Improved Scalp Surgery Results By Controlling Tension Vector Forces in the Tissues by Galea to Pericranium Fixation Sutures

BACKGROUND: Tension, manifesting at the time of wound closure, limits the extent of tissue excision and predisposes to complications. Extensive undermining may be an unreliable technique to reduce tissue tension in surgery. Pericranium is a rarely used tissue in scalp surgery. OBJECTIVE: To show that the surgical technique of deep plane fixation reduces tissue tension at and adjacent to the wound, allowing relatively greater excision and reduced tension closure, and extensive undermining may be an ineffectual and potentially harmful surgical technique. I also update the surgical anatomy of the pericranium and determine its utility in scalp reconstructive surgery. METHODS: More than 1000 scalp operations, including 700 clinical investigative procedures, were done which included pericranial flaps, subgaleal and subperiosteal scalp reductions, and deep plane fixation. RESULTS: The alopecia removal operation described herein utilizing deep plane fixation is largely complication free and achieves tension-reduced closure and between 18% and 50% greater tissue removal compared with conventional alopecia reduction procedures. CONCLUSION: Pericranium is a valuable and readily usable tissue in reconstructive scalp surgery.     

Management of Large Surgical Defects of the Forehead and Scalp by Imbrication of Deep Tissues

BACKGROUND: When facing surgical defects, the dermatologic surgeon follows certain basic principles that help reduce the inherent tension to allow for a better cosmetic outcome. These commonly include the use of undermining, releasing technique such as galeotomy if applicable, selection of suture material of appropriate tensile strength, and closure along relaxed skin tension lines. OBJECTIVE: To review the imbrication of deep tissues, another surgical principle aimed at wound tension reduction and widely utilized by cosmetic surgeons in forehead lifts and scalp reductions, as it applies to dermatologic surgeons in the repair of large surgical defects of the upper face and scalp. The latter may be utilized both with primary closure and with local flaps. METHODS: We describe in detail the technique of imbrication of deep tissues and provide illustrations for a better understanding of how to correctly use this surgical principle. RESULTS: The dermatologic surgeon has an additional tool, termed imbrication of deep tissues, available to aid in the closure of sizable wounds of the forehead and scalp as seen following Mohs surgery for cutaneous malignancies by providing deep tissue support. CONCLUSION: Imbrication of deep tissue is an effective tool that may be used by dermatologic surgeons in conjunction with the more commonly utilized basic surgical principles to enhance the cosmetic outcome in the closure of large, high-tension defects of the forehead and scalp.     

Closure of craniofacial defects after cancer resection

Resection of malignancies of the upper face and skull base may result in complex bone and soft tissue defects. To better define the optimal management of these defects, we conducted a retrospective review of 75 consecutive patients who underwent closure of 76 craniofacial defects after malignant tumor excision from 1966 to 1990. Wound complications requiring further surgery occurred in 30% of the defects (23 of 76). Wound complications at anterior, temporal, or combined sites were correlated with each method of reconstruction (scalp flap or split thickness skin graft, pedicled myocutaneous flap, and free flap). The presence of a large combined defect involving both frontal and temporal areas was the only significant risk factor for development of a wound complication requiring secondary surgery. These data suggest that anterior or temporal craniofacial defects may be closed with either scalp flaps and split thickness skin grafts or pedicled myocutaneous flaps with reasonable wound complication rates of 16% to 22%. Large combined defects have high wound complication rates (90%) when local tissue is used; therefore, other methods of closure such as free tissue transfer should be strongly considered in these patients.     

Purse-string closure of scalp defects following tissue expansion: an effective aesthetic alternative.

Primary closure of scalp defects under tension can be complicated by scar widening and alopecia, and large defects usually require the use of local flaps, skin grafts or free flaps. Tissue expansion facilitates the use of local flaps to cover large defects, but multiple expanders and complex flaps with extensive incisions may cause significant scars and alopecia. We describe a purse-string closure of expanded scalp tissue following excision of a large congenital nevus sebaceous. This scalp reconstructive technique minimises iatrogenic scars and uses the predictable forces of scar contracture and skin re-draping to achieve a superior aesthetic result.     

Operative treatment of deep burns of the scalp and skull.

