Aesthetic Dermatology

SCOTTSDALE, ARIZ. — Negative pressure wound therapy need not be restricted to adults, Dr. Bindi Naik-Mathuria said at the annual meeting of the Wound Healing Society.

"The results of our large retrospective review suggest that negative pressure wound therapy is effective in children of all ages and for a wide variety of wounds, and the therapy can be safely used in this population, with appropriate precautions," said Dr. Naik-Mathuria of the division of pediatric surgery, Baylor College of Medicine and Texas Children's Hospital, both in Houston.

In adults, negative pressure wound therapy (NPWT) removes excess wound fluid and exudate, increases wound vascularity, and promotes granulation tissue. Data on its use in children are limited.

This study, which prompted some debate during the presentation's question and answer period, evaluated a single institution's experience with a vacuum-assisted closure (VAC) system to manage a variety of wounds in children ranging in age from 7 days to 18 years.

Between 2003 and 2005, Dr. Naik-Mathuria and her colleagues identified 71 patients with 87 wounds. The gender ratio was evenly divided, and the average age was just short of 9 years. There were seven neonates in the VAC therapy group. "These numbers make this study one of the largest reported in pediatric patients to date and certainly the largest in infants and very young children," she said.

NPWT was used for various wound types, including pressure ulcers, dehisced surgical wounds, open sternal wounds, extremity wounds, wounds with fistula, and abdominal wall defects in neonates (gastroschisis, omphalocele, and abdominal compartment syndrome). "What's especially interesting about these cases is how negative pressure was used in creative ways to heal complex wounds [for] neonates and infants, and how it worked so well that additional surgery was, in many cases, avoided," said Dr. Naik-Mathuria, who cited examples:

▸ A 1-year-old with a large thickness wound following liver transplantation was too ill to undergo reoperation to close, requiring the application of a VAC dressing. The wound contracted significantly; granulation tissue filled the wound rapidly.

▸ A 1-year-old with necrotizing fasciitis was left with exposed vital structures of the lower leg after wide debridement. Instead of applying a complicated free flap, the surgeon used a local rotational muscle flap to cover the ankle joint and applied a VAC dressing. "Only 17 days later, granulation tissue filled the wound bed and provided a nice bed for skin grafting," she said.

"A total of 56 wounds were analyzed by type. The average decrease in wound volume was 80%, and 95% of wounds benefited from negative pressure therapy," she said, adding that for five wounds, follow-up data were not collected because the patients were transferred.

The four wounds that did not decrease in volume involved an immunocompromised patient, a chronically contaminated ischial wound, and two patients with persistent underlying infections. "This prompted us to examine how infection played a role in healing the other wounds, and we noted that while 26 wounds had documented infections that were being treated at wrap placement, 88% decreased in size without the progression of infection," she said.

On average, therapy duration was 25 days. Outpatient use of NPWT was documented in 19% and the therapy was generally well tolerated. "In fact, there was no discontinuation of use because of lack of tolerance or patient request, though it was discontinued in one neonate who developed a coagulopathy, causing concern about bleeding with continued treatment," Dr. Naik-Mathuria explained.

Minor complications included skin rash, maceration, and pain or minor bleeding with dressing changes.

Since "there are no guidelines for appropriate negative pressure therapy use in children, we tended to use lower pressures—down to 50 mm Hg—in younger children and in wounds with exposed organs. The normal pressure used in adults—125 mm Hg—is what we used in children aged 4 and older," said Dr. Naik-Mathuria, adding that, higher pressures can be used on denser tissues in the groin and extremities, while lower pressures should be used over the sternum and abdomen.

SCOTTSDALE, ARIZ. — Negative pressure wound therapy need not be restricted to adults, Dr. Bindi Naik-Mathuria said at the annual meeting of the Wound Healing Society.

"The results of our large retrospective review suggest that negative pressure wound therapy is effective in children of all ages and for a wide variety of wounds, and the therapy can be safely used in this population, with appropriate precautions," said Dr. Naik-Mathuria of the division of pediatric surgery, Baylor College of Medicine and Texas Children's Hospital, both in Houston.

In adults, negative pressure wound therapy (NPWT) removes excess wound fluid and exudate, increases wound vascularity, and promotes granulation tissue. Data on its use in children are limited.

This study, which prompted some debate during the presentation's question and answer period, evaluated a single institution's experience with a vacuum-assisted closure (VAC) system to manage a variety of wounds in children ranging in age from 7 days to 18 years.

Between 2003 and 2005, Dr. Naik-Mathuria and her colleagues identified 71 patients with 87 wounds. The gender ratio was evenly divided, and the average age was just short of 9 years. There were seven neonates in the VAC therapy group. "These numbers make this study one of the largest reported in pediatric patients to date and certainly the largest in infants and very young children," she said.

NPWT was used for various wound types, including pressure ulcers, dehisced surgical wounds, open sternal wounds, extremity wounds, wounds with fistula, and abdominal wall defects in neonates (gastroschisis, omphalocele, and abdominal compartment syndrome). "What's especially interesting about these cases is how negative pressure was used in creative ways to heal complex wounds [for] neonates and infants, and how it worked so well that additional surgery was, in many cases, avoided," said Dr. Naik-Mathuria, who cited examples:

▸ A 1-year-old with a large thickness wound following liver transplantation was too ill to undergo reoperation to close, requiring the application of a VAC dressing. The wound contracted significantly; granulation tissue filled the wound rapidly.

▸ A 1-year-old with necrotizing fasciitis was left with exposed vital structures of the lower leg after wide debridement. Instead of applying a complicated free flap, the surgeon used a local rotational muscle flap to cover the ankle joint and applied a VAC dressing. "Only 17 days later, granulation tissue filled the wound bed and provided a nice bed for skin grafting," she said.

"A total of 56 wounds were analyzed by type. The average decrease in wound volume was 80%, and 95% of wounds benefited from negative pressure therapy," she said, adding that for five wounds, follow-up data were not collected because the patients were transferred.

The four wounds that did not decrease in volume involved an immunocompromised patient, a chronically contaminated ischial wound, and two patients with persistent underlying infections. "This prompted us to examine how infection played a role in healing the other wounds, and we noted that while 26 wounds had documented infections that were being treated at wrap placement, 88% decreased in size without the progression of infection," she said.

On average, therapy duration was 25 days. Outpatient use of NPWT was documented in 19% and the therapy was generally well tolerated. "In fact, there was no discontinuation of use because of lack of tolerance or patient request, though it was discontinued in one neonate who developed a coagulopathy, causing concern about bleeding with continued treatment," Dr. Naik-Mathuria explained.

Minor complications included skin rash, maceration, and pain or minor bleeding with dressing changes.

Since "there are no guidelines for appropriate negative pressure therapy use in children, we tended to use lower pressures—down to 50 mm Hg—in younger children and in wounds with exposed organs. The normal pressure used in adults—125 mm Hg—is what we used in children aged 4 and older," said Dr. Naik-Mathuria, adding that, higher pressures can be used on denser tissues in the groin and extremities, while lower pressures should be used over the sternum and abdomen.

SCOTTSDALE, ARIZ. — Negative pressure wound therapy need not be restricted to adults, Dr. Bindi Naik-Mathuria said at the annual meeting of the Wound Healing Society.

"The results of our large retrospective review suggest that negative pressure wound therapy is effective in children of all ages and for a wide variety of wounds, and the therapy can be safely used in this population, with appropriate precautions," said Dr. Naik-Mathuria of the division of pediatric surgery, Baylor College of Medicine and Texas Children's Hospital, both in Houston.

In adults, negative pressure wound therapy (NPWT) removes excess wound fluid and exudate, increases wound vascularity, and promotes granulation tissue. Data on its use in children are limited.

This study, which prompted some debate during the presentation's question and answer period, evaluated a single institution's experience with a vacuum-assisted closure (VAC) system to manage a variety of wounds in children ranging in age from 7 days to 18 years.

