Scar revision

Different scar revision techniques are compared on similar scars, all on the same patient. Comparison of the final results is unique and interesting and provides insight into choosing the "optimal" technique for these procedures. Historical perspective is provided.     

Scar recollagenation

Objectives: This study was designed to show that native collagen could be regenerated in an area of prior tissue loss. Study Design: Prospective. Methods: Preserved, irradiated human cadaver fascia lata was inserted intradermally to restore topographic skin irregularities. Graft insertion was performed through a skin perforation created by a sterile, hypodermic 20-gauge needle hole into an intradermal pocket. Eighteen subjects with posttraumatic depressions were treated over a 13-month period and examined periodically afterward. Biopsies of selected sites were taken. Results: Of the 44 defects treated in the study group, 14 were judged to be excellent or resolved, 23 were improved, and seven were unchanged at 24 weeks' follow-up. Biopsies showed graft preservation and fibroblast invasion at 12 weeks. Discussion: Recollagenation is the application of a stimulator material into an area of prior collagen destruction to induce collagen production. Commonly, banked human cadaver fascia has been used to enhance the tissue volume in depressed acne scars, but this process has been successfully performed on a variety of postinflammatory and posttraumatic lesions. The process of fascia graft assimilation into human skin is demonstrated histologically. Conclusion: Recollagenation is an effective process for elevation of depressed, posttraumatic scars. Key Words: collagen, graft, scar, fascia, skin.     

Scar revision

Individuals bearing scars deemed functionally or cosmetically undesirable often seek the services of a surgeon to eliminate the scars and to restore the tissue to its preinjury state. The foremost task of the physician is to inform the patient that elimination of scars is almost impossible, but that improvement is realistic. It should be stressed to the patient that scar revision replaces one scar for another in an attempt to improve the acceptability of that scar. A patient with realistic expectations is more likely to be a satisfied patient. This article examines the nature of scars and scar revision and the different surgical techniques available.     

Scar revision and camouflage

The successful revision and camouflage of facial scars is as much an art as a science, and the best teacher is continued experience; however, common sense, a broad knowledge of available options, technical ability, and patience are all necessary if one chooses to practice in this challenging field. Patients with facial scars are vulnerable in a way that few others are, and it is the responsibility of the facial plastic surgeon to evaluate these patients properly and realistically, to prepare them for a process that may involve multiple procedures, and to see them through this process with all the expertise and compassion possible. If this is done, the rewards to the patient and to the surgeon can be immeasurable.     

Scar management: prevention and treatment strategies

PURPOSE OF REVIEW: Aberrant wound healing results in unsightly scar, hypertrophic scar, and keloid formation, causing functional and cosmetic deformities, discomfort, psychological stress, and patient dissatisfaction. Scar prevention and management, both surgical and nonsurgical, continue to be important issues for the otolaryngologist. RECENT FINDINGS: Both animal and human models continue to point to the integral role of transforming growth factor-beta in aberrant healing. Multiple extracts have promising results as therapies for scarring and are widely marketed but need to be further investigated. Scar prevention advancements include refinements in surgical technique, nutritional supplementation, and optimal wound care. Steroid injections continue to play a major role in the regression of scars and keloids. Dermatography assists in the minimization of scar appearance. Dermatography, laser therapies, intralesional 5-fluorouracil, and adjuvant radiotherapy are emerging therapies. Topical vitamin E utility is revisited. New surgical scar revision techniques include modified excision techniques and skin grafting. SUMMARY: Despite optimal efforts to avoid scar formation, aberrant wound healing may occur. The use of topical agents and intralesional steroid injections can minimize early scar formation. Strategies for prevention and management of keloids and hypertrophic scars continue to develop, as the basic science mechanisms underlying aberrant wound healing are elucidated.     

Scar formation after drug-induced cochlear insult.

Structural and molecular changes in the guinea pig organ of Corti were studied using histochemistry and electron microscopy in the course of drug-induced hair cell degeneration. Actin filaments disappear from the cuticular plate and the stereocilia. An actin-rich bridge appears in the apical region of dying hair cells. Two supporting cells form a scar for a given hair cell. The supporting cells expand and invade the spaces of Nuel and then the region previously occupied by the hair cell. The scar region becomes cytokeratin-labeled. In this study, the apical domain of the hair cell is the last part of the cell to degenerate. Hair cell degeneration coincides temporally with scar formation. We define the resulting scar as a 'type I' scar. The results provide preliminary information about the molecular composition of the type I scar and suggest a structural basis for the dynamics of scar formation.     