Traditional surgical treatment of deep burns of the scalp and skull involve the excision of necrotic bone and soft tissues with trephanation of the bone to permit granulation tissue formation and subsequent grafting. This approach prolongs wound time, adds additional trauma and, even after initial healing, necessitates secondary soft tissue and bone reconstruction. The treatment described here is an alternate and more aggressive one involving early excision of necrotic soft tissue without bone resection followed by immediate coverage with well-vascularized axial flaps from adjacent intact scalp. This method provides an optimal environment for healing and regeneration of areas of destruction to the skull. This surgical method was used in the treatment of 22 patients with deep burns of the scalp with satisfactory clinical results. Bone regeneration was confirmed by roentgenological investigations.     

Squamous Cell Carcinoma of the Scalp After Radiotherapy for Tinea Capitis

BACKGROUND: Radiotherapy for tinea capitis was widely used in the 1930s and 1940s. There is a fourfold increase in the risk for developing nonmelanoma skin cancer in the scalp. Excision of lesions is challenging, as tissue around the wound is atrophic and susceptible to ischemia. OBJECTIVE: To discuss the risk of skin cancer in the older patient who received scalp radiotherapy in childhood and options for scalp reconstruction after excision. METHODS: A woman developed squamous cell carcinoma on the scalp 67 years after radiotherapy for tinea capitis. RESULTS: The large excision defect was successfully grafted, avoiding the need for complex scalp reconstruction. CONCLUSION: Patients who received scalp radiotherapy in childhood are at increased risk of developing nonmelanoma skin cancer. The unique anatomy of scalp tissue makes it difficult to close excisional defects. Skin grafting often fails, and complex flaps or the importation of vascularized tissue may be required.     

Rotation Flaps

Background. Rotation flaps are arcuate repairs that redistribute tension vectors and recruit adjacent and/or distant tissue laxity. Rotation allows for the closure of wounds that cannot be repaired along a single tension vector. A rich and evolving literature details the evolution of rotation as an elegant method of repair for surgical wounds.
Objective. The goal of this article is to understand the basic principles and proper execution of tissue rotation for the repair of facial operative wounds, with special attention given to the concept of pivotal restraint and with a step-by-step regional approach.
Methods and Materials. A review of the literature of dermatologic surgery, plastic surgery, and otolaryngology leads to a detailed understanding of rotation flap design and execution.
Results. Proper rotation flap design allows for the closure of large and complex wounds that will not close along one motion while minimizing tension vectors that affect adjacent free margins.
Conclusions. The concept and execution of rotation are integral to the practice of dermatologic surgery. Proper design and undermining are essential to create an adequately sized flap and to free pivotal restraint to facilitate wound closure. In many cases, the arc of a rotation flap may be hidden within a natural cosmetic boundary, allowing for an elegant and minimally visible reconstruction.     

The TopClosure? 3S System, for skin stretching and a secure wound closure

The principle of stretching wound margins for primary wound closure is commonly practiced and used for various skin defects, leading at times to excessive tension and complications during wound closure. Different surgical techniques, skin stretching devices and tissue expanders have been utilized to address this issue. Previously designed skin stretching devices resulted in considerable morbidity. They were invasive by nature and associated with relatively high localized tissue pressure, frequently leading to necrosis, damage and tearing of skin at the wound margins. To assess the clinical effectiveness and performance and, to determine the safety of TopClosure? for gradual, controlled, temporary, noninvasive and invasive applications for skin stretching and secure wound closing, the TopClosure? device was applied to 20 patients for preoperative skin lesion removal and to secure closure of a variety of wound sizes. TopClosure? was reinforced with adhesives, staples and/or surgical sutures, depending on the circumstances of the wound and the surgeon's judgment. TopClosure? was used prior to, during and/or after surgery to reduce tension across wound edges. No significant complications or adverse events were associated with its use. TopClosure? was effectively used for preoperative skin expansion in preparation for dermal resection (e.g., congenital nevi). It aided closure of large wounds involving significant loss of skin and soft tissue by mobilizing skin and subcutaneous tissue, thus avoiding the need for skin grafts or flaps. Following surgery, it was used to secure closure of wounds under tension, thus improving wound aesthetics. A sample case study will be presented. We designed TopClosure?, an innovative device, to modify the currently practiced concept of wound closure by applying minimal stress to the skin, away from damaged wound edges, with flexible force vectors and versatile methods of attachment to the skin, in a noninvasive or invasive manner.     

Granulation Tissue Flap Technique in Extensive Wounds for Covering Exposed Bone After Tumor Excision

BACKGROUND: Second intention partial wound healing followed by skin grafting is a well-established method in dermatosurgery. In wide tumor excision, where periosteum is removed, growth of granulation tissue in the central areas of bare bone can be prolonged. OBJECTIVE: We describe a new technique for a faster, reliable closure of large defects utilizing granulation tissue flaps. METHODS: Postoperative wounds were treated with wet dressings until granulation tissue had developed on the wound edges. The central defects were then covered with lateral granulation tissue flaps. Subsequently split skin grafting was performed. RESULTS: Thirty-eight patients (37-99 years old) were treated between 1991 and 1999. Skin defects were located primarily on the scalp and forehead, and ranged from 3 to 13 cm in diameter. Wound bed preparation for skin grafting was achieved in all patients. Only minor complications, such as partial granulation flap necrosis in 5 of 38 patients or delayed skin graft healing in 4 of 38 patients, were seen. CONCLUSIONS: This technique for the closure of extensive skin defects is safe and effective.     

Management of full-thickness burns of the scalp and skull

Full-thickness burn injury of the scalp, with or without necrosis of underlying bone, is a complex therapeutic problem. Inability to diagnose depth of injury, controversy regarding wound closure, and a high incidence of acute morbidity are all associated with it. We reviewed the records of 17 patients who had suffered such injury. Wound closure was accomplished by split-thickness autograft alone in three patients, by bone dermabrasion and split-thickness autograft in six, by bone excision and split-thickness autograft in five, and by immediate local rotation flap in three. Systemic and/or local septic complications developed in 50% of all patients who underwent bony debridement. When feasible, early excision followed by immediate flap coverage is the procedure of choice. It avoids the multiple operative procedures required by the more conservative approach to wound closure, thereby shortening the period of primary hospitalization and virtually eliminating the risk of sepsis.     

Soft tissue coverage of the knee joint following burns

Full-thickness burns around the knee joint are usually associated with exposure of bone, tendon or ligaments. Following excision of the deep burns, there is no viable wound bed to which skin grafts can be applied. Although vacuum-assisted closure has been used to encourage granulation tissue, exposure of the tendons and ligaments following excision usually requires muscle flaps or fasciocutaneous flaps.     

Ideal suture methods for skin, subcutaneous tissues and sternum

Non-absorbable sternal closure methods such as stainless steel wiring have been widely used, but biocompatibility and osteoconductivity of absorbable materials have advantages in acceleration of wound healing. Combined use of stainless steel wires with absorbable materials may contribute to minimizing sternal complications.Fascial tension reduction sutures, where the tension is placed on the layer of deep fascia and superficial fascia, are recommended for skin/subcutaneous closure. This means that the use of dermal sutures is minimized;indeed, dermal sutures can be avoided altogether if the wound edges can be joined naturally under very small tension. We prefer 0, 2-0 polydioxanone sutures (PDS II) for deep/superficial fascia sutures, 4-0 or 5-0 PDS II for dermal sutures (if they are necessary), and 6-0 or 7-0 polypropylene or nylon sutures (Proline or Ethilon) for superficial sutures. The consequence of such suturing is that the wound edges are elevated smoothly with minimal tension on the dermis that appears to prevent the development of large scars.     

Patterns of high tension electrical injury in children and adolescents and their management.

High tension electrical burn injury occurred in twenty-nine patients over a period of seven years, causing two deaths, and demonstrating two reasonably distinct patterns. Major surface thermal burns from involvement in an electric arc, augmented by flame burns of ignited clothing, occurred in eleven patients. By contrast, eighteen children demonstrated wounds of entrance and exit of current and varying effects of deep thermal injury along the path of the maximally conductive blood vessels and nerves of extremities. An aggressive surgical approach was taken in patients with both types of injury, with the objective of prompt identification and excision of devitalized tissues and closure of thw wound. In the deep condictuve type of injury, frozen section and subsequent histologic study served as a guide to adequacy of excision and preservation of viable tissue. Even so, amputation of fifteen extremities and four other major excisions were required in twelve patients.     

