You're Invited!

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Tomorrow night Sid Schwab, MD will be interviewed by Dr Anonymous on The Doctor Anonymous Show. Dr. Schwab is one of my favorite medical bloggers. He is author of Surgeonsblog and also the book, Cutting Remarks. Both are good reads. If you haven't already, I hope you will check them out.

Dr. Anonymous has offered this invitation:

"Join us on Thursday, February 7th, 2008 at 9 pm Eastern Time where we will be talking about his blog, his book, and a lot more. You can also join us in the live chat room or even call into the show to ask Dr. Schwab a question. Now, it's been a couple of weeks since I've had my show. Hopefully, I remember how to do the show. We'll see what happens this time. Tune in tomorrow for details!"

Consider yourself invited to the party. Please, come and join us.

Hair Transplantation

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Just as some want to remove hair, others want to replace lost hair. The loss may be from male pattern balding or trauma or previous surgery (loss of side burns from a face lift).

HISTORY

Modern day hair transplant surgery began in 1952 when a New York Dermatologist by the name of Dr. Norman Orentreich performed the first known hair transplant in the US on a man suffering from male pattern baldness. However, the "roots" were actually cultivated in Japan in the late 1930's, but were not known to western medicine due to WWII, etc. In 1939, Dr Okuda, a Japanese dermatologist, described in detail his groundbreaking work (burn victims). He used a punch technique to extract round sections of hair bearing skin, which were then implanted into slightly smaller round holes. These holes were prepared in the scared or burned areas of the scalps of his patients.

In 1943 Dr. Tamura, another Japanese dermatologist, refined Okuda's technique by using significantly smaller grafts consisting of one to three hairs. Dr. Tamura used an elliptical incision to extract the donor tissue and then dissected each individual graft. Interestingly enough, Dr. Tamura's technique was very similar to the techniques being used today (follicular unit micro grafting).

The work of Norwood, Ayers, and Stough defined candidates for hair transplantation. Dr Walter Unger defined the ideal graft size of 4.0-4.5 mm for maximum hair growth. Additionally, particular patterns for best aesthetic results were reviewed. Uebel and others developed the approach of micrografts (1-3 follicles) or minigrafts (3-8 follicles) to improve the natural appearance of the grafts.

WHO ARE CANDIDATES

As with any surgical procedure, there must be realistic expectations. With hair loss patients, they must also (depending on their cause of hair loss) realize that there may be continued hair loss. Care should be taken in transplanting young patients in whom the full extent of alopecia at age 40, 50, or 60 years cannot be determined.

That said, the best candidates for hair restoration surgery are:

• Men who have been losing their hair due to male pattern baldness (MPB) for more than five years or who have progressed to a Norwood class 3 or above.
• Men who have been balding for many years and who's pattern has stabilized and are interested in just adding some hair to provide a more youthful appearance.
• Men and women who have lost hair due to trauma or burns
• Men and women who have lost hair due to other cosmetic procedures such as face-lifts (often the side-burns, along the incision sites).
• Women who have suffered hair loss due to mechanical or traction Alopecia (non hormonal)
• Women who have a distinct pattern of baldness, similar to that of male pattern baldness. This includes, hairline recession, vertex thinning, and a donor area that is not affected by androgenetic Alopecia.
• Women with alopecia marginalis, a condition that looks very similar to traction alopecia.

Staging alopecia into both pattern and degree of severity can be accomplished through the Norwood-Hamilton classification for men and the Ludwig Classification of female balding.

As can be appreciated from the above picture (male patterns), Hamilton I and II have very early limited alopecia requiring minimal treatment, if any. Conversely, patients with patterns VI and VII may no longer be candidates for the surgery since their alopecia is so extensive there may be inadequate donor sites. The very best candidates fall into patterns IV to V, which produce the best, most natural results.

MEDICAL THERAPY

Medical therapy is often used in conjunction with hair restoration surgery.

Minoxidil (Rogaine) is available in 2% and 5% topical solutions. Cosmetically useful hair is obtained in only about one third of cases. Minoxidil must be used indefinitely to maintain a response.

Finasteride (Propecia) is a type 2 5 alpha -reductase inhibitor available in 1 mg tablets and given once daily. It lowers the dihydrotestosterone on the scalp and the serum of treated patients. Clinical trials have shown finasteride to be effective in preventing further hair loss and increasing hair counts to the point of cosmetically appreciable results. Interestingly, hair loss on the temples is not improved. Patients must remain on the drug indefinitely since the benefit may be lost after discontinuation.

SURGICAL TRANSPLANTATION

These technical innovations give the transplant surgeon the ability to harvest and implant large numbers of mini-micrografts and cover large areas of balding scalp. In the mid-1980s, extensive mini-micrografting was very popular. Not uncommonly, patients received 700-1000 minigrafts to cover extensive areas of bald scalp. It was also common to perform transplants in younger patients with bald frontal and occipital areas who were thinning in other areas.

Dr Emanuel Marritt has examined the consequences of the procedures on patients 10 and 15 years after surgery. Those who have progressed to more extensive baldness have developed deformities in hairline and hair growth. Particular problems have occurred as the progression of hair loss has left some unnatural appearance of hair growth / balding or left exposed scars from scalp reduction procedures.

A sobering conservative view is emerging in the field of hair transplantation: the surgeon should evaluate the patient both with regard to the improvement he or she can provide in the immediate future and for long-term results. The problem remains that surgeons cannot always predict which patients will progress to grade VI and VII classification and produce these unnatural results. Care should be taken in transplanting young patients in whom the full extent of alopecia at age 40, 50, or 60 years cannot be determined.

Harvest Techniques

A number of different techniques are available for harvesting hair follicles. In androgenic alopecia, there are "protected hair follicles". These are hair follicles that are usually not lost. They tend to be found in the inferoposterior scalp and inferior parietal scalp. It is important that only protected follicles be transplanted to ensure maximal survivability. In all the techniques for harvesting, the punch, blade, and blades used are angled parallel to the hair follicles and not perpendicular to the scalp so as not to injury the follicle. 

• Punch Harvesting -- This technique was used most commonly for harvesting donor follicles until the late 1980s or early 1990s. With the punch harvesting technique, a small hand engine is used (which spins approximately 10,000-15,000 revolutions per minute) with a 2- to 6-mm punch. Defects created from harvesting may be left to heal by secondary intention or may be closed using sutures or skin staples. Healing by secondary intention has been abandoned, largely because of results that are cosmetically inferior.
• Excision -- The donor site is excised as an elongated fusiform ellipse of full-thickness scalp using a scalpel blade size 10 or 15, taking care not to damage hair follicles at the edge of the donor tissue. The resultant defect is closed using suture or skin staples, and the scar is minimal. Then, donor tissue is dissected carefully into the desired number of grafts, which can vary in size.
• Strip harvesting -- A scalpel containing 2 or more size 15 blades mounted in parallel is used to cut strips of donor tissue. This facilitates the division of donor scalp into minigrafts and micrografts. Several multibladed scalpel handles currently are available that can accommodate as many as 6 or more No. 15 blades, which most commonly are spaced 1.5-2.5 mm apart. This technique may carry a higher risk of follicle transection than excision.

Grafts obtained by punch grafting can be transplanted directly or cut into smaller grafts using a size 15 blade or razor blade. These round grafts can be cut into halves or quarters, or they can be dissected down to single hair grafts. Grafts harvested by excision or strip harvesting can be cut to single grafts, minigrafts (3-8 hairs per graft), or micrografts (1-2 hairs per graft) by using a size 15 blade or razor blade. This is done using magnifying loupes or a dissecting microscope to aid the dissection of grafts.

Recipient Site Preparation

Several techniques are used for preparing recipient sites (where grafts are to be placed). They include:

• Single hair and slit grafting (micrografting) is most often used to recreate the frontal hairline.
• Dilation (modified slit grafting) -- Micrografting (grafts containing 1-2 hair follicles) or minigrafting can be performed using dilation. Micrografting most often is used to recreate the frontal hairline. This method has not become popular as it is typically slower than slit grafting and may result in compression of the grafts, especially when more than one hair follicle is grafted.
• Punch grafting -- a defect is created at the recipient site using a 1-4 mm diameter punch into which the graft may be inserted. The larger the size of the graft, the more likely it is to have what is termed a "doll's hair" or "cornrow" appearance.
• Laser-assisted grafting -- Carbon dioxide laser has been used to create recipient sites. Significant delay in the growth of the transplanted hairs usually occurs after laser-assisted transplantation.

After creating recipient sites, dilators may be used to enlarge the opening, by pushing adjacent scalp aside, and/or to provide hemostasis. Many surgeons believe that this aids in the insertion of grafts and reduces the trauma to the grafts during insertion. Most surgeons use jeweler's forceps or similar small non–toothed forceps to insert grafts. This is done by grasping the fat immediately beneath the hair follicle rather than the hair/hair follicle. Some surgeons use a needle to insert and tease grafts gently into place.

POST-PROCEDURE CARE

Medications

• Antibiotic use -- Significant controversy remains regarding the use of prophylactic antibiotics in hair transplant surgery. The most appropriate time to administer prophylactic oral antibiotics (as single dose) is 1 hour preoperatively. Some surgeons use oral antibiotics for 3-5 days postoperatively to reduce risk of infection. For most patients, first-generation cephalosporin is used, unless a history of cephalosporin allergy exists and then azithromycin or ciprofloxacin may be substituted. Some surgeons also use topical antibiotics during the postoperative period to reduce risk of wound infection, although no benefit has been established yet.
• Corticosteroids -- Many surgeons administer oral or intramuscular corticosteroids to reduce postoperative swelling, although few data are available supporting this practice.
• Pain medications -- Some patients require oral narcotics for the first few days after hair transplantation. Usually, Tylenol with codeine, Percocet, or Lortab 5 is sufficient to alleviate most postoperative discomfort.

Postoperative dressings

Many surgeons advocate use of surgical dressings to minimize risk of graft loss. This would include applying (1) topical antibiotic, (2) Telfa nonstick gauze, (3) gauze, (4) Kerlix gauze, and (5) Coban wrap to create a turban-like dressing. Most often, this dressing is removed after 24 hours; no dressing is required thereafter. The current trend of some surgeons is to use no postoperative dressing and require patients to wear a baseball cap. Most allow the patient to shower and shampoo their hair the day after hair restoration surgery.

COMPLICATIONS

As with any surgical procedure, there are risks. Fortunately they are infrequent. Postoperative edema is expected, so is not a complication. It may be severe. The risks of hair transplant surgery include:

• Bleeding
• Infection
• Scarring at donor site
• Scarring at recipient sites
• Dyspigmentation at recipient sites
• Cobblestone appearance at recipient sites
• Failure of graft
• Cyst formation
• Poor results -- too large plugs used, doll's hair or corn-row appearance, poorly planned hairline, etc.

Hair Transplant Surgery Process: Photo Journal -- shows photos taken along the process, very nicely done.

Revised April 6, 2008
REFERENCES
Hair Replacement Surgery, Hair Transplantation; Jorge l de la Torre MD, Gary D Monheith MD, John D Kayal MD; eMedicine Article, June 6, 2006
Surgical Hair Restoration -- American Hair Loss Association
Hair Replacement Surgery, Hair Transplantation in Women; Mark E Krugman MD and others; eMedicine Article, August 20, 2005
Hair Graft Transplantation for Baldness; Jeffrey S Epstein MD and others; eMedicine Article, October 17, 2005
Bernstein Medical Center for Hair Restoration Web-site (very nice with lots of information) and Blog

Permanent Hair Removal

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Recently I posted on using hair for charity--raising money or making wigs. There are many of us who chose to remove unwanted body hair for cosmetic, social, cultural, or medical reasons. This includes both men and women. Even the indications that are considered "Medical indications" are influenced by the social and cultural norms. The hair on a chest like Tom Selleck's should be left alone (just my opinion), hairy backs are another thing.

The medical indications include:

• Hirsutism, which is excess terminal hair in the distribution of hair growth influenced by androgens (ie, face, chest, back, abdomen)
• Hypertrichosis, which is congenital or drug-induced increase in hair growth in areas that are not androgen dependent.
• Pseudofolliculitis
• Hair growth from a grafted donor site
• Sex-change operations performed in men.

IMPORTANT TERMINOLGY

Temporary hair reduction is defined as a delay in hair growth, which usually lasts 1-3 months, consistent with the induction of telogen.

Permanent hair reduction refers to a significant reduction in the number of terminal hairs after a given treatment. This reduction must remain stable for a period of time longer than the complete growth cycle of hair follicles at the given body site. It has recently been suggested to add another 6 months to this posttreatment observation time (ie, the time necessary for a damaged follicle to recover from the laser injury and reenter a normal growth cycle). Note that "permanent" does not mean no regrowth of hair.

Complete hair loss refers to a lack of regrowing hairs (ie, a significant reduction in the number of regrowing hairs to zero). Complete hair loss may be either temporary or permanent.

METHODS of HAIR REMOVAL

There are many methods available for temporary or permanent hair removal. Each has its own relative efficacy and adverse effects. Different methods for the removal of body hair include the following:

• Temporary hair removal - Shaving, epilation, depilation, bleaching

• Temporary hair reduction - Eflornithine hydrochloride (VANIQA cream 13.9%), laser-assisted hair removal
• Permanent hair removal - Electrolysis, Laser-assisted Hair Removal (LHR), Intense Pulsed Light Hair Removal (IPL)

Electrolysis

Electrolysis (or electrology) involves the insertion of a small, fine needle into the hair follicle, applying a pulse of electric current that damages and eventually destroys the hair follicle. Multiple treatment sessions are required to achieve a clinically significant result. The 2 types of electrolysis are galvanic electrolysis (direct current electrolysis) and thermolysis (alternating current electrolysis).

Proper electrolysis requires accurate needle insertion technique and appropriate intensities and duration of current. In addition, only anagen-phase hairs should be treated because telogen-phase hairs are believed to be more resistant to damage. Anagen-phase hairs can be distinguished easily from telogen-phase hairs by shaving the area to be treated and, in a few days, treating only those hairs visible on the skin surface (anagen-phase hairs).

Potential adverse effects of electrolysis include:

• Scarring (ie, keloid formation)
• Postinflammatory hyperpigmentation
• Hypopigmentation
• Pain--can be diminished with the use of topical anesthetic creams (Emla, ELA-Max, Topicaine) applied 1 hour prior to the procedure.
• Local bacterial and viral infections

The adverse effects (and success) of electrolysis are dependent on technician experience and the duration and intensity of the current. Electrolysis is not safe for patients with pacemakers and should not be used on these patients.

Hair removal with light (laser, IPL)

Since 1996, when hair removal laser technology first became available for general use, numerous advances have occurred in laser hair removal. This has resulted in the many different types of lasers now available for treatment of excessive hair. Laser hair removal is based on the theory of selective photothermolysis, or selective destruction of the follicular unit, resulting in significant hair reduction in treated areas.

• Selective photothermolysis --This principle predicts that selective thermal damage of a pigmented target structure will result when sufficient fluence at a wavelength, preferentially absorbed by the target, is delivered during a time equal to or less than the thermal relaxation time of the target. [When enough heat damage is done to the target --hair in this case]
• Melanin is the natural chromophore (light-absorbing molecule)for targeting hair follicles. It's absorption spectrum is 250-1200 nm, which spans the entire ultraviolet, visible, and infrared light ranges.
• When melanin absorbs energy in the form of heat from a pulse of laser light, there is "selective" heating which causes thermal injury to the melanin-containing cell (in this case, the hair follicle) and its surroundings. Ideally, the laser energy is absorbed selectively by the melanocytic hair bulb and matrix, thus destroying the hair follicle and its capacity to regrow, while protecting the surrounding tissue where the melanin concentration is minimal.
• Melanin in the epidermis presents a competing site for absorption. In persons with darker skin, the higher levels of melanin in heavily pigmented skin (tanned, Asian, Blacks, etc) compete as a chromophore for the laser light. This light is converted to heat and can cause skin blistering or changes in skin pigmentation.
• Selective cooling of the epidermis has been shown to minimize epidermal injury. Cooling can be achieved by various means, including ice, a cooled gel layer, a cooled glass chamber or sapphire window, a pulsed cryogen spray, or cooled airflow.
• Laser treatment usually produces complete but temporary hair loss for 1-3 months, followed by partial but permanent hair loss. Multiple treatments may be necessary.

Before the widespread use of longer wavelengths and pulse durations and more effective cooling devices, laser-assisted hair removal was best used to treat individuals with light skin and dark hair. More recently, however, long-pulsed lasers have been used to safely and effectively treat patients with darker skin types.

Laser light sources currently used in hair removal treatments include:
Long-pulsed ruby

• The long-pulsed ruby laser was the first widely used laser for hair removal. Its light energy has the most selective absorption by melanin and the shortest depth of penetration (wavelength of 694 nm).
• Use of this laser for hair removal is indicated in individuals with light skin and dark hair.
• Its efficacy has been demonstrated in numerous studies, ranging from 20-60% hair reduction after one treatment and up to 50-78% reduction after multiple treatments.
• The ruby laser penetrates the skin by only 1-2 millimeters and can cause significant absorption by epidermal melanin of thermal energy. The use of this laser on patients with darker skin types is not recommended.

Long-pulsed alexandrite

• The 755-nm alexandrite laser has now been widely used for laser hair removal. It is recognized as being efficacious and generally safe.
• This laser is still typically used for patients with lighter skin types, but its longer wavelength allows for deeper penetration into the skin, and it can be used for patients with darker skin.
• Studies have reported hair reduction from 4-56% after only a single treatment and from 33-95% hair reduction after multiple treatments, depending upon number of treatments and body location.
• The adverse effects of this laser, when used on patients with darker skin types, can include blistering, crusting, and alterations of pigment, even when skin cooling devices are used. In patients classified as having the darkest skin, residual hypo- or hyperpigmentation is the rule with the alexandrite laser.

Long-pulsed diode

• The 810-nm long-pulsed diode laser has been demonstrated to have hair removal capacity comparable to those of the ruby or alexandrite lasers. After a single treatment, hair reductions of 32-34% have been reported, and up to 84% hair reduction has been reported after multiple treatments.
• The diode laser can be used in darker skin types because of its longer wavelength and adjustable pulse duration. It should be used with an efficient skin-cooling device.
• Still, temporary adverse effects have been reported with the use of the diode laser in the form of postinflammatory hyperpigmentation when used on individuals with dark skin.

Long-pulsed Nd:YAG

• The Nd:YAG laser is the safest type used to treat unwanted hair on patients with dark skin and is most suitable for patients in this group. At 1064 nm, this laser penetrates the skin deeper than other lasers (to a level of 4-6 mm) with less absorption at the skin.
• It is also less effectively absorbed by melanin. This leads to lower instances of adverse effects and better tolerance in patients with dark skin, but also lower efficacy for hair removal.
• Permanent hair loss has been reported, however, with reported hair reductions of 27-53%, depending on the number of treatments administered and the body location.
• The FDA has approved the long-pulsed diode and the long-pulsed Nd:YAG lasers for use in hair removal in patients with darker skin classifications. All FDA-approved laser systems used for hair removal must have efficient and effective epidermal cooling devices incorporated as part of the system.

Intense pulsed light systems

• Intense pulsed light (IPL) systems utilize a xenon bulb as a light source, which produces polychromatic light with wavelengths from 550-1200 nm. This is in contrast to laser light sources, which produce monochromatic light of a specific wavelength. Light emitted by the bulb passes through a filter that excludes shorter wavelengths that may severely damage skin.
• The ability to "tune" the wavelength of light emitted by these systems gives IPL systems the advantage of versatility. Using different filters, a pulsed light system could mimic any number of laser systems, allowing the operator to treat many different conditions amenable to light therapy, including, of course, the removal of unwanted hair.
• Studies have shown intense pulsed light to be an effective method of hair removal. In a study of 210 patients who underwent hair removal by IPL, a mean hair reduction of 80% was reported after 3-5 treatments.
• Minimal adverse effects, including transient erythema and localized edema, were reported.

Skin Prep and Safety

• Patients should be instructed to avoid sunlight and active tanning prior to treatment.
• Patients may shave or use depilatory creams up to the day prior to treatment. Tweezing should not be done, as the hair follicle/shaft is needed for the treatment to work.
• Topical anesthetic creams may be applied to the treatment area to reduce discomfort during the procedure. Cold compresses are also effective in reducing discomfort, erythema, and edema at the treatment area.
• The skin surface must be thoroughly cleansed of all makeup, anesthetic creams, and other applicants immediately prior to laser treatment. This may be done with water, followed by alcohol swabs, and should be allowed to dry completely.
• Laser systems are dangerous hazards to the eye. The highest concentration of melanin in the body is contained in the retina, which is highly susceptible to damage by laser light. Every person in the room during laser treatment should wear protective eyewear that is certified for the wavelength of the laser in use. Because the patient usually lies supine, he or she may require full occlusive eye protection to prevent laser light from entering underneath a sunglasses or goggle type of protective eyewear.
• A higher occurrence of adverse effects and adverse reactions has been noted at the neck region in women; higher fluences in this area should be used with caution.
• For treatment of the chin, perioral region, or upper lip, tooth enamel should be protected from excessive laser light exposure. Inappropriate exposure to certain laser light may induce hard tissue disintegration in the tooth and irreversible damage to dental pulp.
• During laser treatment, each laser spot should overlap by no more than one third of the spot size. Further overlapping of continuous pulses causes accumulation of thermal injury and potentially causes epidermal damage. No overlapping of spots could result in missed areas in the treatment area.

Post-procedure Care:

• Cold compress or ice pack may be used to decrease pain and reduce swelling.
• Patients may also be given a topical corticosteroid cream to decrease local erythema.
• If minor skin damage has occurred, a topical antibiotic ointment may be applied until the skin has sufficiently healed.
• For more serious skin damage, an oral antibiotic may be prescribed for prophylaxis if deemed necessary by the health care provider.
• Makeup may be applied to treated areas the day following the procedure if no epidermal damage has occurred.
• Patients should be told that hair casts will shed from treated areas over the following week and that this should not be confused with new hair growth.

Future treatments should be planned when they are likely to be most effective. Timing depends upon the body surface area to be treated.

• Hair on the trunk and extremities grows more slowly than on the face and head, and future treatments to the trunk and extremity should be planned after 2-4 months.
• In women, facial hair is lighter in color and finer in texture than on other parts of the body. These hair properties make the face a resistant area to treatment. Therefore, greater numbers of treatments are often required, and at shorter intervals. Treatments of the face should be timed at intervals of approximately 4-6 weeks.

Complications:

Immediate effects after a single treatment of laser-assisted hair removal include perifollicular erythema and edema. These are expected after treatment and should not be considered adverse effects. They are minimized by cold application and resolve in a few hours.

The risk of developing adverse effects or complications after laser-assisted hair removal varies widely and depends upon many factors including the type of laser used, skin color, etc.

• Blistering -- is a result of injury to the epidermis, possibly due to high fluences or increased overlapping of laser pulses. It is the most common complication and can occurs with all lasers/IPL.
• Scab formation is another common adverse effect of laser treatment. Blistering and minimal epidermal crusting have been reported in up to 15% of patients treated with both ruby and alexandrite lasers. These occurrences are more common in patients with tanned skin and darker skin types.
• Hyperpigmentation is a darkening of the skin and can occur after laser treatment. This phenomenon is usually reversible and is due to a stimulation of melanin production in skin melanocytes. This reaction is similar to a suntan.
• Hypopigmentation, or lightening of the skin, can occur after laser treatments. This is caused by damage to the epidermal melanocytes after their melanin absorbs laser light energy, causing destruction of these cells. This type of damage may be permanent and occurs more commonly in patients with darker skin.

REFERENCES
Nonlaser Hair Removal Techniques; Alicia Barba MD, Leslie S Baumann MD, and Esperanza C Welsh; eMedicine Article, December 15, 2004
Electrolysis - DermNet NZ
Laser-Assisted Hair Removal; Christine Dierickx MD; eMedicine Article, April 12, 2006
Laser Hair Removal; Joseph A Molnar MD, Christian N Kirman MD, and Samer Alaiti MD; eMedicine Article, February 21, 2007
On the Physics of Laser-induced Selective Photothermolysis of Hair Follicles: Influence of Wavelength, Pulse Duration, and Epidermal Cooling; Journal of Biomedical Optics, Vol 9, No 2, pp 353-361; Lars O Svaasand, J Stuart Nelson

SurgeXperiences 114 is Up!

Updated 03/2017--links removed as many are no longer active.

SurgeXperiences 114 is up over at Notes of an Anesthesioboist.  I hope you will go over and check it out.  Very nice edition!
The next edition (#115) will be February 17, hosted by Chris from Made a Difference!  Glad you are back safely from Iraq, Chris!

Twisted Ribbon Quilt

I made this quilt in 2004. The white is a cotton flannel. The black is a cotton velvet left over after making a dress for one of the nieces. The print is a cotton-linen found in the bargain bin at the fabric store. The limited amounts of the black and print determined the size and helped dictate the border. I found the block design in Jinny Beyer's book, The Quilter's Album of Blocks and Borders (copyright 1980). A friend found the book at an "antique" store for $4. It is a wonderful book. 

The quilt is 45 inches X 56 inches and usually lays over the back of my husband's lazy-boy chair. Rusty insisted on getting in the picture.

A close-up. Sorry the quilting doesn't show better. The centers are quilted with roses. The ribbons are out-lined quilted.

Hair for Charity

 Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Fellow medical blogger, Shadowfax, over at Movin' Meat is going to shave his head for charity. You can read his posts--"I'm a Beautiful Man" and "I get letters" that highlight his reasons.

St. Baldrick's is a fundraising foundation dedicated to raising funds for pediatric cancer research. Currently, only $1 of every $100 spent on cancer research goes to funding all of pediatric cancer research. Since the organization's inception in 2000, they have raised over $34 million for research funding. 83 cents of every dollar goes to funding, a very high percentage for a charitable foundation. Their fundraising centers around shaving the head of a volunteer, to promote solidarity with all these great kids who lose their locks to chemo. How it works: a volunteer will sponsor a child, and gets friends and family to contribute money to his fundraising efforts. There is then a public shaving to celebrate!

Well, I'm not sure that I (being female and not Britney Spears or Sinead O’Connor) will ever willing shave my head, but I have donated my hair twice for Locks of Love. They are a public non-profit organization that provides hairpieces to children under age 18 suffering from long-term medical hair loss from any diagnosis. Most of the children helped by Locks of Love have lost their hair due to a medical condition called alopecia areata, which has no known cause or cure. The first time I donated, the length they asked for was 15 inches. It is now only 10 inches. Here are their guidelines if you wish to donate.

• 10 inches measured tip to tip is the minimum length needed for a hairpiece. This includes hair that is colored or permed.
• Hair must be in a ponytail or braid before it is cut.
• Hair must be clean and completely dry before it is mailed in.
• Place the ponytail or braid inside of a plastic bag, and then inside of a padded envelope.
• Fill out the hair donation form, or write your name and address on a separate sheet of paper and include inside the envelope.
• All hair donations must be mailed to Locks of Love at: 2925 10th Avenue N, Suite 102
  Lake Worth, FL 33461-3099

Please Note:

• Shorter hair will be separated from the ponytails and sold to offset the manufacturing costs. Although the shorter hair cannot be used in the hairpieces, it still greatly helps to reduce costs.
• Gray hair will be accepted and sold to offset the manufacturing costs.
• Hair that has been bleached (usually this refers to highlighted hair) is not usable. If unsure, ask your stylist.
• Hair that is swept off of the floor is not usable.
• Hair that is shaved off and not in a ponytail or braid is not usable.
• We cannot accept dreadlocks. Our manufacturer is not able to use them in our children’s hairpieces. We also cannot accept wigs, falls, hair extensions or synthetic hair.

Then there is the Wigs for Kids program. Their guidelines for hair donation are similar to the above ones for Locks of Love. The history of this organization goes back over 25 yrs:

" founder Jeffrey Paul cannot believe his incredible journey. He was a successful hairdresser with a thriving business. He traveled all over the world to work with powerful presidents and gorgeous models. But one day, his 15-year-old niece walked into his salon, crying. She tearfully begged him to stop her hair from falling out. My immediate thoughts were not serious.

But when I saw the look in her father’s eyes, I knew it was something more.” It turned out that she had just been diagnosed with leukemia. “Uncle Jeff, you know I’ve been trying to get on the gymnastics team all my life,” she cried. “My hair is going to be falling out when it’s time to try out.”

Although chemotherapy would help save her life, it would also leave her with no hair. “I promised her that she would have hair,” Paul says. “And when you make a promise to a kid, you keep it.” Read more here.

I hope you will consider making a monetary donation for Shadowfax/ St Baldwick's and maybe donating some of hair to one of the groups that make wigs. Hair, like blood, is a renewable resource. A bad haircut is only temporary.

Elbow (Olecranon) Bursitis

Odd topic for a plastic surgeon. Maybe. Maybe not when it's the plastic surgeon who has the problem (olecranon bursitis). That's right, earlier this week, (truly out of the blue) I set my left elbow down on the desk while writing a note. I noticed it was kind of sore/tender. Ignored it, but as the day went on it became more so. I went to the full length mirror in one of the exam rooms so I could really look at it. Red, swollen, no breaks in the skin. I didn't recall any trauma to my elbow. None of that "I hit my funny bone" stuff that makes you take notice. I still ignored it for another day as I had no elevated temp. It got worse. I called up one of the hand surgeons I had done my fellowship with back in 1989-1990. He is an orthopedic trained hand surgeon. He worked me into his busy schedule. The x-rays of my elbow were pristine. No joint abnormalities, no bone spurs, no hairline fractures, nada. That's good, but then what set off my elbow bursa? He wasn't any more sure than I was. He put me on antibiotics (red, warm to touch) and had his therapists make me a splint. He wanted to put me on an anti-inflammatory, but Aleve (helps my joints, etc) gives me severe esophagitis. Severe--burns from the posterior tongue all the way to the stomach.

Damn, I hate this splint. It's amazing the elbow motions you take for granted and the shoulder can only move in so many ways.

• I hold the phone with my left hand, so my right is free for taking notes. Can't do that with the splint on.
• Can't scratch my nose or much of any area above the waist, front or back, with my left hand with the splint on.
• Tough to reach into the washer to pull out clothes with the left arm. Hadn't realized that I used my left arm for that more than the right (interesting).
• Can't scrub in for a case with the splint on.
• Not sure it would inspire confidence in me if patients saw me using it

Okay, I love the splint for these reasons:

• Keeps me from knocking my elbow on the washing machine, the car door, the table top, etc
• Able to wash dishes with the splint on (started to put this in the neutral or hate column, but recalled my Thanksgiving post and couldn't do it)

Neutral about the splint for these reasons:

• Able to use the keyboard while wearing the splint.
• Able to walk my dog in the splint fairly normally.
• Did manage to do some quilting (both hand and machine) with the splint on.
• Did manage to drive my car (safely) with the splint on.

Interesting insights, but Thank God it's not my right!!! I will honestly admit I don't wear the splint full time, but do think I have done better than 50%. My elbow is improving quickly (not as fast as the bursitis appeared but). Also, the elbow joint will get stiff if not moved. I have tried to be (and think I have) careful of not banging it or putting any pressure on it when the splint is off. I don't sleep with it on, I'm afraid I might accidentally hit my husband with it.

Here are a couple of sights with more information (medical) on elbow bursitis:
Elbow Bursitis -- American Association of Orthopedic Surgeons
Olecranon Bursitis; Patrick M Foye MD and Todd P Stitik MD; eMedicine Article, November 22, 2006

Lip Reconstruction -- Part II

 Updated 3/2017 --photos and all links removed (except to my own blogpost) as many no longer active and it was easier than checking each one.

Refer back to Lip Reconstruction -- Part I for the basic information and history. As with the smaller, non-full thickness defects, symmetry should be strived for with as little disturbance of the surrounding anatomic features as possible. Keep in mind the subunits of the lip and landmarks (white roll, philtrum, etc).

Small full-thickness defects of both the upper and lower lip can usually be treated with wedge excision and primary closure (less than a fourth to a third of the total lip missing).

For optimal cosmetic and functional results, full-thickness lip resections should be repaired in 4 layers.

• First, the submucosa is repaired by using a small-caliber (5-0), soft, nonirritating suture such as silk or Vicryl. The knots should be buried to prevent irregular wound contours and suture spitting.
• Second, the orbicularis oris is repaired by using an absorbable suture (4-0 or 5-0) such as Vicryl, Dexon, or PDS. Careful and meticulous reapproximation of the orbicularis oris is necessary to maintain competence of the oral sphincter.
• Third--realign the vermilion-cutaneous border with an epidermal vertical mattress suture prior to proceeding with the dermis/subcutaneous layer of the cutaneous lip. Proper and exact restoration of this border is crucial for a good aesthetic outcome. At the risk of being redundant, even a 1 mm discrepancy in the outline of the white roll is noticeable at a distance of 3 feet (Zide).
• Fourth, the skin is closed with a monofilament suture, taking great care to maximally evert the wound edges to prevent a depressed and noticeable scar. Small-caliber 5-0 or 6-0 sutures are preferred in this area.

RECONSTRUCTION OF Large Full-Thickness Defects

Upper lip reconstruction is guided by the need to provide a central philtrum and two lateral elements.

Subtotal central defects are best addressed by advancement of lateral elements carrying the orbicularis oris sphincter into an Abbe-Sabattini flap philtral reconstruction.

• Abbe-Sabattini Flap -- First record of this flap belongs to Pietro Sabattini (1838). Gurdon Buck used a cross-lip lap during the Civil War, but it wasn't until 1898 when Robert Abbe pulished his "new plastic operation" that other surgeons took note and named the procedure after him. It is good for replacement of one third to one half of the upper or lower lip. It allows for immediate reconstruction and will give continuity to the oral stoma (mouth). The donor site is closed primarily. The patient must be cooperative as the two lips will be temporarily "connected" until the flap is divided at a second procedure 10-14 days later.

• Reverse Fan Flap -- The flap is based inferiorly rather than superiorly. With the fan flap the lip may have some sensation, but muscular function may be compromised.

• Webster's Combination procedure adds a cross-lip lap to form the philtrum.

• Von Bruns's Nasolabial Flaps (1857) --the flaps are inferiorly based and pivoted on the commissures. The mucosa lining the flaps is later everted to form the vermillion. There are variations of this flap by Fujimori, Gurel, Mavili, and Meyer.

• Karapandzic's Inferiorly based Orbicularis Rotation Flap or Reversed Karapandzic Flap-- This innervated orbicularis oris flap was described in 1974 by Karapandzic and is often called by that eponym. It is composed of the orbicularis oris muscle with vermilion, overlying skin, and underlying mucosa mobilized on peripheral neurovascular pedicles containing the fifth and seventh cranial nerves. This flap preserves motor and sensory innervation, and provides excellent functional restoration. The principal limitation of this technique is the increasingly severe microstomia and accompanying abnormal appearance that result with progressively larger lip defects.

When a lateral element is completely missing, a flap designed as a lateral element aesthetic unit is transferred from a nasolabial site or lower lip midline to replace the missing lateral lip elements. Inclusion of the levator anguli oris muscle in a distally based nasolabial flap restores the oral sphincter of the upper lip.

• Reverse Estlander Flap--In 1872 Estlander described a rotation flap from the lateral upper lip around the commissure to repair a defect of the lateral lower lip. The classic Estlander flap will need a secondary revision to restore the sharp angle (commissure) at the corner of the mouth. However, the modified Estlander or reverse Abbe flap preserves the commissure. 

• Webster's Flap adds crescentic perialar excisions to bilateral cheek advancement flaps to yield excellent results in lateral upper lip defects. It is not sufficient for total upper lip reconstruction.

• Levator anguli oris flap (Tobin and O'Daniel, 1990) is an innervated flap that is based at the oral commissure and transposed to replace the lateral lip element.

Lower lip reconstruction

In the lower lip, innervated advancement of the preserved lateral lip elements are preferred to depressor anguli oris flaps unless the defect reaches the commissure on one side.

• Bilateral orbicularis oris flaps (Karapandzic) can be used to reconstruct as much as three fourths of the lower lip. While it provides a complete oral sphincter and oral competence, it often results in a small oral aperture which can be a problem for denture wearers.

• Freeman (1958) or Webster-Coffey-Kelleher (1960) modification of the Bernard bilateral cheek advancement flap technique. Both approaches preserve motor and sensory innervation to the residual lateral lip elements although both distort the oral commissures, and oral circumference is progressively lost as the defect enlarges.

• Gillies's fan flap is basically an extension of the Estlander-type vermillion-bordered flap, enlarged to include tissue lateral to the corner of the mouth. When used unilaterally it is good for defects up to a half of the lower lip. It does not decrease the size of the stoma (mouth opening) much, if at all. The donor defects close directly. The commissure and width of the mouth remain unchanged. However, there is little or no muscular function because it is a denervated flap. This can lead to problems with oral competence and decreased/poor sensation. There may also be some blunting or obliteration of the nasolabial folds.

RECONSTRUCTION of Total Lip
Upper lip reconstruction

• The Abbe-Sabattini flap philtral reconstruction may be performed either concurrently with the lateral element reconstruction or later. Deferring it can be particularly valuable if the reconstruction is asymmetric because the Abbe flap can be placed precisely in the midline after the lip has settled and the lateral element junctional scar ignored.

• Bilateral levator anguli oris flap (Tobin and O'Daniel, 1990) is an innervated flap that is based at the oral commissure and transposed to replace the lateral lip element. In combination with an Abbe flap, it can reconstruct the entire upper lip.

• Bilateral Karapandzic's Inferiorly based Orbicularis Rotation Flap use in combination with an Abbe flap. (picture)

• Bilateral Fan Flap (Gillies') is good for total defects of both the lower or upper lip.

