Galeo-pericranial flaps in the forehead: a study of blood supply and volumes.

Despite their extensive use in anterior cranial base reconstruction, very little is understood about the blood supply of galeo-pericranial flaps derived from the forehead region. The goal of this study was to define the extent of the reliable axial blood supply and to determine the volumes of these flaps. The blood supply to anteriorly based galeo-pericranial flaps depends entirely upon the deep branches and a variable component of the superficial branches of the supraorbital and the supratrochlear vessels. The axial component of the blood supply to these flaps is 20-70 mm. The extent of "random' pattern blood supply distal to this could not be adequately assessed. The volumes of various galeo-pericranial flaps range from 3 to 48 cc. The well vascularized proximal portions of galeo-pericranial flaps may well serve the reconstructive needs of the anterior cranial base. Use of more distal portions of these flaps should be undertaken with caution. Some increase in bulk and vascularity may be achieved if the pericranial and the galeal-frontalis myofascial flaps are harvested as a single unit, the composite galeal-frontalis-pericranial flap. Due to the vascular and volume limitations of galeo-pericranial flaps, consideration should be given to the use of microvascular free tissue transfers in instances where large soft tissue defects and a large "dead space' occur.

The accuracy of duplex ultrasonography in the planning of skin flaps in the lower extremity.

The septocutaneous perforators represent one of the major sources of the blood supply to the skin of the lower extremity. Despite several well-described anatomic accounts, the location of lower leg septocutaneous perforators, as they originate from each of the three main infrapopliteal vessels in the leg, remains inconsistent as a result of individual anatomic variations. With the aid of duplex ultrasonography (color Doppler imaging), preoperative, mapping and size determination of these perforators can be provided. The skin paddle can then be designed to lie exactly over these perforators, ensuring blood supply to the skin paddle. The location and distribution of medial septocutaneous perforators in the leg, which originate from the posterior tibial artery, were mapped using anatomic dissections (29 lower extremities). These findings were then compared with duplex ultrasonographic data in 9 living volunteers (18 lower extremities). The medial septocutaneous perforators were chosen for this study because they course directly over the posterior tibial artery, making their location difficult to assess with standard Doppler techniques. The hand-held Doppler is incapable of distinguishing flow originating from the perforators versus the posterior tibial artery. No significant difference existed between cadaver and duplex distributions. "Large" perforator vessels (> 1 mm outer diameter) were evenly distributed with a central tendency at 140 to 150 mm from the medial malleolus. The distribution of "small" perforator vessels (< 1 mm outer diameter) was skewed. Fifty percent were found within 80 mm of the medial malleolus and the remainder spread proximally in the leg.(ABSTRACT TRUNCATED AT 250 WORDS)

The gastrocnemius muscle as a free-flap donor site.

Despite the fact that the pedicled gastrocnemius flap has been used clinically for almost two decades, precise data on its neurovascular anatomy are lacking. A detailed knowledge of the neurovascular anatomy of this flap may encourage its more extensive use as a donor site by the means of microvascular free-tissue transfer. The femoral or popliteal artery in 27 fresh cadavers was injected with radiopaque contrast material to study the gross vascular supply of 54 medical and 50 lateral gastrocnemius muscles. The intramuscular vascular anatomy also was analyzed in 29 medial and 24 lateral gastrocnemius muscles using x-ray technique. Depending on the number of the sural arteries that supply the gastrocnemius muscle, flaps were classified as type 1 or type 2. Type 1 muscle bellies (lateral or medial gastrocnemius muscle belly) are supplied by one sural artery, while in type 2 muscles two arteries supply one muscle belly. Eighty-five percent of medial and 84 percent of lateral gastrocnemius muscle bellies had single vascular pedicles (type 1). The point of origin of the sural artery(s) permitted us to further classify the blood supply to the muscle bellies as subtypes A, B, and C. Intramuscular vascular anatomy is characterized as either a single vessel (dominant type) or two vessels (nondominant type). A single motor nerve, from the tibial nerve, accompanied the primary vascular pedicle into each muscle belly. When there were two vascular pedicles supplying one muscle belly, only one motor nerve accompanied the major pedicle.(ABSTRACT TRUNCATED AT 250 WORDS)

Atraumatic enophthalmos: a report of two unusual cases.