Negative-pressure dressings in the treatment of hidradenitis suppurativa

Negative-pressure dressings have been used in the treatment of a variety of open wounds, and as a bolster for skin grafts. The benefits of these dressings include increased oxygen tension in the wound, decreased bacterial counts, increased granulation formation, and the prevention of shear force on wounds. Also, by virtue of the diminished need for daily dressing changes, there are the additional advantages of enhancing patient comfort, decreasing nursing work, and diminished cost of wound care. Hidradenitis suppurativa (HS) is a chronic infection of the apocrine sweat glands. Treatment options range from oral isotretinoin to radical excision. Wound closure may be achieved by secondary intention, skin grafting, or flap closure. Complications may still arise and include disease progression and squamous cell carcinoma. Radical excision yields the best results in terms of disease eradication. The authors describe using the negative-pressure dressing in two cases of bilateral axillary HS to secure skin grafts firmly to the wound bed after radical excision of all involved tissues. Patient comfort and acceptance was high, and skin graft take was excellent. The dressings themselves are simple to apply and are highly effective.     

The Dog-Ear Rotation Flap for the Repair of Large Surgical Defects on the Head and Neck

BACKGROUND: The Mohs micrographic surgeon is often faced with the daunting challenge of having to repair very large surgical defects on the head and neck where cosmesis and maintenance of normal function are of paramount importance. OBJECTIVE: We describe a novel flap, the dog-ear rotation flap, for the repair of such defects. We will demonstrate that this flap offers superior cosmetic and functional results to many other closure options, particularly for extensive defects of the cheek, temple, forehead and scalp. METHODS: The dog-ear rotation flap is a combination repair. It is executed by first closing one end of the surgical defect in a primary side-to-side-fashion, to a point at which tension across the wound precludes any further closure. A rotation flap is then developed to close the remaining defect, using tissue from the large dog-ear created at the distal end of the wound. RESULTS: In our experience, the dog-ear rotation flap is able to close substantial head and neck defects with less tension across the wound edges when compared to other closure types, resulting in diminished scarring and little to no distortion of surrounding anatomic structures. It also provides an excellent tissue match, is relatively quick and easy to perform, and has an extremely low incidence of flap necrosis. CONCLUSIONS: The dog-ear rotation flap is an excellent choice for the repair of very large surgical defects on the head and neck, particularly the cheek, temple, forehead and scalp, and, in our experience, provides a superior cosmetic and functional result to other closure options.     

Early Tangential Excision and Immediate Mesh Autografting of Deep Dermal Hand Burns

Thermal injuries to the hand constitute not only one of the most common burns, but one of the most difficult for the burn surgeon to treat. Early wound closure is mandatory if maximum functional return is to be attained and scarring minimized. Over the last three and one-half years, 60 patients with deep dermal dorsal hand and finger burns were treated by tangential excision and immediate mesh autografting. All patients were admitted to the hospital within 24 hours of injury and excision was performed between the third to the tenth post burn day. Operative technique consisted of sequential eschar excision using the Humby knife or Goulian-Weck dermatome until viable dermis was visible. Mesh autograft, ratio 1 to 1(1/2) without expansion, was applied. There was 100% graft take in all but four hands. Hand function with full range of motion returned by the tenth postoperative day. Complications were minor. Patient follow-up ranged from six months to three and one-half years. No patient has required subsequent surgery for scar revision or contracture release. Range of motion in all patients has been excellent and all patients have continued to maintain normal hand function. The cosmetic appearance has been good except for the early "mesh" appearance of the graft which has become less apparent with time. In summary, early tangential excision and immediate mesh autografting of deep dermal dorsal hand burns has fulfilled the following burn principles-preservation of tissue, prevention of wound infection, maintenance of function and early wound closure.     

Vacuum-assisted closure therapy guided by C-reactive protein level in patients with deep sternal wound infection

