procedure using significant amounts of anesthesia can render the pupil dilated or an unusual shape intraoperatively or just postoperatively. Eyelid tattooing or artificial pigmentation may be a cause for eyelid pathology (9). Is there pigment or tattoo at the lid margins? Granulomas occurring postoperatively (the result of tattoo reactions adjacent to the hair follicle) may be blamed inadvertently on the surgical procedure. Round faces, hypertrichosis, and thinned eyebrows raise endocrinological concerns. Protuberant globes and sweating may be assosited with hyperthyroidism.

VI.

PTOSIS (LIDS)

Does the eyelid margin approach or cover of limbus or edge of the colored iris? In most people, the eyelid margin rests 2 mm below the limbus. In mild ptosis, the margin rests 2 mm more, or 4 mm, over the limbus and just touching the upper pupil. In moderate ptosis, the lid margin slightly covers the pupil. In severe ptosis, the lid margin may bisect the pupil. Grade the ptosis as normal/nonexistent, mild, moderate, or severe. The function of the levator apparatus is assessed next by placing a millimeter ruler vertically in front of the pupil. Have the patient look from far upgaze to downgaze with the eyebrow fixed over three trials. A normal measurement for the lid margin to move on the test is 12–16 mm; 8–12 mm still documents good function. Fair function is 5–7 mm, whereas poor function is < 4 mm.

VII.

VISUAL FIELDS

Visual fields can be crudely diagrammed with the nose of the patient pointing straight in the Frankfort plane and not moving while the patient gazes straight into the distance ‘‘through the examiner’s head.’’ The examiner’s fingers are moved in an arc 10–20 cm from the patient. The test is best conducted with the opposite eye occluded. The spaces provided on the XY axes are for crude diagramming by shading. A rough percentage of field loss may be written over the diagram as well. Initially, the test is performed with the eyelids untouched and recorded on the diagram. Then the brows

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only are elevated by the patient or examiner and the test is again conducted and recorded. Finally, both the eyelids and brows are elevated. The lids may be taped and the brows manually lifted to complete and record the test. The vertical palpebral fissure (space between the upper and lower eyelid margins on a line vertically bisecting the pupil) is noted. Normal is between 8 and 10 mm. Next, the horizontal fissure is observed and measured; this measurement is important when comparing results of canthoplasty procedures, which may alter the horizontal dimensions of the eyelids. The skin thickness of upper lid is assessed next. Is it very thin, thin, normal, or thick? Thickness estimates help the surgeon focus and decide on how much tissue to thin on the upper lid just inferior to the brow in order to create a match. The upper lid skin may be subject to contact dermatitis, seborrheic dermatitis, rosacea, or other malady (10). This should be noted in the margin of this section. Skin thickness, texture, and quality may be influenced by many factors; one such major feature of skin in cosmetic blepharoplasty is the degree of wrinkling and it has been categorized (11). The estimated excess upper lid skin is recorded (in the ‘‘SX’’ section), in millimeters, by pinching with smooth forceps without a need to mark the skin. Estimate and record, in millimeters, the natural crease height by pulling up on the lower eyebrow or placing the patient supine. Note the natural crease, which is the fold created most repetitively by gentle closing and opening of the eyelid. Estimate, in millimeters, the upper lid skin that needs excision. Note that this measurement is not necessarily equal to the excess skin estimate, because a blepharoplasty with heavy fat, orbicularis, and dermis excision becomes a three-dimensional event, creating desirable concavities, it is hoped. In cases with a flat preoperative orbit, what one might consider ‘‘extra skin’’ should be left behind to line the created folds. With today’s resurfacing lasers, that extra skin, or safety blanket, may be safely ‘‘taken-up’’ at a later date, allowing for some tolerance in the scalpel excisional procedure. More advanced levator and associated tests include those on Muller’s muscle and the neosynephrine response.

VIII.

UPPER LID FATTY POCKETS

Upper lid fatty pockets are assessed with the eyes closed for recording purposes. Observe the fatty pockets with the lids open and closed gently. The patient is also asked to gaze fully superiorly to address fully the lower lids and inferiorly to address the upper lids. Although some surgeons feel the best assessment is when the lids are closed tightly, P.J.W. disagrees with tight closure. Some surgeons suggest that gentle pressure also may be


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exerted on the globes to determine the lower grades of protuberance such as 0 or þ. However, more gross grades such as þ to þþ will be evident just on sitting upright. It is best not to make this assessment on a patient lying supine, because the fat and facial structures will gravitate and stretch back and downward and foul the reading. Record the excess fat for both the upper and lower lids.

IX.

LOWER EYELIDS

The presence of the ‘‘bags on bags’’ phenomenon is also known as orbicularis festooning (12). If this is present, it should be described to the patient in a mirror as well as noted and the degree of severity should be recorded ð0= þ = þ þÞ. Does the patient have an allergic history; for example, hayfever, asthma, or atopy? Is there a history of renal or thyroid disease that may be interacting with the periocular tissues? The degree of scleral ‘‘show’’ (amount of white showing between the circumference of the iris and eyelid margins) varies in the population; thus some surgeons even consider its presence as a variant of normal (13). Nonetheless, many may consider it to be abnormal, a possible detraction from a cosmetic result or even a potential complication (14). Record the degree of any scleral show in millimeters. Is there eyelid edema or erythema present? Is there tattoo or pigment present on the lower eyelid margins? Assess the degree of hypertrophic orbicularis muscle. The muscle assessment may be difficult even for experienced surgeons, because other elements, including elastosis, edema, fibrosis, and fibrofatty tissue, may play a role. This phenomenon, as well as others, contributes to the presence of ‘‘baggy lids,’’ which has been reviewed and categorized previously (15). Is there a lack of inferior structure support such as hypoplasia of the maxilla or malar eminences? Lack of support comes under the heading of periocular biomechanics. Lack of support usually increases as the patient ages. The horizontal tone or laxity of the lower eyelid is assessed next. Pull on a small amount of lower lid skin just inferior to the margin to conduct a traditional ‘‘snap-back test.’’ Pull the eyelid margin away from the globe of the eye for 2 s as far as it will go. Request the patient not to blink. Record how many seconds it takes for the margin to return to the globe. If the margin was very slow to return, how many blinks (orbicularis ‘‘cheating’’) were necessary to effect a return of the margin to the globe. Record this number as well. Perform the Tenzel snap-back test. Record the laxity gradation as being ‘‘mild’’ if there was no show and the lid moves slowly back, ‘‘moderate’’ if there was 1 mm of ‘‘show’’ with two to three blinks for return, and ‘‘marked’’ with > 1 mm of ‘‘show’’ and/or ectropion remaining.

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A margin distraction ‘‘pull test’’ reveals laxity if the eyelid margin can be pulled > 6–8 mm from the globe (depending on the size of the periocular and ocular tissues). View the lateral canthal tendon area. If a ‘‘web’’ is present, record its degree. A lateral web usually indicates a degree of dehiscence or dissolution of the lateral canthal apparatus. Assess the distance between the lateral orbital rim and canthus in millimeters. Normal is usually much less than 1 fingerbreadth, or 10 mm. The medial canthal tendon is abnormal if it can be pulled to the medial limbus under mild tension. Tenzel states that it is abnormal if it can be pulled > 3 mm from the medial canthus. Record the amount of medial tendon pull on the sheet.

X.

OTHER FACTORS

Note patient anxiety or unreasonable expectations on the patient’s part. Look for signs of ‘‘perfectionism.’’ How does the patient appear; for example, unkempt or with inappropriate hygiene? Note complaints of ‘‘dry eyes,’’ difficulty with contacts drying out, difficulty in dry climates (these may all be signs of borderline dry-eye states). Note all scars. Reassess thyroid history. Who desires or motivates the eyelid surgery? Is it the patient or a significant other? Are there any other underlying concerns; for example, social, business, or other? Check for brow aches, eye ‘‘fatigue,’’ visual field loss, history of bleeding, aspirin and nonsteroidal product usage, arthritis history, hypertension, or a family history of ptosis. If the patient is ptotic, are there any childhood pictures? Is there a daily history of varying ptosis that could indicate myasthenia gravis? Most importantly, has the patient had previous eye surgery involving cataract, retina, trauma, neovascularization, or others? Blepharochalasis is a rare eye disease compared with the ubiquitous dermatochalasis (16). Some surgeons mistakenly use the terms synonymously. Inquire regarding any potential signs of blepharochalasis (difficult to treat surgically), including bouts of allergic edema starting at around puberty. Is there a family history of similar symptoms?

XI.

CONCLUSIONS

It may be helpful for surgeons to allow patients to record accurately their desires and pertinent history via the use of a questionnaire. This may help direct the evaluation and surgical plan as well as document the patient’s desire or focus, which may be of medicolegal value at a later time. Proper preoperative documentation of the pertinent ophthalmic-plastic surgical


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physical examination may be of medicolegal assistance as well as improving patient care or serving as an immediate intraoperative reference. Nowadays cosmetic surgeons may spend much time dictating the physical examination and the formulation a surgical plan. Unfortunately, time constraints can limit the amount of information transferred to the actual medical record; this can have medical and medicolegal implications. Transcription or notation in ophthalmic plastic surgery may be facilitated by the use of standardized documentation, such as follows. BLEPHAROPLASTY EXAMINATION Patient Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . Eyebrow: Hair density: 0 þ þþ þ þ þ Symmetry?: R vs L Brow insertion (at or above) orbital rim (circle): . . . . . . . . . . . . . . . . . . . . . Segmental brow ptosis? If yes, what is the lift necessary (mm)? R lat( ) R mid( ) R nasal( ) ~ L nasal( ) L mid( ) L lat( ) ðþ=Þ High forehead; ðþ=Þ receding hairline; ðþ=Þ sparse scalp hair Lacrimal Gland (þ or , L or R) ( )Visible temporal fullness; ( )lid double eversion; ( )Visible on digital globe pressure; Schirmer test in mm R( ) vs L( ) ðþ=Þ anesthetized Visual Acuity with contacts or glasses in: ( )20/20 Right, ( )20/20 Left Opthalmologist or Optometrist (circle): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Refraction: R: . . . / . . . L: . . . = . . . Exam date: . . . . . . . . . . . . . . . . . . . . . . . . Other ( )R L( ) Bell’s Phenomenon Perrla: þ or (circle) Pigment or tattoo at lid margins: upper . . . . . . . . . lower lids . . . . . . . . . ( )Round facies: ( )Hypertrichosis: ( )Thinned eyebrows; ( )Protuberant globes; ( )sweating Ptosis Lids: (lid margin coverage of limbus) ‘‘norm’’ = 2 mm below limbus ‘‘mild’’ = 2 mm below ‘‘norm’’ = pupil ‘‘mod’’ = 3 mm below ‘‘norm’’ = slightly covers pupil ‘‘severe’’ = 4 mm below ‘‘norm’’ = bisects pupil Ptosis grade: ( )R middle ~ L middle( ) Levator function: ( )R middle ~L middle( )mm excursion upper lid from far upgaze to downgaze with the eyebrow fixed over 3 trials (normal ¼ 12–16 mm; good ¼ 8–12; fair ¼ 5–7; poor < or ¼ 4 mm) Visual fields: {2–3 00 from examiner, opposite eye occluded.}

