Excision Of Scar Tissue Research Articles

Cervical metastasis from Spitz nevus of the buccal mucosa

A 23-year-old woman was presented with a prolonged history of a small lump in the buccal mucosa. A local excision was performed. The morphology diagnosed a Spitz nevus and she underwent supplementary excision of scar tissue. Two years later a submandibular lump appeared on the ipsilateral side of the neck. Cytology from fine needle aspiration indicated spread of a melanocytic tumor and she underwent a modified supraomohyiod neck dissection. One of the lymph nodes showed an inclusion of cells in the deep layers with epitheloid and spindle cells in a pattern similar to that of the primary oral lesion. The finding suggests a mechanical spread of melanocytes from the Spitz nevus to the regional lymph node. After more than 3 years of follow-up there is no further manifestation of disease. It is believed that this may be an example of how a Spitz tumor, although inherently benign, can spread along lymphatics in a pseudometastatic fashion. To our knowledge this is the first report of an oral Spitz melanoma with metastatic behavior.

Stomaplasty-anterior advancement flap and lateral splaying of trachea, a simple and effective technique

Stomal stenosis after laryngectomy is a common and distressing complication. Once sets in, it is generally progressive, causes problems and needs active intervention. To evaluate effectiveness of new simple method of stomaplasty in solving troublesome complication of stoma stenosis. Charts of eight patients who underwent modified stomaplasty and completed 1 year were reviewed. A modified anterior advancement flap and lateral splaying of trachea for stoma plasty are described. This involves excision of scar tissue of the anterior two-third of trachea and interposition of the defect with an inferiorly based triangular skin flap. The tracheo-esophageal-prosthesis (TEP) site is left untouched. Outcome were measured in relation with need for further stenting or any other revision procedure required and ability to use TEP for speech production. Eight patients underwent stoma revision surgery. Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally. Postprocedure, one patient required intermittent stenting at nighttime. All patients could use the TEP effectively. One patient who underwent salvage laryngectomy following chemoradiotherapy developed flap dehiscence. This is a simple and effective technique for stomaplasty. All patients treated with this technique had adequately large stoma for breathing and use of TEP.

Severe Multiple Extensive Postburn Contractures: A Simultaneous Approach With Total Scar Tissue Excision and Resurfacing With Dermal Regeneration Template

Deep partial or full-thickness burns if untreated, neglected, or managed conservatively can develop dysfunctional scar contractures with severe deformities and significant reduction in patient's activities of daily life. These burn sequelae can require multistage procedures to restore anatomy and function. These include single scar release, use of skin grafts, skin expansion, regional or free musculocutaneous or fasciocutaneous flaps to achieve adequate functional improvement. The use of dermal regeneration template (Integra), initially used in primary burns reconstruction, has been already described and compared in single scar contracture-releasing procedures, but to our knowledge, it has not been used in the simultaneous releasing of multiple severe extensive postburn contractures. A simultaneous approach with total scar tissue excision and resurfacing with Integra may reduce the number of operations and the prolonged time period of treatment required by conventional procedures of multistage scar contracture release. A 7-year-old girl, who developed severe postburn scar contractures involving the right upper limb, right axilla, neck, and face after healing of a deep 16% total body surface area burn injury, was treated with this approach. Restoration of anatomy and function, with significant improvement in the range of movement of the involved regions, was achieved in a relatively short period of time (15 weeks) with limited donor-site morbidity and preservation of donor areas for possible future procedures. Total scar tissue excision and resurfacing with Integra should be considered as a valid option in case of simultaneous management of severe multiple extensive scar contractures.

Laryngotracheal augmentation using titanium mesh

The management of laryngotracheal stenosis is still a serious surgical challenge. The fact that there are currently numerous reconstruction procedures indicates that there is at present no standard treatment. Titanium mesh was used instead of traditional homografts in reconstruction of the anterior laryngotracheal wall in 12 tracheostomised patients with benign chronic laryngotracheal stenosis. The anterior laryngotracheal wall was split, followed by excision of scar tissue and fixation of the titanium plate at the split end. A Silastic stent was inserted above the tracheostomy tube and fixed in place by running sutures fixed to the skin by buttons. The stent was removed endoscopically six weeks later and a trial of decannulation was undertaken. Endoscopically, good epithelisation was seen on the inner surface of the mesh in 10 cases and decannulation was possible. Four of these patients required endoscopic debulking of granulation tissue. Decannulation was impossible in two cases, one due to excessive granulation tissue and the other due to prolapse of the titanium mesh into the tracheal lumen (the mesh was removed endoscopically and a Montgomery T-tube inserted). Titanium mesh was found to be a good alternative for augmentation of the anterior laryngotracheal wall. It offered rigid support, with fewer of the complications reported with other grafts.

