Introduction The unpredictability of hypertrophic scars HTSs

Introduction The unpredictability of hypertrophic scars (HTSs) and keloids can confuse the most experienced physicians. In 2014, the International Advisory Panel on scar management published a revision of the recommended practices promoted by the first advisory panel in 2002, resulting in new treatment algorithms. However, the numerous treatment options available, combined with contrasting data, continue to make deciding on a course of treatment difficult. Based on a review of existing data, this study attempts to rationalize treatment options after observing the clinical behavior of scars and examining the evidence associated with various modalities, traditional as well as emerging, used to treat excessive scarring.
Discussion
Conclusions
Introduction Endoscope-assisted resection of forehead masses is a well-established, widely accepted procedure. This technique is used to treat lesions including lipoma, hemangioma, dermoid cyst, epidermal cyst, neurofibroma, and osteoma. In comparison with simple direct excision of the forehead mass, forehead endoscopic surgery has advantages in safety, accessibility, visualization of the mass, avoidance of visible scar or pigmentation on the forehead, lp-pla2 inhibitor in the risk of bleeding, hematoma formation, nerve injury, and paresthesia. Osteoma is a benign osseous tumor. It is a protruding mass and easily identified in the forehead. It is fixed, nontender, and slow growing. Most of the time, it is asymptomatic and can be differentiated from lipoma, hemangioma, or other soft tissue tumors by physical examination. It is juxtacortically located and can be separated from the underlying normal frontal bone easily. The incidence of forehead osteoma is low (0.014–0.43%) and the reported average size is small. The increasing number of reports of endoscope-assisted forehead has indicated that endoscopy is important for the treatment of forehead soft tissue tumors. Because of the unique location and characteristics of forehead osteoma, experienced surgeons can diagnosis this condition preoperatively and perform superficial ostectomy from remote access with the aid of endoscopy. The supraorbital nerve is an important sensory nerve in the forehead and scalp, which is at risk in many forehead surgeries. Injury to the deep branch of the nerve will result in scalp numbness and paresthesia, which is a distressful sequela for both patients and surgeons. Theoretically, surgeons should be able to use their understanding of anatomy and function to avoid injury to the nerve. However, the deep branch of the supraorbital nerve is vulnerable in forehead endoscopic surgeries, and caution should be exercised to avoid injury to the nerve. For endoscope-assisted osteoma resection, two- or three-port approaches are routinely suggested with a mean operative time of around 15–30 minutes. However, our experience has shown that a single port is enough for the resection of an osteoma. The fewer incision sites needed may also be instrumental in minimizing the risk of injury to the supraorbital nerve. In our hospital, most forehead osteomata have been excised through single remote scalp incision since 2003, and we here describe our experiences.
Materials and methods Forehead osteoma was diagnosed from history and physical examination. Sonography was performed in uncertain cases to rule out soft tissue tumors. None of the lesions was larger than 3 cm in diameter. The presurgery medications prescribed included midazolam (Dormicum; Roche, Basel, Switzerland) 7.5 mg and tramadol (Grünenthal, Aachen, Germany) 50 mg administered via the oral route 60 minutes before surgery, and regional block of the supraorbital nerve was routinely used. After adequate sensory block, the planned vertical incision line of about 2–3 cm in length was drawn above the hairline and infiltrated with 2% xylocaine with 1:200,000 epinephrine. The dissection area from the incision point to 1 cm distal to the osteoma with a width of around 2–3 cm was infiltrated with tumescent solution (0.1 mL epinephrine 1 mg/mL, 4 mL 2% xylocaine, and 2 mL 7% sodium bicarbonate added to 100 mL Ringer\'s lactate solution) subperiosteally (Figure 1). After gentle massage of the infiltrated area for a few minutes, a vertical scalp incision about 2–3 cm in length was made directly to the level of the bone. Subperiosteal dissection straight towards the osteoma with periosteal elevation can be performed under the guidance of the fingers of the opposite hand. Total elevation and separation of the tumor from the surrounding soft tissue was easy in all cases, and this is the key to successful surgery. Endoscopic inspection was carried out after isolation of the tumor to confirm the diagnosis of osteoma and ensure adequate release of the tumor from other soft tissues. After the withdrawal of the endoscope, a curved osteotome of a suitable size was engaged at the junction of the tumor and frontal bone. The osteoma was levered gently with the osteotome until experiencing a sudden give feeling, indicating that the tumor had disconnected from the bony forehead. The wound was irrigated with normal saline and then the removed osteoma was squeezed toward the scalp incision manually. After the osteoma was removed, the endoscope was again inserted through the incision to ensure the result. The scalp incision was closed with 4-0 Nylon interrupted sutures. Patients were instructed to use cold packs over the forehead for a couple of days, and acetaminophen 500 mg four times/d was prescribed. Stitches were removed 1 week after surgery.