Endoscopic-Assisted Total Thyroidectomy via Lateral Keloid Scar Incision

Thyroidectomy is traditionally performed by the transcervical approach. To avoid or reduce visible scarring, diverse innovative surgical trials have been reported. Here we report a patient who underwent endoscopic thyroidectomy via a lateral keloid scar due to a previous traffic accident. A 30-year-old woman presented with a papillary thyroid carcinoma. Total thyroidectomy was performed via a keloid scar incision. The keloid scar was then revised. The total thyroidectomy was successful, resulting in no acute complications, such as neural injury, hematoma, or seroma formation. The keloid scar healed with excellent cosmetic results and the patient remains free of disease 12 months after excision. Endoscopic total thyroidectomy via a lateral keloid scar incision healed not only the physical disease but also the mental disease.     

Scar formation following impulse noise-induced mechanical damage to the organ of Corti

The terminal stages of the healing process of the organ of Corti in the chinchilla following exposure to blast-waves at 160 dB peak SPL, were studied by scanning electron microscopy (SEM) and by surface preparation technique. Extensive lesions of the sensory epithelia consisting in the absence of the OHC's, Deiter cells and Hensen cells, were replaced by scar tissue formed by single, flat, irregularly polygonal cells, arising from the Claudius cell area sealing off the endolymphatic spaces. When the pillar cells have been destroyed the scar epithelium from the Claudius cells has reached the IHC's, which show a remarkable resistance to acoustic trauma. Their presence in a large healed area may be the only remnants of a previous sensory region. When even the IHC's are absent, the entire organ of Corti can be replaced both by Claudius cells and by inner sulcus cells covering the denuded basilar membrane without any clear morphological difference between the two cellular sources.     

Scar contracture prevention with local steroid injections in transoral videolaryngoscopic surgery

ObjectiveThe aim of this study was to evaluate the efficacy and safety of local steroid injections to prevent scar contracture after transoral videolaryngoscopic surgery (TOVS) in hypopharyngeal cancer patients.MethodsPatients were enrolled in this study if they had received a local steroid injection during TOVS and had attended an outpatient clinic after at least three months. All patients were being treated for hypopharyngeal cancer and received a single session of triamcinolone acetonide, injected using a 21-gage needle. Retrospective chart reviews were performed, and the degree of scar contracture, pharyngeal stenosis, vocal fold movements, and adverse events were evaluated. Scar contracture was assessed using a scoring system, which compared the endoscopic findings of treatment and matched pair control groups.ResultsA total of 20 patients received local steroid injections during TOVS and were enrolled in the treatment. Scar contracture was seen in 14 patients (70%); however, the degree of scar contracture was significantly decreased when compared to control cases. Vocal fold immobility was observed in five patients, but no pharyngeal stenosis was noted. Adverse effects, such as postoperative laryngeal chondritis or cervical spondylitis, were seen in three patients who had previously been treated with resection to the muscularis propria or definitive irradiation.ConclusionLocal steroid injection during TOVS significantly reduced the degree of postoperative scar contracture. However, caution should be used when treating with local steroid injection during TOVS, as this may complicate wound healing in patients who have already received treatment.     

Scar neuroma following tumor operations of the head and neck. Immunohistologic studies, differential diagnosis, therapy

Amputation neuromas occasionally follow division of the cervical plexus during classical neck dissection. They present as painful, subcutaneous, and fixed tumours. They must be removed to exclude recurrence of the primary disease. The differential diagnosis includes neurilemmoma, solitary neurofibroma, neurofibromatosis, neuro-muscular hamartoma, and benign myxoid tumours. Histological diagnosis is particularly easy especially if immunohistochemistry with markers against neural tissues is used. However, to prevent recurrence, the central nerve stump should be exposed, ligated after removal of the neuroma and then transposed to scar free subcutaneous tissue.     

