Showing papers in "Plastic and Reconstructive Surgery in 1990"
TL;DR: It is suggested that large abdominal- wall defects can be reconstructed with functional transfer of abdominal-wall components without the need for resorting to distant transposition of free-muscle flaps.
Abstract: Closure of large abdominal-wall defects usually requires the transposition of remote myocutaneous flaps or free-tissue transfers. The purpose of this study was to determine if separation of the muscle components of the abdominal wall would allow mobilization of each unit over a greater distance than possible by mobilization of the entire abdominal wall as a block. The abdominal walls of 10 fresh cadavers were dissected. This demonstrated that the external oblique muscle can be separated from the internal oblique in a relatively avascular plane. The rectus muscle with its overlying rectus fascia can be elevated from the posterior rectus sheath. The compound flap of the rectus muscle, with its attached internal oblique-transversus abdominis muscle, can be advanced 10 cm around the waistline. The external oblique has limited advancement. These findings were utilized clinically in the reconstruction of abdominal-wall defects in 11 patients, ranging in size from 4 x 4 to 18 x 35 cm. This study suggests that large abdominal-wall defects can be reconstructed with functional transfer of abdominal-wall components without the need for resorting to distant transposition of free-muscle flaps.
1,185 citations
TL;DR: There is a correlation between the degree of difficulty and the anatomy of the oropharynx in the same patient, and any screening test which adds to ability to predict difficulty in intubation must be welcomed, as failure to intubate can potentially lead to fatality.
Abstract: This is a retrospective study of patients whose tracheas were impossible to intubate on a previous occasion. There is a correlation between the degree of difficulty and the anatomy of the oropharynx in the same patient. The study was initially on obstetric patients but was extended to nonobstetric surgical patients in order to increase the number of cases investigated. The incidence of failed intubations in the obstetric group over a 3-year period was seven out of 1980 cases, whereas in the surgical group the results were six out of 13,380 patients. Any screening test which adds to our ability to predict difficulty in intubation must be welcomed, as failure to intubate can potentially lead to fatality.
690 citations
TL;DR: It is concluded that reconstruction of nerve gaps of up to 3.0 cm with a bioabsorbable PGA tube gives clinical results at least comparable to the classic nerve graft technique while avoiding donor-site morbidity.
Abstract: Microneurosurgical techniques to reconstruct nerve gaps with nerve grafts frequently fail to achieve excellent functional results and create donor-site morbidity. In the present study, 15 patients had gaps of 0.5 to 3.0 cm (mean 1.7 cm) in digital nerves reconstructed by one surgeon with a bioabsorbable polyglycolic acid (PGA) tube. A final evaluation of sensibility was done by a second surgeon at a mean postoperative interval of 22.4 months (range 11 to 32 months). These were all secondary reconstructions. The evaluation included a digital nerve block with local anesthetic for the intact (not reconstructed) digital nerve. Excellent functional sensation (moving two-point discrimination less than or equal to 3 mm and/or static two-point discrimination less than or equal to 6 mm) was present in 33 percent and good functional sensation (moving two-point discrimination of 4 to 7 mm and/or static two-point discrimination of 7 to 15 mm) in 53 percent of the digital nerve reconstructions. One patient with poor sensory recovery and one with no recovery were judged as functional failures (14 percent). Absence of pain at the site of reconstruction was judged by the patient to be excellent in 40 percent, good in 33 percent, and poor in 27 percent. We conclude that reconstruction of nerve gaps of up to 3.0 cm with a bioabsorbable PGA tube gives clinical results at least comparable to the classic nerve graft technique while avoiding donor-site morbidity.
518 citations
TL;DR: The deep-plane rhytidectomy is described, which addresses the problem of laxity of the nasolabial folds and the step-by-step techniques for the face and neck dissection are described.
Abstract: Lack of significant improvement in redundant nasolabial folds has always been a problem in face lift procedures. The purpose of this paper is to describe the deep-plane rhytidectomy, which addresses the problem of laxity of the nasolabial folds. A Skoog-type sub-SMAS dissection is extended superiorly over the zygomaticus muscles and medially beyond the nasolabial folds, totally releasing all SMAS attachments and creating a thick musculocutaneous flap comprised of skin, all subcutaneous fat of the cheeks, and the platysma muscle. Four-hundred and three patients have been operated on with minimal complications. Dramatic postoperative improvements in the nasolabial folds are demonstrated, and the step-by-step techniques for the face and neck dissection are described.