Urethroplasty by midline longitudinal incision of the dorsal wall of urethra at the site of the fistula: A useful adjunct to the conventional method of repair of urethrocutaneous fistula developing after hypospadias surgery

In cases of repair of urethrocutaneous fistulae developing after primary hypospadias surgery, tubularisation often becomes difficult after excision of scar tissue. It is also well-known that this type of fistulae has a high recurrence rate. In this study of 15 cases, the aim is to analyze the results of conventional urethrocutaneous fistula repair, augmented with the principle of Midline longitudinal incision of the dorsal wall of the urethra at the site of the fistula according to the concept of Tubularised Incised Plate Procedure with the hope of preventing recurrence. Here, the excision of scar tissue around the urethrocutaneous fistulae, tubularisation of urethra is done after incising the dorsal urethral plate. Then the mucosa is closed over a 6F/8F catheter and the resultant suture line is covered first with the dartos flap or adjacent tissue and then, the skin. The skin layer is minimally rotated so as to avoid suture-line overlap. Results of this method has been found to be quite satisfactory, as only in two[2] patients the fistula recurred. Thus it may be concluded from this study that the Tubularised Incised Plate Urethroplasty along with conventional urethral fistula repair is a good adjunctive procedure in prevention of their recurrence.

Surgical treatment of colostomy complications.

One hundred and twenty-three patients (M:F, 0.9:1; mean age 62 years) underwent 156 operations between 1954 and 1984 for correction of late colostomy complications (stenosis 65 patients, prolapse 16 patients, paracolostomy hernia 42 patients). Sixty-three per cent of patients eventually had a good result but in some up to 5 operations were necessary. Local excision of scar tissue at the mucocutaneous junction was associated with a 61 per cent (43/71) success rate for relief of colostomy stenosis. Where local fixation failed to prevent recurrent colostomy prolapse (13/20, 65 per cent of local fixation operations), colectomy and ileostomy was the most effective second procedure (2/3, 67 per cent success rate). Where local repair of a paracolostomy hernia failed (15/32, 47 per cent of local operations), resiting of the stoma to the umbilicus or right side of the abdomen produced better results (3/7, 43 per cent success rate) than resiting to another trephine on the left side of the abdomen (2/14, 14 per cent success rate).

Docetaxel and Nedaplatin Chemotherapy for Advanced Oral Squamous Cell Carcinoma : A Case Report

A new chemotherapy regimen consisting of intravenous docetaxel (60 mg/m2) and nedaplatin (70 mg/m2) was performed in a 51-year-old patient with unresectable squamous cell carcinoma of the tongue (T4N0M0). After 2 courses of chemotherapy and follow-up irradiation, complete tumor regression was observed (clinical CR). Except for short-term grade 4 neutropenia and mucositis, severe toxicities were not observed. Excision of scar tissue at the tumor site was performed without causing tongue dysfunction, and pathological CR was confirmed. In the present case, DOC/CDGP chemotherapy followed by radiotherapy was effective against locally advanced squamous cell carcinoma of the tongue.

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited.

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.

Failed posterior urethroplasty: lessons learned

Objectives To determine the factors contributing to unsuccessful results after posterior urethroplasty and to establish some guidelines for its prevention. Methods From 1977 through 2000, 130 patients (3 to 58 years old) underwent 145 anastomotic urethroplasty procedures for post-traumatic posterior urethral distraction defects. Bulbo-prostatic anastomosis was performed through the perineum in 105 cases and by a perineo-abdominal transpubic procedure in 40. Factors that might have an impact on the surgical result, such as the size and type of sutures, urethral stents, and use of antibiotics were standardized. The records of all patients with unsuccessful results during a follow-up of 2 to 20 years were analyzed. Results Overall, the results were unsuccessful in 12 cases (8%). A negative result was related to incomplete excision of the scar tissue in 3 cases, inadequate fixation of the prostatic mucosa in 6 cases, and anastomotic tension in 2 cases; 1 patient was lost to follow-up. Previous repair, length of distraction defect, and urinary infection had no statistically significant influence on the result. Conclusions The essential operative details of posterior urethroplasty include complete excision of scar tissue involving the membrano-prostatic region, lateral fixation of pliable prostatic mucosa, and creation of a tension-free anastomosis. If a tension-free anastomosis cannot be achieved through the perineum, the perineo-abdominal progressive approach or the elaborated perineal technique should be used at the same setting. Previous repair, a long distraction defect, and urinary infection do not preclude successful posterior urethroplasty.