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———— ————— — R nasal

(brows only elevated) —

————— R nasal

(lids and brows elevated) - ————— ———— R nasal —

———— ————— L nasal — ———— ————— L nasal — ———— ————— L nasal ——— ———

Vertical palpebral fissure fN ¼ 8–10 mm} ( )R middle ~ L middle( ) Horizontal fissure (mm) ( )R ~ L( ) Skin thickness of upper lid (circles): very thin, thin, normal, thick Upper lid XS-skin (mm): R lateral ( ) R middle( ) R nasal ( ) ~ L nasal( ) L middle( ) L lat( ) Upper lids (cont’d): Natural crease height {by pulling up on lower eyebrow} in mm: R lat( ) R mid( ) R nasal( ) ~ L nasal( ) L mid( ) L lat( ) Estimated excision {mm necessary} upper lid SKIN: Muller’s muscle/epi. Test: neosynephrine response ( )R middle ~ L middle( ) Fatty pockets (eyes closed tightly, gentle pressure on globes, 0, þ, or þþ): uppers: R lat( ) R mid( ) R nasal( ) ~ L nasal( ) L mid( ) L lat( ) lowers: R lat( ) R mid( ) R nasal( ) ~ L nasal( ) L mid( ) L lat( ) Lower lids: ‘‘Bags on bags’’ {orbicularis festooning}, 0= þ = þ þ ( )R middle ~ L middle( ) If þ and not longstanding: Allergy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Renal: . . . . . . . . . . . . . . . . . . Thyroid: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Schleral ‘‘Show’’ {mm}: uppers ( )R middle ~ L middle( ); lowers ( )R mid ~ L mid( ) Eyelid edema/erythema: ( )R middle ~ L middle( ) . . . . . . . . . . . . . . . . . . Hypertrophic orbicularis muscle: ( )R middle ~ L middle( ) Hypoplasia of maxilla, malar eminences? Y/N, if ‘‘yes’’ discuss: .................................................................. .. Horizontal Tone ‘‘Snap-back test’’ {w/o blinking} 0= þ = þ þ . . . . . . seconds :( )R middle ~ L middle( ) {orbicularis ‘‘cheating’’ = with . . . . . . # of blinks} . . . . . . #: ( )R middle ~ L middle( )


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Tensel ‘‘Snap-back’’ {laxity gradation: ‘‘mild’’ = no ‘‘show’’, slowly back; ‘‘mod’’ = > 1 mm ‘‘show’’, 2–3 blinks for return; ‘‘marked = > 1 mm of ‘‘show’’ and/or ectropion} Margin Distraction {‘‘pull test’’ 6–8 mm = lax} ( )R middle ~ L middle( ) Lateral Canthal Tendon: Lateral canthal ‘‘web’’: 0, þ, þþ ( )R middle ~ L middle( ) Distance between lateral orbital rim and canthus in mm {N 1 fingerbreadth} Medial Canthal Tendon: Abn., if able to be pulled to medial limbus: ( )R ~ L( ) {Tenzel: abn., if pulled >¼ 3 mm from med canthus): ( )R ~ L( ) Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pt. Anxiety level {0(lowest) - 5(high)}: . . . . . .; Unreasonable expectations of ‘‘Perfectionist’’: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appears: ( ) unkempt ( ) hygiene; ‘‘dry eyes’’. . . . . . . . .; ‘‘scars’’. . . . . . . . . .. Thyroid sx: . . . . . . . . . . . . . . .; Who desires blepharoplasty? . . . . . . . . . . . . . . . . . . Underlying concerns: ( ) social ( ) business ( ) other . . . . . . . . . . . . . . . . . . . . . Brow aches . . . . . . . . . . . .; eye ‘‘fatigue’’ . . . . . . . . . . . .; visual field loss . . . . . . . . . . . .; bleeding hx . . . . . . . . . . . .; ASA products . . . . . . . . . . . .; arthritis . . . . . . . . . . . .; hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FH ptosis: . . . . . . . . . . . .; child pictures if ptotic? . . . . . . . . . . . . . . . . . . . . . . . . . . . Daily history of varying ptosis (myasthenia gravis): . . . . . . . . . . . . . . . . . . . . . . . . Previous eye surgery {cataract, retina, trauma, neovascularizing diseases, etc.} . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Blepharochalasis {@ puberty, bouts of allergic edema, þFH} . . . . . . . . . . . .. BLEPHAROPLASTY QUESTIONNAIRE Patient Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . . . . Date of your last eye exam: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name and address of the physician who performed the examination: . . . . . . ........................................................................:: Circle the answer. Please use other side of page for longer answers. No No No

Yes Yes Yes

1. 2. 3.

No

Yes

4.

No

Yes

5.

Do you wear glasses or contact lenses? (circle which) Do you have any history of glaucoma or other eye disease? Have you had any injuries or surgery to the eyes or lids? Explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Do you have frequent irritations to the eyes themselves or the skin of the lids? Do you now take or have you taken medications or drops for the eyes? Explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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No No No

Yes Yes Yes

6. 7. 8.

No

Yes

9.

No

Yes 10.

No

Yes 11.

No

Yes 12.

Are you bothered by dry eyes? Do your eyes tear excessively? Do you now have or have you ever had visual problems with one or both eyes? Explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . Are there any other problems we have not asked about that you feel we should know? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . On looking in a mirror, do you notice any differences between the right and left eyes? . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you notice any intermittent or cyclical swelling of the eyes? How often are the cycles? . . . . . . . . . . . . . . . . . . . . . . . . . . . Are you pleased with the appearance of your eyebrows? If not, why? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(Please refer to the diagram below) What do you believe are the problem areas of your eyes (as far as appearance is concerned)? Indicate by circling. Which of the following seven items regarding your eyes would you like to be changed (circle): Color texture Fine wrinkles ‘‘Bagginess’’ Coarse wrinkles Thin skin Crow’s feet How many years younger do you wish your eyes to look? (circle) 20 10 5 or (appropriate for my age) Please read the following and carry out the instructions: Cover your RIGHT eye and read THIS sentence with your LEFT eye only. Are you able to read it comfortably? . . . . . . with glasses (Y or N) . . . . . . without glasses (Y or N) Cover your LEFT eye & read THIS sentence with your RIGHT eye only. . . . . . . with glasses . . . . . . without glasses. If there is any difference in your vision please indicate: . . . . . . Both eyes same (approximately) . . . . . . Right eye stronger . . . . . . Left eye stronger


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I signify that the information provided above is correct to the best of my knowledge X ..........................................

........................

REFERENCES 1.

2. 3. 4. 5. 6. 7.

8.

9. 10. 11. 12. 13. 14. 15. 16.

Hornblass A, Gross ND. Evaluation of the blepharoplasty patient. In: Hornblass A, ed. Oculoplastic, Orbital, and Reconstructive Surgery. Baltimore: Williams & Wilkins. 1994:467–473. Wolfort FG, Gee J, Pan D, Morris D. Nuances of aesthetic blepharoplasty. Ann Plast Surg 1997; 38:257–262. Frankel AS, Kramer FM. The effect of blepharoplasty on eyebrow position. Arch Otolaryngol Head and Neck Surg 1997; 123:393–396. Beer GM, Kompatshcer P. A new technique for the treatment of lacrimal gland prolapse in blepharoplasty. Anesthet Plast Surg 1994; 18:65–69. Hornblass A, Ingis JM. Lacrimal function tests. Arch Ophthalmol 1979; 97:1654–1655. Gudmundsen KJ, O’Donnell BF, Powell FC. Schirmer testing for dry eyes in patients with rosacea. J Am Acad Dermatol 1992; 26:211–214. McKinney P, Zukowski ML. The value of tear film breakup and Schirmer’s tests in preoperative blepharoplasty evaluation. Plast Reconstr Surg 1989; 84:572–576. Rees TD, LaTrenta GS. The role of the Schirmer’s test and orbital morphology in predicting dry-eye syndrome after blepharoplasty. Plast Reconstr Surg 1988; 82:619–625. Wolfley DE, Flynn KJ, Cartwright J, Tschen J. Eyelid pigment implantation: Early and late histopathology. Plast Reconstr Surg 1988; 82:770–774. Nethercott JR, Nield G, Holness L. A review of 79 cases of eyelid dermatitis. J Am Acad Dermatol 1989; 21:223–230. Loeb R. Esthetic blepharoplasties based upon the degree of wrinkling. Plast Reconstr Surg 1971; 47:33–36. Furnas DW. Festoons of orbicularis muscle as a cause of baggy eyelids. Plast Reconstr Surg 1978; 61:540–546. Mackinnon SE, Fielding JC, Dellon AL, Fisher DM. The incidence and degree of scleral show in the normal population. Plast Reconstr Surg 1987; 80:15–20. Tenzel RR. Complications of blepharoplasty. Orbital hematoma, ectropion and scleral show. Clin Plast Surg 1981; 8:797–802. Beyer CK, McCarthy RW, Webster RC. Baggy lids: a classification and newer aspect of treatment to avoid complications. Ophthal Surg 1980; 11:169–174. Bergen DJ, McCord CD, Berger T, Friedberg H, Waterhouse W. Blepharochalasis. Br J Ophthalmol 1988; 72:863–867.

87 Manual Punch for Tattooing Mohan B. Gharpuray and Sharad Mutalik Maharashtra Medical Foundation, Pune, India

I.

INTRODUCTION

Localized, stable patches of vitiligo that are resistant to the conventional treatment can be camouflaged permanently by tattooing. Four different shades of ferric oxide are used to prepare the pigment, which is deposited in the papillary dermis with the help of a tattooing gun or machine. The conventionally used tattooing gun consists of a stainless steel tube in which a stainless steel needle bar is moved up and down by an electric motor. A number of conical needles are soldered onto the needle bar. The needles are arranged in two rows of either two and four or four and five needles. The length of the needle is 36 mm, the length of the conical part is 1.1 mm, and the thickness of the needle is between 0.36 and 0.41 mm. The ideal depth to reach the papillary dermis is 1.1–1.3 mm. Up and down movement of the needle bar is regulated between 500 and 3000 rpm. The needles are the same as those used in microsurgery and entemology (1).

II. INSTRUMENT Nowadays, most of the things are now available in their microforms. Surgeons have also started preferring and recommending instruments of smaller size. Smaller and shorter versions are replacing the traditional larger, longer, and heavier instruments. Applying the same principle, we have designed a manual punch for tattooing (2). We use stainless steel for this punch, which consists of a handle with a nozzle and a screw cap (Figure 1). 585

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Figure 1

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Drawing of the manual punch for tattooing: Type I.

The effective length of the punch is 9 cm, the width of the handle is 9 mm, the width of the screw cap is 15 mm, and the weight is 180 gm. Another variety of the punch consists of a handle with a screw-like projection and a disposable cartridge holding 10 needles that can be fixed over the screw (Figure 2). This manual tattooing punch (Figure 3) has some advantages compared to the conventionally used electric tattoo gun. It is lighter in weight, can be held like a pen, and therefore makes the operation easier. Being manually operated, one has control over the depth of penetration and the number of strokes at a given place. This helps to keep the epidermis intact,

Figure 2

Drawing of the manual punch for tattooing: Type II.

Manual Punch for Tattooing

587

and the chances of damaging the dermis are minimized. This facilitates faster healing, minimal crust formation, negligible scarring, and good retention of pigment. The metal parts are autoclavable and the needles can be sterilized either by 1% gluteraldehyde or formaldehyde tablets. The conventionally used tattoo gun has needles arranged in rows, which leaves holes arranged in a linear fashion, whereas our instrument has needles arranged in a group, which leaves holes arranged in a circular fashion, thereby covering the desired area in a uniform fashion and in a shorter time span. The needles or the cartridge are discarded after a single use. The electric gun is good for linear drawings or decorative tattoos, but it has the disadvantage of tearing the epidermis while covering patches. If used by an inexperienced person, it can also cause injury to the dermis by going deeper than the desired depth. This can result in excessive crust formation, washing away of the pigment, and scar formation.

III.

CONCLUSIONS

The manual punch is inexpensive and does not require any maintenance. The only disadvantage with this instrument is the limitation of hand movement, making it difficult to cover larger areas at a time. However, this is a very minor disadvantage, as we recommend tattooing only in selected cases of vitiligo with small patches.

ACKNOWLEDGMENT Our sincere thanks to N.S. Attarde and S.Y. Shaligram, who prepared the drawings.

Figure 3 Manual punch for tattooing. This instrument is manufactured in India by Associated Engineers, Pune.

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REFERENCES 1. 2.

Eddy M, Velden, BD, et al. Cosmetic tattooing as a treatment of port-wine stains. Int J Dermatol 1993; 32:372–376. Gharpuray MB, Mutalik S. Manual punch for tattooing. J Dermatol Surg Oncol 1994; 20:548–550.

88 A Simple Cryotechnique for the Treatment of Cutaneous Soft Fibromas Giuseppe Monfrecola University of Naples Federico II, Naples, Italy

I.