362 citations
TL;DR: The results showed that significant numbers of adipocytes were ruptured after suction procedures, and adipocytes appeared to survive better for a short term in a more vascularized bed (rectus muscle) than in a low vascular area (ear dermis).
Abstract: In recent years, adipocytes obtained by suction-assisted lipectomy have been used for implantation by injection methods. This study is designed to assess the appearance of suctioned and excised adipose tissue and its survival after being injected or implanted into different tissues (0.5 cc into the rectus muscle and 0.5 cc into the dorsal ear skin) of New Zealand White rabbits. The results showed that significant numbers of adipocytes were ruptured after suction procedures. The intact cells represented approximately 10 percent of the fat cell population. Fat cells in aspirated and excised samples remained intact and did not differ histologically. After being injected into tissue, adipocytes appeared to survive better for a short term in a more vascularized bed (rectus muscle) than in a low vascular area (ear dermis). Long-term studies at 6- to 9-month intervals revealed transplanted adipose tissue, taken by suction or excision, being replaced with fibrosis, although cystic spaces and only a small number of surviving adipocytes were still present. Insulin did not show any protective effects on survival of the adipocytes during their transplantation.
352 citations
TL;DR: Changes in surgical technique have improved the acceptability and minimized the problems associated with this donor site and no longer reconstruct the radial artery as a matter of routine.
Abstract: The radial forearm flap, although widely used, has been criticized for the poor quality of its donor site. To investigate the causes of morbidity, 100 radial artery free-flap donor sites have been reviewed. Sixty-seven patients required skin grafting (group 1), and the remaining 33 patients were closed directly (group 2). Seventeen patients in the series had compound osteocutaneous flaps (group 3). Wound healing proved to be a significant problem in groups 1 and 3, and fracture of the radius occurred in 4 of the 17 patients in group 3 and was the most significant cause of morbidity. The radial artery was reconstructed in 12 patients, but only 6 of the arteries (50 percent) were patent at the time of review. Subjective assessment on a scale of 0 to 10 demonstrated a relatively pain-free donor site with low pain scores (2.5 of 10). The cosmetic result was acceptable in men (1.5 of 10) but was less so in women (4 of 10). Angulated fracture of the radius produced an unacceptable cosmetic result (7 of 10). In light of this experience, we no longer reconstruct the radial artery as a matter of routine. The donor defect is closed directly wherever possible using an ulnar artery-based transposition flap when required. A "boat shaped" osteotomy is used in preference to right-angled bone cuts when harvesting a segment of radius to avoid the complications and sequelae of fracture. These changes in surgical technique have improved the acceptability and minimized the problems associated with this donor site.
282 citations
TL;DR: Using fresh cadaver dissection, the anatomy of the buccal fat pad is delineated and its relationship to the masticatory space, facial nerve, and parotid duct is defined and an intraoral approach for buCCal fat harvesting is described.
Abstract: The buccal fat pad is an anatomically complex structure that has great importance in facial contour. In properly selected individuals, judicious harvesting of buccal fat can produce dramatic changes in facial appearance by reducing the fullness of the cheek and highlighting the malar eminences. Using fresh cadaver dissection, the anatomy of the buccal fat pad is delineated and its relationship to the masticatory space, facial nerve, and parotid duct is defined. An intraoral approach for buccal fat harvesting is described based on these anatomic findings. Clinical experience manipulating the buccal fat pad for aesthetic modification of facial contour is illustrated.
260 citations
TL;DR: It is concluded that the radial forearm flap, used in head and neck reconstruction, soft-tissue cover of an extremity, and as a new technique for penile reconstruction is valuable in a variety of reconstructive applications.
