摘要:

Endoscopic facial surgery is gaining wide acceptance, as results are providing comparable if not superior to the standard, superficial musculoaponeurotic system rhytidectomy, with minimal scarring. Frontal branch facial nerve injury remains a troublesome complication. The purpose of our study was to determine if a subciliary retrograde dissection would decrease facial nerve injury and allow for more accurate midfacial suspension. Fresh cadaver dissections were performed using endoscopic equipment. Anterograde temporal incisions in the scalp and retrograde subciliary incisions were studied. The anterograde temporal dissection was developed deep to the superficial layer of the deep temporal fascia. Retrograde subciliary dissection was subperiosteal. Forty-nine endoscopic-assisted midface lifts were performed. Midfacial suspension was accomplished with nonabsorbable sutures placed in the suborbicularis oculi fascia, anchored to the deep temporal fascia. Two of three endoscopic-assisted procedures done in the anterograde fashion, without a subciliary incision, experienced transient frontal branch injury, which resolved within 6 weeks. The remaining forty-six patients, operated with a combined subciliary and temporal approach, experienced no frontal branch injuries. We have found that the retrograde dissection through a subciliary incision substantially reduced the incidence of facial nerve injury, provided direct visualization of the suborbicularis oculi fascial layer (allowing more accurate midfacial suspension), and reduced total operative time.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Management of fractures involving the nasofrontal duct region of the frontal sinus has focused on preserving function when possible or obliterating the sinus and duct when fracture patterns potentiate ductal obstruction and possible transcranial seeding of bacteria. When frontal sinus preservation is in doubt, controversy surrounds the use of cranialization versus obliteration, and the method of obliteration. Perioperative and late postoperative infections are uncommon, but their occurrence jeopardizes an often complex reconstruction and can be life threatening. This paper describes the design and indications for a pedicled transverse glabellar muscle flap for obliteration of the nasofrontal duct, thereby isolating the anterior cranial base from the aerodigestive system. This vascularized muscle flap utilizes the corrugator supercilii and procerus muscles, which are introduced into the sinus via a small, surgically created window in the superomedial orbital wall without disturbing the central facial aesthetic contours. Six patients with comminuted fractures at the nasofrontal duct level associated with displaced posterior frontal sinus fractures have been treated with the transverse glabellar flap. Follow-up ranges from 8 to 30 months. There have been no early or late postoperative complications. The transverse glabellar flap is a reliable and versatile method of partitioning the upper aerodigestive tract from the anterior cranial base with vascularized tissue, thus minimizing the risk of infectious complications. The resulting donor site deformity is more acceptable than that seen with the traditional pedicled galeal frontalis flap.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Endoscopic-assisted carpal tunnel release (CTR) is a blending of the techniques of the open and endoscopic methods of carpal tunnel release. Endoscopic-assisted CTR increases visualization and safety over commonly performed endoscopic techniques while retaining the advantage of a smaller, more distally located scar and less dissection.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

The midpalmar approach involves making a 2.5-cm incision in the palm, sparing the skin directly overlying the carpal tunnel. Through this incision, a small fiber-optically illuminated retractor is introduced, which allows direct inspection of the transverse carpal ligament and any anatomic variations of the median nerve. The transverse carpal ligament can then be safely and completely divided under direct visualization. This approach also allows inspection of the carpal tunnel for any space-occupying masses or neurolysis, if deemed necessary. By avoiding a skin incision directly over the carpal tunnel, the postoperative course is very gentle and very similar to that of an endoscopic release. Unlike the endoscopic release, this approach is versatile, easy to learn, allows complete visualization of the anatomy, and does not require expensive instrumentation.