Showing papers in "Plastic and Reconstructive Surgery in 1989"
TL;DR: The fibula was investigated as a donor site for free-flap mandible reconstruction and the aesthetic result of the reconstruction was excellent in most patients, particularly in "bone only" defects.
Abstract: The fibula was investigated as a donor site for free-flap mandible reconstruction. It has the advantages of consistent shape, ample length, distant location to allow a two-team approach, and low donor-site morbidity. It can be raised with a skin island for composite-tissue reconstruction. Twelve segmental mandibular defects (average 13.5 cm) were reconstructed following resection for tumor, most commonly epidermoid carcinoma. Five defects consisted of bone alone, and four others had only a small amount of associated intraoral soft-tissue loss. Eleven patients underwent primary reconstructions. At least two osteotomies were performed on each graft, and miniplates were used for fixation in 11 patients. Six patients received postoperative radiation, and two patients received postoperative chemotherapy. The flaps survived in all patients. All osteotomies healed primarily. The septocutaneous blood supply was generally not adequate to support a skin island for intraoral soft-tissue replacement. The aesthetic result of the reconstruction was excellent in most patients, particularly in "bone only" defects. There was no long-term donor-site morbidity.
1,392 citations
TL;DR: It was shown that animals with selective nerve injuries gave walking tracks that were consistent, predictable, and based on known neuromuscular deficits, and the new formula for sciatic functional index was compared with previously described indices.
Abstract: Quantification of peripheral nerve regeneration in animal studies of nerve injury and repair by histologic, morphologic, and electrophysiologic parameters has been controversial because such studies may not necessarily correlate with actual nerve function. This study modifies the previously described sciatic functional index (SFI), tibial functional index (TFI), and peroneal functional index (PFI) based on multiple linear regression analysis of factors derived from measurements of walking tracks in rats with defined nerve injuries. The factors that contributed to these formulas were print-length factor (PLF), toe-spread factor (TSF), and intermediary toe-spread factor (ITF). It was shown that animals with selective nerve injuries gave walking tracks that were consistent, predictable, and based on known neuromuscular deficits. The new formula for sciatic functional index was compared with previously described indices. The sciatic functional index, tibial functional index, and peroneal functional index offer the peripheral nerve investigator a noninvasive quantitative assessment of hindlimb motor function in the rat with selective hindlimb nerve injury.
1,190 citations
TL;DR: The results of the analyses suggest that disease progression to distant sites does not occur exclusively via the axillary lymph nodes, but rather that lymph node status serves as an indicator of the tumor's ability to spread.
Abstract: Two of the most important prognostic indicators for breast cancer are tumor size and extent of axillary lymph node involvement. Data on 24,740 cases recorded in the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute were used to evaluate the breast cancer survival experience in a representative sample of women from the United States. Actuarial (life table) methods were used to investigate the 5-year relative survival rates in cases with known operative/pathologic axillary lymph node status and primary tumor diameter. Survival rates varied from 45.5% for tumor diameters equal to or greater than 5 cm with positive axillary nodes to 96.3% for tumors less than 2 cm and with no involved nodes. The relation between tumor size and lymph node status was investigated in detail. Tumor diameter and lymph node status were found to act as independent but additive prognostic indicators. As tumor size increased, survival decreased regardless of lymph node status; and as lymph node involvement increased, survival status also decreased regardless of tumor size. A linear relation was found between tumor diameter and the percent of cases with positive lymph node involvement. The results of our analyses suggest that disease progression to distant sites does not occur exclusively via the axillary lymph nodes, but rather that lymph node status serves as an indicator of the tumor's ability to spread.
960 citations
TL;DR: Investigations of the various uses of free fat autotransplantation in animals and humans provide an understanding of the problems associated with the use of fat as a free graft and evidence of the dynamic nature of adipose tissue that strongly supports the cell survival theory and gives explanation to the unpredictable behavior of freefat autografts.
