No abstract

Currently accepted conservative treatments of hypertrophic scars are limited to steroid injections, radiation therapy, and silicone occlusive therapy. However, the use of Mederma for these problematic lesions has become quite prevalent in the clinical setting. Little scientific evidence exists to support the efficacy of this product in reducing hypertrophic scars. The aim of this study was to study the effects of Mederma on hypertrophic scars in the rabbit hypertrophic scar model, allowing the histologic quantification of scar elevation, dermal collagen organization, vascularity, and inflammation and the gross examination of scar erythema. Full-thickness wounds down to cartilage, four per ear, were created in four New Zealand White rabbits, for a total of 32 scars. Twenty-eight days after the initial wounding, the hypertrophic scars were photographed, and treatment of half of the scars on each ear was begun with Mederma three times per day for a total of 4 weeks. The untreated scars served as control scars and were left exposed to air. After 4 weeks of treatment, the scars were once again photographed. The rabbits were then killed, and the scars were analyzed histologically. The pretreatment and posttreatment photographs were compared by using computer quantification of magenta, yellow, and cyan expression within the scars. Histologic analysis demonstrated no significant reduction in scar hypertrophy or scar elevation index. However, a significant improvement in dermal collagen organization was noted on comparing Mederma-treated scars with untreated control scars (p < 0.05). No significant difference in dermal vascularity or inflammation was noted. Computer analysis of the scar photographs demonstrated no significant reduction in scar erythema with Mederma treatment. The active product in Mederma, allium cepa, has as its derivative quercetin, a bioflavonoid noted for its antiproliferative effects on both normal and malignant cells, and its antihistamine release effects. These properties could theoretically prove beneficial in reversing the inflammatory and proliferative responses noted in hypertrophic scars. Despite the authors' inability to demonstrate a reduction in scar hypertrophy, the improvement in collagen organization noted in the Mederma-treated scars suggests it may have an effect on the pathophysiology of hypertrophic scar formation.

Background: Hypertrophic scar formation at sites of healed cutaneous injury often produces functional and esthetic deficits. Treatments have been limited in part by (Aesthetic Surg J 2002;22:147-153.)

All three groups may claim to be satisfied with their own personal choices. Many patients will continue to choose tissue expander/implant reconstruction in an effort to avoid scars and more extensive surgery. Being less satisfied is not wrong or bad, provided it is known. Tissue expander/implant patients should be thoroughly informed in the preoperative setting about the final aesthetic outcomes and the immediate perioperative expansion period, which may involve a considerable amount of patient commitment and discomfort in some women.

No abstract

Midline ventral hernia repair with bilateral sliding myofascial rectus abdominis flaps, or the "separation of parts" technique, has low hernia recurrence rates. However, this technique, as originally described, creates massively undermined skin and subcutaneous tissue flaps. These undermined skin flaps can suffer marginal skin loss, fat necrosis, and delayed wound healing. The authors propose that preserving the periumbilical rectus abdominis perforators to the abdominal skin flaps will decrease the prevalence of postoperative superficial wound complications. A retrospective review of 66 consecutive, large, midline hernia repairs using a separation of parts technique was undertaken to identify any correlation between the preservation of periumbilical rectus abdominis perforators to the skin flaps and the prevalence of postoperative wound complications. In 25 cases, the standard separation of parts technique was performed with wide undermining of the skin and subcutaneous tissues. In 41 cases, the modified separation of parts technique was performed with maintenance of the periumbilical rectus abdominis perforators to the abdominal skin flaps. Comparison of these two groups revealed no difference in age; sex; body mass index; initial hernia size on physical examination; prevalence of smoking, diabetes, or steroid use; or prevalence of a simultaneous intraabdominal procedure. A statistically significant difference was noted in postoperative wound complications between the two groups (p < 0.05). Of patients who underwent the standard separation of parts technique, five of 25 patients (20 percent) had wound complications as compared with one of 41 patients (2 percent) who underwent the modified separation of parts technique with perforator preservation. The postoperative hernia recurrence (7 percent and 8 percent, respectively) and hematoma (4 percent and 2 percent, respectively) rates were similar in both groups. A trend of increased wound complications was noted when separation of parts was combined with an intraabdominal procedure (18 percent versus 3 percent, p = 0.08). Interestingly, within this group, the modified separation of parts technique with preservation of the periumbilical rectus abdominis perforators demonstrated a trend of fewer wound complications as compared with the standard separation of parts technique (7 percent versus 31 percent, p = 0.15). The authors conclude that preservation of the periumbilical rectus abdominis perforators significantly reduces the prevalence of major postoperative superficial wound complications in separation of parts hernia repairs. Simultaneous intraabdominal procedures with separation of parts hernia repairs seem to increase the prevalence of wound complications. This increased prevalence of wound complications seems to be minimized when the modified separation of parts technique is performed.

