Asunto(s)
Procedimientos de Cirugía Plástica , Neoplasias de la Base del Cráneo , Animales , Biopolímeros , Pérdida de Líquido Cefalorraquídeo/cirugía , Chinchilla , Endoscopía , Humanos , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Base del Cráneo/cirugía , Neoplasias de la Base del Cráneo/cirugía , Compuestos de SulfhidriloRESUMEN
High-risk nonmelanoma skin cancers of the head and neck may be identified through a variety of tumor risk factors, including location on the lips or ears, size > 2 cm, recurrence, patient immunocompromised status, poor tumor differentiation, > 6 mm thickness, Clark level V depth of invasion, and presence of perineural spread. Surgical excision is the mainstay of treatment, with Mohs' micrographic surgery typically preferred to standard surgical excision. When reconstructing these defects, ensuring negative margins is of utmost importance and delaying reconstruction until confirmation of margins is recommended. Attention to the impact of immunosuppression and adjunct radiation therapy on wound healing is important for an optimal cosmetic outcome. As with all high-risk cancer patients, close follow-up and surveillance of these patients is imperative.
Asunto(s)
Recurrencia Local de Neoplasia/cirugía , Neoplasias Cutáneas/cirugía , Humanos , Cirugía de Mohs , Cicatrización de HeridasRESUMEN
The goal of cheek reconstruction is to restore an illusion of "normal." Attention must be directed toward the contralateral cheek skin color, texture, thickness, and contour, because this serves a template for reconstruction. The cheek is a peripheral facial subunit and largely frames the more central subunits (eyelids, nose, lips). As such, avoiding distortion or disfigurement of the central subunits is of paramount importance. The cheek possesses significant tissue laxity, elasticity, and mobility, thus allowing for the vast majority of cheek defects to be addressed with primary closure, local flaps, or locoregional flaps.
Asunto(s)
Mejilla , Procedimientos Quirúrgicos Dermatologicos/métodos , Neoplasias Faciales/cirugía , Neoplasias Cutáneas/cirugía , Colgajos Quirúrgicos , HumanosRESUMEN
Management of anterior skull base defects is an area of continued innovation for skull base surgeons. Various grafting materials have been advocated for the repair of skull base defects depending on needs, availability, harvest site morbidity, and surgeon preference. Spontaneous bony closure of small skull defects is known to occur in animal models without bone grafts, but this phenomenon has been unexplored in the human skull base. The objective of this study was to evaluate osseous skull base closure in patients undergoing endoscopic repair of skull base defects. A retrospective review was performed on 13 patients who underwent endoscopic repair of skull base defects with free bone grafts who were followed with postoperative computed tomography scans. This cohort was compared to postoperative radiology from patients undergoing transsphenoidal surgery without rigid reconstruction to evaluate for spontaneous osseous closure of sellar defects. Free bone grafts are incorporated into the bony skull base in the majority of patients (84.6% with at least partial incorporation) at mean of 5.3 years postoperatively. By comparison, patients undergoing pituitary surgery did not demonstrate spontaneous osseous closure on postoperative imaging. Human anterior skull base defects do not appear to spontaneously close, even when small, suggesting that there is no "critical size defect" in the human skull base, in contrast to the robust wound healing in animal models of skull convexity and mandibular defects. Free bone grafts incorporate into the skull base over the long-term and may be utilized whenever a rigid skull base reconstruction is desired, regardless of the defect size.
Asunto(s)
Trasplante Óseo/métodos , Fosa Craneal Anterior/cirugía , Endoscopía/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Regeneración Ósea/fisiología , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/fisiopatología , Estudios Retrospectivos , Colgajos Quirúrgicos/cirugía , Tomografía Computarizada por Rayos XRESUMEN
Comprehensive rejuvenation of the periorbital region commonly involves management of the brow, as well as the upper and lower eyelids. Browlifting, upper and lower blepharoplasty, fat transfer, and neuromodulators are frequently utilized with excellent results. However, surgery in this region can be fraught with potential complications ranging from a poor cosmetic outcome to orbital hematoma and vision loss. Although avoidance of complications is preferred, it is incumbent on the surgeon to have a detailed understanding of the pathophysiology, prevention, and management of these complications. The authors examine the more common complications of periorbital surgery.
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Blefaroplastia , Párpados/patología , Frente/cirugía , Órbita/cirugía , Complicaciones Posoperatorias , Blefaroplastia/efectos adversos , Lesiones de la Cornea , Síndromes de Ojo Seco/etiología , Párpados/cirugía , Hematoma/etiología , Humanos , Hemorragia Posoperatoria/etiología , Trastornos de la Visión/etiologíaRESUMEN
The authors discuss how, in performing an endoscopic brow lift, meticulous surgical technique, adherence to anatomic dissection planes, and direct visualization used at key points in the procedure enable a safer, more-complete dissection and a better outcome. Anatomy as it relates to the procedure is discussed. Patient evaluation and patient expectations are reviewed with a discussion of the points to present to patients about outcomes of this surgery. Detailed steps of the endoscopic brow-lift technique are presented. Complications are discussed and the authors conclude with a summarization of what the ideal brow-lift procedure would accomplish.