Abstract: Thirty-five consecutive patients treated with the radial forearm flap were reviewed. This flap was used in head and neck reconstruction in 25 patients, soft-tissue cover of an extremity in 9 patients, and as a new technique for penile reconstruction in 1 patient. Osteocutaneous flaps were used for mandibular reconstruction in 13 patients. In 6 patients innervated flaps were used to provide sensation on the dorsum of the hand or on the weight-bearing surface of the foot. There was only one total flap failure and no partial failures. Recipient-site complications were few, with prompt healing and very acceptable appearance. Donor-site complications included partial loss of the skin graft with tendon exposure in 10 patients (33 percent), an unsatisfactory appearance in 5 patients (17 percent), and one case of radial fracture (8 percent). On functional testing, there was no significant loss of strength or joint mobility in the donor extremity in 19/20 patients. The authors recommend measures to reduce donor-site morbidity and conclude that, with an acceptable donor site, this flap is valuable in a variety of reconstructive applications.
256 citations
TL;DR: The universally favorable patient acceptance and the return of measurable two-point discrimination indicates the effectiveness of autogenous vein grafts as nerve conduits when selectively applied to bridge a small nerve gap on nonessential peripheral sensory nerves.
Abstract: The purpose of this study was to determine the efficacy of autogenous vein grafts as nerve grafts (AVNC) for bridging of small peripheral sensory nerve gaps as compared with direct repair and with conventional nerve grafting techniques (ANG). Patients with painful neuroma or segmental nerve injury of 3 cm were chosen as the test group. Those amenable to direct repair were classified as controls. Between 1982 to 1988, a total of 22 patients were enrolled in this study. A total of 34 nerves were repaired, 15 with a venous nerve conduit, 4 with a sural nerve graft, and 15 with direct repair. Significant symptom relief and satisfactory sensory function return were uniformly observed. The two-point discrimination measurements indicated superiority of direct repair and probably of conventional nerve grafting. However, the universally favorable patient acceptance and the return of measurable two-point discrimination indicates the effectiveness of autogenous vein grafts as nerve conduits when selectively applied to bridge a small nerve gap (less than or equal to 3 cm) on nonessential peripheral sensory nerves.
245 citations
TL;DR: This is a staged design for correction of classic clefts of the lip and palate that facilitates the continuance of the failed embryonic "migrations" toward a normal end point.
Abstract: The improved combination of surgical and dental teamwork in the primary treatment of clefts presented here is consistent with principles. In fact, this is a staged design for correction of classic clefts of the lip and palate that, based on biological principles, facilitates the continuance of the failed embryonic "migrations" toward a normal end point. Positioning of the alveolar segments, dissection of mucoperiosteum out of the cleft, and union of mucoperiosteum across the alveolar and anterior hard palate cleft make it possible to create a periosteal tunnel across the bony gap and set up a condition conducive to bone formation and eventual tooth eruption in the cleft area. Lip closure by adhesion reduces the tension of the primary lip closure and allows gentle molding until solidification of the arch occurs. Thus a complete cleft has been rendered an incomplete cleft. With a balanced, stabilized maxillary platform, the definitive lip and nose corrections can be carried to completion early (by 2 to 4 years of age). These planned actions bypass a persistent cleft, fistulas, raw areas, malposition of alveolar segments, and probably the necessity for later bone grafting. The only question not totally answered is the effect of this approach on final growth. Although most reports seem to indicate that growth has and will proceed within normal limits, another 10 years of careful follow-up is indicated and, in fact, is in progress.
227 citations
TL;DR: Facial fractures have been classified by anatomic location and pattern of comminution and displacement in the CT scan as discussed by the authors, which can be used to define guidelines for exposure and fixation.
Abstract: Facial fractures have formerly been classified solely by anatomic location. CT scans now identify the exact fracture pattern in a specific area. Fracture patterns are classified as low, middle, or high energy, defined solely by the pattern of segmentation and displacement in the CT scan. Exposure and fixation relate directly to the fracture pattern for each anatomic area of the face, including frontal bone, frontal sinus, zygoma, nose, nasoethmoidal-orbital region, midface, and mandible. Fractures with little comminution and displacement were accompanied by subtle symptoms and required simple treatment; middle-energy injuries were treated by standard surgical approaches and rigid fixation. Highly comminuted fractures were accompanied by dramatic instability and marked alterations in facial architecture; only multiple surgical approaches to fully visualize the "buttress" system provided alignment and fixation. Classification of facial fractures by (1) anatomic location and (2) pattern of comminution and displacement define refined guidelines for exposure and fixation.