Release of extra-articular ankylosis by coronoidectomy and insertion of a free abdominal flap: case report

Introduction: It is generally agreed that an effective treatment for extra-articular ankylosis may be coronoidectomy and excision of scar tissue. But these conventional procedures have shown a high rate of recurrence of ankylosis due to heterotopic bone and fibrous tissue formation. Objective and Patient: We report a case in whom a coronoid osteotomy and insertion of a free abdominal flap was used to treat ankylosis of the mandible following radiotherapy for maxillary cancer. Results: This procedure prevented recurrence of ankylosis by heterotopic bone and fibrous tissue formation. In addition, this flap reduced the risk of postoperative infection and promoted primary healing. Conclusion: The procedure, coronoidectomy and insertion of a free flap, was successful because the well-vascularized musculocutaneous flap occupied the dead space, and replaced the shortage of oral mucosa consequently inhibiting the recurrence of extra-articular ankylosis.

Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty.

Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain, but frequently the alar cartilages are missing--unilaterally, bilaterally, completely, or incompletely--with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised, or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columellar retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance, or malposition have been noted. Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear, and rib cartilage, fixed to the residual medial crura and/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair. Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to the surgeon's advantage. A rigidly supported framework with a nasal shape can mold a covering forehead flap or the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal. Anatomic alar cartilage reconstructions were used in eight reconstructive and eight secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized.

Penile implant success in patients with corporal fibrosis using multiple incisions and minimal scar tissue excision

Objectives. To establish the efficacy of “minimal scar tissue excision” in the treatment of penile fibrosis. Methods. Thirty-four patients with extensive penile fibrosis who underwent placement of penile implant from October 1989 to April 1998 were evaluated by a chart review of the patient’s follow-up data. Function of the implant was evaluated at follow-up visits. The follow-up ranged from 4 to 84 months (mean 23.7, median 22). All patients had undergone minimal scar tissue excision of the fibrous tissue in the penis. Results. All patients underwent successful introduction of the penile implant, and in no patient was the procedure abandoned because of technical difficulty. Intraoperatively, 1 patient developed a tear in the crus. It was not recognized during the initial operation but was repaired at a subsequent date by Gore-Tex grafting. The Uniflate prosthesis of another patient failed 2 years after the initial surgery and was replaced with the Mentor alpha-1 implant. None of the patients developed infection. All the patients had a functioning implant at the time of last review. Conclusions. Minimal scar tissue excision is a safe and effective method in the management of extensive penile fibrosis.

The management of extensive penile fibrosis: a new technique of 'minimal scar-tissue excision'.

To evaluate the results of excising minimal scar tissue in patients undergoing insertion of a penile prosthesis for extensive corporal fibrosis. Twelve patients (mean age 58 years, range 44-73) with extensive corporal fibrosis who underwent the insertion of a penile prosthesis were evaluated. Eleven patients had a defect of varying extent after the insertion of the penile prosthesis, and a polytetrafluoroethylene graft was used to cover the area. All 12 patients tolerated the procedure well and currently have a functioning penile implant. Minimal excision of scar tissue provided better results and fewer complications when compared to other studies which used extensive excision.

Late reconstruction after pelvic ring injuries

Pelvic malunions or nonunions are the result of inappropriate treatment of rotationally or linearly unstable injuries of the pelvic ring. Long-term sequelae such as chronic pain in the posterior pelvic ring, gait abnormalities, leg length discrepancy, sitting discomfort, neurological problems or impingement on the visceral organs may be secondary to the disturbed integrity of the pelvic ring. The late correction of the deformity is technically much more demanding than the treatment of acute pelvic ring injuries. Depending on the specific problem, osteotomies at the site of the deformity, excision of scar tissue and callus, release of ligaments, bone grafting, and an adapted technique of reduction and fixation may be required. Possible complications include nerve or vascular injuries, incomplete reduction of the deformity, failure to unite, incomplete pain relief, and infection. Prior to surgery, a careful clinical and radiological examination is mandatory to assess the relationship between the presenting anatomical deformity and the complaints of the patient. The final decision for surgery has to be made by the patient taking into account reasonable expectation and the potential complications associated with the corrective procedure.

Anal Stenosis

Anal stenosis is an abnormally tight inelastic anal opening that resists digital examination and is most commonly the result of excessive scarring following anorectal surgery. Surgical correction consists of excision of scar tissue, judicious internal sphincterotomy, and replacement of tissue with healthy skin or mucosa. The author's preferred procedure of advancement mucosal anoplasty is described in detail.

Management of postburn contracture of the neck

Five hundred and sixty-two patients with postburn contractures were treated by a plastic surgeon in the Central Hospital of the capital city, Lusaka. There were 37 patients with neck contractures of whom 18 were classified as major, all but two were burned by fire and two-thirds were female. Release of contracture and excision of scar tissue followed by surface cover with skin grafting was the mainstay of treatment and was carried out in 31 of 37 patients. Careful perioperative management and the basics of plastic surgery such as skin grafting are within the competence of many general surgeons. Because burn contractures are common in the developing world, it is recommended that plastic surgery be included in the training of general surgeons and that selected cases be managed by them. The more complex cases should be referred to a plastic surgery centre.