INTRODUCTION

Soft fibromas (SFs), also called skin tags, are one of the most common benign cutaneous tumors, usually occurring on the neck, axillae, groin, and eyelids. They range in size from 1 to 2 mm up to 1 to 2 cm and present as pedunculated, flesh-colored or brown skin lesions with an irregular or smooth surface (1). Their microscopic picture shows a polypoid tumor with a flattened or folded epidermis that sometimes is acanthotic or pigmented; the dermis is composed of loosely arranged collagen fibers with dilated blood vessels (2). Aside from the unsightly appearance, SFs become symptomatic if the pedicle twists and infarction occurs. Treatment of SFs, required only for cosmetic reasons, depends on their location and size; smaller lesions (no more than 1–2 mm in diameter) can be removed, without anesthesia, by curved scissors or thermocautery or electrocoagulation, whereas for largest ones (more than 3 mm in diameter), local anesthesia before the electrodesiccation is needed. The analgesia is easy to perform in the case of patients with two to three SFs, but it is often difficult to convince the patient to undergo several injections of anesthetic in the case of multiple large SFs. Preoperative analgesia for exophytic lesions is rarely necessary using cryosurgery (3) with liquid nitrogen (196 C), so, in order to avoid multiple injections of anesthetic drugs, this technique can be employed for multiple 589

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SFs. There are basically two cryosurgical methods presently available: the open technique (spray) and the closed technique (probes placed directly on the lesion). Of course, the first method is mainly indicated for protuberant cutaneous lesions; nevertheless, the major problem consists of the possibility that the cryogen spray could also affect the healthy skin adjacent to the target. In the case of SFs, it is very difficult to direct the liquid nitrogen spray exclusively on the lesion and spare the skin surrounding the base of the pedicle; therefore, the treatment can be painful and sometimes dyschromias can occur at the end of the healing process. The following method overcomes this problem by allowing freezing of the entire SF without affecting the surrounding skin (4).

II. METHOD Taking the SF between two blades of a flat-nose forceps, the liquid nitrogen spray has to be directed, parallel to the skin, on the forceps itself and not on the SF (Figure 1). In this way, the freezing first occurs on the forceps and subsequently it reaches the SF. The delivery of the liquid nitrogen has to be

Figure 1

Treatment of Cutaneous Soft Fibromas

591

administered so that the freezing does not proceed beyond the base of the pedicle. Depending on the size of the lesion, the freezing time can vary from 30 s to 1 min and, during the cryosurgical session, the same SF has to undergo two or three freeze-thaw cycles. Usually, the patient does not complain of any pain during the treatment. Five to 10 minutes from the thaw, the SF shows a mild erythema, and 3–4 days after the treatment, the SF becomes reddish and swollen. Subsequently, as the necrotic process becomes more evident, medications with antiseptic solutions or antibiotic creams can be employed. Complete recovery usually takes about 2–3 weeks depending on the size of the SF and, particularly, on the thickness of the pedicle. According to my own experience, a disappearance of up to 95% of SF can be achieved treating patients with multiple SF ranging in size from 3 to 6 mm in diameter; lesions exceeding this size have a much too long necrotic process and, sometimes, need an additional treatment session in order to remove the lesion completely.

III.

DISCUSSION

This technique is based on some fundamental concepts that should be taken into account when performing any cryosurgical procedure: rapid freezing and slow thawing. In order to produce cell death, the freezing process has to be as rapid as possible: in this way, the ice crystals are formed first in the intracellular space and then in the intercellular space. A slow thawing process induces the cell dehydration that, in turn, produces an abnormal concentration of electrolytes. The cryosurgery efficacy on living tissues is enhanced by doubling the cycles of freezing-thawing, which produces a lethal thermal shock with a subsequent denaturation of macromolecules (e.g., structural and enzymatic proteins, lipoproteins) and a vascular stasis giving rise to anoxia and necrosis. This method has the following advantages: (1) precise, simple, and safe to perform, also for particular skin areas such as eyelids; (2) good compliance from the patient (fairly painless); (3) useful for patients allergic to anesthetic drugs and for patients with pacemakers (no electrical connection); and (4) good cosmetic results. The only disadvantage is the long recovery time for larger SFs.

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REFERENCES 1.

2.

3. 4.

From L, Assaad D. Neoplasms, pseudoneoplasms and hyperplasiaa of the dermis. In: Freedberg IM, Eisen AZ, Wolff K, et al., eds. Dermatology in General Medicine. 5th ed. New York: McGraw Hill, 1999:1166–1167. Lever WF, Schaumburg-Lever G. Tumors of fibrous tissue. In: Lever WF, Schaumburg-Lever G, eds. Histopathology of the Skin. 7th ed. Philadelphia: Lippincott, Company, 1990:664–665. Kuflik EG. Cryosurgery updated. J Am Acad Dermatol 1994; 31:925–944. Monfrecola G, Riccio G, Viola R, Procaccini EM. A simple cryo-technique for the treatment of cutaneous soft fibromas. J Dermatol Surg Oncol 1994; 20:151–152.

89 Computer-Generated Operative Reports: How to Save up to 30 Minutes per Day James M. Swinehart Colorado Dermatology Center, Denver, Colorado

I.

INTRODUCTION

The use of a standardized, but flexible, operative checklist, completed by the staff, with the report executed by a medical transcriptionist, can, in many instances, free the surgeon from the necessity to dictate most operative reports. If one assumes that a Mohs surgeon spends 5 min in dictation for each of six cases per day, the resultant savings of up to 30 min/day can be invaluable.

II. METHODS This process should begin with the design of a standardized operative report sheet (Figure 1). The surgeon should make this as comprehensive as possible and incorporate as many contingencies as possible. Clarity and ease of completion by the nursing staff should be emphasized. If possible, the report should fit on one side of an 8 12 11 inch sheet. Items should include the following:

From Swinehart JM. Computer-generated operative reports: how to save up to 30 minutes per day. J Am Acad Dermatol 1990; 23:508–512. Copyright # 1990 by the American Academy of Dermatology, Inc.

593

594

Swinehart

Figure 1 Operative report checklist, completed by the surgical nursing staff after a Mohs surgical procedure, followed by a skin graft repair.

Computer-generated Operative Reports

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

595

Patient demographics and date Preoperative diagnosis Surgical procedure Wound preparation and sterile technique Anesthesia Detailed operative procedure description Wound closure repair Time of procedure Wound dressings Blood loss and other complications Photographs Nursing staff Postoperative medications Surgical follow-up Final diagnosis and procedure

Once the operative report has been designed, the surgeon must write a phrase or sentence describing each possible contingency as it is to appear in the final report. Thus, the primary master file becomes a compilation, or tabulation, of these descriptive phrases (Figure 2). Obviously, not all of these phrases or sentences will appear in any one report; some may even be contradictory. However, the transcriptionist now has a computerized menu with which to compose the final report. Before and during the actual surgical procedure, the operative report sheet can be filled in entirely by the circulating nurse or operating room assistant. Specific details (such as number of buried sutures used) can be recorded by the circulating nurse from direct observation of the procedure. After the conclusion of the procedure, the report can be quickly reviewed and signed by the surgeon. It is then routed to the transcriptionist for typing and completion. The result is the final, finished operative report (Figure 3). WordPerfect (or Microsoft Word) uses a merge function to merge information from a secondary file (which actually is the intraoperative checklist (see Figure 1) into a master primary file (a list of possible sentences, phrases, and surgical events stored in the computer [see Figure 2]) (1). In practical terms, each blank on the operative report sheet is keyed to a specific phrase or sentence in the master primary file. Within this primary file, a merge code, or separate key stroke (the symbol @ may be used, because it is rarely used in the medical field) directs the transcriptionist to ‘‘fill in each blank’’ with the appropriate information from the operative report sheet (e.g., the patient’s name). Once this blank has been filled in, the entire phrase or sentence will appear in the completed final report (to see this,compare equivalent sections of Figures 1–3).

596

Swinehart

Figure 2 Primary master file, demonstrating appropriate blanks filled in by word processor directly from checklist. (Only first page is shown; the complete file may be obtained by writing directly to James M. Swinehart, MD.)


597

Figure 3 Final operative report (shown only in part) with the use of a letter quality printer. (The completed three-page operative report may be obtained by writing directly to James M. Swinehart, MD.)

In case events develop during the procedure that are not included in the primary master file, WordPerfect uses a merge pause (separate key stroke and command) to let the transcriptionist enter this information directly from the keyboard. In this manner, items (e.g., blood pressure readings, treatment of actinic keratoses) can be custom typed in and added to the final report.

598

Swinehart

With surgical procedures that consistently involve uniform features (e.g., a description of the standard sterile technique and surgical preparation, or a standard method of local anesthesia), the appropriate descriptive phraseology can be automated into prenamed macros (a larger unit of text, such as a finished paragraph). These macros incorporate a set of many commands (which previously had to be entered at the keyboard level) into one or more standard paragraphs produced with one simple key stroke. In this fashion, the surgeon does not have to dictate a detailed description each time of the povidone-iodine (Betadine), draping, preparation, and strict sterile technique that were used during the operation.

III.

DISCUSSION

A computerized operative report can be designed for any operation that is repetitively performed in a more or less consistent and routine pattern. However, procedures that often possess greater variability or ‘‘free-lancing’’ might be harder to describe with this format. Examples of this latter category might include the following: hair transplantation (especially where grafts of varied sizes are placed in different locations on the scalp); dermabrasion (where fraises and brushes of varying sizes and coarseness are changed frequently according to the skin consistency and location on the patient’s face); and liposuction, in which several different cannulae might be used in one or more areas at varied intervals. The advantages offered by computerized operative reporting are numerous (2). Record keeping is accomplished in a complete, thorough, and comprehensive fashion. Nothing need be left to chance; the operative staff should be instructed to ‘‘fill in each and every blank’’ before the final repot is handed in. Details that are not obvious to the circulating nurse can be obtained from the surgeon by direct query during the procedure. The final, generated report will be professional in appearance with perfect grammar, spelling, and punctuation. A professional letterhead, specifically designed for surgical reports, can be used. The acknowledgment of the medical necessity of a procedure before reimbursement by an insurance company is often enhanced by the submission of a formal typed report. The duration of a long procedure, as well as information concerning the complexity and skill required, can be provided. For medicolegal purposes, the advantages are numerous; the accuracy and completeness of a descriptive operative summary will lessen the chances of any errors and omissions. Finally, the incorporation of a computerized data base can provide operative figures, facts, and details for tabulation for research purposes (3).


599

Patient demographics, individual physician productivity, frequency of performance of each procedure, and many other items can be analyzed in a variety of fashions (4,5).


WordPerfect Word Processing Software. Orem, Utah: WordPerfect Corp., 1986. Rigel DS. Is it time for a computer in your practice? J Dermatol Surg Oncol 1985; 11:215–216. White R. Data base management systems: how they work in dermatology. Dermatol Clin 1986; 4:569–578. Rigel DS. Computers in dermatology: review of communication software for dermatology. J Am Acad Dermatol 1987; 16:606–609. Rigel DS. The future of computers in dermatology. Dermatol Clin 1986; 4:665–668.

90 Prevention of Hypertrophic Scars by Long-Term Paper Tape Application Robert S. Reiffel White Plains Hospital, White Plains, New York

I.

INTRODUCTION

Observation of healing wounds, created either by trauma or elective surgery, demonstrates that scars which are parallel to flexion creases generally heal without hypertrophy, whereas those that cross flexion creases have a tendency to hypertrophy (see Figure 2A). Some anatomical areas are protected from lengthwise stretching owing to an underlying structure, such as the palmar fascia, as can be seen in Figure 1. The portion of the scar that overlies the fascia does not elongate and contract with wrist movement and does not hypertrophy. However, the portion of the scar that overlies the more supple volar forearm tissues is not protected from such forces and does hypertrophy.

II. METHOD AND MATERIALS Lengthwise stretching and relaxation of the healing wound must therefore be a contributing factor in the hypertrophic scar formation process. Consequently, any method that can reduce or eliminate the lengthwise stretching of the newly healing scar should limit the amount of hypertrophy that develops. 601

602

Reiffel

Figure 1 A longitudinal incision that overlies both the palmar fascia and volar wrist. The unyielding fascia has protected the distal portion of the scar from hypertrophy. (Courtesy of Lippincott Williams & Wilkins, Baltimore, Maryland.) From Ref. 3.