TL;DR: An aggressive approach to exploration was responsible for an increase in flap survival in the entire series from 90 to 98 percent and the efficacy of clinical monitoring, the role of early exploration, and the durability of microvascular anastomoses.
Abstract: One-hundred and fifty consecutive free-tissue transfers were reviewed to evaluate the role of emergent exploration in flap survival. Eleven flaps exhibited signs of circulatory failure between 1 hour and 6 days postoperatively and required return to the operating room. In eight patients the preoperative diagnosis was venous thrombosis, and in three patients it was arterial thrombosis. The average time from the first abnormal examination to exploration was 1.5 hours. There were no false-positive explorations. All 11 flaps were salvaged following correction of the cause of circulatory compromise. In eight patients this was due to inflow or outflow obstruction in the recipient vessels proximal to the anastomosis, in two patients it was due to extrinsic compression of the flap from a tight wound closure, and in one patient it was due to obstruction of the recipient vein by a drain. Primary anastomotic thrombosis was not encountered as the cause of circulatory compromise in any patient. An aggressive approach to exploration was responsible for an increase in flap survival in the entire series from 90 to 98 percent. The results of this study demonstrate the efficacy of clinical monitoring, the role of early exploration, and the durability of microvascular anastomoses.
TL;DR: It is concluded that rigid fixation is the method of choice in all circumstances where onlay bone grafts may be exposed to motion, shear, and torsional forces.
Abstract: Much attention has recently been focused on rigid fixation as a method of improving fracture healing. Whether such fixation, when applied to onlay grafting, improves graft take and volume is unknown. To examine this question, we compared survival of both endochondral and membranous grafts fixed rigidly and nonrigidly in areas of low motion (snout) and high motion (femur) in a rabbit model. Gross morphology, histologic analysis, and graft volume kinetics were evaluated. Findings demonstrate that in areas of high motion, the application of rigid fixation improves graft survival, whereas in a low-motion region, no differences in graft volume retention as a function of fixation were observed. Histologically, no differences with the method of fixation employed were seen, and similar revascularization patterns were noted. By kinetic analysis, rigid fixation appears to exert its most profound effect early in the postgraft period. Membranous bone grafts remain superior to endochondral grafts under all circumstances. From these studies, we conclude that rigid fixation is the method of choice in all circumstances where onlay bone grafts may be exposed to motion, shear, and torsional forces.
TL;DR: The venous architecture of the integument and the underlying deep tissues was studied in six total-body human fresh cadavers and a series of isolated regional studies of the limbs and torso and demonstrated radiologically and by microdissection that the branches of these arteries are accompanied by veins that drain in the opposite direction and return to the same locus.
Abstract: The venous architecture of the integument and the underlying deep tissues was studied in six total-body human fresh cadavers and a series of isolated regional studies of the limbs and torso A radiopaque lead oxide mixture was injected, and the integument and deep tissues were dissected and radiographed The sites of the venous perforators were plotted and traced to their underlying parent veins that accompany the source (segmental) arteries A series of cross-sectional studies were made in one subject to illustrate the course of the perforators between the integument and the deep tissues The veins were dissected under magnification to identify the site and orientation of the valves Results revealed a large number of valveless (oscillating) veins within the integument and deep tissues that link adjacent valved venous territories and allow equilibration of flow and pressure throughout the tissue Where choke arteries define the arterial territories, they are matched by boundaries of oscillating veins in the venous studies The venous architecture is a continuous network of arcades that follow the connective-tissue framework of the body The veins converge from mobile to fixed areas, and they "hitchhike" with nerves The venous drainage mirrors the arterial supply in the deep tissues and in most areas of the integument in the head, neck, and torso In the limbs, the stellate pattern of the venous perforators is modified by longitudinal channels in the subdermal network However, when an island flap is raised, these longitudinal channels are disconnected, and once again the arterial and venous patterns match Our venous studies add strength to the angiosome concept Where source arteries supply a composite block of tissue, we have demonstrated radiologically and by microdissection that the branches of these arteries are accompanied by veins that drain in the opposite direction and return to the same locus Hence each angiosome consists of matching arteriosomes and venosomes The clinical implications of these results are discussed with particular reference to the design of flaps, the delay phenomenon, venous free flaps, the pathogenesis of flap necrosis, the "muscle pump," varicose veins, and venous ulceration
TL;DR: Comparisons ofBlood flow to the deep surfaces of the flaps showed that blood flow to muscle in musculocutaneous flaps increased rapidly during the first 24 hours and then plateaued, while that to subcutaneous tissue plus fascia in fasciocutaneously flaps demonstrated a gradual and steady increase.
