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Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Clefts of the lip and palate are the most common significant congenital birth anomaly of the orofacial region. The condition may vary from a minor easily correctable cleft to a significant functional and cosmetic incapacitation. This is the first epidemiological study of orofacial clefts in the Negev region in Israel.To establish the frequency of cleft lip and palate in the population of the Negev, characterize the demographic features of affected individuals and find possible risk factors, compare the risk in two major population groups: Bedouin and Jewish in a well-defined geographic area, and determine whether there is a change overtime in the birth of babies with facial clefts.We conducted a retrospective survey of the Soroka Medical Center archives. The sample population comprised all 131,218 babies born at Soroka during the 11 year period 1 January 1996 to 31 December 2006. Statistical tests used Pearson's chi-square test, Student's t-test and Spearman's correlation coefficient test according to the type of parameter tested.During the study period 140 babies were born with orofacial cleft. The overall incidence of cleft lip and palate was 1.067/1000. The incidence of facial clefts was 1.54/1000 among Bedouins and 0.48/1000 among Jews (P0.001). Cleft palate was significantly more frequent in female than male babies (P = 0.002). Over the study years we found a significant decrease in the incidence of facial clefts in the Bedouin population, with Spearman's correlation coefficient rank -0.9 (P0.01).A significant decrease occurred in the incidence of facial clefts among Bedouin. This change may be attributed to prenatal care in the Bedouin Negev population as part of social and health-related behavior changes. The reduction in rates of congenital malformations, however, does not mean a reduction in the number of cases in a growing population. Also, with a modern western lifestyle, the expectancy and demand for reconstructive facial surgery and comprehensive care for these children are on the rise.

Cording, an unusual form of superficial thrombophlebitis, is a variant of the disease first described by Fage in 1870 and subsequently characterized by Henry Mondor in 1939 as sclerosing thrombophlebitis of the subcutaneous veins of the anterior chest wall. Similar lesions have also been found in the penis, groin, abdomen, arm, and axilla and have been reported under a variety of names. In the axilla the condition is termed axillary web syndrome (AWS) and is seen after axillary lymph node dissection and sentinel lymph node biopsy. A recent report suggests that pathophysiology of AWS is lymphatic in origin rather than venous. We report a unique case of unilateral AWS after excision of an axillary accessory breast and discuss the pathophysiology.

Most physicians diagnose skin malignancy using theoretical criteria and clinical experience. Apart from dermatoscopy, noninvasive means for skin tumors' diagnosis are highly expensive and are not in daily use. We developed a simple, handy and relatively inexpensive tool for non-invasive diagnosis of skin tumors. The Differential Optical Spectropolarimetric Imaging system (DOSI) is based on collecting information from the surface and depth of skin tumors, using the advantage of liquid crystal devices (LCDs].DOSI feasibility study in order to diagnose skin tumors non-invasively.Skin tumor optical data was collected in order to create image indicators for specific skin tumors. Spectral images of skin tumors are captured before the lesion that was scheduled for removal was surgically excised. Repeating features of images of each tumor type (which was histologically diagnosed) that characterize the specific tumor and show distinction from the features of other tumors are recorded.The feasibility of DOSI has been demonstrated for research, but it is not yet mature for clinical use. Specific images, indicating specific skin tumors could not yet be reliably concluded. One relatively obvious characteristic for malignancy seems to be crescent-like and finger-like growth patterns. In the non-malignant lesions: crescent and finger-like structures are of less pronounced orders of magnitude. Crescents are more open and radius of curvature are of larger orders of magnitude than in malignant specimen.The advantage of using LCD is the ability to manipulate light electronically, without any movable components. LCDs are the building blocks of optical filters and polarization controllers. Using optical filters and polarization controllers, we are able to electronically manipulate the polarization and wavelength of our light source without any movable components. The light source emits different wavelengths (colors) that penetrate the tissue at different depths. The camera (CCD) captures the diffused reflected light from a skin lesion as a sequence of images for each polarization stage. By applying our novel method for each polarization stage we are able to overcome the noise of the diffused reflection and emphasize the scattering areas. Emphasizing the scattering areas provided images that may indicate malignancy.The feasibility of DOSI has been demonstrated. In order to obtain reliable diagnostic image indicators for specific skin tumors, more clinical tests are necessary.