Often, elective incisions can be planned in such a way as to place them in a natural flexion crease, which protects the scar from longitudinal stretching. However, sometimes a clear single flexion crease is not present, such as on the shoulder or breast region. In addition, the need for proper surgical exposure, such as on the abdomen or near a joint, may dictate making an incision that crosses the natural skin flexion creases. Such scars are exposed to elongation and contraction during movement of the subjacent body part. Furthermore, traumatic wounds occur in completely random orientation with respect to flexion creases, frequently crossing them at oblique angles. In all the above instances, hypertrophic scars commonly result. Alternative methods of limiting scar length have been tried in the past, such as using nonabsorbable sutures left in place for long periods. However, just as skin stretches in response to the forces exerted by surgical expanders, it must also accommodate to such sutures, which therefore lose their effectiveness. Other methods, such as pressure dressings, splints, gel pads, and steroid injections, have also been of limited usefulness (1,2). Initial attempts at preventing scar widening by transverse application of tape proved to be ineffective (3). However, by limiting the lengthwise stretching of the wound, tape applied longitudinally did prove to be effective in keeping hypertrophy to a minimum. The daily reapplication of the tape renews the longitudinal compressive force each day, thereby maintaining the desired effect.

Prevention of Hypertrophic Scars

603

Figure 2A shows a patient who underwent tenosynovectomy through a dorsal flap incision. The limb of the incision that is parallel with the natural skin creases has become soft and flat, whereas the limb that is more longitudinal in orientation is hypertrophic. When she needed a second operation, paper tape was used, starting 2 weeks after surgery. The tape was applied with the wrist extended, so that it prevented the scar from stretching when the wrist was flexed, as can be seen in Figure 2B. The patient wore the tape continuously for 6 months and intermittently for 3 more months. The final result, at 1 year, is visible in Figure 2C. The process of scar maturation and softening varies significantly with the area of the body and the individual involved. The process of taping must be continued until the scar is visibly pale and palpably flat. Figure 3 A–D shows a scar on the breast, which became soft and flat at 2.5 months, allowing for discontinuance of the tape at that point. Since the rate of collagen synthesis is relatively slow for the first 2 weeks after injury, the process of tape application can be delayed until that point, allowing for epidermal regeneration and wound closure. The tape should be applied to skin that is clean and free of oil or moisturizers, usually after showering once daily. The skin must be thoroughly dry. The use of a liquid adhesive such as tincture of benzoin or Mastisol (Ferndale Laboratories, Inc., Ferndale, MI) may help if the tape does not adhere well. If a blister develops, a tiny dab of petrolatum or bacitracin ointment can be placed directly on the blister and the tape applied directly over it. For most patients, the tape should be changed once daily. However, for those individuals who have extremely dry skin, if the tape remains quite secure, it may be left in place for 2 days at a time. Most of the time 1-inch wide tape is sufficient. However, in difficult areas, such as the abdomen, 2-inch wide tape may be necessary. Paper tape should always be used, since it does not stretch at all and is less likely to cause an allergic reaction. Hair may need to be shaved, as necessary, for comfort. It is important to demonstrate to the patient that the tape must be placed in such a manner as to prevent lengthening of the scar. If an underlying joint can be extended (as in the example above) or flexed (if the wound is on the flexor surface) during tape application, that will suffice. However, in areas such as the breast or abdomen, the tape should be applied while compressing the scar so as to shorten it. This is easily accomplished by applying the tape to the normal skin just beyond one end of the scar and then, while holding that end down, pulling the tape and skin in the direction of the scar, thereby compressing it, while applying the tape down on top of the scar.

Figure 2 (A) The limb of the scar that is in the natural flexion creases has not thickened, while the limb that crosses the flexion creases has become hypertrophic. (B) The same patient needed a second operation, after which paper tape was applied beginning at 2 weeks. (C) After 6 months of continuous taping, and 3 more months of intermittent taping, the final result is shown at 1 year. (Courtesy of Lippincott Williams & Wilkins, Baltimore, Maryland.) From Ref. 3.


605

Figure 3 (A) A 25-year-old female had undergone rib resection for thoracic outlet syndrome and developed a hypertrophic scar from her axilla onto her breast. The anterior portion was 10 mm wide and pruritic. (B) Close-up view of the scar. (C) After scar revision and taping, the appearance at 2.5 months, at which time the tape was discontinued. (D) Final result at 2.5 years. The scar is barely perceptible. (Courtesy of Lippincott Williams & Wilkins, Baltimore, Maryland.) From Ref. 3.

The patient is examined about 2 weeks into treatment, with the tape in place, to ensure that the tape is being applied properly. Thereafter, monthly examinations are continued until it is felt safe to stop the treatment. In many instances, the scar reaches the point of maximal hypertrophy at 6 weeks. The taping is continued beyond that time until the scar becomes pale and soft; sometimes as early as 2–3 months.

606

Figure 3

Reiffel

continued

However, as can be seen in Figure 2, some areas in some individuals continue to remain thickened longer, so the tape must be continued faithfully by the patient. The endpoint is when the scar is pale, soft, and flat. If any doubt remains, the tape may be continued part time during periods of peak activity, such as work or sports. However, the patient should be cautioned to resume treatment if the scar begins to thicken up at all, because this treatment will help prevent scars from thickening and widening but will not make wide scars thin.


607

REFERENCES 1. 2.

3.

Cohen IK, Diegelmann RF, Lindblad WJ. Wound Healing: Biochemical and Clinical Aspects. Philadelphia: Saunders, 1992: 110–112. Sproat JE, Dalcin A, Weitauer N, Roberts RS. Hypertrophic sternal scars: silicone gel sheet versus kenalog injection treatment. Plast Reconstr Surg 1992; 90:988. Reiffel RS. Prevention of hypertrophic scars by long-term paper tape application. Plast Reconstr Surg 1995; 96(7):1715–1718.

Index

Abrasive trauma, 521 Absorbable tissue adhesive, split-skin grafting, 351–354 Accessory ear, correction, 50 Acne surgery paper clip comedo extractor, 207–209 method, 207–209 Acrochordons, razor blade surgery, 107 Actinic cheilitis lower lip, 1 spindle cell carcinoma, 7 W-plasty technique, 6–7 Adson forceps, 110, 211–212, 230 disadvantages, 211–212 Alar batten grafts, 394–397 Alar composite grafts delayed intranasal knot placement, 373–377 technique, 374–376 Alar edge, demolition, 280 Allografts autologous fat transfer pinch technique, 517 Anesthesia automated subcutaneous infusion tumescent, 193–199

[Anesthesia] bilevel, blunt dissection, 187–190 slow infusion tumescent, 193–199 ultrasonic scalpel, rhinophyma, 220 Antibiotics autologous fat transfer, pinch technique, 516 Anticoagulants oral vascular anomalies, transfixion technique, 173–174 Antihelix basal cell carcinoma, 336 case report, 336–337 Apex cutaneous suture, TSR, 105 Apex line, TSR, 103 Apical paranasal lesion, 279 Aquaplast stent, 344–345 Mohs surgery defect, 346 Arcus marginalis, release, 554, 560 Argon laser, hemangiomas, 88 Arterial vascular malformations, 173 Arthroscopic blade Beaver, Mohs micrographic sections, 151–152, 156 Artificial pigmentation, eyelids, 575 Artificial waterlogging, 166 Asians, multiple Z-plasty, 54 609

610 Auricular cartilage excised, 332 harvesting, 331–333 technique, 331–332 Autoclaving paper clip comedo extractor, 207 Autologous epidermal grafting vitiligo, 357–363 blister production, 358 follow-up, 362–363 harvesting, 359–362 recipient area preparation, 359 Autologous fat transfer pinch technique, 515–518 manual bilateral palpation, 518 materials and methods, 516–517 Autologous fibrin glue cost, 402 fibrinogen concentration, 401 full-thickness skin grafts, 436 skin graft fixation, 399–402 preparation and application, 400–401 Automated subcutaneous infusion tumescent anesthesia, 193–199 indications, 195–196 method, 193–195 anesthetic solutions, 194 equipment, 193–194 infusion speed, 195 infusion volumes, 194–195 injection depth, 194 medication, 195 monitoring, 195 needles, 194 preoperative supervision, 195 waiting period, 195 results, 196–197 Automation hair transplantation, 489–502 goal, 493–494 need, 493 tools, 495–499

Bags on bags phenomenon, 577

Index Balloon intraoperative nasal ala immobilization, Foley catheter, 96–99 Bandage pressure, vs. tie-over dressing, 464 Basal cell carcinoma antihelix, case report, 336–337 ear, 146, 336 MMS, 336, 381 nose, 344 operative report, 594–597 palm, 368 partial-thickness nasal alar defect, MMS, 394 razor blade surgery, 107 scalp, 412 SITA, 196 temporal region, 289 Basement membrane zone, 388 Beaver arthroscopic blade Mohs micrographic sections, 151–152, 156 Beaver eye blade Mohs micrographic sections, 151, 153–156 Beriplast P, 436 Betadine split ear lobe, tongue depressor blade, 532 Bilateral advancement flap popularity, 261 sliding capacity, 261 Bilateral fan flaps hospital discharge, 241 lip semimucosa, 238 obtention, 238 postoperative care, 239 stitches, 239 structure, 239 surgical technique, 238 upper lip reconstruction, 237–242 Bilayered loop buried absorbable wound closure, 31

Index Bilevel anesthesia blunt dissection, 187–190 advantages, 189–190 technique, 188–189 Bilobed flap compound, nose, 277–282 mobilization, 281 principle, 270 reconstruction, 277–282 cases, 279–282 techniques, 277–279, 281 types, illustrated, 278 Biobrane stent, 341 Biopsy oral lesions, 165–171 excision, 166 incisional, 166 Biotin supplements, nail brittleness, 130 Bipedicle flap, 294, 296 Bipolar, 554 Biterminal, 554 Blades breaker and holder Castroviejo, 107–111 Mohs micrographic sections curved, 149–157 ophthalmic, 151 Schick Double Edge, 109 Bleeding, tongue, 167–170 Blepharochalasis, 578 Blepharoplasty. See also Tractionmodified blepharoplasty examination evaluation documentation, 579–581 poliglecaprone suture, 16 questionnaire, 581–583 transconjunctival, 564, 568–569 transconjunctival lower, 553–554 upper, 558–560 upper eyelids, technique and modifications, 548 Blister formation disposable suction syringe epidermal grafting, 388

611 Blood thinners autologous fat transfer, pinch technique, 516 Blunt dissection bilevel anesthesia, 187–190 advantages, 189–190 technique, 188–189 Bolsters, 432–435 advantages, 115 cutaneous surgery, 113–116 fibrin glue, 435–437 gauze, free-loop stitches, 329 graft, 325 ideal properties, 342–346 Reston technique, 433–435 sponge, 433–435 stents, 432 tied down, 330 traditional, 432–433 unsuture technique, 433 Boudjema, Pascal, 498 Bowen’s disease, 365 Braided polyglactin, 15 Braided sutures, 16 Bridging, capillaries, 335 Buried absorbable wound closure, 25–34 advantages, 33–34 vs. conventional bilayered closure techniques, 32 disadvantages, 32 postoperative, 33 previous studies, 31–32 technique, 26–30 Buried vertical mattress stitch, 24 Burned-out panniculitis autologous fat transfer pinch technique, 517 Burn net, 407–408 Burns fibrin sealant, 436 wireframe, sheet skin grafting, 472–473 Burow’s triangle, 262 advancement flap, 249–259, 283 basal cell carcinoma, 256

612 [Burow’s triangle] double, 252 elliptical incisions, 250 examples, 251 final closure, 256 incision lines, 254–255 lesion distance, 250 mandibular, 258 operation diagram, 258 operation scheme, 256 technique, 249–251 variants, 251 rotation flap, 284 Bury-and-knot sutures, 79–85 technique, 79 Butyl cyanoacrylate safety, 351