Abstract: Regional nutrient blood flow to musculocutaneous and fasciocutaneous flaps was studied in dogs using 15-microns radiolabeled microspheres, and correlations to bacterial inoculation into closed wound spaces were sought. During the 6-day study period, no differences were found between blood flow to noinoculated versus inoculated flaps. Comparisons of blood flow to the deep surfaces of the flaps showed that blood flow to muscle in musculocutaneous flaps increased rapidly during the first 24 hours and then plateaued, while that to subcutaneous tissue plus fascia in fasciocutaneous flaps demonstrated a gradual and steady increase. The most rapid decline in bacterial counts at the undersurface of both flaps occurred within 24 hours, dropping significantly lower within musculocutaneous flaps. In addition to such surface properties of muscle as tissue ingrowth, rapid early augmentation of muscle blood flow may be largely responsible for superior bacterial suppression observed beneath musculocutaneous flaps.
TL;DR: Long-term results indicate that microlymphaticovenous anastomoses have a valuable place in the Treatment of obstructive lymphedema and should be the treatment of choice in these patients.
Abstract: Over the last 14 years, 134 patients with obstructive lymphedema have been treated with microlymphaticovenous anastomoses. Ninety patients were available for long-term follow-up study. Of these, 52 patients were treated by microlymphatic surgery only and 38 of them also had segmental or radical reduction surgery, either at the same time or secondarily. Objective assessment was undertaken by volume and circumferential measurements. Initially, lymphangiography was used, but a study demonstrated increased edema immediately following the investigation in one-third of the patients and it was abandoned, both preoperatively and postoperatively. In the microlymphaticovenous anastomoses only group (N = 52), subjective improvement occurred in 38 patients (73 percent). Objectively, volume changes showed a significant improvement in 22 patients (42 percent), with an average reduction of 44 percent of the excess volume. In the microlymphaticovenous anastomoses and reduction surgery, usually segmental, group (N = 38), subjective improvement occurred in 30 patients (78 percent) and objective improvement occurred in 23 patients (60 percent), with an average reduction of 44 percent of the excess volume. Of those followed up, 67 patients (74 percent) have been able to discontinue the use of conservative measures, with an average follow-up of 4.0 years and average reduction in excess volume of 26 percent. There was a 58 percent reduction in the incidence of cellulitis following surgery. In those patients who were improved, drainage resulted in increased softness of the limbs. Edema of the hand diminished considerably in most patients, although this was difficult to measure. These long-term results indicate that microlymphaticovenous anastomoses have a valuable place in the treatment of obstructive lymphedema and should be the treatment of choice in these patients. Reduction surgery can be used as an adjunct in some of these patients, especially in the posteromedial aspect of the upper arm. Liposuction has been used in failed cases or in patients in whom no lymphatics could be found. Improved results can be expected with earlier operations because patients referred earlier usually have less lymphatic disruption.
TL;DR: A safe anatomic approach to the zygomatic arch allows exact anatomic restoration of the zykomatic arch using miniplates and screws and results in the reconstruction of an outer facial frame with a correct anteroposterior projection and facial width.
