E. Beausang

Wound healing in adult human skin results in varying degrees of scar formation, ranging clinically from fine asymptomatic scars to problematic hypertrophic and keloid scars, which may limit function and restrict further growth. At present, no good objective method of clinically assessing scars exists, which is problematic for the evaluation of scar prevention or treatment regimens. Similarly lacking are histologic correlates of what we consider good and bad clinical scars. The objective of this study was to quantitatively assess human scarring (1) clinically, by developing a comprehensive rating scale, (2) photographically, using an image capture system and a scar assessment panel, and (3) by histologic analysis following scar excision. We assessed 69 scars, with a wide clinical range of severity, in patients who were undergoing surgery, for whatever reason, that involved removal of an old scar. Preoperatively, patients had their scars assessed, clinically using our newly developed scale and photographically using a computerized image capture system. These photographs were then sent to a panel for assessment using similar criteria to those used clinically. Assessment of scars from photographs correlated well with the clinical scar evaluation, indicating its potential utility in multicenter scar prevention/treatment trials. Following excision, scars were processed and analyzed for histology. We also found a strong correlation between the macroscopic and microscopic appearance of scars, particularly between the clinical appearance and histologic scores of features in the epidermis and papillary dermis. This suggests that our clinical scale is a sensitive instrument in scar assessment, allowing validated quantification of the severity of a wide range of scars.

BACKGROUND: Microvascular free tissue transfer has become an accepted and versatile method of reconstruction in the head and neck region, offering a one-stage procedure and thus reducing the number and length of hospital stays. Many of the patients requiring head and neck free flaps are elderly, with concomitant medical problems, including respiratory and cardiovascular compromise, and are therefore potentially at higher risk of adverse outcomes. In addition, they frequently have a history of heavy alcohol and cigarette consumption, which can compound the risks. METHODS: We analyzed a series of 288 intraoral free flap reconstructions and arbitrarily divided them into four groups depending on age: <50, 51-60, 61-70, >70. These reconstructions were all performed for malignant lesions. Preoperative medical problems, including ischemic heart disease, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, and diabetes, were assessed and compared among the different age groups. CONCLUSIONS: Our results suggest that free flap surgery is a safe technique in elderly patients with comparable surgical complications to a younger patient population. As a result of concomitant medical problems, however, postoperative medical complications are more frequent in the older age groups, with a resultant increase in length of hospital stay.

Approximately 5 percent of microvascular free-tissue transfers fail; often this is due to microvascular or peri-anastomotic thrombosis. Various reports have advocated the use of thrombolytics for salvage of these flaps, although clinical evidence supporting this approach is sparse. The authors attempted to review their own and other published results and present an algorithm for the use of thrombolytics in the management of failing free flaps. A retrospective review of 590 free flaps, revealed 71 (12 percent) requiring re-exploration for impending flap failure, determined by standard clinical indicators. Forty-four (62 percent) were found to have pedicle thrombosis and 20 (28 percent) received thrombolysis with streptokinase or urokinase. All 44 flaps were grouped by final outcome and thrombolytic use for comparison. In 24 (55 percent) of the flaps with evidence of thrombosis, the use of thrombolytics was felt to be inappropriate or unnecessary; 13 (54 percent) of these were salvaged. Twenty flaps, however, did receive thrombolysis and 6 (30 percent) of these were salvaged. There was no statistically significant difference among groups with respect to preoperative risk factors, age, gender, flap type, and site of anastomotic thrombosis. There was a twofold higher use of vein grafts in the failed vs. salvaged flaps (36 percent vs. 15.7 percent), and no flaps with vessel grafts were salvaged with thrombolytics. Despite the fact that all flaps were re-explored within 3 hr of a problem being detected, the mean time from the initial operation to re-exploration was significantly higher in flaps that did not respond to thrombolytics (63. 8 vs. 32.8 hr, respectively, p=0.0457). Also, the mean time to re-exploration was significantly higher in the salvaged flaps receiving thrombolysis vs. those that did not (32.8 vs. 22.3 hr, respectively, p=0.0264). While early detection and re-exploration are crucial for salvaging failing free flaps, those flaps unresponsive to other standard interventions may benefit from the selective use of thrombolytics.

A prospective controlled trial was carried out to assess the healing efficacy of calcium alginate and paraffin gauze on split skin graft donor sites. Thirty patients were randomised to the calcium alginate group and 21 to the paraffin gauze group. The donor sites were assessed at 10 days post harvesting to determine if they were completely healed (100%) or not. Twenty one of the 30 patients dressed with calcium alginate were completely healed at day 10, while only 7/21 in the paraffin gauze group were healed (p < 0.05). There were two infections in the study, both occurring in the alginate group while there was no difference in dressing slippage between the two groups. Calcium alginate dressings provide a significant improvement in healing split skin graft donor sites.

In Brief Thirteen head and neck reconstructions were performed using DIEAP perforator flaps with a single failure occurring at the time of flap dissection. Advantages included permanent tissue bulk, ability to elevate simultaneously with ablation, and minimal donor site morbidity and visibility.