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Previous publications have described persistent postganglionectomy symptomatology. One report demonstrated scapholunate instability in a small number of patients. We specifically examined our ganglionectomy patients for wrist instability. Ninety-one consecutive cases of wrist ganglionectomy performed from 1987 through 1993 by the senior author (FMW) were studied. Most patients were contacted by telephone and questioned with a standardized interview format. Postoperative course, job changes and occupational restrictions, and patient satisfaction were queried. Range of motion, grip strength, scaphoid mobility, and radiographs were studied to characterize scapholunate static and dynamic relationships. Seventy-one percent (N = 61) of the operated patients were interviewed at an average postoperative interval of 44 months. Twenty-five percent (N = 21) had wrist symptoms. There was no late ganglion recurrence. Twenty of the 21 symptomatic patients (95%) had normal ranges of motion and no carpal instability. Grip strengths averaged 12% below normal in 45% of the dominant operated hands. Radiographs demonstrated no scapholunate dissociation or dynamic instability patterns. Wrist ganglionectomy does not destabilize the wrist, particularly the scapholunate joint. Thorough and meticulous extirpation of the ganglion is warranted. Additional minor problems, both as consequences of the operation and as unrelated concomitants, do occur and deserve attention. Hand surgeons assume cure of the problematic wrist because of the patient's failure to report tolerable problematic sequelae. A late revisit may reveal (1) treatable problems emanating from the dynamic forces contributing to original ganglion formation; (2) additional, unanticipated, treatable conditions resulting and not resulting from the ganglionectomy itself; and (3) ganglion recurrence.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Plagiocephaly is a term commonly used to describe congenital forehead asymmetry. Previous classification systems based on the various etiologies of dysmorphic crania have been used in an effort to categorize the patients into groups and to assist in treatment planning. The system most commonly used today was described by Bruneteau and Mulliken in 1992. The authors separated frontal plagiocephaly into three types: synostotic, compensational, and deformational. The present study was undertaken in order to define a simple system for classifying plagiocephaly based on Bruneteau and Mulliken's system using the patients' preoperative craniofacial computed tomography scans. The involvement of the entire coronal ring in synostotic plagiocephaly led to the choice of 20 skull base landmarks as the basis of the analysis. Nine lateral landmarks (the superior orbital fissure, the optic foramen, the zygomatic arch, the greater palatine foramen, the foramen ovale, the mastoid tip, the hypoglossal canal, the external auditory canal, and the internal auditory canal) and two midline landmarks (the crista galli and the internal occipital protuberance) were used. The changes that occurred in these landmarks were analyzed in 30 patients. The results demonstrated that Bruneteau and Mulliken's classification system underestimated the number of different subtypes of plagiocephaly. As a result, three major types of frontal plagiocephaly and several different subtypes based on the different etiologies were described. Type I plagiocephaly includes plagiocephaly resulting from cranial suture synostosis. Type II includes those with a nonsynostotic etiology. Type III describes patients with craniofacial microsomia-associated plagiocephaly. Statistical analysis was unavailable because of the small number of patients in each subtype. With a larger number of patients, we hope to refine this system for use by the surgeon in preoperative diagnosis and surgical planning. The analysis is unique in its ability to quantitate changes from normal on the x-, y-, and z-coordinates, and therefore allows for identification of both horizontal (frontal bone deviation) and vertical (ear shear) growth disturbances.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Advances in surgical intensive care have improved survival in patients with major traumatic or infectious intra-abdominal insults. Patients who recover are often left with massive abdominal wall defects. Sufficient autogenous tissue may not be available for reconstruction and synthetic mesh followed by skin grafting can lead to unaesthetic results or complications. We report on four patients with abdominal wall defects and their reconstruction after intra-abdominal injury. Treatment involved local wound care to stimulate granulation tissue, which is eventually skin grafted to close the wound. Patients are then allowed to make a full recovery. Soft-tissue expanding prostheses are placed during a second operation and inflated over subsequent weeks. Finally, the skin graft is excised, a polytetrafluoroethylene patch is placed into the fascial defect, and the expanded skin is used to achieve wound closure.