Abstract: Collapse of the zygomatic arch following trauma results in inadequate anteroposterior projection of the zygomatic body and an increase in facial width. Accurate assessment of the position of the zygomatic arch in relation to the cranial base posteriorly and the midface anteriorly is the key to the acute repair of complex midfacial fractures and the secondary reconstruction of posttraumatic deformities of the orbitozygomaticomaxillary complex. Loss of projection of the zygomatic arch may occur with injuries confined to the orbitozygomaticomaxillary region or in association with complex midfacial fractures. A safe anatomic approach to the zygomatic arch allows exact anatomic restoration of the zygomatic arch using miniplates and screws and results in the reconstruction of an outer facial frame with a correct anteroposterior projection and facial width. The zygomatic arch injury is diagnosed using axial CT scanning. Three-hundred and seventeen arches have been exposed through a coronal incision following acute trauma and 47 arches have been exposed in patients requiring late correction of a posttraumatic orbitozygomaticomaxillary deformity. Permanent palsy to the frontal branch of the facial nerve has occurred in one patient following the exact definition of the anatomy of this region.
TL;DR: It is hypothesized that the differences found in bone grafts of membranous and endochondral origin differ greatly in their cortical to cancellous diploe ratios and architectural configuration are related to the three-dimensional osseous architecture rather than to the embryonic origin of bone per se.
Abstract: A prospective study using 46 young adult New Zealand rabbits was designed to evaluate onlay bone grafts to the craniofacial skeleton with respect to embryonic origin (membranous or endochondral), gross morphology (unicortical or bicortical), and orientation (cortex-to-bed relationship). Quantitative and qualitative data were analyzed and contrasted at both periods of evaluation (1.5 and 3.0 months)
TL;DR: A surgically implanted device for expanding soft tissues for subsequent use in surgery is described in this article, which consists of an envelope portion constructed of a material that is substantially impermeable to extracellular body fluids.
Abstract: A surgically implanted device for expanding soft tissues for subsequent use in surgery The device consists of an envelope portion constructed of a material that is substantially impermeable to extracellular body fluids A window portion is attached to the envelope and constructed of a material which is readily permeable by extracellular body fluids An osmotic agent is disposed within the device and induces an osmotic differential across the window portion causing extracellular body fluids to be drawn into the device As increasing amounts of extracellular fluid are drawn into the device, the material of the envelope expands and subsequently causes the overlying tissue to also expand A substantially rigid base may be provided to limit the direction of this expansion The window and osmotic agent may also be incorporated into a remotely positioned fill port The fill port is connected to the envelope by a conduit which permits the transfer of fluid from the port to expand the envelope
TL;DR: The effect of lymph vessel transplantation has been evaluated by volume measurements and lymphatic scintiscans, showing a persistent patency of grafts, improvement of the transport index, and a persistent reduction in volume of the affected limbs.
Abstract: Lymphedemas due to a local blockade of the lymphatic system can be treated by bridging the defect with autologous lymphatic grafts. Under the microscope, grafts are anastomosed to peripheral lymphatics distal to and central lymphatics proximal to the regional blockade. In this way, the diminished transport capacity can be restored. In the case of unilateral blockade at the groin or pelvis, the grafts connect the lymphatics of the thigh of the affected leg with lymphatics in the contralateral healthy groin. Between June of 1980 and December of 1986, 55 patients with lymphedemas have been treated by lymphatic grafting. The effect of lymph vessel transplantation has been evaluated by volume measurements and lymphatic scintiscans, showing a persistent patency of grafts, improvement of the transport index, and a persistent reduction in volume of the affected limbs. The reduction reached a level of 80 percent in patients with a follow-up of at least 3 years. The transport index showed an improvement of 30 percent. Autologous lymph vessel transplantation has been shown to be a fundamental step toward the microsurgical treatment of lymphedema.
TL;DR: Electron micrographs confirm structural defects created in the membranes by the applied electric field pulses, and represent the first clear demonstration of rhabdomyolysis in intact muscle due to electroporation, providing compelling evidence in support of the postulate.