There are many causes of enophthalmos other than those directly related to maxillofacial trauma. As plastic surgeons, we should be aware of these, in the event that we are consulted concerning their treatment. We have presented two cases that, while not unique to the literature, are uncommonly seen by plastic surgeons. In both these cases, CT scans were valuable in the preoperative diagnosis, as well as in the surgical treatment planning. We feel that, ideally, orbital volume content measurements would assist in better assessment of each patient. When a patient presents with enophthalmos and denies any history of facial trauma, one needs to be diligent in the investigation of its etiology.

The prevention and treatment of lower lid ectropion following blepharoplasty.

Ectropion and scleral show are the most common complications following lower lid blepharoplasty. Certain conditions predispose patients to ectropion, and these should be evaluated. In some cases, the addition of a wedge tarsectomy or tarsal strip procedure to a blepharoplasty in association with careful technique and postoperative measures is important in prevention of postblepharoplasty ectropion. Postoperative ectropion should initially be treated conservatively with massage. This may be effective up to 6 months postoperatively. If conservative measures fail, the etiology of the ectropion should be addressed. Laxity of the tarsus and canthal ligaments benefit from a horizontal lid-shortening procedure. Where there is vertical shortening from excessive skin resection or scarring of the orbital septum, there should be release and grafting of the deficiency.

Syringe aspiration and fat concentration: a simple technique for autologous fat injection.

Autologous fat grafting, a technique used earlier this century, has recently been proposed for reconstruction of contour defects, especially of the face. A simple technique is described for harvesting fat, removing serum, blood, and liquid fat, and then injecting the concentrated fat into contour defects. Atraumatic harvesting and fat concentration are the keys to greater fat graft survival.

Use of cartilage graft for an orbital socket implant.

After enucleation, a spherical implant of some material is placed into the muscle cone to give bulk to the orbital socket area. This also allows better movement of the artificial eye prosthesis, which is placed in the socket to give the appearance of a normal eye. If there is loss of the spherical implant because of infection or extrusion for other reasons, there is a resulting enophthalmos of the prosthetic eye. Replacement of this spherical implant with another implant of alloplastic material often results in secondary extrusion. In other cases, there is downward displacement of the spherical implant with pressure against the prosthesis and lower lid. This causes undue stretching of the lower fornix and lid area with inability to hold the prosthesis in place. To correct these two problems, we have found that an autogenous cartilage graft is useful for an implant that will not extrude and that holds its position. Examples of this technique and preoperative and postoperative cases are described here. We have used this technique over the past 11 years and have achieved good success in 15 patients.

Simple suction drainage: an adjunct to septal surgery.

Postoperative hematoma is a complication of septal surgery that can be associated with significant morbidity and possibly even mortality in some cases. A simple suction drainage technique using a scalp vein cannula and vacuum tube can prevent a septal hematoma without the need for bulky nasal packing (with its attendant nasal obstruction and risk of bleeding on removal). The technique is also useful for postoperative drainage of an established septal hematoma or abscess secondary to trauma.

Cosmetic and functional considerations in ptosis surgery. The elusive "perfect" result.

Correction of ptosis to achieve a fair or even good result is usually possible, but the "perfect" result is often elusive. Many factors play a part in diagnosis and repair of the ptotic lid, and these factors may enhance or inhibit the achievement of the best result. The correct operation must be selected for each type of ptosis with the realization that the best obtainable result may necessarily fall short of the elusive "perfect" result.

Surgical anatomy of the eyelids.

The key to precision surgery of the eyelids and orbital area is a complete knowledge of surgical anatomy. The author reviews the form and function of individual anatomic constructs as they pertain to surgery.

Levator advancement technique for eyelid ptosis.

There have been many procedures advocated for the treatment of eyelid ptosis. The technique advocated in this paper consists of careful dissection and identification of anatomic landmarks, including preaponeurotic fat, Whitnall's superior transverse ligament, and the vertically oriented blood supply of the levator muscle. The attachment of the levator muscle into the cephalad portion of the levator muscle into the cephalad portion of the levator aponeurosis can be identified and easily dissected in order to perform the procedure of detachment and advancement to the tarsal plate. This procedure for ptosis has been successful in management in moderate to severe ptosis and in some cases has actually increased the muscle function, thereby enhancing the result. In this technique, the full length of levator muscle remains, so maximum excursion is achieved postoperatively. In addition, this surgical approach may be utilized for levator-lengthening procedures in cases of thyroid exophthalmus or overcorrected ptosis simply by performing the reverse procedure of detachment and insertion of a spacer based on the same ratio. Good results have been achieved in over 20 patients, with the exception of two patients who had absent to poor function and in whom undercorrection was present postoperatively.