Between 2003 and 2005, Dr. Naik-Mathuria and her colleagues identified 71 patients with 87 wounds. The gender ratio was evenly divided, and the average age was just short of 9 years. There were seven neonates in the VAC therapy group. "These numbers make this study one of the largest reported in pediatric patients to date and certainly the largest in infants and very young children," she said.

NPWT was used for various wound types, including pressure ulcers, dehisced surgical wounds, open sternal wounds, extremity wounds, wounds with fistula, and abdominal wall defects in neonates (gastroschisis, omphalocele, and abdominal compartment syndrome). "What's especially interesting about these cases is how negative pressure was used in creative ways to heal complex wounds [for] neonates and infants, and how it worked so well that additional surgery was, in many cases, avoided," said Dr. Naik-Mathuria, who cited examples:

▸ A 1-year-old with a large thickness wound following liver transplantation was too ill to undergo reoperation to close, requiring the application of a VAC dressing. The wound contracted significantly; granulation tissue filled the wound rapidly.

▸ A 1-year-old with necrotizing fasciitis was left with exposed vital structures of the lower leg after wide debridement. Instead of applying a complicated free flap, the surgeon used a local rotational muscle flap to cover the ankle joint and applied a VAC dressing. "Only 17 days later, granulation tissue filled the wound bed and provided a nice bed for skin grafting," she said.

"A total of 56 wounds were analyzed by type. The average decrease in wound volume was 80%, and 95% of wounds benefited from negative pressure therapy," she said, adding that for five wounds, follow-up data were not collected because the patients were transferred.

The four wounds that did not decrease in volume involved an immunocompromised patient, a chronically contaminated ischial wound, and two patients with persistent underlying infections. "This prompted us to examine how infection played a role in healing the other wounds, and we noted that while 26 wounds had documented infections that were being treated at wrap placement, 88% decreased in size without the progression of infection," she said.

On average, therapy duration was 25 days. Outpatient use of NPWT was documented in 19% and the therapy was generally well tolerated. "In fact, there was no discontinuation of use because of lack of tolerance or patient request, though it was discontinued in one neonate who developed a coagulopathy, causing concern about bleeding with continued treatment," Dr. Naik-Mathuria explained.

Minor complications included skin rash, maceration, and pain or minor bleeding with dressing changes.

Since "there are no guidelines for appropriate negative pressure therapy use in children, we tended to use lower pressures—down to 50 mm Hg—in younger children and in wounds with exposed organs. The normal pressure used in adults—125 mm Hg—is what we used in children aged 4 and older," said Dr. Naik-Mathuria, adding that, higher pressures can be used on denser tissues in the groin and extremities, while lower pressures should be used over the sternum and abdomen.

LAS VEGAS — There's no one right way to do facial soft tissue augmentation, so success depends on both scientific and artful practice, a panel of experts agreed at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

The members shared tips and compared their preferences for soft tissue augmentation, beginning with the various fillers they use in their practices.

Dr. Kimberly J. Butterwick does a lot of fat transfers. Most of her patients understand the need to come back for maintenance, so she hasn't used the permanent fillers. "When they come back every 4–6 months for Botox you can put in your Restylane or your filler. They may also want a light peel at the same time. So I use a lot of the Restylane and Hylaform products because patients like to get all their maintenance at one visit, and do that two or three times a year," said Dr. Butterwick, who practices in San Diego.

"I think patients are looking for bulk implants, not fillers, but the problem with permanent fillers in this country is that we don't have enough experience looking at the adverse events—hypersensitivity, granulomas, and long-term effects. It's not something that I recommend for my patients," said Dr. Neil S. Sadick of Cornell University in New York.

Most patients in his practice are moving on to three-dimensional volumetric filling, with Sculptra probably accounting for the largest increase in share. "Even Radiesse is gaining increasing usage. Patients are looking for something that will last 1–2 years, which I think is the optimal duration for a given filler," he said.

Dr. Suzan Obagi also avoids permanent fillers. "Patients might say they want something permanent, but I explain to them that, from a safety standpoint, something we can adapt over time" may be better, said Dr. Obagi of the University of Pittsburgh.