Abstract: High-voltage electrical trauma frequently results in extensive and scattered destruction of skeletal muscle along the current path The damage is commonly believed to be mediated by heating Recent experimental and theoretical evidence suggests, however, that the rhabdomyolysis and secondary myoglobin release that occur also can result from electroporation, a purely nonthermal mechanism Based on the results of a computer simulation of a typical high-voltage electric shock, we have postulated that electroporation contributes substantially to skeletal muscle damage and could be the primary mechanism of damage in some cases of electrical injury In this study, we determined the threshold field strength and exposure duration required to produce rhabdomyolysis by the electroporation mechanism The change in the electrical impedance of intact skeletal muscle tissue following the application of short-duration, high-intensity electric field pulses is used as an indicator of membrane damage Our experiments show that a decrease in impedance magnitude occurs following electric field pulses that exceed threshold values of 60 V/cm magnitude and 1-ms duration The field strength, pulse duration, and number of pulses are factors that determine the extent of damage The effect does not depend on excitation-contraction coupling Electron micrographs confirm structural defects created in the membranes by the applied electric field pulses, and these represent the first clear demonstration of rhabdomyolysis in intact muscle due to electroporation These results provide compelling evidence in support of our postulate
TL;DR: This text describes the open structure approach to rhinoplasty, with step-by-step examples of the surgical procedure, including preoperative evaluation, surgical highlights, and precise schematic operative diagrams.
Abstract: This text describes the open structure approach to rhinoplasty, with step-by-step examples of the surgical procedure. Provides numerous case studies of primary and secondary open technique rhinoplasty, including preoperative evaluation, surgical highlights, and precise schematic operative diagrams. Also discusses alar base reduction, harvesting conchal cartilage, chin augmentation, tip grafting and more. Augments in depth descriptions with over 710 color illustrations and photographs, and 200 black and white operative drawings.
TL;DR: The effect of increased quantities of abdominal fat is greater than that of a similar increase in total body fat on the risks of ill health associated with obesity.
Abstract: Obesity--defined by a body mass index above 30 kg per m2--is a major problem for affluent nations. Its prevalence is higher in North America than in Europe--between 9% and 12% of the population. Reduced energy expenditure from exercise or metabolism or both may be an important contributory factor in the development of obesity because of a failure to reduce food intake sufficiently to maintain energy balance. A high ratio of abdominal circumference relative to gluteal circumference carries a twofold or greater risk of heart attack, stroke, hypertension, diabetes mellitus, gallbladder disease, and death. The effect of increased quantities of abdominal fat is greater than that of a similar increase in total body fat on the risks of ill health associated with obesity. Genetic factors appear to contribute about 25% to its etiology.
TL;DR: In patients with advanced cancer, extensive esopha-geal resection into the chest is often required, and gastric pull-up seems to be an easier and more direct form of reconstruction, andFree jejunal transfer is simpler and avoids mediastinal dissection, as well as other advantages and disadvantages of both techniques will be discussed.
Abstract: Use of enteric grafts is a popular method for reconstruction of the cervical esophagus and hypopharynx. Free jejunal transfer (FJT) and gastric pull-up (GP) are the most popular methods used. This discussion is a retrospective review of our experience with 50 cases of free jejunal transfer and 15 cases of gastric pull-up. The graft survival rate was 94 percent (47 of 50) for free jejunal transfer and 87 percent (13 of 15) for gastric pull-up. Successful swallowing was achieved in 88 percent (44 of 50) of free jejunal transfers and 87 percent (13 of 15) of gastric pull-ups. Patients with free jejunal transfers were able to swallow and leave the hospital sooner: 10.6 versus 16.0 days and 22.3 versus 29.0 days, respectively. Fistulas occurred in 16 percent (8 of 50) of free jejunal transfers, most of which (6 of 8) healed spontaneously. Fistulas occurred in 20 percent (3 of 15) of gastric pull-ups, only one of which healed spontaneously. Stricture was the most common late complication for free jejunal transfers, 22 percent (11 of 50), whereas reflux was most common in gastric pull-ups, 20 percent (3 of 15). In patients with advanced cancer, extensive esophageal resection into the chest is often required, and gastric pull-up seems to be an easier and more direct form of reconstruction. In limited resection of the hypopharynx and esophagus, especially with proximal lesions, free jejunal transfer is simpler and avoids mediastinal dissection. This concept as well as other advantages and disadvantages of both techniques will be discussed.