BACKGROUND: Deep sternal wound infection is a serious and potentially lethal complication of cardiac surgery when performed through a median sternotomy. We describe the outcome of a new treatment strategy with C-reactive protein level-guided vacuum-assisted closure used at our department. METHODS: Data from 16 consecutive adult patients who had deep sternal wound infections after cardiac surgery were reviewed. Patients with superficial infection or sterile dehiscence were not included. All patients with postoperative deep sternal wound infections were treated with first-line vacuum-assisted closure therapy, followed by direct surgical closure. A purpose-built vacuum-assisted closure system consisting of polyurethane foam pieces and a special pump unit was used. The foam was placed in the wound after debridement of foreign material and necrotic tissue. The wound was covered with adhesive drape and connected to the pump unit, which was programmed to create a continuous negative pressure of 125 mm Hg in the wound cavity. Intravenous antibiotics were given according to tissue-culture results. The patients were immediately extubated after the operation. When ingrowth of granulation tissue was observed in all parts of the wound and the plasma C-reactive protein level showed a steady decline to 30 to 70 mg/L or less without confounding factors, such as tissue injuries or concomitant infections, the sternotomy was rewired, and the wound was closed. RESULTS: All patients were alive and free from deep sternal wound infection 3 months after the operation. The median vacuum-assisted closure treatment time until surgical closure was 9 days (range, 3-34 days), and the median C-reactive protein level at closure was 45 mg/L (range, 20-173 mg/L). The median hospital stay was 22 days (range, 12-120 days). CONCLUSIONS: Early vacuum-assisted closure treatment, followed by surgical closure guided by the plasma C-reactive protein level, is a reliable and easily applied new strategy in patients with postoperative deep sternal wound infection.     

Wedge-Shaped Excision and Modified Vertical Mattress Suture Fully Buried in a Multilayered and Tensioned Wound Closure

Background  A successful deep multilayered wound suture should provide a firm tension-relieving closure, good wound-edge eversion, hemostasis, and minimal intradermal extraneous materials. However, this is not always achieved with a single standard technique. The authors describe their modification of a wound closure method that can rapidly and reliably achieve these results. Methods  A wedge-shaped excision was adopted to obtain a trapezoid pattern transect, after which a modified fully buried vertical mattress suture technique was used to close the wound. These techniques were compared with the standard excision and suture techniques used for the same patient at different times after surgery. Results  The wedge-shaped excision can facilitate good wound-edge eversion, and the modified fully buried vertical mattress suture can provide firm tension relief and optimal apposition. Compared with conventional excision and suture techniques, the described techniques brought about a better outcome in terms of hypertrophic scar prevention. Conclusion  The described modified technique seems to be more efficient than conventional procedures used to prevent hypertrophic scar formation.     

烧伤后24小时内削痂对深Ⅱ度创面局部炎症反应的影响

目的探讨烧伤后24h内行削痂手术对深Ⅱ度创面局部炎症反应以及组织损害的影响。方法选择12例烧伤患者,伤后24h内对深Ⅱ度创面行削痂手术,将患者同一创面分为3个标本采集区,即手术前、手术后和未手术区。手术前标本取自削痂术前创面,手术后和未手术区创面标本于伤后5—7d获取。采用组织培养和比色法测定创面组织释放白细胞介素(IL)8、髓过氧化物酶(MPO)和丙二醛(MDA)的水平,通过HE和Masson染色对创面组织坏死程度进行形态学观察。结果削痂手术后,患者创面组织局部释放IL8、MPO、MDA的水平分别为(6.83±1.85)μg/L、(4.07±0.87)U/g、(8.94±5.66)μmol/g,与未手术创面比较明显降低(P<0.01)。形态学观察显示,手术前创面有凝固性坏死灶;未手术创面炎症反应明显,坏死组织范围扩大;削痂手术后创面局部的炎症反应得到改善,未见坏死组织范围扩大。结论伤后24h内行削痂手术,可以改善深Ⅱ度烧伤创面局部的炎症反应,防止创面进行性加深,有利于创面及早愈合。     

Excision and simple primary closure of chronic pilonidal sinus.

OBJECTIVE: To evaluate the outcome of asymmetrical complete excision of pilonidal sinus with simple primary closure without using drains or tension sutures. DESIGN: Prospective study. SETTING: Teaching hospital, Jordan. SUBJECTS: 46 patients with chronic pilonidal sinus treated between November 1994 and October 1998 by excision of the sinus down to the sacrococcygeal fascia and simple primary closure of the wound without tension sutures or drains. RESULTS: Patients stayed in hospital for 48 hours and postoperative pain was minimal. Complete healing was achieved in 41 patients (89%) after a mean follow up period of 36 months (range 12-60). Two patients (4%) developed recurrent sinuses and in three (7%) the wound broke down. All the patients who healed completely were back to work within three weeks of the operation. CONCLUSION: Excision and simple primary closure is a cost-effective way of treating chronic pilonidal sinus.