Calvitron, 498–499 Capillaries, bridging, 335 Carbon dioxide laser, 537 resurfacing, 558–560, 564–569 rhinophyma, 219 Sharplan Silk Touch, 543 vaporization, nail plate, 140–141 Cartilage removal sharp dissection, 337 skin grafts, 335–339 Castravjego forceps, 211 Castroviejo blade breaker and holder, 107–111 advantages, 111 development, 108 instruments, 108–111 shave technique, 107–108 Cavitation, ultrasonic scalpel, 218 Central pedicle, 292 Cephalosporin traumatic tattoos, dermabrasion, 522–523 Chalazion, oral biopsy, 166–167 Chalazion clamp, 533 Chalazion forceps, 532 Cheek lentigo maligna excision, 119–121

Index Cheilitis, 420 actinic lower lip, 1 spindle cell carcinoma, 7 W-plasty technique, 6–7 grazing lower lip, 5 Children hernia repair, purse string suture, 41 SITA, 199 Choi Hair Transplanter, 495–496 Chondritis, ear, 143 Chronic inflammatory disease lower lip, overgrafting, 422–423 Ciprofloxacin, ear lesions, 145 Clamp Chalazion, 533 Iowa-Freer avulsion, 204–205 Clavicle, relaxed skin tension lines, 381 Clavicular grafts, 379–384 donor sites postoperatively, 383–384 repair, 381–382 donor skin harvesting, 379–381 Cleft ear lobe. See Split ear lobe Cleft lip repair, 58–59 Cleft wound, 226 Close skin lesions simultaneous removals, 283–290 Clothes lines, 51–52 COAG electrosurgical energy, 562 COAG mode, 555–556 Cold scalpel procedure, 2 Coloboma lobuli, 531 Colorado needle, 537, 550, 553, 561, 563 Colorado probe, 562, 564 Comedo extractor, paper clip acne surgery, 207–209 autoclaving, 207 Compazine traumatic tattoos, dermabrasion, 523 Compound bilobed flap, nose, 277–282 Computer-generated operative reports, 593–599

Index [Computer-generated operative reports] methods, 593–598 Concha, basal cell carcinoma, 336 Conchal defects, 243–247 closure, 245 closure technique, 246 island flap, 246 tension, 246 wounds, 244 Conchal perforations reconstructive closure, 246 Contact laser surgery hemangiomas, 88 Continuous-interlocking sutures, 71 Continuous locking suture multiple Z-plasty, 52 Continuous over and over sutures, 71 Conventional bilayered closure techniques vs. buried absorbable wound closure, 32 Cosmetic eyelid surgery, scarification, 547 Cosmetic oculoplastic surgery evaluation documentation, 573–583 visible incision reduction, 547–571 results, 570–571 Cost, autologous fibrin glue, 402 Cream, depilatory stitch removal, 45–46 Cryosurgery closed technique, 590 cutaneous soft fibromas, 589–591 labial mucocele, 184 open technique, 590 Curet, ear cartilage debridement, 145–146 Curved blade Mohs micrographic sections, 149–157 material and methods, 151 results, 151, 154 Curvilinear scar creating, 117–121 technique, 117–119

613 Cutaneous atrophy bolster techniques, 115 Cutaneous lesions removal, 249 rhomboid exeresis, 283 Cutaneous mastocytomas ultrasonic scalpel, 221 Cutaneous soft fibromas cryosurgery, 589–591 Cutaneous surgery bolster techniques, 113–116 operative report, 594, 596–597 Defect preparation, IPF, 298, 299 Deformed ear lobe, tongue depressor blade, 531–534 Dehydration, stents, 342 Delayed intranasal knot placement alar composite grafts, 373–377 technique, 374–376 Dental spatula, nail avulsion, 202–203 Depilan, 46 Depilatory cream, stitch removal, 45–46 Dermabrasion safety razor, sandpaper, 527–529 traumatic tattoos, 521–524 Dermostitches, double-tipped suture needle, 55–56 Dexon suture oral vascular anomalies, transfixion technique, 174–175 Diathermy vs. knife, oral biopsy, 166 Diazepam traumatic tattoos, dermabrasion, 523 Digit, squamous cell carcinoma, 367 Disposable suction syringe epidermal grafting, 387–391 instrumentation, 387–388 procedure, 389–390 results, 390 suction magnitude, 388–389 Documentation evaluation

614 [Documentation] blepharoplasty examination, 579–581 cosmetic oculoplastic surgery, 573–583 eyebrows, 574 lacrimal gland, 574 visual acuity, 574 visual fields, 576–577 Donor site autologous fat transfer, pinch technique, 516 repair, clavicular grafts, 381–382 split-thickness grafts, primary closure, 457–459 Double-edge razor blade, 108 quarter section, 110 Double elliptical lesion, 251 Double-interlocking suture techniques, 71–77 advantages, 71–72 materials, 71–72 postoperative edema, 73 technique, 74–77 Double-tipped suture needle dermostitches, 55–56 method, 55–56 Drainage tube, nail splinting, 135–137 Drains, free skin grafting, 413–417, 463–464 Dressing free skin grafting, 461–465 suction drain, 463–464 Dry eyes, 578 Dual lateral pedicle, 292 Dufourmentel transposition flap illustrated, 285 rotation flap, 284 variant, 285 Dural leaks, fibrin glue, 400 Ear accessory, correction, 50 basal cell carcinoma, 146, 336 piercing, 531 repiercing, 533–534

Index [Ear] skin graft, suction catheter, 408–409 Ear cartilage Mohs surgery defects, 143–147 cartilage debridement, 145 ear lesions, 144–145 framework, 144 healing, 144 infection, 143–144 Ear lobe. See also Split ear lobe deformed, tongue depressor blade, 531–534 Edema postoperative, double-interlocking suture techniques, 73 Egg crate foam rubber, 407 Elderly malignant otitis externa, 144 Electric tattoo gun vs. manual punch, 586–587 Electrocoagulation, 539 Electrodesiccation, 136, 554 Electrofulguration, 554 Electrosurgery, rhinophyma, 219 Electrosurgical generator, 537 Elevator Freer, 331 Freer septum, nail avulsion, 202–205 periosteal, 126 Epidermal grafting disposable suction syringe, 387–391 instrumentation, 387–388 procedure, 389–390 results, 390 suction magnitude, 388–389 Epinephrine lidocaine, blunt dissection, 188 Esthetics, plastic surgical procedure, 229 Evaluation documentation blepharoplasty examination, 579–581 cosmetic oculoplastic surgery, 573–583 eyebrows, 574

Index [Evaluation documentation] lacrimal gland, 574 visual acuity, 574 visual fields, 576–577 Excisional lines, shortening, 103–105 Excision biopsy, oral lesions, 166 Explosive trauma, 521 Extravasation mucoceles, etiology, 180 Eye, dry, 578 Eye blade Beaver, Mohs micrographic sections, 151, 153–156 Eyebrows evaluation documentation, 574 thinned, 575 Eyelid artificial pigmentation, 575 cosmetic surgery, scarification, 547 lower evaluation documentation, 577–578 horizontal tone, 577 simultaneous lateral anterior and posterior, 564 techniques and modifications, 552–554 traction-modified blepharoplasty, 542 ptosis, evaluation documentation, 576 skin grafted defect, 406 tattooing, 575 upper, skin thickness, 576 wireframe, sheet skin grafting, 475–479 Eyelid blepharoplasty lower simultaneous lateral anterior and posterior, 564 techniques and modifications, 552–554 Eyelid plate Jaeger, transconjunctival lower blepharoplasty, 540, 553

615 Face defects, 515 elliptical defects, subcuticular poliglecaprone, 16 excisional defect, 68 Face lift, fibrin glue, 400 Facial injuries traumatic tattoos, immediate treatment, 521–522 Facial lesion, excision, 263 Facial scars wireframe, sheet skin grafting, 473–475 Facial skin cancer round block distorting purse string suture, 61–69 complications, 62–63 results, 62–63 technique, 62 Far-far loop running vertical mattress suture technique, 11–12 short-hand vertical mattress stitch, 21–23 Fat harvesting autologous fat transfer, pinch technique, 516 Fat tissue flap surgery, 319 subdermal, free skin grafting, 447 Fat transfer autologous, pinch technique, 515–518 manual bilateral palpation, 518 materials and methods, 516–517 Fatty pockets upper eyelids, evaluation documentation, 576–577 Fenestrating incisions, 343 Fibrin glue advantages, 437 applications, 400 autologous cost, 402 fibrinogen concentration, 401 full-thickness skin grafts, 436

616 [Fibrin glue] skin graft fixation, 399–402 bolsters, 435–437 disadvantages, 437 safety, 399 Fibrinogen concentration autologous fibrin glue, 401 Fistulae, fibrin glue, 400 Flap axis, rotation degree, 270 Flap defatting ultrasonic surgical aspirator, 319–323 cases illustrated, 322, 323 physical principle, 319–320 surgical technique, 320–323 Flap dynamics, changes, 293 Flap movement after lesion removal, illustrated, 272 Flaps. See also Bilateral fan flaps; Bilobed flap; Island pedicle flap (IPF); Modified bilateral advancement flap; Transposition flap bilateral advancement, 261 bipedicle, 294, 296 Dufourmentel transposition, 284, 285 Gillies fan, 241 Imre, rotation flap, 284 kite, 291–299 Limberg, elevation, 214 rhomboid transposition, 244 rotation, reconstruction, 283–290 serial transpositions, 270 skin, umbilicus reconstruction, 301–307 skin or muscle traction-modified blepharoplasty, 539 subcutaneous pedicle, 291–299 trilobed, simultaneous repair, 269–274 tunneling, 296–298 Flap surgery, fat tissue, 319 Flap variants, types, 269 Flip-flop flap, 295

Index [Flip-flop flap] illustrated, 296 Fluid adsorption, stents, 342 Foam rubber, egg crate, 407 Foam rubber stent, 341 properties, 342–343 Foley catheter intraoperative nasal ala immobilization, 95–102 nostril, 100–101 Follicular trauma, hair graft harvesting, 495 Follicular unit transplantation problems, 490–493 Foot instep, skin grafts, 370 Forceps Adson, 110, 211–212 disadvantages, 211–212 Castravjego, 211 Chalazion, 532 design, 230 platypus nail-pulling, nail avulsion, 202–203 skin hook, 211–214 Forearm, split-thickness grafts, 416 Free cartilage grafts nasal alar reconstruction, 393–397 technique, 395 Free-loop stitches, gauze bolster, 329 Free loop sutures, 326–329 graft inspection, 329 threading suture loop, 327–328 Freer elevator, 331 Freer septum elevator, nail avulsion, 202–205 Free skin graft dressing suction drain, 461–465 case reports, 463–464 Free skin grafting consecutive, 446 dressing, 461–465 historical development, 445 large whole-piece, 446 nonvascular anastomosis, 447 nylon thread, 413–417 technique, 414–415

Index [Free skin grafting] preserved subcutaneous vascular network, 446–447 subdermal fat tissue, 447 transparent gasbag tie-over, 445–453 dressing modifications, 447–452 skin graft inner structure, 446–447 Fresh tissue technique Mohs micrographic surgery, 159 ultrasonic scalpel, 221 FTSG. See Full-thickness skin graft (FTSG) Full-thickness skin graft (FTSG) advantages, 370 donor sites, 370 fibrin sealant, 436 MMS hand defects, 365–371 materials and methods, 366–367 results, 368 vs. split-thickness grafts, 379, 381–382

Gasbag pressure free skin grafting, transparent gasbag tie-over, 448–449 Gasbag tie-over transparent, free skin grafting, 445–453 Gas-sterilized surgeon’s bonnets traction-modified blepharoplasty, 536 Gastroschisis, umbilicus absence, 303 Gauze, traction-modified blepharoplasty, 535–536 transconjunctival lower blepharoplasty, 540 Gauze bolster free-loop stitches, 329 Generator, electrosurgical, 537 Gentamycin, ear lesions, 144 Gillette Super Blue Blades, 109 Gillies fan flaps, 241 Glabella nose lesions, illustrated, 273–274 wrinkles, trilobed flaps, 273