Abstract: Free fat graft autotransplantation for soft-tissue replacement has been a neglected subject in recent years. In a review of the literature, investigations of the various uses of free fat autotransplantation in animals and humans provide an understanding of the problems associated with the use of fat as a free graft. Results of free fat autotransplantation were found to be quite unpredictable, with wide variations in the resulting bulk of the graft. Microscopic studies of this behavior led to controversy as to whether the graft ultimately was made of surviving graft adipocytes (cell survival theory) or host adipocytes (host replacement theory). Studies revealed a "fibroblast-like" mesenchymal cell within adipose tissue that was believed to be an immature adipocyte precursor or preadipocyte. Further characterization of the preadipocyte and its complete differentiation was accomplished using tissue-culture techniques. These investigations provide evidence of the dynamic nature of adipose tissue that strongly supports the cell survival theory and gives explanation to the unpredictable behavior of free fat autografts. Many conditions treated by plastic surgeons require soft-tissue augmentation. Autogenous adipose tissue is the most appropriate and natural replacement material. With new culturing techniques, preadipocytes in a single cell suspension may provide an injectable soft-tissue replacement. This subject appears ripe for investigation.
486 citations
TL;DR: A keloid results when a healing skin injury produces excess connective tissue that extends beyond the confines of the original wound and which tends to recur after excision.
Abstract: A keloid results when a healing skin injury produces excess connective tissue that extends beyond the confines of the original wound1 and which tends to recur after excision. Keloids were first described centuries ago in the Smith papyrus, later in 1770 by Retz, and in 1802 by Alibert, 2–4 who propo
450 citations
TL;DR: The zygomatic ligaments (McGregor's patch) anchor the skin of the cheek to the inferior border of the zygoma just posterior to the origin of the Zygomaticus minor muscle; the mandibular ligaments tether the overlying skin to the anterior mandible; these four ligaments are useful as anatomic landmarks during facial dissections.
Abstract: The zygomatic ligaments (McGregor's patch) anchor the skin of the cheek to the inferior border of the zygoma just posterior to the origin of the zygomaticus minor muscle. The mandibular ligaments tether the overlying skin to the anterior mandible. Both these ligaments are obstacles to surgical maneuvers intended to advance the overlying skin. They also restrain the facial skin against gravitational changes, and they delineate the anterior border of the "jowl" area. The platysma-auricular ligament is a thin fascial sheet that extends from the posterosuperior border of the platysma and that is intimately attached to the periauricular skin; it serves as a surgical guide to the posterosuperior border of the platysma. The anterior platysma-cutaneous ligaments are variable fascial condensations that anchor the SMAS and platysma to the dermis. They can cause anatomic disorientation with dissection of false planes into the dermis. These four ligaments are useful as anatomic landmarks during facial dissections. The tethering effects of the zygomatic and mandibular ligaments must be interrupted if a maximum upward movement of the facial skin is desired.
436 citations
TL;DR: Functional and cosmetic results were generally satisfactory and were excellent in bone-only reconstructions and to improve results in large or more lateral through-and-through defects, an accessory pectoralis musculocutaneous flap proved advantageous.
Abstract: Sixty vascularized iliac crest free-tissue transfers were used for oromandibular reconstruction, 46 as osteocutaneous and 14 as osseous flaps. Forty-one patients had preoperative radiotherapy, and 8 had failed previous attempts at reconstruction. Forty-nine of the 60 reconstructions were carried out primarily, most commonly following ablative surgery for radiorecurrent squamous carcinoma. Ages ranged from 19 to 85 years, and follow-up ranged from 2 months to 5 years. Flap survival was 95 percent. Eight-six percent of patients returned to their previous activities. There were 2 perioperative deaths, and 31 patients were alive at follow-up. Horizontal defects from 5 to 16 cm were reconstructed, and in 22 patients, both oral lining and skin coverage were replaced. Radiographic evidence of bone union was noted in 96 percent of synostoses, and clinical union was seen in all but one patient. One patient required bilateral hemimandibular reconstructions for sequential primaries at different operative sittings. Functional and cosmetic results were generally satisfactory and were excellent in bone-only reconstructions. Several surgical principles evolved to minimize bulk and eliminate the need for intermaxillary fixation or external fixation postoperatively. To improve results in large or more lateral through-and-through defects, an accessory pectoralis musculocutaneous flap proved advantageous. Cosmetic and functional results depend largely on three factors: the extent of the surgery, the leanness of the patient, and his or her position on the surgical learning curve.
399 citations
TL;DR: The free TRAM flap appears to be as safe as the conventional technique with the advantages of a more limited rectus muscle harvest, improved medial contour of the breast due to the lack of tunneling, and perhaps a healthier flap because of the large donor vessels.
Abstract: Immediate breast reconstruction using the transverse abdominal myocutaneous island (TRAM) flap was performed in 54 patients over the past 3 years at our institution. This represented approximately 59 percent of patients undergoing all types of immediate breast reconstruction. In 10 patients, the abdominal island flap was transferred as a free flap based on the deep inferior epigastric pedicle. These patients were compared with the other 44 patients, in whom the flap was transferred using the conventional technique. The TRAM flap is well suited for immediate breast reconstruction because the procedure can be carried out simultaneously with mastectomy using separate operating teams and instruments. The operation is safe and relatively free of complications. The free TRAM group compared favorably with the conventional group in terms of complications, operating time, estimated blood loss, hospitalization, and return to functional baseline. The free TRAM flap appears to be as safe as the conventional technique with the advantages of a more limited rectus muscle harvest, improved medial contour of the breast due to the lack of tunneling, and perhaps a healthier flap because of the large donor vessels.
300 citations
TL;DR: The blood supply to the skin of the perineum, medial groin, and upper thigh was studied in fresh female cadavers and the pudendal-thigh flap was designed as a result to reconstruct the vagina.
Abstract: The blood supply to the skin of the perineum, medial groin, and upper thigh was studied in fresh female cadavers. The pudendal-thigh flap was designed as a result to reconstruct the vagina. The flaps are raised bilaterally in the groin crease just lateral to the labia majora and then are transposed toward the midline and sutured together to form a skin-lined cul-de-sac which opens at the introitus. The technique has been used successfully in three patients to reconstruct the vagina. The first patient, an adult, was reconstructed after total pelvic exenteration for malignancy, while two children had reconstructions for congenital vaginal anomalies. This technique is superior to currently available methods because it is simple and reliable. No stents or dilators are needed. It is safe technique without complications in our hands. The reconstructed vagina has a natural angle for intercourse and is sensate. The donor scars in the groin are well hidden.
291 citations
TL;DR: The pivoting septal flap provides nasal support from the radix to the most distal nasal tip and from the tip to the columella base—plus a large bonus of lining tissues for the nasal vault and vestibules.
Abstract: Assured of a robust blood supply by its narrow pedicle centered on the septal branch of the superior labial artery, the pivoting septal flap provides nasal support from the radix to the most distal nasal tip and from the tip to the columella base--plus a large bonus of lining tissues for the nasal vault and vestibules. Lining flaps from such intranasal tissues are thin, vascular, and flexible. They allow the use of primary cartilage grafts and the establishment of a subsurface architecture in the shape of a nose. When visualized through a conforming forehead flap, the normal landmarks and highlights are restored. In cases of total nasal amputation, a pivoting septal flap permits the fabrication of dorsal nasal support weeks before lining and cover flaps are assembled.
256 citations
TL;DR: Techniques for fat-graft injection obtained from liposuction and the instruments specially designed for this procedure are presented, and the final results obtained with this method are compared with different filling materials used for aesthetic and reconstructive purposes.