Background Debridement of the burn eschar is a cornerstone of burn wound care. Rapid enzymatic debridement with a bromelain-based agent (Debriding Gel Dressing-DGD) has recently been investigated. The current study was designed to further investigate the selectivity of DGD to burned eschar in a larger number and more varied types of wounds. Methods A systematic animal experiment was conducted to determine the effects of DGD on normal, non-injured skin, burns, exposed dermis of donor sites, and skin punch biopsy wells. Partial thickness dermal burns and partial thickness skin graft donor sites were created on a pig and treated with a 4-h application of DGD or its control hydrating vehicle that does not have any activity except hydration. Punch biopsy samples were taken before and after treatment and microscopically assessed for evidence of tissue viability and its respective components thickness. Results Rapid dissolution of the burn eschar was noted in all DGD but not vehicle treated burns. There was no apparent damage to the underlying sub eschar dermis, donor sites, normal skin or punch biopsy wells after exposure to DGD. While the thickness of the treated tissues slightly increased due to edema, the increase in dermal thickness was similar after treatment with DGD or its vehicle. The increase in the cross section surface area of the treated punch biopsy wells was similar after treatment with DGD and its control vehicle. Conclusions Exposure of the burn eschar to DGD results in its rapid dissolution. Exposure of normal skin or non-burned dermis to DGD has no effects demonstrating its selectivity to eschar.

Background The burned hand is a common and difficult to care-for entity in the field of burns. Due to the anatomy of the hand (important and delicate structures crowded in a small limited space without sub-dermal soft tissue), surgical debridement of the burned tissue is technically difficult and may cause considerable complications and, therefore, should be performed judiciously. Selective enzymatic debridement of the burn wound can preserve the spontaneous epithelialisation potential and reduce the added injury to the traumatised tissue added by a surgical debridement. Objective The aim of the study was to assess the implication of a selective enzymatic compound (Debrase ® – Ds) in the special field of deep hand burns, by comparing the actual burn area that required surgical coverage after enzymatic debridement to the burn area clinically judged to require skin grafting prior to debridement. Materials and methods This was a retrospective data collection and analysis from 154 complete files of prospective, open-label study in 275 hospitalised, Ds-treated burn patients. Results A total of 69 hand burns diagnosed as ‘deep’ was analysed; 36% of the wounds required surgical intervention after enzymatic debridement; 28.6% of the total burned area estimated initially as deep was covered by skin graft (statistically significant p Conclusion Debridement of deep-hand burns with a selective enzymatic agent decreased the perceived full-thickness wound area and skin-graft use.

Skin basal and squamous cell carcinomas together account for over half of all newly diagnosed cancer cases. Frozen section control of surgical margins is often required in the head and neck region. A paraffin permanent section does not always confirm the results of a frozen section.To test the diagnostic accuracy of frozen section histopathological analysis in determining the free margins of excised tumors.This was a retrospective study of 169 cutaneous basal and squamous cell carcinomas excised with surgical margins diagnosed by frozen section and confirmed by permanent paraffin sections. The data included patients' age, gender, clinical and histopathological diagnosis, as well as characteristics of the lesions.There were 149 (88%) basal cell carcinomas and 20 (12%) squamous cell carcinomas. False negative margins were found in 19 cases (11.2%) and false positive margins in 11 (6.6%). We did not find any correlation between false positive or false negative margins and patients' age, gender, tumor size, tumor location, or the presence of sun-damaged skin. A significantly lower rate of false negative results was found in the residual tumor group.Our findings support the use of frozen section margin control in selected patients suffering from non-melanoma skin cancer of the head and neck.

The aim of this study was to identify risk factors for incomplete excision of squamous cell carcinomas (SCCs).A cross-sectional study of 369 patients who underwent a primary excision of SCCs was performed within an outpatient and a hospital plastic surgery department setting.Incomplete excision occurred in 25 of 369 primary excisions of SCC (6.8%). Location of the tumors on the forehead, temples, peri-auricular region, ears, cheeks, nose, lips or neck was significantly associated with incomplete excision of the tumors. In particular, high incomplete excision proportions were observed for tumors located on the ears (16.7%), neck (16.7%), temples (11.1%), nose (10.8%) or lips (7.1%). Incomplete excision of SCC was associated with the setting of the operation in the hospital as compared to ambulatory settings (p = 0.046) and was inversely associated with the specimen thickness (p = 0.002). There was no statistically significant association between incomplete excision of SCC and gender, age, clinical appearance of the lesion (suspected SCC vs other diagnoses), differentiation pattern, diameter of the tumor, length or width of the excised specimen, solar changes or ulceration.We recommend that in patients with SCCs located in the forehead, temples, periauricular region, ears, cheeks, nose, lips or neck surgeons should commence particular surgical measures to avoid inadequate excisions of the tumors. In particular, surgeons should use wider excisional margins in tumors located in the embryonic fusion planes (e.g. eyelids and naso-labial folds).