617 Glue. See Fibrin glue Gomco suction, wart tissue removal, 125 Graft. See also Skin grafts; Splitthickness grafts alar batten, 394–397 alar composite, delayed intranasal knot placement, 373–377 technique, 374–376 autologous epidermal, vitiligo, 357–363 clavicular, 379–384 epidermal, disposable suction syringe, 387–391 free cartilage, nasal alar reconstruction, 393–397 free skin, 413–417, 445–453, 461–465 full-thickness skin, 365–371, 379–382 hair, 495–497 meshed skin, preparation, 467–469 punch, 441–443 sheet skin, 413, 471–481 split skin, severely damaged skin, 351–354 split-thickness skin, 369 Graft bolster, 325 Graft cutting, instruments, 494 Grafted leg defect, tie-over dressings, 407 Graft harvesting follicular unit transplantation, 490 multibladed knives, 494 Graft inspection, free loop sutures, 329 Graft placement follicular unit transplantation, 490–493 h-factor, 492–493 staff, 491 x-factor, 491–492 instruments, 494–495 Graft reinspection, reusable loop sutures, 325–330 Graft-tome, 494 Granulation tissue, skin graft, 335 Grapefruit knife, 149–150 Grazing cheilitis, lower lip, 5

618 Hair-bearing areas stitch removal, 45–46 technique, 46 Hair graft tools harvesting, 495 placement, 495–497 Hair implanter pen, 498 Hair transplantation automation, 489–502 goal, 493–494 need, 493 tools, 495–499 Hair Transplanter, Choi, 495–496 Hamra’s composite rhytidectomy, 552 Hand dorsal surface, 365, 370 MMS defects skin grafts, 365–371 palmar surface, 370 skin graft, 465 Handheld thermocautery unit nail plate excision, 123–128 nail plate removal, 125 vaporization, 124–125 Harvesting auricular cartilage, 331–333 technique, 331–332 Heat generation, ultrasonic scalpel, 218 Hemangiomas contact laser surgery, 88 hemostatic studies, 88–93 oral mucosa, 173 port-wine, 89 surgical excision, 87–93 thermoscalpels, 88 Hemaseel APR, 436 Hematomas free skin graft dressing, suction drain, 463 sheet skin grafting, 413 skin graft, 425 Hemolymphangiomas transfixion technique complications, 177

Index Hemorrhage hemangiomas, surgical excision, 87 Hemostasis hemangiomas, surgical excision, 87, 92–93 lower lip, 3 stent dressing technique, 405 W-plasty, 6 Hemostat, 126 nail avulsion, 202–203 clamp, 201–205 Hemostatic studies, hemangiomas, 88–93 Hernia repair children, purse string suture, 41 H-factor graft placement, follicular unit transplantation, 492–493 Horizontal oblique dermal suture, TSR, 104–105 Hypertrichosis, 575 Hypertrophic orbicularis, 554–570 modification closed technique, 557–569 open technique, 555–557 Hypertrophic scars, 16 long-term paper tape application, 601–606 multiple Z-plasty, 54 Ice pick acne scars punch grafts, lubrication jelly, 441–443 Immobilization, stents, 342 Imre flap, rotation flap, 284 Incisional biopsy, oral lesions, 166 Incisions fenestrating, 343 pie-crusting, 343 reduction cosmetic oculoplastic surgery, 547–571 upper blepharoplasty, 559–560 Infants plastic surgery, stitch removal, 57–60 Infection, oral biopsy, 170

Index Infection barrier, stents, 342 Inflammatory disease lower lip, overgrafting, 422–423 Infusomats, SITA, 198 Ingrown toenails granulation tissue, 136 nail splinting, 135–137 operative technique, 135–136 Insulin injections autologous fat transfer, pinch technique, 517 Intranasal knot placement delayed alar composite grafts, 373–377 Intraoperative nasal ala immobilization Foley catheter, 95–102 technique, 95–97 Iowa-Freer avulsion clamp, 204–205 IPF. See Island pedicle flap (IPF) Iris scissors, 550 Iris technique, umbilical reconstruction, 313–317 ablation and flap design, 314 Island pedicle flap (IPF) defect preparation, 298, 299 design and advancement, 293 innovation, 291–299 innovations biomechanics, 291–292 modifications, 292–298 Jaeger lid plate, transconjunctival lower blepharoplasty, 540, 553 Keloids, 16 multiple Z-plasty, 54 Kirschner wire, 471, 473 Kite flap, 291–299 Knives vs. diathermy, oral biopsy, 166 grapefruit, 149–150 multibladed, graft harvesting, 494, 495 Knot, short-hand vertical mattress stitch, 23

619 Labial mucocele cryosurgery, 184 diagnosis, 180 etiology, 180 excision, 180–183 incision and drainage, 183 large untreated, 181 management, 180–185 marsupialization, 183 micromarsupialization, 183–184 removal, 179–185 steroids, 184–185 Labial muscle Z-plasty flaps, 235 inked delineation, 234 lip seal reestablishment, 233–236 postoperative result, 235 preoperative photograph, 234 reconstruction, 236 surgical specimen, 235 surgical technique, 233–235 Lacrimal gland, evaluation documentation, 574 Lagophthalmos, 548 Large Z-plasty, 309–311 indications, 311 schematic drawing, 310 transposition, 311 Laser argon, hemangiomas, 88 carbon dioxide, 537 rhinophyma, 219 finishing, 568 resurfacing, 564 carbon dioxide, 558–560, 564–569 traction-modified blepharoplasty, 543 Sharplan Silk Touch, 543, 568 Laser surgery contact, hemangiomas, 88 Laser vaporization carbon dioxide, nail plate, 140–141 Laterally based pedicle, nasal dorsum, 295 Laterally based pedicle flap, 293–294

620 Lateral nail, squamous cell carcinoma, 124 Layered closure, monofilament, 15–18 Left alar region, lesion, 279 Lenticular excision, 117–118 circular fashion, 119 markings, 118 postoperative view, 120 immediate, 120 six-week, 120 Lentigo maligna cheek, excision, 119–121 Leukoderma lower lip, overgrafting, 419–424 vs. vitiligo, 419 Leukoplasia, lower lip, 1 Lidocaine epinephrine, blunt dissection, 188 Lids. See Eyelids Limberg flap, elevation, 214 Lip. See also Lower lip inflammatory disorders, 420 reconstruction cleft, 224 Cupid’s bow, 226 height, 225 hemi-lip, 225 mirror, 226 mistakes, 223 superimposition, 227 trauma, 224 vermilion-skin border, 223–228 Liposuction cannulae tips, 504–505 traditional, 503 ultrasonic, 503 Liposuction divots autologous fat transfer, pinch technique, 517 Long-term paper tape application hypertrophic scars, 601–606 Looped square knot, 57–60 method, 58–59 Loose loop sutures, 325–326 Lower eyelids. See Eyelids

Index Lower lip actinic cheilitis, 1 limitations, 233 atrophic area, 233–234 chronic inflammatory disease overgrafting, 422–423 focal neoplastic region, 233–234 grazing cheilitis, 5 hemostasis, 3 leukoderma, overgrafting, 419–424 leukoplasia, 1 mucosa, 234 spindle cell carcinoma, 1 vitiligo, overgrafting, 420–421 Lower transconjunctival blepharoplasty, 567 open method, 558–559 L-plasty, 533 Lubrication jelly punch grafts, pitted acne scars, 441–443

Mafenide acetate, ear lesions, 144 Malignant melanoma poliglecaprone suture, 17 purse string suture, 41–43 Malignant otitis externa, elderly, 144 Mammary gland tumor, biopsy, 50 Mangubat Graft Cutter, 494 Manual punch vs. electric tattoo gun, 586–587 tattooing, 585–587 Marsupialization, labial mucocele, 183 Mastisol, 603 Mastocytomas cutaneous, ultrasonic scalpel, 221 Matricectomy, phenol alcohol partial splitting nail, 130–132 Mattress stitch, buried vertical, 24 Mattress sutures, 37, 332–333 Melanoma, biopsy, 166 Meperidine traumatic tattoos, dermabrasion, 523

Index Mepivacaine oral vascular anomalies, transfixion technique, 174 Meshed skin grafts, preparation, 467–469 Microforms, 585 Micromarsupialization labial mucocele, 183–184 Microtia, depressed deformity, 85 Mini Z, 309–311 transverse linear tension, operative techniques, 310 Minoxidil, nail brittleness, 130 MMS. See Mohs micrographic surgery (MMS) Modified bilateral advancement flap, 261–267 advantages, 267 application, 262 basal cell carcinoma, 264 bilateral capacity, 267 closure, 264 complications, 267 design, 263 flap advanced closure, 266 forehead, 264 improvements, 261 incision lines, 263 location, 262 operation results, 265 operations, 262 pedicle, 263 reconstruction results, 265 skin defect, 266 skin lesions, 266 technique, 262 temporal defect, 265 tension, 261 Modified buried dermal suture, 37–40 disadvantages, 39 placement, 40 postoperative, 40 pulley, 38 technique, 38–39 Modified buried vertical mattress suture, 25–34

621 Mohs layer, removal, 127 Mohs map, 102, 159–164 Mohs micrographic sections, curved blade, 149–157 Mohs micrographic surgery (MMS) basal cell carcinoma, 336, 381 defect, Aquaplast stent, 346 ear cartilage defects, 143–147 hand defects, skin grafts, 365–371 intraoperative nasal ala immobilization, Foley catheter, 95–102 tissue specimens, 159–164 trilobed flap cases, 271 Monocryl, 15 vs. braided sutures, 16 Monofilament, layered closure, 15–18 Monofilament poliglecaprone, 15 Monopolar, 554 Monoterminal, 554 Morphea autologous fat transfer, pinch technique, 517 Mucoceles extravasation, etiology, 180 multiple retention, etiology, 180 Mucosa, 240 Multibladed knives, graft harvesting, 494, 495 Multifilament sutures, 16 Multiple retention mucoceles, etiology, 180 Multiple Z-plasty Asians, 54 continuous locking suture, 52 design, 53 flap, 311 hypertrophic scars, 54 keloids, 54 new skin suture technique, 51–54 technique, 51–52 Muscle flap lower blepharoplasty, traction-modified, 539 Muscle reconstruction, 223 Nail, squamous cell carcinoma, 124

622 Nail avulsion, 201 indications, 201 nail elevator/hemostat clamp, 201–205 Nail brittleness, prevention, 129–130 Nail elevator, 139–140 nail avulsion, 201–205 design, 203–204 technique, 205 Nail hydration, promotion, 130 Nail-mending kits, 130 Nail plate carbon dioxide laser vaporization, 140–141 vaporization, 124–125 Nail plate excision handheld thermocautery unit, 123–128 postoperative site, 128 postoperative wound care, 125–128 regional anesthesia, 123 technique, 123–127 occlusive dressing, 127 Nail plate removal, handheld thermocautery unit, 125 Nail splinting drainage tube, 135–137 ingrown toenails, 135–137 operative technique, 135–136 Nail splitter, 139–140 Nasal alar defect partial-thickness, basal cell carcinoma, 394 Nasal alar immobilization intraoperative, Foley catheter, 95–102 Nasal alar reconstruction, free cartilage grafts, 393–397 technique, 395 Nasal dorsum, laterally based pedicle, 295 Near-far-far-near sutures, 37 Near-far loop, running vertical mattress suture technique, 13

Index Near-near loop running vertical mattress suture technique, 12 short-hand vertical mattress stitch, 21–22 Needles automated subcutaneous infusion tumescent anesthesia, 194 Colorado, 537, 550, 553, 561, 563 double-tipped suture, dermostitches, 55–56 holders, 108 Neovascularization, skin graft, 335 Nevi, razor blade surgery, 107 Nonsteroidal anti-inflammatory drugs autologous fat transfer, pinch technique, 516 Nonvascular anastomosis, free skin grafting, 447 Nonvolumetric tissue expansion, 483 Norfloxacin, ear lesions, 145 Nose basal cell carcinoma, 344 compound bilobed flap, 277–282 Foley catheter, 100–101 multiple defects, 269–274 Nylon thread free skin grafting, 413–417 technique, 414–415 Octylcyanoacrylate film adhesive, 353 Oculoplastic surgery, cosmetic evaluation documentation, 573–583 visible incision reduction, 547–571 Omphalocele, umbilicus absence, 303 Operative reports computer-generated, 593–599 methods, 593–598 cutaneous surgery, 594–597 filling out, 594–597 Ophthalmic blade, Mohs micrographic sections, 151, 153–156 Optimal wound closure, goals, 26 Opti-Mold, 344–345