TL;DR: Parallel treatment of different sites of the same lesion coupled with skin biopsies and histologic examination revealed that a change in the wavelength from 577 to 585 nm allowed the laser light to penetrate from the midreticular dermis into the subcutaneous fat.
Abstract: Although the flashlamp-pulsed-dye laser has been successfully used for the treatment of port-wine stains (PWS) at 577 nm, a number of adult patients had incomplete clearance of their birthmarks with this treatment modality because of residual vessels lying beyond the 0.75-mm penetration depth of 577-nm irradiation. Fifteen adult patients, of whom nine were previously treated with limited success at 577 nm (group A), and six untreated patients (group B) were included in the study. For the group A patients, treatment with 585 nm produced successful clearance of the birthmark. For the six patients in group B, parallel treatment of different sites of the same lesion coupled with skin biopsies and histologic examination revealed that a change in the wavelength from 577 to 585 nm allowed the laser light to penetrate from the midreticular dermis into the subcutaneous fat. This explained the clearance achieved at 585 nm and not at 577 nm.
TL;DR: This paper reports the experience in facial reanimation using free innervated muscle transfer in 69 patients with long-term facial palsy and believes that use of the same cranial nerve is superior to methods that involve other cranial nerves, where spontaneity is often not achieved.
Abstract: This paper reports our experience in facial reanimation using free innervated muscle transfer in 69 patients with long-term facial palsy. The majority of patients were treated in two stages with cross-facial nerve graft as the first stage and microvascular muscle transfer at the second stage. The gracilis muscle was used in 62 patients. A system of grading results has been utilized in the long-term evaluation. The overall final result was excellent or good in 51 percent of 47 patients who were available for follow-up. Although the results are not completely satisfactory, they justify the use of this approach to a difficult clinical problem. The results are improving as technical modifications to the procedure have evolved. The gracilis muscle is a reliable free transfer with internal anatomy conductive to use for reanimation of the paralyzed face. This type of transfer, in our experience, has proved superior to nonmicrosurgical methods for treatment of complete and severe incomplete facial palsy. The seventh cranial nerve is used in the innervation of the transferred muscle, the ipsilateral being preferable if available. The authors believe that use of the same cranial nerve is superior to methods that involve other cranial nerves, where spontaneity is often not achieved.
TL;DR: Although revascularization is a necessary precondition for bone resorption and deposition, biomechanical and structural factors may be a more satisfactory explanation for the differences observed in the maintenance of bony volume.
Abstract: This paper investigates the relationship between bone resorption, the process of bone revascularization, and graft fixation. Vital staining techniques and microangiography were used to study the extent of graft revascularization of fixed and nonfixed endochondral (rib) and membranous (skull) onlay b
TL;DR: It is hypothesized that the pathogenesis of Romberg's disease involves chronic cell-mediated vascular injury and incomplete endothelial regeneration along branches of the trigeminal nerve (lymphocytic neurovasculitis).
Abstract: Romberg's disease is an uncommon and poorly understood condition manifested by progressive hemifacial atrophy of skin, soft tissue, and bone. In order to better define the natural history and anatomic variation of this disorder, we evaluated 41 patients by history, physical examination, and facial radiographs. Light microscopic studies were performed on tissue from 19 patients, and ultrastructural analysis was performed on specimens from 6 patients. The average age at inception of the disease was 8.8 years. Atrophy, within one or more trigeminal nerve dermatomes, progressed at a variable rate (mean period of active tissue dissolution = 8.9 +/- 6 years). In 26 patients with skeletal involvement, the mean age of onset was 5.4 years, versus 15.4 years for 15 patients without skeletal involvement, a statistically significant difference (p less than 0.01). However, there was no correlation between the severity of soft-tissue deformity and the age of onset. Electron microscopy demonstrated lymphocytic infiltrates in neurovascular bundles and abnormalities of vascular endothelium and basement membranes. We hypothesize that the pathogenesis of Romberg's disease involves chronic cell-mediated vascular injury and incomplete endothelial regeneration along branches of the trigeminal nerve (lymphocytic neurovasculitis).