A prospective, non-comparative study design was used to describe our experience with a bromelain-derived debriding agent, Debridase, in 130 patients with 332 deep second degree and third degree burns treated between 1984 and 1999. Debridase was applied after saturating the burns with a moist dressing for 2-24h. Debridase was applied for a period of 4h under an occlusive dressing. Mean patient age was 18.6 +/- 19.3, 42 (32.3%) were female, and 63 (48.5%) were children under age 18. Most burns were small. Debridase was applied once in 241 (72.6%) of the 332 wounds, twice in 67 (20.18%) cases, three times in 12 (3.61%) cases, and four times in 2 (0.6%) cases. The percentage debridement by number of applications was 89 +/- 21% for a single application, 77 +/- 27% for two, and 62 +/- 27% for three Debridase applications, respectively. There were no significant adverse events. The availability of a fast acting, reliable and complication-free enzymatic debriding agent may open new horizons and provide a new treatment modality for burns.

Incomplete excision of basal cell carcinomas (BCCs) may be followed by recurrence of the tumor. In order to detect risk factors for incomplete excision of BCCs we performed a cross-sectional study of 1278 patients who underwent a primary excision of BCCs, during a four-year period, within an ambulatory and hospital plastic surgery department setting. Incomplete excision occurred in 159 of 1478 primary excisions of BCCs (10.8%) and was significantly associated with location of the tumors in the eyelids (OR 3.64, 95% CI 1.96-6.71), ears (OR 2.51, 95% CI 1.25-4.94), naso-labial folds (OR 2.26, 95% CI 0.99-5.04) and nose (OR 1.88, 95% CI 1.30-2.71). There was an inverse association with location of the tumors in the upper limbs (OR 0.44, 95% CI 0.21-0.90), back (OR 0.12, 95% CI 0.02-0.48) or chest (OR 0.09, 95% CI 0.00-0.57). Baso-squamous differentiation was associated with incomplete excision of BCCs (p = 0.03). No association was observed between incomplete excision of BCCs and gender, age, setting of the operation (ambulatory vs. hospital), clinical appearance of the lesion (suspected BCCs vs. other diagnoses) or diameter of the lesions. In conclusion, incomplete excision of BCCs was associated with location of the tumors in the eyelids, ears, naso-labial folds and nose. We recommend that in patients with BCCs located in these sites, surgeons should commence particular surgical measures to avoid inadequate excisions of the tumors.

Aim: Skin grafting is a common clinical practice for plastic surgeons, yet primary contraction of these grafts is a neglected topic. This study was designed to investigate primary contraction and introduce the shape of skin graft as a possible factor that modifies primary contraction behavior, using porcine models. Methods: In the first series, full-thickness skin grafts (FTSGs) and split-thickness skin grafts (STSGs) were compared. In a second series, how the shape of the skin graft affected the degree of contraction was examined. Results: The mean percentage of FTSG shrinkage was 12.04%, and the median was 12.18%. The mean percentage of STSG shrinkage was 6.87%, and the median was 5%. Circle-shaped and square-shaped FTSGs showed mean/median graft shrinkage of 5.83%/6.93% and 4.15%/3.75%, respectively. In STSGs, the circle-shaped and square-shaped grafts had mean/median graft shrinkage of 1.07%/0% and 0.31%/0%, respectively. Conclusion: Our preliminary report revealed an expected greater shrinkage of FTSGs compared with STSGs. Furthermore, in a limited number of specimens, the shape of the skin graft seemed to affect the primary contraction of the STSGs.

Mini vacuum drains can be helpful in reconstructive surgery. The drains may be assembled using a scalp needle and a vacuum tube. The addition of the adapter that is used with the vacuum tubes for blood sampling improves the ease of use and practicality of these drains and increases their safety.