Index Oral lesions biopsy, 165–171 complications, 168–171 diagnosis, 165–166 Oral stoma, 236 Oral vascular anomalies transfixion technique, 173–177 complications, 177 materials, 173 method, 174–175 preoperative assessment, 173–174 Orbicularis, 539 festooning, 577 Otitis externa malignant, elderly, 144 Overgrafting lower lip chronic inflammatory disease, 422–423 leukoderma, 419–424 vitiligo, 419

Palm, basal cell carcinoma, 368 Panniculitis burned-out, autologous fat transfer, 517 Paper clip comedo extractor acne surgery, 207–209 autoclaving, 207 Paranasal lesion apical, 279 right, 279 Partial-thickness nasal alar defect basal cell carcinoma, MMS, 394 Pate procedure, 483 Perfectionism, 578 Perforated concha, 244 Perichondritis, ear, 143 Perichondrium, removal, 335 Periosteal elevator, 126 Persistent pressure free skin grafting, transparent gasbag tie-over, 449, 452

623 Phenol alcohol partial matricectomy splitting nail, 130–132 Pie-crusting incisions, 343 Piffard, Henry, 207 Pigmentation, artificial eyelids, 575 Pinch technique, autologous fat transfer, 515–518 Pitted acne scars punch grafts, lubrication jelly, 441–443 Plastic bead tie-over, 341 Plastic discs, free skin grafting transparent gasbag tie-over, 448 Plastic surgery infants, stitch removal, 57–60 Platypus nail-pulling forceps nail avulsion, 202–203 Pleural leaks, fibrin glue, 400 Plication, SMAS, 381 Poland syndrome, 83 Poliglecaprone applications, 16 monofilament, 15 Poliglecaprone suture advantages, 16 blepharoplasty, 16 Polyglactin, braided, 15 Polymyxin B, ear lesions, 144 Port-wine hemangiomas, 89 Postoperative edema, doubleinterlocking suture techniques, 73 Povidone split ear lobe, tongue depressor blade, 532 Preserved subcutaneous vascular network free skin grafting, 446–447 Pressure, stents, 342 Pressure bandage, vs. tie-over dressing, 464 Pressure button, 341 Prilocain automated subcutaneous infusion, 193–199

624 Probe, Colorado, 562, 564 Prochlorperazine traumatic tattoos, dermabrasion, 523 Protein denaturation, ultrasonic scalpel, 218 Proteus, ear, 143 Pseudomonas, ear, 143 prevention, 145 Ptosis eyelids, evaluation documentation, 576 Pulley sutures, 37 scalp reduction surgery, 483–487 technique, 484–485 Pull test, 578 Pulsoximetry, automated subcutaneous infusion tumescent anesthesia, 195, 197 Punch grafts pitted acne scars, lubrication jelly, 441–443 Purse string sutures advantages, 43 malignant melanoma, 41–43 pediatric hernia repair, 41 round block distorting facial skin cancer, 61–69 technique, 42–43 Quadruple-interlocking suture techniques, 73 Questionnaire, blepharoplasty, 581–583 Quintuple-interlocking suture techniques, 73 Radiation therapy, 233 Rapid Fire Hair Inserter, 496–497 Rapid stapler tie-over fixation, skin grafts, 411–412 Razor, safety sandpaper, 527–529 Razor blade double-edge, 108 quarter section, 110

Index [Razor blade] surgery, 107–111 instruments, 108–111 shave technique, 107–108 Reconstruction, principle, 243 Reconstructive surgery, goals, 243 Red Rubber Robinson (RRR), 113–116 compressibility, 115 materials, 113–114 method, 114–115 placement, 116 Relaxed skin tension lines, clavicle, 381 Reston foam, 433–434 Reston pad, 343 Reston stent, 344 Reston technique advantages, 435 bolsters, 433–435 disadvantages, 435 Reusable loop sutures graft reinspection, 325–330 Reversible stretching lateral tendon, lower lids, 541, 553 Rhomboid exeresis, cutaneous lesions, 283 Rhomboid transposition flap, 244 Rhytidectomy, Hamra’s composite, 552 Right paranasal lesion, 279 Ring disc, 341 Romberg’s syndrome autologous fat transfer, pinch technique, 517 Ropivacain, automated subcutaneous infusion, 193–199 Rosacea, 219 Rotating IPF, 294 Rotation angles, transposition flap, 286 Rotation degree, flap axis, 270 Rotation flap reconstruction, 283–285 cases, 286–290 Round block distorting purse string suture advantages, 67

Index [Round block distorting purse string suture] facial skin cancer, 61–69 complications, 62–63 results, 62–63 technique, 62 Round faces, 575 RRR. See Red Rubber Robinson (RRR) Rubber bands tie-over dressings, 407 Rubber band tie-over, 341 Running vertical mattress stitch, 24 Running vertical mattress suture technique, 11–14 tension distribution, 13

Safety razor sandpaper, dermabrasion, 527–529 Sandpaper safety razor, dermabrasion, 527–529 Scalp basal cell carcinoma, 412 nevus, SITA, 199 reduction surgery pulley suture, 483–487 technique, 484–485 Scalpel Shaw, rhinophyma, 219 ultrasonic, 217–222 Scarification, cosmetic eyelid surgery, 547 Scars autologous fat transfer, pinch technique, 517 hypertrophic, 16 long-term paper tape application, 601–606 multiple Z-plasty, 54 ice pick acne punch grafts, lubrication jelly, 441–443 lenticular excision, postoperative view, 120 pitted acne, punch grafts, 441–443

625 [Scars] purse string suture, 43 transfixion technique, complications, 177 Schamberg, Jay Frank, 207 Schick Double Edge blades, 109 Scissorless stitch removal, 57–60 Scissors, iris, 550 Sears nail avulsion clamp, 203–205 Seborrheic keratoses, ultrasonic scalpel, 221 Semimucosa, creation, 240 Sensation impairment, oral biopsy, 171 Serial transpositions flaps, 270 Seroma skin graft, 425 Severely damaged skin split skin grafting, 351–354 techniques, 352–353 Sharplan Silk Touch Laser, 543, 568 Shaw scalpel, rhinophyma, 219 Sheet skin grafting adverse effects, 413 wireframe, 471–481 case reports, 472–478 materials and methods, 471–472 Short-hand vertical mattress stitch, 21–24 needle reversal, 22–23 Silicone gel sheet free skin grafting, transparent gasbag tie-over, 448 Silver sulfadiazine, ear lesions, 144 Simple buried vertical mattress stitch, 38–39 Simultaneous lateral anterior and posterior lower lid blepharoplasty (SLAP), 564 Single-interlocking sutures, 71–72 SITA, 193–199 Skin lesion, shave removal, 110 severely damaged, split skin grafting, 351–354

626 Skin cancer facial, round block distorting purse string suture, 61–69 Skin defects, repair, 269 Skin flap, umbilicus reconstruction, 301–307 Skin grafting. See also Free skin grafting sheet adverse effects, 413 wireframe, 471–481 Skin grafts. See also Full-thickness skin graft adherence, 425–426 cartilage removal, 335–339 ears, suction catheter, 408–409 failure, 425 fixation autologous fibrin glue, 399–402 preparation and application, 400–401 foot instep, 370 granulation tissue, 335 hand, 465 hematoma, 425 innovative techniques, 431–438 meshed, preparation, 467–469 neovascularization, 335 rapid stapler tie-over fixation, 411–412 seroma, 425 split-thickness, 369 stent dressing techniques, 405–409 methods and material, 405–408 stents, 341–347 vascular supply, 335 wrist, 370 Skin hook, 229 epidermis, 230 Skin hook forceps, 211–214 flap elevation, 214 utilization, 212–213 Skin or muscle flap lower blepharoplasty traction-modified blepharoplasty, 539

Index Skin tags. See Soft fibromas Skin tension lines relaxed, clavicle, 381 Skin ultrastructure disposable suction syringe, epidermal grafting, 388 SLAP, 564 Slipper hitch, 57 Slow infusion tumescent anesthesia (SITA), 193–199 SMAS, plication, 381 Snap-back test, 577 Social stigma, vitiligo, 357 Soft fibromas cutaneous, cryosurgery, 589–591 SOOF, 554 Spatula, dental nail avulsion, 202–203 Spindle cell carcinoma actinic cheilitis, 7 lower lip, 1 Splinters subungual, direct extraction, 139–140 Split ear lobe tongue depressor blade, 531–534 ear repiercing, 533–534 Split skin grafting severely damaged skin, 351–354 techniques, 352–353 Split-thickness skin graft (STSG), 338, 369 donor site, primary closure, 457–459 fibrin glue, 400 fixation, 411–412 forearm, 416 vs. full-thickness skin grafts, 379, 381–382 Splitting nail medical treatment, 129–130 phenol alcohol partial matricectomy, 130–132 post-treatment, 131 wound treatment, 131 pretreatment appearance, 130 Sponge bolsters, 433–435

Index Squamous cell carcinoma digit, 367 face, round block distorting purse string suture, 64–65 lateral nail, 124 razor blade surgery, 107 Staff graft placement, follicular unit transplantation, 491 Staphylococcus aureus, ear, 143 Stasis ulcers fibrin sealant, 436 Steatoblepharon, 547, 552 Stent, Charles, 344 Stent dressing techniques skin grafting, 405–409 methods and material, 405–408 Stents Aquaplast, 344–345 Mohs surgery defect, 346 Biobrane, 341 bolsters, 432 foam rubber, 341 properties, 342–343 ideal properties, 342–346 Reston, 344 skin grafts, 337–338, 341–347 Steri-strips, 434 thermoplastic, 341, 344–345 tie-over, 341 Sterile tapes, traction-modified blepharoplasty, 536 Steri-strips, stent, 434 Steroids, labial mucocele, 184–185 Stitches. See also Sutures buried vertical mattress, 24 free-loop, gauze bolster, 329 removal, hair-bearing areas, 45–46 running vertical mattress, 24 scissorless removal, 57–60 short-hand vertical mattress, 21–24 needle reversal, 22–23 simple buried vertical mattress, 38–39 Stoppers tie-over dressings, modified, 426–428

627 Strip thinning, tissues, 550 Stryker drill, 523 STSG. See Split-thickness skin graft (STSG) Subcutaneous pedicle flap, 291–299 Subcuticular running suture simple securing, 47–50 technique, 48 surface tension, 49 Subdermal fat tissue, free skin grafting, 447 Sublingual vascular anomaly transfixion technique, 176 Submucosal procedure, 236 Suborbicularis oculi fat (SOOF), 554 Subungual splinters direct extraction, 139–140 forcep extraction, 141 nail plate avulsion, 139–140 treatment, 139–141 extraction techniques, 139–141 Suction catheter, ear skin graft, 408–409 Suction drain, free skin graft dressing, 461–465 Suction syringe, disposable epidermal grafting, 387–391 Suicide scar, 370 Superciliary arch, trilobed flaps, 273 Superficial muscular aponeurotic system (SMAS), plication, 381 Surgical assistants, traction-modified blepharoplasty, 535, 541 Sutures. See also Stitches apex cutaneous, TSR, 105 braided, 16 bury-and-knot, 79–85 technique, 79 continuous-interlocking, 71 continuous locking, multiple Zplasty, 52 continuous over and over, 71 Dexon, oral vascular anomalies, 174–175 double-interlocking, 71–77 free loop, 326–329

