The subtarsal incision: where should it be placed?

PURPOSE: The subtarsal incision is a frequently used approach to orbital floor fractures. Compared with the subciliary incision, there is a lower rate of lower lid retraction. Unlike the transconjunctival incision, there is no need to perform a lateral canthoplasty to restore canthal integrity. Despite its widespread use, the exact location of the subtarsal incision is not uniform among surgeons. MATERIALS AND METHODS: Twenty patients underwent open reduction and internal fixation of orbital floor fractures by a single surgeon over a 4-month period, using the subtarsal incision. Postoperative photographs of the first 7 consecutive patients were analyzed by 4 nonmedical personnel and 4 plastic surgeons regarding scar visibility. Pearson correlation coefficients were calculated to determine if a correlation existed between more inferior placement of the scar and scar visibility. RESULTS: No patients in the series developed any complications such as lower lid retraction or enophthalmos. One patient developed transient facial palsy. The results of the survey showed a positive correlation between distance from lash line to scar and scar visibility at the level of the lateral limbus (Pearson r coefficient, 0.73) and at the level of the lateral canthal angle (Pearson r coefficient, 0.65). CONCLUSIONS: The results of this study indicate that the optimal placement of the subtarsal incision is as close as possible to the inferior border of the tarsal plate. The incision should be placed within an existing skin crease, if possible, and should be made with the knowledge that the more inferior the incision is placed, the greater the visualization of the fracture, but the more visible the scar.

Radial forearm free flap morbidity: A rare case of a normal preoperative arteriogram and acute intraoperative hand ischemia.

Since its first description in 1981, the radial forearm free flap has become a valuable tool for reconstructive microsurgery. However, there are potential complications associated with the flap - the most feared being hand ischemia from sacrifice of the radial artery. Fortunately, acute ischemic complications are exceedingly rare, with only two cases reported in the literature. Options for preoperative evaluation of the donor extremity include the Allen's test, ultrasonography and angiography. A preoperative arteriogram is considered to be the definitive method to evaluate arterial anatomy, patency, and collateralization between the radial and ulnar arteries. The current article presents the authors' experience with a patient who had a delayed Allen's test and a normal arteriogram of his left upper extremity, and who developed acute intraoperative hand ischemia, requiring reconstruction of his radial artery, after elevation of a radial forearm free flap.Although exceedingly rare, the occurrence of acute vascular insufficiency is always a possibility and must be kept in mind when harvesting a radial forearm free flap. The surgeon should be prepared to perform an interposition vein graft reconstruction to avoid any potential complications. Clinical examination and judgment may be more important than radiological studies in certain cases.

Umbilical hernia repair in conjunction with abdominoplasty: a surgical technique to maintain umbilical blood supply.

Abdominal wall hernias are often diagnosed on clinical examination or encountered intraoperatively during an abdominoplasty. Traditional surgical techniques for abdominoplasty and umbilical hernia repair, when performed simultaneously, can potentially compromise the vascular supply to the umbilicus. The authors describe a simplified surgical technique for the correction of umbilical hernias in conjunction with abdominoplasty. This procedure avoids any fascial incisions immediately adjacent to the umbilicus, thereby maintaining a maximal blood supply to the umbilical stalk. Over a six-year period, 17 patients underwent the described procedure. None have had a recurrence of their hernia or umbilical necrosis, and the aesthetics of the umbilicus have been improved.

Ethnic considerations in buttock aesthetics.

There has been increased interest in buttock contouring and augmentation in recent years, which has translated into increased demand for these procedures. In addition, we are witnessing a growing number of patients from all ethnic groups requesting cosmetic surgery in the United States. Buttock aesthetic surgery today consists of either augmentation or recontouring of the gluteal region by one of three methods: (1) liposuction (if only reductive shaping is required); (2) liposuction and augmentation by micro fat grafting; and (3) gluteal implants. Whereas there certainly exists a "universal ideal" of beauty in buttock augmentation, there are fundamental ethnic differences that must be recognized to achieve a desirable surgical outcome. We present an article reviewing current trends in buttock aesthetic procedures and discuss issues relevant to the ethnic populations.

"Universal" and ethnic ideals of beautiful buttocks are best obtained by autologous micro fat grafting and liposuction.

Recently there has been a dramatic increase in the number of patients seeking buttocks enhancement and in the degree of augmentation requested. To fulfill these requests,aesthetic plastic surgeons must understand the patient's personal requests and ethnic identity, as well as any universal ideal of proportions and contours that create the impression of beautiful buttocks. "Universally" perceived ideal buttocks are 1.4 times the circumference of the waist, which is consistent cross-culturally and throughout history. Beyond this are important ethnic differences in the image of perfect buttocks shape. The combination of autologous micro fat grafting and liposuction is the best and possibly only way to obtain various ideal shapes, and offers a lower incidence of complications compared with buttock implants.

Complications of buttocks augmentation: diagnosis, management, and prevention.

Over the past several years, there has been a tremendous growth and interest in buttocks augmentation in the United States. Surgical techniques have evolved over time to correct anatomical deficiencies and fulfill patient requests, including silicone implant placement (subcutaneous, intramuscular, submuscular, and subfascial) and autologous micro fat grafting. Unfortunately, these techniques have presented great challenges with regard to the incidence, diagnosis, management, and prevention of various postsurgical complications. Extensive collaboration and transparency in discussing complications has resulted in refinement of both surgical technique and medical management,resulting in improved outcomes for patients undergoing buttocks augmentation.

Objective outcome analysis of soft shell helmet therapy in the treatment of deformational plagiocephaly.

Deformational plagiocephaly, cranial asymmetry secondary to positioning, continues to be a leading cause of head shape abnormalities in infants. Treatment recommendations include nonintervention, positioning therapies, and helmet therapy. Although most agree that surgical intervention is rarely indicated, the ideal therapy is not agreed on. Some even debate the necessity of treatment, especially third-party payers. The purpose of this prospective study is to use an objective outcome analysis tool, computerized tomography, to assess the efficacy of a soft shell helmet therapy. Sixty-nine children with a diagnosis of deformational plagiocephaly were enrolled in this study to assess the success of a soft shell helmet for the correction of cranial asymmetry. Computed tomography scanning was done before therapy and 6 months after the initiation of therapy. Three-dimensional reconstructions of these scans were reformatted into a standardized orientation by utilizing the nasion (radix), frontozygomatic suture lines, and posterior aspect of the foramen magnum. Intracranial volumes were calculated on a quadrant basis, and asymmetry was evaluated with regard to the hemispheres (left versus right) and the posterior quadrants. Thirty-four children (27 boys and 7 girls) completed the study protocol. The side involved was the right in 62% of cases and the left in 38%. Mean age at the initial scan was 6.3 months, and mean age at the follow-up scan was 14 months. Mean duration of helmet therapy was 7 months. Compliance with therapy was average to above average in 88% of the children and poor in 12%. There was a 36% to 54% improvement in asymmetry in the compliant patients over the 6-month study period. Soft shell helmet therapy is an effective technique to decrease cranial asymmetry based on objective outcome measurements. Additionally, it is cost-effective, with the total cost of therapy for the helmet and office visits ranging from 600 dollars to 700 dollars. This therapy compares favorably with other more expensive and time-consuming therapies that have been reported in the literature.