For patients who do want something permanent, she does fat transfers. "About 80% of my transfers use fat, and 20% use the other fillers," she said.

When it comes to harvesting fat, she goes to areas where the fat is not likely to fluctuate. "If the patient loses or gains 10 pounds, fat from there is less likely to hypertrophy. For some patients it's abdominal fat; for some patients it's the hips," she said.

After reviewing the literature, Dr. Butterwick says she believes that there is no evidence that fat from one area survives better than from any other, so she also harvests from areas that are least resistant to dietary changes. "I do like the outer thigh; it comes out quickly and is avascular," she said.

In a radioisotope study, "we found no difference in terms of fat aging and longevity from different anatomic sites," Dr. Sadick remarked. People who were thinner had greater fat longevity. For thin patients, he usually harvests from the abdomen and hips.

With thin patients, "there's very little margin for error to avoid indentation," Dr. Obagi pointed out. "I do augmentation in a lot of yoga instructors and marathon runners. Usually you have to go to the buttock, and you have to be very good at your technique." For these patients, she uses a standard cannula because it has more of a blunted tip.

Dr. Butterwick said that "sometimes you have to hunt around and harvest from the arms or from multiple areas. It takes longer, so you might just choose to use Sculptra in that patient."

When the discussion turned to fat contouring in the midface and periorbital area, she suggested that the facial autografting muscle injection system's anatomic approach gives a result similar to the Coleman technique and that "the fat may survive longer because of the proximity to the muscle."

Dr. Obagi uses a modified Coleman technique, as does Dr. Sadick. He said that "the key to success and greater longevity is in layering the fat or filler in different anatomic areas."

With thin patients, such as marathoners, 'there's very little margin for error to avoid indentation.' DR. OBAGI

LAS VEGAS — There's no one right way to do facial soft tissue augmentation, so success depends on both scientific and artful practice, a panel of experts agreed at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

The members shared tips and compared their preferences for soft tissue augmentation, beginning with the various fillers they use in their practices.

Dr. Kimberly J. Butterwick does a lot of fat transfers. Most of her patients understand the need to come back for maintenance, so she hasn't used the permanent fillers. "When they come back every 4–6 months for Botox you can put in your Restylane or your filler. They may also want a light peel at the same time. So I use a lot of the Restylane and Hylaform products because patients like to get all their maintenance at one visit, and do that two or three times a year," said Dr. Butterwick, who practices in San Diego.

"I think patients are looking for bulk implants, not fillers, but the problem with permanent fillers in this country is that we don't have enough experience looking at the adverse events—hypersensitivity, granulomas, and long-term effects. It's not something that I recommend for my patients," said Dr. Neil S. Sadick of Cornell University in New York.

Most patients in his practice are moving on to three-dimensional volumetric filling, with Sculptra probably accounting for the largest increase in share. "Even Radiesse is gaining increasing usage. Patients are looking for something that will last 1–2 years, which I think is the optimal duration for a given filler," he said.

Dr. Suzan Obagi also avoids permanent fillers. "Patients might say they want something permanent, but I explain to them that, from a safety standpoint, something we can adapt over time" may be better, said Dr. Obagi of the University of Pittsburgh.

For patients who do want something permanent, she does fat transfers. "About 80% of my transfers use fat, and 20% use the other fillers," she said.

When it comes to harvesting fat, she goes to areas where the fat is not likely to fluctuate. "If the patient loses or gains 10 pounds, fat from there is less likely to hypertrophy. For some patients it's abdominal fat; for some patients it's the hips," she said.

After reviewing the literature, Dr. Butterwick says she believes that there is no evidence that fat from one area survives better than from any other, so she also harvests from areas that are least resistant to dietary changes. "I do like the outer thigh; it comes out quickly and is avascular," she said.

In a radioisotope study, "we found no difference in terms of fat aging and longevity from different anatomic sites," Dr. Sadick remarked. People who were thinner had greater fat longevity. For thin patients, he usually harvests from the abdomen and hips.

