BackgroundA variety of island flaps can be based on the superficial temporal artery with variable tissue composition. They can be used for defect reconstruction, cavity resurfacing, facial hair restoration, or contracture release.MethodsSeventy-two patients underwent facial reconstruction using a superficial temporal artery island flap from October 2010 to October 2014. The defects had various etiologies, including trauma, burns, tumors, exposed hardware, and congenital causes. We classified the patients by indication into 5 groups: cavity resurfacing, contracture release, facial hair restoration, skin coverage, and combined. The demographic data of the patients, defect characteristics, operative procedures, postoperative results, and complications were retrospectively documented. The follow-up period ranged from 24 to 54 months.ResultsA total of 24 females and 48 males were included in this study. The mean age of the patients was 33.7±15.6 years. The flaps were used for contracture release in 13 cases, cavity resurfacing in 10 cases, skin coverage in 17 cases, facial hair restoration in 19 cases, and combined defects in 13 cases. No major complications were reported. Conclusion: Based on our experiences with the use of superficial temporal artery island flaps, we have developed a detailed approach for the optimal management of patients with composite facial defects. The aim of this article is to provide the reader with a systematic algorithm to use for such patients.

Background:Facial burns represent between one-fourth and one-third of all burns. The long-term sequelae of periorbital burns include significant ectropion and lagophthalmos as a result of secondary burn contractures in the lower and upper eyelids, in addition to complete or incomplete alopecia of the eyebrows.Methods:A retrospective study of 14 reconstructive procedures for 12 postburn faces was conducted with all procedures performed since 2010 at the Department of Plastic Surgery, Al-Hussein University Hospital, and at the Craniofacial Unit, Nasser Institute Hospital. Four patients experienced chemical burns, and 8 patients experienced thermal burns. All patients underwent periorbital reconstruction using a bifurcated superficial temporal artery island flap to reconstruct the eyebrows, correct the lagophthalmos, and release the ectropion in both the upper and the lower eyelids. Two patients underwent bilateral periorbital flap reconstruction. The mean age of patients was 29 years, and the study was conducted on 8 males and 4 females. Patient satisfaction was assessed using a questionnaire completed by all patients postoperatively.Results:The complete release of both the upper and the lower eyelids was achieved in all cases, together with ideal replacement of brow hair; no complications were noted, apart from one case in which a loss of hair density in the new eyebrow was observed, combined with the partial loss of the flap in the lower eyelid. Patient satisfaction results were collected and assembled in a table.Conclusion:A bifurcated superficial temporal artery island flap is an innovative flap for reconstructing both burned eyebrows and eyelids.

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BACKGROUND: Current guidelines recommend ticagrelor or prasugrel as first line agents in the context of patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI). De-escalation from ticagrelor or prasugrel to clopidogrel, is a common occurrence in clinical practice. However, inappropriate de-escalation, especially when a change between potent agents is an option may put patients at risk of ischemic complications. There is a paucity of data to indicate whether patients are appropriately de-escalated. We evaluated the indication for de-escalation of P2Y12 inhibitor therapy in a large contemporary cohort, to determine whether the rationale was appropriate and to quantify potential patients who may derive benefit with a change in therapy in lieu of de-escalation. METHODS: A retrospective cohort study was performed using the CAPITAL PCI registry. Patient charts were screened for de-escalation of P2Y12 therapy. The charts were then reviewed to itemize rationale for de-escalation. The indication for de-escalation was then classified as appropriate or inappropriate. De-escalation was considered appropriate if the indication was: bleeding, need for the addition of an anticoagulant, PCI in the context of stable angina or PCI in the context of heart failure. All other indications were classified as inappropriate and further sub-categorized. RESULTS: Of the 878 patients, 92 (10.4%) had de-escalation of therapy. The average age of those with de-escalation was 63.9 +/-12.7. Other baseline demographics in the de-escalation group include: 18.5% with diabetes, 63% with hypertension, 44.6% with dyslipidemia, 44.6% smokers and 6.5% with atrial fibrillation. Chart review to determine rationale for de-escalation found 22 (23.9%) to have appropriate indications, 38 (41.3%) to have inappropriate indications and 32 (34.8%) with inadequate documentation to determine appropriateness of treatment. Among those with appropriate de-escalation, the most common reasons are: need for anticoagulation therapy (50%) and bleeding (36.3%). Of those with inappropriate de-escalation, the rationale was subcategorized as demonstrated in Figure 1. CONCLUSION: De-escalation of P2Y12 inhibitor therapy is common in contemporary clinical practice. However, the majority of these patients appear to have inappropriate reasons for de-escalation. As these patients may potentially be deprived the benefits of a change to the alternate 1st line P2Y12 agent, further understanding of physician decision making will be integral to optimize outcomes.

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