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Endoscopía/métodos , Cejas/anatomía & histología , Frente/cirugía , Ritidoplastia/métodos , Frente/anatomía & histología , Humanos , Rejuvenecimiento , Envejecimiento de la PielRESUMEN
BACKGROUND AND OBJECTIVE: Hepatitis C virus (HCV) transmission occurs in 0.2%-10% of people after accidental needlestick exposures. However, postexposure prophylaxis is not currently recommended. We sought to determine the safety, tolerability, and acceptance of postexposure prophylaxis with peginterferon alfa-2b in healthcare workers (HCWs) exposed to blood from HCV-infected patients. DESIGN: Open-label pilot trial of peginterferon alfa-2b for HCV postexposure prophylaxis. SETTING: Two academic tertiary-referral centers. METHODS: HCWs exposed to blood from HCV-infected patients were informed of the availability of postexposure prophylaxis. Persons who elected postexposure prophylaxis were given weekly doses of peginterferon alfa-2b for 4 weeks. RESULTS: Among 2,702 HCWs identified with potential exposures to bloodborne pathogens, 213 (7.9%) were exposed to an HCV antibody-positive source. Of 51 HCWs who enrolled in the study, 44 (86%) elected to undergo postexposure prophylaxis (treated group). Seven subjects elected not to undergo postexposure prophylaxis (untreated group). No cases of HCV transmission were observed in either the treated or untreated group, and no cases occurred in the remaining 162 HCWs who did not enroll in this study. No serious adverse events related to a peginterferon alfa-2b regimen were recorded, but minor adverse events were frequent. CONCLUSION: In this pilot study, there was a lower than expected frequency of HCV transmission after accidental occupational exposure. Although peginterferon alfa-2b was safe, because of the lack of HCV transmission in either the treated or untreated groups there is little evidence to support routine postexposure prophylaxis against HCV in HCWs.
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Antivirales/uso terapéutico , Personal de Salud , Hepatitis C/prevención & control , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Interferón-alfa/uso terapéutico , Polietilenglicoles/uso terapéutico , Profilaxis Posexposición , Antivirales/administración & dosificación , Antivirales/efectos adversos , Patógenos Transmitidos por la Sangre , Hepacivirus/efectos de los fármacos , Hepacivirus/genética , Hepacivirus/aislamiento & purificación , Hepatitis C/transmisión , Hepatitis C/virología , Humanos , Interferón alfa-2 , Interferón-alfa/administración & dosificación , Interferón-alfa/efectos adversos , Lesiones por Pinchazo de Aguja/virología , Exposición Profesional , Proyectos Piloto , Polietilenglicoles/administración & dosificación , Polietilenglicoles/efectos adversos , ARN Viral/sangre , Proteínas Recombinantes , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
Hepatitis C virus (HCV) is currently the leading indication worldwide for orthotopic liver transplantation. However, the majority of patients receiving transplant for HCV eventually develop histopathologic evidence of recurrent allograft HCV and approximately 10% die or require retransplantation within the first 5 post-operative years because of accelerated graft injury and cirrhosis. Traditional induction immunosuppressive regimens and intensive immunosuppression used to treat episodes of acute cellular rejection (ACR) are associated with enhanced viral replication and higher likelihood and severity of recurrent HCV. At our institution, therefore, we have used low-dose steroid therapy in an effort to limit HCV replication. However, this practice has been associated with frequent early presentations consistent with ACR. Here, we present three cases consistent with histologic ACR treated with conventional antirejection therapy that improved transiently, but evolved rapidly to progressive HCV. A fourth patient with a similar presentation experienced dramatic improvement in aminotransferases when treated solely with interferon and ribavirin. We propose that histologic characteristics traditionally associated with ACR may, in fact, represent early recurrent HCV as both processes share common immunopathogenetic mechanisms, or alternatively, that both ACR and recurrent HCV may be present simultaneously. We conclude that in cases suggestive of ACR, careful consideration should be given to treatment for recurrent HCV in lieu of or in concert with intensive immunosuppression.
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Antivirales/uso terapéutico , Rechazo de Injerto/etiología , Hepatitis C/complicaciones , Hepatitis C/tratamiento farmacológico , Interferón-alfa/uso terapéutico , Trasplante de Hígado , Ribavirina/uso terapéutico , Enfermedad Aguda , Adulto , Anciano , Aspartato Aminotransferasas/sangre , Femenino , Glucocorticoides/uso terapéutico , Rechazo de Injerto/tratamiento farmacológico , Humanos , Inmunosupresores/uso terapéutico , Interferón alfa-2 , Masculino , Persona de Mediana Edad , Prednisolona/uso terapéutico , Proteínas Recombinantes , RecurrenciaRESUMEN
BACKGROUND: Evidence suggests that mild head injuries in humans can result in cumulative damage. No investigation to date has considered the effects of multiple subacute mild head injuries in an animal model. METHODS: Forty-one male Long-Evans hooded rats were trained in a Morris water maze. All animals were fitted with a hollow intracranial screw. Concussions were generated using a fluid percussion device. Animals were then evaluated in the water maze until performance returned to baseline. Control animals received no concussions. The remaining animals were randomized to receive one, two, or three concussions. Animals were allowed to return to baseline after each concussion and were then killed. Motor performance was evaluated on a balance beam both before and after concussions. RESULTS: After one concussion, 85% of animals showed performance deviation from baseline as measured by time to reach the platform, returning to baseline within a mean of 14.0 trials. After two concussions, 48% of animals showed deviation, with a mean return to baseline of 6.8 trials. After three concussions, 25% of animals showed deviation, with a mean return to baseline of 2.3 trials. Of postconcussive animals, 42% developed new inconsistent baseline levels of performance. Balance beam performance was unaffected. CONCLUSION: Multiple concussions cause immediate transient impairment in spatial recognition and have extended effects on baseline performance in rats. Motor performance is not affected.