Abstract: Autogenous graft tissue is better than homologous and heterologous tissue for the improvement of body contour to eliminate deep defects in the skin surface. This paper presents techniques for fat-graft injection obtained from liposuction and the instruments specially designed for this procedure. An analytical study is presented, and the final results obtained with this method are compared with different filling materials used for aesthetic and reconstructive purposes. A statistical study of 253 operated patients in a long-term follow-up (1984-1988) is registered. Special comments have been included relative to patient recovery, the amount of fat absorption and the amount of fat tissue remaining, and fat injection revisions and complications.
TL;DR: The deep temporal fascia and superficial temporal fat pad are anatomically important structures which adjoin the periosteum of the zygomatic arch and lie deep to the frontal nerve.
Abstract: The anatomy of the temporal region, with reference to the frontal branch of the facial nerve, was examined in 12 fresh cadaver dissections. In all dissections, the frontal branch traveled in a constant plane along the undersurface of the temporoparietal fascia and was quite superficial as it crossed the zygomatic arch. The deep temporal fascia and superficial temporal fat pad are anatomically important structures which adjoin the periosteum of the zygomatic arch and lie deep to the frontal nerve. Based on these relationships, a safe method of dissection within the temporal region is formulated.
TL;DR: A new hypothesis linking these two findings proposes that the trapped white cells occlude the capillaries and result in ischaemia of the skin of the leg.
Abstract: Previous hypotheses about the causes of venous ulceration are inconsistent with recently published data. In patients with chronic venous insufficiency the number of functioning capillary loops visible in the skin on microscopy fell after the legs had been dependent for 30 minutes. Another study had shown that leucocytes became trapped in the circulation in dependent legs. A new hypothesis linking these two findings proposes that the trapped white cells occlude the capillaries and result in ischaemia of the skin of the leg.
TL;DR: The flap was utilized clinically in 38 patients: 24 to close primary cleft palates that required palate lengthening, 12 to close palatal fistulas, 1 to treat a mandibular osteitis, and 1 to repair the palate after tumor resection.
Abstract: Since 1984, we have used the buccinator muscle mucosal flap for the treatment of mucosal defects after tumor resection, osteomyelitis of the mandible, closure of cleft palate fistulas, primary closure of very wide cleft palates, and lengthening of the soft palate. A study was made in the facial regions of 14 cadavers, and a comparison was made to descriptions found in the anatomic literature. It was confirmed in our dissections that the buccal artery, which reaches the posterior half of the muscle, is the major arterial pedicle of the buccinator and that it runs very close to the buccal nerve. Several veins originating from the lateral aspect of the muscle make the venous drainage of the buccinator even richer than its arterial supply. The abundant vascular supply from multiple interconnected pedicles supports the blood supply of the buccal mucosa. The motor innervation of the buccinator muscle comes from the facial nerve. The buccinator is considered to be a part of the sphincteric muscular system involving the functions of sucking, whistling, propelling food during mastication, and voiding the buccal cavity. The flap was utilized clinically in 38 patients: 24 to close primary cleft palates that required palate lengthening, 12 to close palatal fistulas, 1 to treat a mandibular osteitis, and 1 to repair the palate after tumor resection. We had three small fistulas as complications in our series owing to technical mistakes.
TL;DR: Eight pediatric patients with giant congenital nevi confluent over 21 to 51 percent body surface area were treated by excision and grafting, allowing a larger area of excision than would have been possible with split-thickness skin grafts alone and, therefore, a more rapid removal of nevus.
Abstract: Eight pediatric patients with giant congenital nevi confluent over 21 to 51 percent body surface area were treated by excision and grafting. The nevus was excised to the muscle fascia, and the open wound was grafted with cultured epithelial autografts and split-thickness skin grafts. The patients ha
TL;DR: It is felt that major suction lipectomy has a low complication rate and is a reasonably safe procedure.