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Intraoperative skin expansion is not a new concept. We have developed a technique using readily available inexpensive material to achieve wound closure. In this prospective study, 15 patients (age range, 1–72 years) with melanoma, giant nevi, scars, meningocele, gastroschisis, alopecia, thrombosed renal dialysis fistula, calcified nodule and trauma, with defects on back, limbs, abdomen, scalp, hand, calcaneum, and sole of foot were treated. Only hypodermic needles and dental wire, with an overall cost of less than a dollar, are needed for the immediate skin expansion technique. In contrast, the numerous other commercial devices currently in use are costly and must be ordered in advance. Using our technique, the wound can be gradually approximated and subcutaneous sutures placed with the device in situ. An intradermal or simple running suture is then placed to approximate the skin edges under little or no tension and the device is removed. All patients had a good result with minimal morbidity. The wounds treated by this technique healed by primary intention except in 3 patients, who developed minor dehiscence of the wounds.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

This single-stage nipple reconstruction technique is designed to produce a properly pigmented nipple-areolar complex that projects well above the breast mound without the need of skin grafts. The basic design of this technique consists of a bell-shaped random pattern flap within a circular subcutaneous island flap. The bell-shaped flap is incised, undermined, elevated, and folded into the shape of an inverted box, forming the new nipple. The remainder of the circular island flap is circumferentially incised, partially undermined, and sutured into a flat cone, forming the new areola. The nipple is inset in the center of this cone, completing the new nipple-areolar complex. This complex is then squeezed and pushed forward by the closure of a purse string suture placed on the raw edge of the outer skin circle. Predetermined pigments are tattooed immediately prior to the skin incisions and Montgomery's tubercles can be added after the pursestring closure by high-temperature cautery or biopsy punch. This technique has been attempted on six nipples in 5 patients for breast mounds reconstructed by musculocutaneous flaps or from breast reductions with satisfactory-to-good results in the past 2 1/2 years. However, at this time, it has not been, nor should it be attempted on breast mounds reconstructed solely by implants, due to unpredictable subcutaneous blood supply.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Microvascular thrombosis and free flap failure are complications of free tissue transfer for coverage of lower extremity soft-tissue and bony defects despite appropriate vessel selection and adherence to meticulous technique. Increased rates of flap failure have been associated with reconstruction performed between 3 days and 6 weeks after injury, as well as in patients with thrombocytosis. We have found that serum platelet levels rise significantly after lower extremity injury. It is our theory that a circulating mediator or cytokine is released in response to injury, inducing the thrombocytosis. Twenty-one patients with Gustilo grade IIIb and IIIc injuries were studied prospectively. Serum was collected throughout the postinjury period. Platelet count, leukocyte count, hemoglobin concentration, and hematocrit were determined. Samples were also subjected to a platelet aggregation study as well as enzyme-linked immunosorbent assay for interleukin-3, interleukin-6, interleukin-11, and granulocyte macrophage-colony-stimulating factor. Megakaryocyte growth and development factor enzyme-linked immunosorbent assay and a myleoproliferative leukemia virus-transfected cell line assay for thrombopoietin were performed. Bone marrow was studied with flow cytometric analysis. Mean initial platelet count was 196,000 per cubic millimeter. There was an initial 26% decline to 140,000 per cubic millimeter, followed by an increase to 361% of baseline on day 16. No significant variations in serum leukocyte count or hemoglobin concentration were seen. Spontaneous and induced platelet aggregation responses were normal, Interleukin-6 was detected at elevated levels. However, interleukin-3, interleukin-11, granulocyte macrophage-colony-stimulating factor, and thrombopoietin were not measurable. Marked megakaryocytosis was seen on bone marrow analysis. Interleukin-6 may, therefore, play a role in the mechanism of thrombocytosis. We suggest that because patients with complex bony injuries of the leg experience platelet elevations that peak approximately 2 weeks after injury, microvascular free flap reconstructions should be considered high risk during this time period.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID