Botox Injection
Charles R. Woodard, MD¹; Alexandra L. Elder, BS²; Helen A. Moses, MD¹; C. Scott Brown, MD¹ ¹Duke University Medical Center ²Thomas Jefferson University
Botox injection is one of the most common cosmetic procedures performed. Botox temporarily paralyzes targeted skeletal muscles of the face, reducing the patient’s ability to produce unwanted dynamic wrinkles. Commonly treated areas of the face include the procerus and corrugator supercilii muscles to treat glabellar frown lines, the frontalis muscle to treat horizontal rhytids of the forehead, and the orbicularis oculi muscle to treat “crow’s feet” wrinkles along the lateral aspect of the orbit.
A thorough facial analysis is necessary to develop a treatment plan for each problem area, particularly by engaging the patient to determine what his or her goals for treatment are. Providers must take care when injecting into the face to avoid complications of overtreatment, such as brow ptosis from over-injecting the forehead or elevated brow from over-injecting the periorbital muscles.
Local Tissue Rearrangement for Hypertrophic Chemical Burn: Z-Plasty and VY-Plasty
Daniel N. Driscoll, MD, FACS¹; Lisa Gfrerer, MD, PhD²; Robert Dabek, MD³; Aleia M. Boccardi* ¹Shriners Hospitals for Children – Boston
²Harvard Plastic Surgery Combined Residency Program
³Massachusetts General Hospital
*Touro University College of Osteopathic Medicine
Hypertrophic scarring following burn injuries has been shown to occur in up to 70% of patients, potentially causing both long-term psychological and physical morbidity. Increased rates of depression and anxiety are seen to arise from aesthetic dissatisfaction, affecting patient rehabilitation and subsequent societal interaction. Mobility is jeopardized from contractures that develop within the damaged tissue, leading to decreased range of motion and function of the area. Both sequelae leave the patient with an overall decreased quality of life.
Surgical techniques involving local tissue rearrangement, including Z-plasty and VY-plasty can be employed to improve both the function and cosmetic effects of burn scars. Essentially, these techniques illicit a decrease in tension through a lengthening of contracted tissue of up to 50–70%, allowing for better static alignment and increased mobility over joint surfaces. This video depicts the combination of both tissue rearrangement techniques as applied to hypertrophic scar contractures resulting from prior burn injuries. These techniques are an invaluable part of a reconstructive surgeons’ armamentarium when approaching scar revision.
The goal of ankle fracture management is to restore a stable and congruent joint. Operative management is recommended for most displaced fractures, fractures with dislocations, and open fractures.
This video article walks through the surgical management of a 23-year-old male who sustained a trimalleolar ankle fracture with concomitant dislocation and syndesmotic injury following a motor vehicle collision. Dr. Weaver discusses the surgical landmarks and approaches to the ankle, the methods of fixing the malleoli and the syndesmosis, and common concerns that arise during the surgical management of ankle fractures.
Resection of cutaneous malignancies may result in substantial skin defects. Often, skin grafting is a first-line option for reconstruction of such defects but may be limited by poor cosmetic outcomes and incomplete graft acceptance. Accordingly, skin flaps, tissue rearrangement techniques, and more complex procedures may be needed. This case report presents the successful use of a combination of nasolabial flap and rhomboid flap for reconstruction of a 3-cm × 2-cm left nasal sidewall and ala skin defect that remained following a basal cell cancer Mohs resection. The flaps were quickly and easily fashioned, did not require any special instruments, and resulted in a good cosmetic outcome. There were no wound complications and the flaps healed completely with excellent contour, texture, thickness, color match, and complete patient satisfaction. This case is an example of the technical aspects of successful planning, elevation, and inset of a nasolabial flap and rhomboid flap.
Pilonidal disease is a chronic skin and subcutaneous infection emanating from the center of the natal cleft, often extending to the buttocks. Treatment depends on the disease pattern. An acute abscess is treated with drainage and antibiotics, while a complex or recurring infection is treated surgically with either excision of a cyst or unroofing of a sinus tract. Reconstructive flap techniques such as the Bascom cleft lift procedure, Karydakis flap, rhomboid, or Z-plasty can be done to reduce the risk of recurrence by leaving less scar tissue and flattening the region between the buttocks. Here, Dr. Reinhorn at Tufts University School of Medicine presents the case of a male patient who had previously had flap surgery for pilonidal disease, but experienced recurrence and the development of a sinus tract. Due to the extensive nature of the disease, a deep flap was required to mobilize tissues and close the eventual wound. A deep flap like this is often only required in re-do surgery, rather than for primary disease, for which only a 1-cm subcutaneous flap is required.
Hereditary Diffuse Gastric Cancer (HDGC) syndrome is due to a mutation in the CDH1 gene that predisposes patients to a high lifetime risk of developing gastric cancer. As such, a total gastrectomy is typically recommended for patients with this syndrome. In this case, the patient presented with an incidentally discovered CDH1 mutation on genetic testing obtained after she was diagnosed with early-onset rectal cancer. In this video, Dr. Mullen at MGH demonstrates his technique for performing an open prophylactic total gastrectomy with a Roux-en-Y esophagojejunostomy reconstruction.
Posterior retroperitoneoscopic adrenalectomy (PRA) allows the surgeon to approach the adrenal gland through the back rather than the more traditional laparoscopic transabdominal adrenalectomy (LTA) approach. This technique was popularized in Germany but is being used increasingly throughout the United States. Smilow Cancer Hospital at Yale New Haven was one of the early adopters of this technique in the US, and Dr. Tobias Carling presents the operation here.
Eustachian tube dysfunction can often cause otitis media, tympanic membrane perforation, or conductive hearing loss. In this video article, myringoplasty was performed using a CO2 laser that provided reorganization of collagen fibers and improved compliance of the tympanic membrane. Given the ongoing eustachian tube dysfunction, a pressure equalization tube was placed to prevent recurrent retraction and atelectasis of the eardrum.
In this video article, Dr. Todd Francone at Newton-Wellesley Hospital demonstrates and narrates a robotic low anterior resection for locally advanced rectal cancer after neoadjuvant FOLFOX-based chemoradiation treatment. Low anterior resection is recommended for rectal tumors in which a 1-cm distal margin is achievable without sphincter encroachment. A key component of this operation is a complete mesorectal dissection, which is highlighted with the robotic technique. In this case, the patient had a 2.6-cm tumor located 6 cm above the anal verge, which was treated with 8 cycles of FOLFOX followed by consolidative radiation therapy. A robotic low anterior resection was performed, and the final pathology revealed a complete pathologic response.
In this case, Dr. Carlos Fernandez-del Castillo at MGH performs and narrates an open distal pancreatectomy with splenectomy in a patient who has undergone neoadjuvant treatment for pancreatic adenocarcinoma. This is a unique case of a patient undergoing surgical resection after initial diagnosis of metastatic disease. The patient is a 69-year-old woman who initially presented with abdominal pain and bloating, and was found to have a 2-cm suspicious tumor in the body of her pancreas and biopsy-proven single liver metastasis. She was treated with an extended course of neoadjuvant chemotherapy, and re-staging scans showed significant response. Chemoradiation was completed, and the liver metastasis was no longer visible on imaging. 27 months after diagnosis she was taken to the operating room for distal pancreatectomy and splenectomy; no liver or peritoneal metastases were seen. Her postoperative course was overall uneventful, and she recovered well. Final surgical pathology demonstrated complete pathological response with no evidence of disease seen and 0/11 lymph nodes positive for malignancy.