• Kazanjian-Converse technique of superiorly based lower cheek flaps

Lower lip reconstruction

• Bilateral, innervated, depressor anguli oris myocutaneous flaps serve well. These flaps provide a superior functional restoration compared with previously described methods.
• Webster Cheek Advancement Flap can be used for total lower lip reconstruction. It can often result in a tight lower lip and poor lip function.
• Bilateral Fan Flap --see above Gillies's fan flap
• Karapandzic's Technique can be used to reconstruct up to three fourths of the lower lip.

COMPLICATIONS

• Infection is uncommon but is usually heralded by pain on days 4 to 8. They are managed by antibiotics and wound care.

• Hematomas and seromas can occur and will increase the likelihood of flap necrosis.

• Flap cyanosis in the immediate postoperative period is often the result of venous congestion. If thought to be due to excessive wound tension, suspicious stitches can be removed in an attempt to optimize the outcome.

• Flap failure or necrosis is often due to poor planning or design which underscores the need for careful preparation. Cigarette smoking can increase the risk of flap loss by up to three-fold. When necrosis does occur it will usually involve the distal tip and should be managed expectantly. Unless there are signs of local infection, debridement should not be performed as the eschar will serve as a biologic dressing at worst.

Note--most of the photos were scanned in from the SRPS (5th reference below). This is by no means an exhausted review of the flaps possible for lip reconstruction. When the cheek, as well as the lip is missing often free flaps will need to be done to bring into the area new tissue. Often it is the radial forearm flap that is used when that is necessary.

REFERENCES
RECONSTRUCTION OF THE LOWER LIP BY MENTAL V-Y ISLAND NEUROVASCULAR ADVANCEMENT FLAP; Burić Nikola, Krasić Dragan, Vučković Ivica
Lip Reconstruction by Michael R Shohet MD and Maurice M Khosh MD; eMedicine Article; August 19, 2005
Lip Reconstruction; Gordon R Tobin MD and Wayne Stadelmann MD; eMedicine Article, January 30, 2005
V-Y Advancement Flap in Upper-Lip Reconstruction, IDEAS AND INNOVATIONS; Plastic & Reconstructive Surgery. 105(7):2464-2466, June 2000; Narsete, Thomas A. M.D.
Lip, Cheek, and Scalp Reconstruction and Hair Restoration; Selected Readings in Plastic Surgery, Vol 8, No 14; W P Adams Jr MD, S J Beran MD, and F J Tittle MD
Lip Reconstruction; Yamilet Tirado, M.D.; Baylor College of Medicine Grand Rounds, October 6, 2005
Zide B: Deformities of the lips and cheeks. In: McCarthy JG, ed. Plastic Surgery. Vol 3. Philadelphia, Pa: WB Saunders; 1990.
Lip Reconstruction; Plastic and Reconstructive Surgery, Vol 120, No 4, pp57e-64e, September 15, 2007; Anvar, Bardia A. M.D.; Evans, Brandon C. D.; Evans, Gregory R. D. M.D.
Advancement Flaps; Desire Ratner MD and Joseph M Obadiah MD; eMedicine Article, December 4, 2006
Atlas of Head & Neck Surgery--otolaryngology By Byron J. Bailey; Google eBook
Lip Reconstruction; Sarah Weitzul MD and R Stan Taylor MD; eMedicine Article, April 11, 2006
Local Flaps in Head and Neck Reconstruction; Ian T Jackson MD; The C V Mosby Company, 1985.

Reconstruction of the Lip -- Part I

Updated 3/2017 -- photos and all links removed as many no longer active and it was easier than checking each one. 

There are many reasons that the lip may need surgical repair or reconstruction.

• Neoplastic disorders make up the majority of lip pathology encountered by surgeons. Squamous cell carcinoma (SCC) is the most common malignancy affecting the lip with 90% occurring on the lower lip. Basal cell carcinoma is the most common tumor of the upper lip.

• Trauma -- includes animal bites, automobile accidents, interpersonal violence, and electrical burns. Picture is of a dog bite to the lower lip, before and after repair.

• Congenital disorders -- include cleft lip, hemangiomas, and congenital nevi

The first mention of a labial repair was made in India back in 1000 b.c.. Most modern techniques were developed during the nineteenth century and have continually evolved since that time. Tagliacozzi originally popularized tissue transfer techniques in the late 16th century. Von Burrow first used the technique of skin triangle excisions to facilitate flap advancement in the early 19th century. In 1834, Dieffenbach described the first cheek advancement flap techniques. The late 19th century was a time of the popular contributions of Abbe, Sabattini, and Estlander whose names remain attached to flaps they described and continue to be used today. Karapandzic introduced the myoneurovascular pedicled advancement flap, and Hari and Ohmori performed the microvascular free tissue transfer for lip reconstructions in 1974.

The essential components of lip reconstruction are:

• Complete skin cover and oral lining
• Semblance of a vermillion
• Adequate stomal diameter (large enough mouth opening)
• Sensation
• A competent oral sphincter (controls drool and food loss)

Before proceeding with a lip reconstruction, there are many factors that need to be considered.

• The age of the patient -- An elderly patient, for example, has more loose soft tissue from the relaxed skin tension lines as a result of dynamic facial movements that result in a better ability for advancement, rotation and transposition of the tissues.
• Sex of the patient-- In males , there is the need to consider hair bearing skin prior to advancement or rotation of flaps. On the other hand, women have the ability to apply cosmetics for camouflage, such as lip liner and permanent tattooing.
• Previous operations that may have compromised the labial vessels may be a contraindication to the use of a pedicled labial flap.
• The hexagonal lip esthetic subunit must be consider. In general, entire subunits must be excised and reconstructed to conform to the esthetic principles of scar camouflage.

1. The cosmetic subunits of the upper lip include two lateral segments and one central or philtral unit.
2. The lower lip is a single unit. Still, it is helpful to consider whether the defect is more central or lateral.
3. Another cosmetic subunit to consider is the vermillion. Defects involving only the vermillion should be reconstructed within that cosmetic subunit whenever possible.

• Local tissue should be used whenever possible. This helps to provide both minimal donor-site morbidity and the best overall color and texture match.
• Vermillion and skin must be excised to allow tension-free closure.
• The oral sphincter is reconstructed whenever possible by transposition of the donor muscle into alignment with the sphincteric muscle.
• Categorization into partial or full-thickness defects also identifies ideal reconstructive methods. Defects that involve a full-thickness portion of the lip (i.e., skin, muscle, and mucosa) require full-thickness repair.
• Small full-thickness defects, between a fourth and a third of the lip, may be closed primarily. A major exception is a defect ablating the philtrum, which destroys a significant aesthetic anatomic feature. Such defects are best reconstructed with an Abbe flap from the lower lip midline.
• The junction between the vermilion and surrounding skin is outlined by a linear prominence, the white roll. The excision of the white lip will allow symmetry in primary closure. Excision of tissue is usually in the shape of a V; however, a pentagonal or W technique for resection can be performed. (check out the above photo of the dog bite patient)
• Surgical incisions must cross the skin-vermillion junction at 90-degree angles. This junction must be re-aligned properly during the closure as even a 1-mm discrepancy in the outline of the white roll is noticeable at a distance of 3 feet (Zide).

Partial Thickness Defects of the Vermillion

Small superficial defects limited to the vermillion may be allowed to heal by secondary intention with good results. However, larger or deeper defects or wounds near the vermillion border risk distortion if allowed to heal in this manner. Full-thickness grafts from the labial or buccal mucosa may be used, but often develop trapdoor deformity or mismatch color, texture, and thickness with the surrounding vermillion.

Defects that are less than 40% of the vermillion width may be repaired using a bilateral vermillion rotation flap. This flap utilizes adjacent vermillion to rotate centrally. The arcs of the rotation flap are drawn along the vermillion border with the redundant triangle of skin (dog ear) removed posteriorly.

Advantages include:

• Maintains the anterior-posterior dimension of the lip
• Avoids redirection of beard hairs,
• Decreased risk of persistent hypoesthesia compared to mucosal advancement flap repair.