With thin patients, "there's very little margin for error to avoid indentation," Dr. Obagi pointed out. "I do augmentation in a lot of yoga instructors and marathon runners. Usually you have to go to the buttock, and you have to be very good at your technique." For these patients, she uses a standard cannula because it has more of a blunted tip.

Dr. Butterwick said that "sometimes you have to hunt around and harvest from the arms or from multiple areas. It takes longer, so you might just choose to use Sculptra in that patient."

When the discussion turned to fat contouring in the midface and periorbital area, she suggested that the facial autografting muscle injection system's anatomic approach gives a result similar to the Coleman technique and that "the fat may survive longer because of the proximity to the muscle."

Dr. Obagi uses a modified Coleman technique, as does Dr. Sadick. He said that "the key to success and greater longevity is in layering the fat or filler in different anatomic areas."

With thin patients, such as marathoners, 'there's very little margin for error to avoid indentation.' DR. OBAGI

LAS VEGAS — There's no one right way to do facial soft tissue augmentation, so success depends on both scientific and artful practice, a panel of experts agreed at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

The members shared tips and compared their preferences for soft tissue augmentation, beginning with the various fillers they use in their practices.

Dr. Kimberly J. Butterwick does a lot of fat transfers. Most of her patients understand the need to come back for maintenance, so she hasn't used the permanent fillers. "When they come back every 4–6 months for Botox you can put in your Restylane or your filler. They may also want a light peel at the same time. So I use a lot of the Restylane and Hylaform products because patients like to get all their maintenance at one visit, and do that two or three times a year," said Dr. Butterwick, who practices in San Diego.

"I think patients are looking for bulk implants, not fillers, but the problem with permanent fillers in this country is that we don't have enough experience looking at the adverse events—hypersensitivity, granulomas, and long-term effects. It's not something that I recommend for my patients," said Dr. Neil S. Sadick of Cornell University in New York.

Most patients in his practice are moving on to three-dimensional volumetric filling, with Sculptra probably accounting for the largest increase in share. "Even Radiesse is gaining increasing usage. Patients are looking for something that will last 1–2 years, which I think is the optimal duration for a given filler," he said.

Dr. Suzan Obagi also avoids permanent fillers. "Patients might say they want something permanent, but I explain to them that, from a safety standpoint, something we can adapt over time" may be better, said Dr. Obagi of the University of Pittsburgh.

For patients who do want something permanent, she does fat transfers. "About 80% of my transfers use fat, and 20% use the other fillers," she said.

When it comes to harvesting fat, she goes to areas where the fat is not likely to fluctuate. "If the patient loses or gains 10 pounds, fat from there is less likely to hypertrophy. For some patients it's abdominal fat; for some patients it's the hips," she said.

After reviewing the literature, Dr. Butterwick says she believes that there is no evidence that fat from one area survives better than from any other, so she also harvests from areas that are least resistant to dietary changes. "I do like the outer thigh; it comes out quickly and is avascular," she said.

In a radioisotope study, "we found no difference in terms of fat aging and longevity from different anatomic sites," Dr. Sadick remarked. People who were thinner had greater fat longevity. For thin patients, he usually harvests from the abdomen and hips.

With thin patients, "there's very little margin for error to avoid indentation," Dr. Obagi pointed out. "I do augmentation in a lot of yoga instructors and marathon runners. Usually you have to go to the buttock, and you have to be very good at your technique." For these patients, she uses a standard cannula because it has more of a blunted tip.

Dr. Butterwick said that "sometimes you have to hunt around and harvest from the arms or from multiple areas. It takes longer, so you might just choose to use Sculptra in that patient."

When the discussion turned to fat contouring in the midface and periorbital area, she suggested that the facial autografting muscle injection system's anatomic approach gives a result similar to the Coleman technique and that "the fat may survive longer because of the proximity to the muscle."

Dr. Obagi uses a modified Coleman technique, as does Dr. Sadick. He said that "the key to success and greater longevity is in layering the fat or filler in different anatomic areas."

With thin patients, such as marathoners, 'there's very little margin for error to avoid indentation.' DR. OBAGI