Neurogenesis in the superior olivary complex in the rat

In a previous paper we provided evidence that crossed projection neurons are generated earlier than uncrossed projection neurons in the lateral superior olive. The aim of the present study was to determine if other major nuclei of the superior olivary complex (SOC), the medial superior olivary (MSO), the superior paraolivary (SPN) and the medial trapezoid (MTB) nuclei, are distinguished by their neuronal constitutions of birthdates. Pregnant rats were injected intraperitoneally with 5-bromodeoxyuridine (BrdU), the thymidine analogue, to label the neurons on one of the embryonic (E) days E11-E16. When the progeny rats reached adulthood, the brains were processed for BrdU immunohistochemistry. The MSO was mostly composed of neurons generated on E12 (95%). The remaining neurons in the MSO completed their neurogenesis by E13. The SPN neurons were generated from E12 to E14 with a peak on E13 (80%). Regardless of the morphological heterogeneity, the SPN consisted of a single population of neurons in terms of neurogenesis. The MTB neurons were generated from E13 to E16 with a peak on E14 (73%). In contrast to the previous assumption, no topographical relationship existed between neurogenesis and tonotopicity within each nucleus of the SOC.     

Chasing the dragon in the ear

In the UK, the prevalence of drug misuse has risen in the last decade. Otorhinolaryngological surgeons need to be aware that small amounts of illegal substances, such as heroin, cannabis and cocaine, may be hidden in the external auditory meatus. We report, for the first time, concealment of heroin in the external auditory meatus. The medico-legal and ethical considerations are also discussed.     

Temporal synchronization in the primary auditory response in the pigeon

Spike potentials were recorded from single fibres in the auditory nerve of the pigeon. In responses elicited by tonal stimuli, the timing of each spike relative to stimulus waveform was measured and period histograms were constructed. Phase locking of spikes was estimated in terms of a synchronicity index obtained by vector addition within the period histogram. A second measure of synchrony in the spike responses was obtained, that of temporal dispersion. For a population of fibres, vector strength of phase locking decreased for frequencies above 1 kHz, as reported for several other species. Temporal dispersion, however, also decreased with frequency, indicating enhanced temporal synchrony as frequency increased within the bandwidth of phase locking. The upper frequency limit of phase locking appears to depend on irreducible jitter of biological origin in the timing of spikes. For individual fibres, the bandwidth of synchronization of spikes consistently exceeds the response area, covering in addition the areas of suppression adjacent to the response area. Spike trains suppressed by a tonal stimulus become synchronized to that stimulus. Phase angles of synchronized responses systematically change as a function of tone level, when tone frequency is above or below CF, as reported for other avian species. Synchronicity and phase angle intensity functions are quite independent of spike rate intensity functions.     

Cation transport in the ampulla of the semicircular canal and in the endolymphatic sac

We examined the effects of anoxia and ethacrynic acid on the endolymphatic potential and cation activity in the superior ampulla of the guinea pig, using double-barrelled ion-exchanger microelectrodes. In normal guinea pigs the ampullar endolymphatic potential was + 3.9 +/- 1.2 mV (n = 32), the Cl- activity 130 +/- 4.6 mM (n = 9), and the Na+ activity 18.4 +/- 4.4 mM (n = 20). After anoxia, the ampullar DC potential decreased rapidly and reversed its polarity within 5 min. It then decreased gradually for 60 min and increased afterwards to approximately zero. K+ activity decreased gradually after a latency of 10 min, whereas Na+ activity increased. During the gradual decrease of a negative ampullar endolymphatic potential, an increase in Na+ activity was observed. Thirty minutes after the intravenous injection of ethacrynic acid (100 mg/kg), the potential began to decrease, changed to a negative polarity, and approached a maximum negative level 100 min after the injection. The decrease in K+ activity corresponded to the reduction of potential whereas Na+ activity remained unchanged. The DC potential of the endolymphatic sac in normal guinea pigs was + 14.7 +/- 5.1 mV (n = 17). The Na+ concentration was 103.3 +/- 14.7 mM (n = 14) and the K+ concentration was 11.6 +/- 0.8 mM (n = 4). After anoxia, the DC potential decreased rapidly and approached 0 mV within 8 min. No negative potential could be observed. The Na+ concentration began to increase 2 min after anoxia and reached the extracellular Na+ concentration about 30 min later.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cation transport in the ampulla of the semicircular canal and in the endolymphatic sac