For defects approaching 50% of the vermillion width or greater, a complete vermillionectomy and mucosal advancement flap repair may be necessary.

Advantages include:

• Useful for large defects of the vermillion subunit.
• The removal of the entire vermillion reduces the risk of subsequent malignancy from adjacent actinic cheilitis.
• The "cosmetic unit" is maintained by treating the entire vermillion unit.

Disadvantages include:

• May decrease the anterior-posterior dimension of the lip
• May give a more rounded and reddish color to the reconstructed vermillion
• Patients may have persistent hypoesthesia (decreased sensation)

Cutaneous Lip Defects

Often small cutaneous (skin only, not vermillion, not muscle)defects of the lateral cutaneous lip can be closed in a simple, linear fashion along the relaxed skin tension lines (think of the lines formed when using a straw). It is better for the closure to cross (at 90 degree angle) the vermillion border than to stop short and create a protrusion of tissue.

For larger defects,

Advancement flaps are the very useful for repair for partial-thickness defects of the lateral cutaneous lip. These flaps works well for the upper and lower lip due to the abundant reservoir of cheek and jowl tissue. Advancement flaps are created by incisions which allow for a “sliding”movement of the incised tissue. The movement is in one direction and the flap "advances" directly over the primary defect. The basic design of an advancement flap is to extend an incision along parallel sides of the defect and then directly advance the tissue over the defect. Complete undermining of the advancement flap as well as the skin and soft tissue around the flap pedicle is very important.

The classically designed advancement flap has a flap length to width ratio of around 1:2 and advances tissue a distance approximating the width of the flap. Advancement beyond this is possible, but the tension of the flap may increase dramatically, and the distal blood flow may become compromised and lead to distal flap necrosis. The following are different types of advancement flaps:

• Monopedicle is a single pedicle advancement flap is the most basic of the advancement flaps. The typical ratio of defect length to flap length is 3:1. It is made by wide undermining prior to parallel incisions preferably in skin crease lines. The flap is inset with key stitches prior to removal of standing cones.
• Bipedicle advancement flap is typically made when a single-pedicle advancement flap does not allow sufficient tissue for closure of the defect. The basic principles and technique are the same as those for the monopedicle advancement flap. A disadvantage of this flap may be the potentially long suture line.
• V-Y flap is a unique flap where a V shaped flap is moved into a defect with primary closure of the donor area leaving a final Y shaped suture line. It is pedicled from the underlying subcutaneous tissue rather than the surrounding skin.
• A-T flap represents a type of bilateral advancement flap where a triangular defect is closed by advancing tissue from either side of the defect. The advantage is that the defect can be divided in half by the use of the two flaps allowing placement of the incisions in natural creases, junctions of aesthetic units, or in the hairline. It works very well along the lip with the horizontal limb at the vermillion.
• Cheek advancement flaps are optimally used in the cheek where the increased elasticity and mobility of the skin here allows for wide undermining and closure of medium to large defects along the medial cheek. This flap is not a pure advancement, but also relies on rotation.

The basic rotation flap is a simple pivotal flap. It is curvilinear in shape and rotates around a pivotal point near the defect. It is designed immediately adjacent to the defect and only one side of the defect is the advancing edge of the flap. As with all pivotal flaps, a dog-ear will develop at the base of the flap. A Burow’s triangle can be removed to facilitate repair to the donor site wound. If done at the base of the flap, it will shift the position of the pivotal point and thus change the wound-closure tension vector as well as the location of the standing cutaneous deformity.

There are many advantages to the rotation flap. The flap has only two sides, thus it does lend itself very well to having both edges placed in borders of aesthetic units of the face or into one aesthetic border and one RSTL. The flap is broad based and therefore its vascularity tends to be reliable.

The island pedicle flap can also be useful for defects of the lower lip and the upper lip. This flap carries it's blood supply with it, but the vessels will also limit how far it can move. Care must be taken to adequately undermine and dissect this flap to assure minimal tension on the mobile vermillion border.

Transposition flaps are harvested at one site and transferred to a site immediately adjacent to the base of the flap. They differ from rotation flaps in that their final axis is linear, whereas the rotation flap has a curvilinear axis. This difference enables the final closure to have less wound tension and a scar in a more favorable axis. The most important element of design of a transposition flap is the location of the pivot point. These flaps include:

• Rhomboid or Limberg flap is based on four equal sides with corresponding 60 and 120 degree angles. After careful design there are four potential donor flaps from which to choose in order to appropriately align the final scar in an inconspicuous area and prevent surrounding tissue distortion.
• Dufourmental flap is slightly more complicated with angles varying from 60 to 90 degrees but there still exists the choice of four potential donor flaps.
• Bilobed flaps are double transposition flaps that share a single base. They move around a pivotal point and invariably develop a standing cone (dog-ear) that is dependent upon the arc of rotation. The primary flap is to repair the surgical defect and the secondary flap is used to repair the flap donor site. The secondary flap defect is then closed primarily. The primary use is in closing defects of the lower third of the nose. A disadvantage of the flap is that the resulting scar is unable to follow skin tension lines in many cases.

COMPLICATIONS
Fortunately, complications are not common with local flaps in the face which accounts for their popularity.

• Infection is uncommon but is usually heralded by pain on days 4 to 8. They are managed by antibiotics and wound care.
• Hematomas and seromas can occur and will increase the likelihood of flap necrosis.
• Flap cyanosis in the immediate postoperative period is often the result of venous congestion. If thought to be due to excessive wound tension, suspicious stitches can be removed in an attempt to optimize the outcome.
• Flap failure or necrosis is often due to poor planning or design which underscores the need for careful preparation. Cigarette smoking can increase the risk of flap loss by up to three-fold. When necrosis does occur it will usually involve the distal tip and should be managed expectantly. Unless there are signs of local infection, debridement should not be performed as the eschar will serve as a biologic dressing at worst.

REFERENCES
Lip Reconstruction; Yamilet Tirado, M.D.; Baylor College of Medicine Grand Rounds, October 6, 2005
Zide B: Deformities of the lips and cheeks. In: McCarthy JG, ed. Plastic Surgery. Vol 3. Philadelphia, Pa: WB Saunders; 1990.
Lip Reconstruction; Plastic & Reconstructive Surgery, Vol 120, No 4, pp57e-64e, September 15, 2007; Anvar, Bardia A. M.D.; Evans, Brandon C. D.; Evans, Gregory R. D. M.D.
Lip Reconstruction; Gordon R Tobin MD and Wayne Stadelmann MD; eMedicine Article, January 30, 2005
Novel Flaps for Lip Reconstruction; Advances in Derm Surg, Vol 11, No 6; Daufman A J, Rohrer T E
Advancement Flaps; Desire Ratner MD and Joseph M Obadiah MD; eMedicine Article, December 4, 2006

Lip Reduction

 Updated 3/2017 --photos and all links removed as many no longer active and it was easier than checking each one.

Not all of us may want larger, fuller lips. Many people (both men and women) believe that their lips are too big, and want them reduced. Younger patients are often plagued by insecurities brought on by having larger than average lips and the teasing their classmates may do. These younger patients should wait until their late teens to have their lip size reduced due to maturing of the facial features.

Macrocheilia or prominent lips has multiple etiologies affecting one or both lips. Those caused by disease can become a functional issue and not simply cosmetic in nature.

Congenital causes include

• Double lip deformity occurs because of the persistence of the transverse sulcus between the inner lip (pars villosa) and the outer lip (pars glabra), resulting in glandular hypertrophy along with redundant labial mucosa. The excess tissue forms an accessory lip, which is apparent during smiling. The underlying orbicularis oris muscle is not involved.