Abstract: In March of 1988, a survey form was sent to all 2695 U.S. and Canadian members of the American Society of Plastic and Reconstructive Surgeons. Nine-hundred and thirty-five members responded, for a response rate of 34.7 percent. The purpose of the survey was to ascertain the total number of major liposuction, dermatolipectomy, and abdominoplasty procedures performed from January of 1984 to January of 1988 and to compare nine specific complications that are associated with these three procedures. The 935 surgeons reported a total of 112,756 procedures performed: major liposuction (75,591), dermatolipectomy (10,603), and abdominoplasty (26,562). Nine major complications were surveyed: mortality, myocardial infarction, cerebrovascular accident or transient ischemic attack, pulmonary thromboembolism, fat embolism, major skin loss, anesthesia complication, transfusion complications, and deep venous thrombosis. The findings in this survey showed, when comparing these three procedures and the nine types of complications, that the complication rate for major suction lipectomy was 0.1 percent, for dermatolipectomy 0.9 percent, and for abdominoplasty 2.0 percent. Fat emboli did not prove to be a significant factor associated with any of the three procedures. However, of the 15 reported deaths (major liposuction 2, dermatolipectomy 2, and abdominoplasty 11), pulmonary thromboembolism was the causative factor in 9 deaths (60 percent). Based on these analyzed data, we feel that major suction lipectomy has a low complication rate and is a reasonably safe procedure.
TL;DR: The findings in this study suggest that the complication rate of TRAM flap breast reconstruction does increase in proportion to the degree of obesity, and surgeons can avoid many of the complications fromTRAM flap surgery by not operating on very obese patients.
Abstract: The records of 82 women who had undergone unilateral breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap at the University of Texas M. D. Anderson Cancer Center were analyzed to determine what effect obesity had on the rate of complications and the aesthetic quality of the ultimate result. The patients were divided into four groups--thin, average, moderately obese, and markedly obese--based on a weight/height index derived by dividing the weight in kilograms by the height in meters. In the thin group (13 patients), the complication rate was only 15.4 percent. In the average group (22 patients), the complication rate was 22.7 percent. In the moderately obese group (35 patients), the complication rate was 31.4 percent. In the markedly obese group (12 patients), the rate was 41.7 percent. Aesthetic results in the abdomen tended to be better in the nonobese group, but in the breast they correlated better with the number of revisions performed than with degree of obesity. The findings in this study suggest that the complication rate of TRAM flap breast reconstruction does increase in proportion to the degree of obesity. Surgeons can therefore avoid many of the complications from TRAM flap surgery by not operating on very obese patients. Reports of complication rates from different authors may vary in part depending on their mix of obese and nonobese patients.
TL;DR: Evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.
Abstract: Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.
TL;DR: When added to a collagen-filled nerve guide, purified acidic fibroblast growth factor increased the number of myelinated axons that regenerated across a 5-mm nerve gap distance, and a greater number of primary sensory and motor neurons extended axons through the nerve guide in animals treated with aFGF.
Abstract: When added to a collagen-filled nerve guide, purified acidic fibroblast growth factor (aFGF) increased the number of myelinated axons that regenerated across a 5-mm nerve gap distance. In addition, a greater number of primary sensory and motor neurons extended axons through the nerve guide in animals treated with aFGF. Thus the effect of aFGF on peripheral nerve regeneration is not simply an increase in axonal branching within the nerve guide tube. This is the first highly purified growth factor since nerve growth factor that has been shown to promote nerve regeneration in vivo. This experimental model provides a convenient and quantitative means to assess the effects of putative neuronotropic factors on peripheral nerve regeneration in vivo.
TL;DR: In this study, the only risk factor identified in predicting major morbidity, specifically the occurrence of pulmonary embolus, was obesity, not the complexity of the surgical procedure.