Previous studies have focused on biomechanical and viscoelastic properties of the superficial musculoaponeurotic system (SMAS) flap and the skin flap lifted in traditional rhytidectomy procedures. The authors compared these two layers with the composite rhytidectomy flap to explain their clinical observations that the composite dissection allows greater tension and lateral pull to be placed on the facial and cervical flaps, with less long-term stress-relaxation and tissue creep. Eight fresh cadavers were dissected by elevating flaps on one side of the face and neck as skin and SMAS flaps and on the other side as a standard composite rhytidectomy flap. The tissue samples were tested for breaking strength, tissue tearing force, stress-relaxation, and tissue creep. For breaking strength, uniform samples were pulled at a rate of 1 inch per minute, and the stress required to rupture the tissues was measured. Tissue tearing force was measured by attaching a 3-0 suture to the tissues and pulling at the same rate as that used for breaking strength. The force required to tear the suture out of the tissues was then measured. Stress-relaxation was assessed by tensing the uniformly sized strips of tissue to 80 percent of their breaking strength, and the amount of tissue relaxation was measured at 1-minute intervals for a total of 5 minutes. This measurement is expressed as the percentage of tissue relaxation per minute. Tissue creep was assessed by using a 3-0 suture and calibrated pressure gauge attached to the facial flaps. The constant tension applied to the flaps was 80 percent of the tissue tearing force. The distance crept was measured in millimeters after 2 and 3 minutes of constant tension. Breaking strength measurements demonstrated significantly greater breaking strength of skin and composite flaps as compared with SMAS flaps (p < 0.05). No significant difference was noted between skin and composite flaps. However, tissue tearing force demonstrated that the composite flaps were able to withstand a significantly greater force as compared with both skin and SMAS flaps (p < 0.05). Stress-relaxation analysis revealed the skin flaps to have the highest degree of stress-relaxation over each of five 1-minute intervals. In contrast, the SMAS and composite flaps demonstrated a significantly lower degree of stress-relaxation over the five 1-minute intervals (p < 0.05). There was no difference noted between the SMAS flaps and composite flaps with regard to stress-relaxation. Tissue creep correlated with the stress-relaxation data. The skin flaps demonstrated the greatest degree of tissue creep, which was significantly greater than that noted for the SMAS flaps or composite flaps (p < 0.05). Comparison of facial flaps with cervical flaps revealed that cervical skin, SMAS, and composite flaps tolerated significantly greater tissue tearing forces and demonstrated significantly greater tissue creep as compared with facial skin, SMAS, and composite flaps (p < 0.05). These biomechanical studies on facial and cervical rhytidectomy f...

Four patients were treated successfully with a simple modification of the standard radial forearm free flap. The flexor carpi radialis was harvested along with the radial artery vascular pedicle and forearm skin, producing a tennis racket-shaped flap. The entire flexor carpi radialis can be transferred based on radial artery perforators that enter the distal half of the muscle. The flexor carpi radialis can extend the versatility of the radial forearm free flap, principally by providing good-quality coverage of the vascular anastomoses.