• Labial "pits" -- usually described as blind epidermal invaginations of lip mucosa with occasional drainage of minor salivary gland secretions

• Ethnic variations demonstrate diffuse thickening of all lip structures and may require resection of muscle.

Acquired causes include

• Trauma -- result in an inflammatory infiltration leading to fibrosis and subsequent lip enlargement
• Infections
• Neoplasms
• Syndromes

1. Melkersson-Rosenthal Syndome -- Miescher granulomatous macrocheilitis is a mono-symptomatic presentation of Melkersson-Rosenthal syndrome that is characterized by granulomatous swelling of the lips. The full syndrome is a condition characterized by the triad of facial paralysis, facial edema, and lingua plicata (furrowed tongue), similarly results in an infiltrative process of the lips.

1. Ascher syndrome is identical to double lip deformity with associated blepharochalasis and endocrine disorders.

• Port-wine (capillary) vascular malformations that enlarge the lips (port-wine macrocheilia) are a different category of lesions that have a different pathophysiology and may require complex reconstruction.

CLINICAL PRESENTATION/ EXAM

The patient will most often present complaining of prominent lips or facial disproportion. The protruding lip or lips often stand out as the most prominent feature of the face, attracting undesirable attention.

Functional difficulties may include labial incompetence, interfere with speech, problems with salivary control (drooling), and problems with mastication (chewing).

The lip and its relationship to other facial structures are evaluated by frontal and profile views. If there is a possibility of underlying dental or facial bone problems to explain the prominent lips, then appropriate x-rays should be done. It is important to assess the lips and the relationship to the nose and chin.

From the face-on-view, evaluate the visible vermilion (vertical height) and the transverse lip excess.

From the profile view, evaluate the upper to lower lip relationship as well as the degree of lip eversion.

Prominent lips are not always the result of lip volume but may be caused by lip ectropion or labial eversion. Furthermore, the orbicularis musculature is assessed for its tone and muscular ring for its competence.

MEDICAL TREATMENT

Medical therapy has limited usefulness in treating prominent lips. It can however help alleviate the underlying cause or associated anomalies. Steroid therapy, antibiotics, salazosulfapyridine, and radiation have shown limited success.

SURGICAL TREATMENT

The goals of lip reduction surgery are to achieve a harmonious upper to lower lip relationship that is in balance with the entire face as well as to attain normal lip competence.

The treatment of macrocheilia is should be individualized to the etiology and patient's needs. Some general principles include the following:

1. Correct underlying dento-osseous (teeth/bone)deformities.
2. Establish a balance between upper and lower lips with the individual patient in mind
3. Do not reduce lips if excessive interlabial distance exists.
4. Optimal frontal aesthetics is more important than profile aesthetics

The basic surgical procedure of lip reduction surgery is a transverse fusiform or elliptical mucosal incision between 1 and 1 cm dorsal to the vermillion border between the lateral commissures (Conway method). W- or Z-plasties may be added to prevent dog ears.

The Mouly method may be added. This method includes the excision of two sagittal triangular wedges at the lateral eminences of the philtrum. This enables the natural protrusion of the eminences and the normal central depression of the upper lip to be preserved. The undermining of the wound edges should be limited to that needed for appropriate tissue apposition. Closure of the resection defects is usually performed in two layers, and sutures are removed 7 to 10 days after surgery.

At other times, a wedge excision may be most appropriate.

Surgical methods. A and B, Conway procedure with transverse sickle-shaped mucosal excision. C and D, Conway procedure in sagittal projection, with excision of mucosal and submucosal tissue. E and F, Central wedge excision. G and H, Z-plasty after wedge resection. I and J, Mouly procedure. (from the second reference article)

Some tips from Drs Dev and Wang's article:

• When designing the incision it is imperative to place the anterior aspect of the incision posterior to the lip seal and wet line (transition from inner mouth mucosa and vermillion).
• Avoid the area of Cupid's bow as well. Cupid's bow should always be preserved during correction of a prominent upper lip since it is an important landmark of the lip.
• The marking should be made prior to the use of local anesthetics, which tend to distort the lip architecture.
• The goal should be removal of hypertrophied labial glands, fibrosis from an infiltrative process, or generalized thickened redundant tissue.
• In the upper lip, macrocheilia usually affect the lip in the vertical dimension. If the dry vermilion is not excessively large, the reduction surgery is designed as a transverse ellipse behind the wet line. However, if the entire vermilion is enlarged, then design of the excision may include the dry vermilion.

COMPLICATIONS
Unfortunately, all surgery has risks and complications.
Infection
Chance of asymmetry
Hypertrophic scarring
Numbness -- usually subsides within the first few weeks, but may be permanent
General dissatisfaction

REFERENCES
Lip Reduction by Vipul R Dev MD and Peter Wang MD--eMedicine Article, June 14, 2006
Surgical Treatment of Persistent Macrocheilia in Patients With Melkersson-Rosenthal Syndrome and Cheilitis Granulomatosa; Arch Dermatol. 2005;141:1085-1091; Birgit Kruse-Lösler, MD, DMD; Dagmar Presser, MD; Dieter Metze, MD; Ulrich Joos, MD, DMD
Macrocheilia due to hyperplasia of the labial salivary glands: operative correction. Surg Gynecol Obstet. 1938;66:1024-1031; Conway H
Correction of hypertrophy of the upper lip; Plast Reconstr Surg. 1970;46:262-264; Mouly R

This and That, Catching Up

Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

We made it to the Canstruction. Here's a photo of the Simpsons I took. If you want to see the other photos I took, you can check them out here. I really liked the Big Can Bridge, but don't think it shows as well in the photos as the Simpsons.

Also want to remind everyone about SurgeXperiences #114. It will be hosted at Anesthesioboist on February 3. The deadline for submissions is February 1. The current edition, SurgeXperiences 113 is up over at Counting Sheep. Terry calls her edition "Operating After Hours".

And last, but not least I want to give a "heads up" to an upcoming HBO documentary that is due to air January 29, 2008. It is called "Badhdad Hospital, Inside the Red Zone". As you all may know, Chris over at "Made A Difference For That One: A Surgeon's Letters Home From Iraq" has recently returned to the United States from Iraq. He has the following to say about the upcoming show:

"I only got to see life within the rarified confines of Balad airbase, and once the 86th CSH in Baghdad, so this is a perspective of Iraq I did not have. I will say that I heard some of my patients say things very similar to those portrayed in the clips.

Clip 1: Ambulance pickup at a market after a suicide http://www.youtube.com/watch?v=zUMzO8x0QxM

Clip 2: Introduction in the hospital http://www.youtube.com/watch?v=nkVMm6AgStg I think that the clips were filmed in 2007. Hopefully we see less of thes attacks as time goes by. In the first clip when I heard the line "Only the children playing outside." I could feel a sense of a parent's worry for their own children above one's own safety, yet also a feeling of guilt in knowing they were someone's children."

Snail's Trails or Virginia Reel

I bought these fabrics to plan an Amish Bars quilt which I ended up using only two of the colors. You can see it here in the post on Marking. I am hand quilting it. Then I needed to use the other and left-over fabric, so I decided to try a Snail's Trail in the four colors. Snail's Trail is also known as the Virginia Reel. It can be a challenge keeping the fabrics straight so that the turns of the "trail" stay oriented correctly. There is a nice website (Block Central -- 3/2017, link no longer active) that has several blocks put together into a coloring book. These pages can be printed off so that you can play with the colors you want or just color them, so you can keep yours straight. When only using two colors, all the blocks will be the same. When using four colors, the blocks are like this.

This is how I have put mine together. It is 48 inches X 48 inches. I want to put a border around it of the dark brown and lighter brown. Then I plan to machine quilt this one and perhaps use it as a wall hanging quilt. Or if my friend whom I am making the Amish Bars for wants both, I guess I will give him both as he is the one who wanted "mustard yellow" and "brown".