Summary We examined the effects of anoxia and ethacrynic acid on the endolymphatic potential and cation activity in the superior ampulla of the guinea pig, using double-barrelled ion-exchanger microelectrodes. In normal guinea pigs the ampullar endolymphatic potential was +3.9±1.2 mV (n=32), the Cl^– activity 130±4.6 mM (n=9), and the Na⁺ activity 18.4±4.4 mM (n=20). After anoxia, the ampullar DC potential decreased rapidly and reversed its polarity within 5 min. It then decreased gradually for 60 min and increased afterwards to approximately zero. K⁺ activity decreased gradually after a latency of 10 min, whereas Na⁺ activity increased. During the gradual decrease of a negative ampullar endolymphatic potential, an increase in Na⁺ activity was observed. Thirty minutes after the intravenous injection of ethacrynic acid (100 mg/kg), the potential began to decrease, changed to a negative polarity, and approached a maximum negative level 100 min after the injection. The decrease in K⁺ activity corresponded to the reduction of potential whereas Na⁺ activity remained unchanged. The DC potential of the endolymphatic sac in normal guinea pigs was + 14.7±5.1 mV (n=17). The Na⁺ concentration was 103.3±14.7 mM (n=14) and the K⁺ concentration was 11.6 ±0.8 mM (n=4). After anoxia, the DC potential decreased rapidly and approached 0 mV within 8 min. No negative potential could be observed. The Na⁺ concentration began to increase 2 min after anoxia and reached the extracellular Na⁺ concentration about 30 min later. No significant effect of intravenous administration of ethacrynic acid (100 mg/kg) on DC potential and Na + concentration could be observed. The results suggest the presence of a different ion transport system in the endolymphatic sac from that of the cochlea and the ampullae of the semicircular canals.     

Goblet cells in the laryngeal mucosa in cancer of the larynx

From 70 patients with laryngeal cancer, pieces of mucosa were taken from the subglottis, the entrance to the sinus of Morgagni, and from the ventricular fold. There were 35 taken at the time of diagnosis and the other 35 were taken after radiotherapy. By means of an elective staining method and a whole mount technique, morphological and quantitative studies of the goblet cells were performed. The findings were compared with corresponding investigations of goblet cells in normal larynges. The significantly lower density in the subglottis than in the sinus of Morgagni and ventricular fold observed in normal larynges was not found in the two groups of cancer patients. Instead, there was a tendency to an equalization of the goblet cell density in all 3 laryngeal regions. In the irradiated group the goblet cell density was lower, in all 3 regions, than in the nonirradiated cancer group and in normal larynges. In the close vicinity of the cancer the goblet cell density was reduced, possibly because the cancer process had initiated metaplasia to an epithelium which was poor in goblet cells. Between the two cancer groups and normal larynges there were no morphological differences in the goblet cells.     

The role of the condyle in the growth of the mandible and in facial balance

The condyle is not responsible for the growth of the body of the mandible, as the latter does not extend in length caudally at the expense of the ascending rami (through the classical relocation phenomenon), but does so deep to these, at the level of the lower insertions of the sphenomandibular ligaments (i.e., from the inlet inner border of the inferior dental canals). Philogenetically and ontogenetically, its appearance reflects the adaptation of the mandible of mammals to the morphologic and functional changes that took place in their cephalic skeleton (more erect posture, more vigorous mastication). Its chief role in man is to stabilize the mandibular body and to allow it to be properly mobilized, although contributing also to its forward and downward movements (namely in its posterior aspect). As such, it plays an active role in mandibular growth, and this role varies according to the primary "potential" of the condylar cartilage. Such primary-type potential for condylar growth may be adequately assessed by studying the shape of the mandible, as well as through an analysis of craniofacial architecture. Most of the conventional diagrams depicting mandibular growth are defective. Another figurative system has to be innovated, that will differentiate each skeletal unit--body, condyle, coronoid process, angle, alveolodental arch--, the sum of which confers the shape, the size, and the multiple variations to the mandible as a whole.     

Computed tomography in the evaluation of acquired stenosis in the neonate

We studied the feasibility of computed tomographic evaluation of the neonatal airway. Three neonatal larynges, removed at necroscopy, were examined by computed tomography. Good resolution of soft tissue, cartilage and airway lumen was obtained in these small specimens. On the basis of these findings two neonates with acquired subglottic stenosis were examined by endoscopy, soft tissue airway radiographs, and computed tomography. Measurements of radiation dose revealed that a computed tomographic study delivered 36% of the mean tissue dose of standard image intensifier fluoroscopy. Computed tomography and fluoroscopy both demonstrated the degree and length of this stenosis accurately. An advantage of CT over conventional imaging procedures was better definition of the cross sectional area of the airway.