628 [Sutures] graft inspection, 329 threading suture loop, 327–328 horizontal oblique dermal, TSR, 104–105 loose loop, 325–326 mattress, 37, 332–333 modified buried dermal, 37–40 pulley, 38 modified buried vertical mattress, 25–34 multifilament, 16 near-far-far-near, 37 poliglecaprone, 16 pulley, 37 scalp reduction surgery, 483–487 purse string advantages, 43 malignant melanoma, 41–43 pediatric hernia repair, 41 technique, 42–43 quadruple-interlocking, 73 quintuple-interlocking, 73 reusable loop, graft reinspection, 325–330 round block distorting purse string, 61–69 running vertical mattress, 11–14 single-interlocking, 71–72 subcuticular running simple securing, 47–50 tie-over silk, 411–412 triple-interlocking, 71–77 Suture technique new skin, multiple Z-plasty, 51–54 running vertical mattress, 11–14 far-far loop, 11–12 Suture techniques double-interlocking, 71–77 quadruple-interlocking, 73 quintuple-interlocking, 73 triple-interlocking, 71–77 Swan-neck liposuction cannulae, 503–514 benefits, 511 disadvantages, 511–513

Index [Swan-neck liposuction cannulae] shaft modifications, 506–510 Tangential incision, 250 Tattoo gun electric vs. manual punch, 586–587 Tattoos. See also Traumatic tattoos eyelids, 575 manual punch, 585–587 Telfa strips, 341 Temporal region, basal cell carcinomas, 289 Tenosynovectomy, 603 Tenzel snap-back test, 577 Thermocautery unit, handheld nail plate excision, 123–128 Thermoplastic stent, 341, 344–345 Thermoscalpels, hemangiomas, 88 Thinned eyebrows, 575 Threading suture loop, free loop sutures, 327–328 Tie-over, rubber band, 341 Tie-over dressings, 341, 405, 425–428, 473 grafted leg defect, 407 modified, 426–428 vs. pressure bandage, 464 rubber bands, 407 stoppers, 426–428 Tie-over silk sutures, 411–412 Tie-over stents, 341 Tincture of benzoin, 603 Tissue adhesives, 351 absorbable, split skin grafting, 351–354 advantages, 353 Tissue preservation, 243 Tissues, strip thinning, 550 Tissue-sparing repair (TSR), 103–105 apex cutaneous suture, 105 horizontal oblique dermal suture, 104–105 planning, 103 Tissue specimens Mohs micrographic surgery, 159–164

Index [Tissue specimens] mapping, 102, 159–164 technique, 159–161 Toenails, ingrown granulation tissue, 136 nail splinting, 135–137 Toluidine blue, carcinoma staining, 166 Tongue, excessive bleeding, 167–170 Tongue depressor blade, split ear lobe, 531–534 Toothed forceps, 229 Total nail avulsion, 201 Traction-modified blepharoplasty, 535–544 laser resurfacing, 543 multiple eye plastic procedures, 541–543 skin or muscle flap lower blepharoplasty, 539 transconjunctival lower blepharoplasty, 540–541 upper blepharoplasty, 536–539 Transconjunctival blepharoplasty, 564, 568–569 lower, 553–554, 567 open method, 558–559 Transfixion technique definition, 176 oral vascular anomalies, 173–177 Transparent gasbag tie-over free skin grafting, 445–453 dressing modifications, 447–452 Transposition flap reconstruction, 283, 285–286 cases, 286–290 rotation angles, 286 variant, 285, 287 Transverse linear tension, mini Z, 309–311 Trauma abrasive, 521 explosive, 521 fibrin glue, 400 follicular, hair graft harvesting, 495 Traumatic tattoos dermabrasion, 521–524

629 [Traumatic tattoos] methods, 522–524 immediate treatment, 521–522 Triangular fossa, basal cell carcinoma, 336 Trilobed flaps simultaneous repair, 269–274 cases, 270–273 techniques, 269–270 types, 271 Triple-interlocking suture techniques, 71–77 advantages, 71–72 materials, 71–72 postoperative edema, 73 technique, 74–77 Triport bevel tip liposuction cannulae, 504–505 TSR, 103–105 Tumescent liposuction, 515 Tumors, umbilicus absence, 303 Tunneling flap, 296–298 illustrated, 297 Tusked forceps instrument design, 230 photograph, 231 skin closure, 229–232 wound closure, 231 Ulcerative carcinoma, staining, 166 Ulcers stasis, fibrin sealant, 436 Ultrasonic scalpel, 217–222 advantages, 218–219 generator and handpiece, 218 rhinophyma, 219–220 Ultrasonic surgical aspirator flap defatting, 319–323 cases illustrated, 322, 323 physical principle, 319–320 surgical technique, 320–323 Umbilical cord hernia, 301–303 surgical techniques, schematic diagram, 302 Umbilical reconstruction, iris technique, 313–317

630 Umbilicus absence, 303–306 schematic diagram, 305 surgical techniques, 305–306 Umbilicus reconstruction skin flap, 301–307 surgical techniques, 302–303 Unitome knife blade Mohs micrographic sections, 153–154 Unna, Paul Gerson, 207 Unsuture technique, bolsters, 433 Upper blepharoplasty, 558 incision-reduction, 559–560 traction-modified blepharoplasty, 536–539 Upper eyelids blepharoplasty, technique and modifications, 548 fatty pockets, evaluation documentation, 576–577 skin thickness, 576 Upper lip anatomy, 237 glabrous skin, 237 reconstructive technique, 238 Urethral catheters, 113–116 Valium traumatic tattoos, dermabrasion, 523 Vascular ectasia, 173 Vascular supply, skin graft, 335 Vascular surgery, fibrin glue, 400 Vermilionectomy complications, 3–4 indications, 2 postoperative treatment, 3 W-plasty technique, 4–7 Vermilion-skin border iodate stain, 224–225 lip reconstruction, 223–228 marking, 224 Vermilion zone, 237 Verrucae, razor blade surgery, 107 Vertical mattress stitch, variations, 24

Index Vicryl-rapide, 16 Visible incision reduction cosmetic oculoplastic surgery, 547–571 results, 570–571 Visual acuity, evaluation documentation, 574 Visual fields, evaluation documentation, 576–577 Vitamin E autologous fat transfer, pinch technique, 516 Vitiligo, 357 autologous epidermal grafting, 357–363 blister production, 358 follow-up, 362–363 harvesting, 359–362 recipient area preparation, 359 vs. leukoderma, 419 lower lip, overgrafting, 420–421 social stigma, 357 Volumetric expansion, 483

Wart tissue, removal, 125 Waterlogging, artificial, 166 Wicking, stents, 342 Wireframe free skin grafting transparent gasbag tie-over, 449 sheet skin grafting, 471–481 case reports, 472–478 materials and methods, 471–472 Wire loop bury-and-knot suturing, 79, 82 Wood’s lamp, 42 Word processing merging, operative report, 595 Wounds autologous fibrin glue, 402 closure buried absorbable, 25–34 goals, 26 dehiscence, oral biopsy, 171 tension, 25–34

Index W-plasty disadvantages, 7 hemostasis, 6 simple securing, 47–50 technique, 48–49 actinic cheilitis, 6–7 design, 5, 6 result, 5, 6 vermilionectomy, 4–7 Wrist, skin grafts, 370 X-factor graft placement, follicular unit transplantation, 491–492

631 YAG laser, hemangiomas, 88 YAG laser resurfacing, 570

Zaki infusor, 516 Z-plasty, 533. See also Labial muscle Z-plasty large, 309–311 multiple flap, 311 new skin suture technique, 51–54 transposition, 309–311

About the Editor

MARWALI HARAHAP is Professor of Dermatology at the University of North Sumatra Medical School, Medan, Indonesia. Dr. Harahap is the author of numerous professional publications and the editor or coeditor of eight books, including Skin Changes and Diseases in Pregnancy and Surgical Techniques for Cutaneous Scar Revision (both titles, Marcel Dekker, Inc.). He is a Fellow of the American Academy of Dermatology and a member of the Indonesian Society of Dermatology and Venereology; the International Society of Dermatology; the International Society for Dermatologic Surgery; and the Medical Society for the Study of Venereal Diseases; among others. He received the M.D. degree (1960) from the University of Indonesia, Jakarta.

Innovative Techniques in Skin Surgery (Basic and Clinical Dermatology)

Advanced Techniques in Dermatologic Surgery (Basic and Clinical Dermatology)

Advanced Techniques in Dermatologic Surgery (Basic and Clinical Dermatology)

Photoaging (Basic and Clinical Dermatology)

Retinoids and Carotenoids in Dermatology (Basic and Clinical Dermatology)

Retinoids and Carotenoids in Dermatology (Basic and Clinical Dermatology)

Cosmetic Surgery: An Interdisciplinary Approach (Basic and Clinical Dermatology)

Ethnic Dermatology: Clinical Problems and Skin Pigmentation

Drug Therapy in Dermatology (Basic and Clinical Dermatology)

Sensitive Skin Syndrome (Dermatology: Clinical & Basic Science)

Psychocutaneous Medicine (Basic and Clinical Dermatology)

Wound Healing (Basic and Clinical Dermatology)

Glycolic Acid Peels (Basic and Clinical Dermatology)

Scarless Wound Healing (Basic and Clinical Dermatology)

Cutaneous Lymphomas (Basic and Clinical Dermatology)

Clinical Guide to Sunscreens and Photoprotection (Basic and Clinical Dermatology)

Itch: Basic Mechanisms and Therapy (Basic and Clinical Dermatology)

Dermatology in Clinical Practice

Principles and Practices in Cutaneous Laser Surgery (Basic and Clinical Dermatology)

Vascular Surgery: Basic Science and Clinical Correlations

Clinical Dermatology

Bioengineering of the Skin: Skin Biomechanics (Dermatology Clinical & Basic Science)

Surgery: Basic Science and Clinical Evidence

Bioengineering of the Skin: Skin Imaging & Analysis, 2nd Edition (Dermatology: Clinical & Basic Science)

Basic Science Techniques in Clinical Practice

Phototherapy and Photochemotherapy for Skin Disease, Third Edition (Basic and Clinical Dermatology)

Psoriasis: Third Edition Revised and Expanded (Basic and Clinical Dermatology)

Cutaneous Infection and Therapy (Basic and Clinical Dermatology Series)

The Epidermis in Wound Healing (Dermatology: Clinical & Basic Science)

Topical Absorption of Dermatological Products (Basic and Clinical Dermatology)

Innovative Techniques in Skin Surgery (Basic and Clinical Dermatology)

Advanced Techniques in Dermatologic Surgery (Basic and Clinical Dermatology)

Advanced Techniques in Dermatologic Surgery (Basic and Clinical Dermatology)

Photoaging (Basic and Clinical Dermatology)

Retinoids and Carotenoids in Dermatology (Basic and Clinical Dermatology)

Retinoids and Carotenoids in Dermatology (Basic and Clinical Dermatology)

Cosmetic Surgery: An Interdisciplinary Approach (Basic and Clinical Dermatology)

Ethnic Dermatology: Clinical Problems and Skin Pigmentation

Drug Therapy in Dermatology (Basic and Clinical Dermatology)

Sensitive Skin Syndrome (Dermatology: Clinical & Basic Science)

Psychocutaneous Medicine (Basic and Clinical Dermatology)

Wound Healing (Basic and Clinical Dermatology)

Glycolic Acid Peels (Basic and Clinical Dermatology)

Scarless Wound Healing (Basic and Clinical Dermatology)

Cutaneous Lymphomas (Basic and Clinical Dermatology)

Clinical Guide to Sunscreens and Photoprotection (Basic and Clinical Dermatology)

Itch: Basic Mechanisms and Therapy (Basic and Clinical Dermatology)

Dermatology in Clinical Practice

Principles and Practices in Cutaneous Laser Surgery (Basic and Clinical Dermatology)

Vascular Surgery: Basic Science and Clinical Correlations

Clinical Dermatology

Bioengineering of the Skin: Skin Biomechanics (Dermatology Clinical & Basic Science)

Surgery: Basic Science and Clinical Evidence

Bioengineering of the Skin: Skin Imaging & Analysis, 2nd Edition (Dermatology: Clinical & Basic Science)

Basic Science Techniques in Clinical Practice

Phototherapy and Photochemotherapy for Skin Disease, Third Edition (Basic and Clinical Dermatology)

Psoriasis: Third Edition Revised and Expanded (Basic and Clinical Dermatology)

Cutaneous Infection and Therapy (Basic and Clinical Dermatology Series)

The Epidermis in Wound Healing (Dermatology: Clinical & Basic Science)

Topical Absorption of Dermatological Products (Basic and Clinical Dermatology)

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