Abstract: The clinical records of 563 patients undergoing either abdominoplasty alone or in combination with other major surgical procedures were reviewed in order to determine the relative safety of combined procedures. One-hundred-seventeen patients had abdominoplasty alone; 230 had abdominoplasty with either an intraabdominal or major pelvic procedure with or without an additional major aesthetic procedure; 216 had abdominoplasty with one or more major aesthetic procedures (without intraabdominal or pelvic procedures). The rates of occurrence of major complications, including death, pulmonary embolus, and infection, among the three groups were examined. Also examined were morbidity factors such as length of hospital stay and the need for blood transfusion. In this study, the only risk factor identified in predicting major morbidity, specifically the occurrence of pulmonary embolus, was obesity, not the complexity of the surgical procedure.
TL;DR: The approach is described, which utilizes formal planimetry, cephalometric tracings, and Panorex mandibular radiographs, and uses an oscillating saw to resect the predetermined segment of bone in a patient undergoing a concomitant rhytidectomy.
Abstract: A prominent mandibular angle is considered to be unattractive in the Orient because it gives the face a square and muscular appearance. While described infrequently in the United States, this entity is commonly encountered in the Orient owing to different facial characteristics and different aesthetic sensibilities. We present a retrospective study of 42 female patients who presented requesting the reduction of a prominent mandibular angle for cosmetic reasons. We describe our approach, which utilizes formal planimetry, cephalometric tracings, and Panorex mandibular radiographs. We utilize the intraoral approach and use an oscillating saw to resect the predetermined segment of bone. In 18 of the 42 patients, we resected muscle as well. We also describe using the preauricular incision in a patient undergoing a concomitant rhytidectomy. Our cosmetic results have been generally satisfactory, with only one inaccurate osteotomy. We had three infections which resolved without sequelae.
TL;DR: There is a fair possibility of correcting the cleft lip nasal deformity with a nonsurgical procedure in the early neonatal period, based on experience.
Abstract: Auricular cartilage is soft and plastic at birth, so that congenital auricular deformities can easily be corrected nonsurgically in the early neonatal period. However, as the infant grows older, the flexibility of the auricle decreases. Alar cartilage exhibits the same elasticity as auricular cartilage in the early neonate. When a cleft lip is repaired, typically when the infant is about 3 months of age, it becomes difficult to correct the nasal deformity without surgical intervention. However, based on our experience, there is a fair possibility of correcting the cleft lip nasal deformity with a nonsurgical procedure in the early neonatal period. We performed cleft lip repair accompanied by nonsurgical correction of the nasal deformity in 44 neonates aged 2 to 7 days. A special retainer was placed in the affected nostril for 3 months. Following observation of 31 infants for 12 months or longer, their nasal shapes and symmetry were considered superior to those conventionally operated on at about 3 months of age. Except for one nasal infection, there were no complications.
TL;DR: Fresh cadaver dissections were carried out to accurately determine the anatomy of the buccal fat pad, with particular attention to the ten “oral extension, since this area is frequently disregarded.
Abstract: Interest in the anatomy of the buccal fat pad was aroused by two clinical cases where the fat pad was involved by pathology. In one, there was an extensive lipoma of the buccal fat pad which had been unsuccessfully operated on on two previous occasions. The reason for the lack of success was incomplete removal of the fat pad. In the second case, there was an arteriovenous malformation involving the fat pad which necessitated complete removal. Fresh cadaver dissections were carried out to accurately determine the anatomy. Particular attention was paid to the temporal extension, since this area is frequently disregarded.
TL;DR: A review of previous experiences with end-to-end digital neurorrhaphies and digital nerve grafts suggests that repair of 1- to 3-cm gaps in digital nerves with segments of autologous vein grafts appears to give comparable results to nerve grafting.
Abstract: Twenty-two digital nerve repairs were performed in the finger using autogenous vein grafts. Eighty-two percent of the repairs were available for follow-up. Results of sensibility return were assessed using moving two-point discrimination, Semmes-Weinstein monofilaments, and vibratory testing.Two-poi
TL;DR: This paper chronicles 3 years of a continuing study comparing porous hydroxyapatite to autogenous bone grafts as onlays in maxillofacial surgery, comparing these substances in radiologic longevity, histologic incorporation, clinical function, and aesthetic appearance.