A New Nerve Pedicle for Finger Sensibility

Restoration of sensibility to the traumatized finger can be a difficult problem. Two patients with insensibility to the volar distal finger after trauma underwent delayed digital nerve repair. In the first patient, the dorsal branch of the radial proper digital nerve was approximated to the distal stump as a pedicle to span a 12-mm gap resulting from neuroma excision. The second patient had a 14-mm defect after scar-tissue excision 8 months following primary neurorrhaphy after trauma. Reconstruction was performed by approximating the dorsal branch of the radial proper digital nerve to the distal stump. Both patients had fingertip sensibility restored 1 year postoperatively, as documented by two-point discrimination. Anatomic dissections of 12 fresh cadaver fingers revealed a consistent pattern. Of the 24 proper digital nerves dissected, 23 had a distal dorsal sensory branch arising at the midportion of the proximal phalanx. The dorsal branch-vascularized pedicle of the proper digital nerve has not been described previously as a method for restoring finger sensibility in cases not amenable to primary neurorrhaphy. We believe this technique should be added to the repertoire of the practicing hand surgeon.

Cancrum oris: functional and cosmetic reconstruction in patients with ankylosis of the jaws

Advances in reconstructive surgery allow treatment of established cases of Cancrum oris with total ankylosis of the jaws to produce a satisfactory functional and cosmetic result. This is achieved by radical excision of scar tissue followed by two layered flap closure of the defect. It is recommended that a cervical flap is used for lining and a deltopectoral flap for cheek cover. Ten patients with Cancrum oris are presented to demonstrate the techniques used.

The Management of Erectile Deformity in Adults With Exstrophy and Epispadias

The management of 20 patients with erectile deformities owing to exstrophy and epispadias is described. The type of deformity was defined by cavernosography and intraoperative artificial erections. Of the 20 patients 15 had dorsal chordee, 2 had lateral deviation (1 also had dorsal chordee) and 3 had bilateral rudimentary corpora producing small and inadequate erections. The latter 3 patients were considered inoperable. Of the 15 patients with dorsal chordee 12 were treated by insertion of lyophilized human dura in the concave side of the corpora. The results were good after 1 attempt in 8 and after 2 attempts in 1, while 1 had recurrent chordee distal to the first site and further dural phalloplasty was successful, 1 was improved and 1 was a failure. Of the remaining 3 patients in this group 2 underwent excision of scar tissue (1 also had a ventral Nesbit procedure) and the condition was not bad enough to require an operation in 1. Of the 2 patients with lateral deviation 1 was treated by division of a rudimentary corpus and dural phalloplasty of the normal corpus, which produced a straight but rather unstable erection, and 1 underwent bilateral dural phalloplasty with a good result.

Reconstructive Surgery of the Trachea

The most common cause of the life\x=req- threatening problem of tracheal stenosis are those resuscitative efforts to relieve people of other life-threatening problems. There are only two other books on reconstruction of the trachea, neither of which is in English. Therefore, this is a valuable book that provides historical perspective but draws primarily on the wide personal experience of the coauthors. The sections on embryology, anatomy, pathophysiology, and the causes and prevention of stenosis are crisp and complete. The authors are quick to point out the limitations of conservative therapy by means of medical management and dilatation. The authors report their own experience with 220 tracheal resections with end-to-end anastomosis at their clinic in Lausanne, Switzerland, and state that this is the method of choice for repair of tracheal stenosis from trauma or tumor. In the management of other types of tracheal injury the authors emphasize the basic fundamentals of surgical repair, including excision of scar tissue and the replace¬ ment of the epithelial lining with epi¬ thelium, preferably buccal mucosa, and of providing structural support using cartilage or bone from the rib. Building on these fundamentals, the authors describe many of their own clever and unique methods of recon¬ struction. They describe a method of tracheopexy using rib graft for cer¬ tain types of stenosis. They reserve conchal composite grafts for partial defects of the anterior or lateral wall up to 5 cm. For defects greater than 5 cm, they use buccal mucosal grafts for inner epithelial lining and rib carti¬ lage for support and report their suc¬ cess in 48 such procedures. They also go into detail in describing a twostage technique utilizing flaps with and without rib support. Their section on laryngotracheal stenosis is likewise excellent. They again advocate using mucosal grafts for smaller stenoses and reserve the two-stage reconstruction for more difficult cases. The book is liberally sprinkled with special reconstructive techniques for special situations and well illustrated throughout, with line drawings and photographs. EUGENE N. MYERS, MD Pittsburgh