Abstract: This paper chronicles 3 years of a continuing study comparing porous hydroxyapatite to autogenous bone grafts as onlays in maxillofacial surgery Twenty-five patients, seen from June of 1984 to May of 1985, underwent onlay augmentation on various maxillary and mandibular locations A total of 68 onlay augmentation sites comparing Interpore porous hydroxyapatite and autogenous bone were followed for 2 years or more This long-term study compares these substances in radiologic longevity, histologic incorporation, clinical function, and aesthetic appearance
TL;DR: Clinically, this study relates to reanimating the paralyzed face by taking a strip of facial tissue from each at right angles to the fold and revealing the lip elevator muscles and the “fold muscles” coursing down the lip to traverse the orbicularis oris and insert into the dermis of the upper lip.
Abstract: The nasolabial fold is absent in the face of the newborn, disappears in the paralyzed face, but is retained in the face upon death. There is very little information in the literature on what makes up the fold. Four fresh cadavers were studied by taking a strip of facial tissue from each at right angles to the fold; all soft tissue layers through the face were included. Microscopic studies of the strips showed the fold to be made up of (1) dense fibrous tissue, (2) muscle fibers branching from the levator muscles of the upper lip, and (3) striated muscle bundles originating in the fold fascia. The studies also revealed the lip elevator muscles and the "fold muscles" coursing down the lip to traverse the orbicularis oris and insert into the dermis of the upper lip, the cutaneous vermilion junction, and vermilion. The smile is formed in stages, the first stage raising the lip to the fold by the levator muscles and the muscle bundles originating in the fold. The lip meets resistance at the fold because of cheek fat. The second stage involves the raising of the lip and fold upward by the levator muscles of the upper lip. Clinically, this study relates to reanimating the paralyzed face.
TL;DR: This is the first extensive description of the intricate microanatomy of this complex but unique microneurovascular muscle unit and an exemplary clinical case demonstrating the use of the pectoralis minor muscle for both eye and lower face reanimation.
Abstract: The author introduced this muscle for the first time almost a decade ago, and this is the first extensive description of the intricate microanatomy of this complex but unique microneurovascular muscle unit. Advantages and disadvantages and indications and contraindications for its use in facial paralysis are presented in detail from an extensive clinical experience of almost 50 such microneurovascular transfers. Pitfalls that the reconstructive microsurgeon should beware and strengths in using this muscle for facial palsy are highlighted. The detailed operative approach is presented, with promise of undetectable scars and minimal functional loss. The strategies for how to inset this muscle unit in the new recipient site are given, along with the thought processes involved in selecting the actual sites of anchoring the muscle to reproduce a mirror image of the contralateral normal face. Finally, an exemplary clinical case demonstrating the use of the pectoralis minor muscle for both eye and lower face reanimation is presented in detail, demonstrating the dual nerve supply and the resulting independent eye and smile movements with total lack of mass action and/or synkinesis. Restorations of eye blink and of a symmetrical and coordinated smile are the frequent rewards of using this unique muscle for the correction of facial palsy.
TL;DR: It is concluded that intralesional corticosteroid injections are safe and effective in properly selected infants with hemangiomas.
Abstract: Intralesional corticosteroid injections were performed in 31 hemangiomas in 30 infants aged 1 to 10 months at first injection. One to five injections were given, spaced 6 weeks apart. Lesions were located throughout the head and neck region, except one that was on the buttock. A mixture of betamethasone acetate and triamcinolone acetonide was used. Four lesions (13 percent) virtually disappeared, ten (32 percent) showed greater than 50 percent reduction in volume, ten (32 percent) showed definite but less than 50 percent reduction in volume, and seven (23 percent) showed little or no decrease in size. None showed further growth. All injections were performed without anesthesia, and there were not significant complications. We conclude that intralesional corticosteroid injections are safe and effective in properly selected infants with hemangiomas.
TL;DR: The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back.
Abstract: The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.