Endermologie after external ultrasound-assisted lipoplasty (EUAL) versus EUAL alone.

BACKGROUND: Endermologie, despite its moderate success in the temporary reduction of the appearance of cellulite, has proven unsuccessful compared with lipoplasty for body contouring. OBJECTIVE: The purpose of this study was to determine whether a body contouring program combining Endermologie with lipoplasty would produce better long-term body contouring results than lipoplasty alone. METHODS: A prospective study comparing 2 closely matched, nonrandomized groups of 25 women each was conducted. Those in group 1 underwent external ultrasound-assisted lipoplasty (EUAL) to the superficial and deep subcutaneous areas of the flanks, hips, and thighs, followed in 10 days by a 20-week Endermologie course. Those in group 2 underwent only EUAL to the superficial and deep subcutaneous areas of the flanks, hips, and thighs. Patient evaluation preoperatively and 9 months postoperatively included standardized 35-mm photography; standardized circumferential body measurements of the waist, hips, thighs, knees, and calves; and body composition analysis. Patient satisfaction was assessed through the use of a questionnaire. RESULTS: No significant complications were noted in either group. The average volume of aspirate in the 2 groups was not significantly different (group 1, 2000 mL; group 2, 2100 mL), nor were the results of standard circumferential body measurements and body composition analysis. There was, however, a reduction in the rates of subsequent revisional surgery in the 2 groups (revision rates: group 1, 4%; group 2, 12%). The results of objective blind grading demonstrated no statistically significant difference (P [equals] .30) in body contouring between the 2 groups (group 1, 92% improvement; group 2, 87% improvement). However, a statistically significant (P [lt ] .005) difference was noted for reduction in the appearance of cellulite between the 2 groups (group 1, 50% improvement; group 2, 0% improvement). Patient satisfaction was 96% in group 1 and 92% in group 2. CONCLUSIONS: Endermologie after EUAL improves postoperative results with respect to reduction in the appearance of cellulite and reduces the rate of subsequent revision but demonstrates no significant improvement over EUAL alone with respect to body contour improvement.

Detection of recurrent breast cancer after TRAM flap reconstruction.

Breast cancer remains a significant cause of morbidity and mortality among women today. The transverse rectus abdominis myocutaneous (TRAM) flap has played a substantial role in the reconstruction of defects secondary to mastectomy. Although such reconstruction has not been shown to adversely affect survival or local recurrence, specific screening modalities for recurrence in this population of patients have not been delineated. Three patients were examined retrospectively at the authors' institution. They presented with local recurrences of breast cancer after mastectomy and TRAM flap reconstruction. All patients' recurrences were detected on physical examination, and all had the diagnosis of recurrent carcinoma made on biopsy of the mass. A review of the literature demonstrates that mammography, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), scintimammography, and biopsy have all been used as adjuncts to clinical examination in detecting recurrence. Subsequent treatment of recurrent breast cancer is determined by the results of a metastatic workup and the receptor status of the tumor. The most reliable form of diagnosis of recurrent breast cancer after TRAM flap reconstruction remains fine-needle, core, or open biopsy if indicated.

Tumescent cervicofacial rhytidectomy.

A modification of the tumescent technique for body contouring has been adapted for patients undergoing face lift. Thirty women, average age 56 years, were prospectively studied, with a 1-year follow-up. All surgery was performed in a private ambulatory operating room facility. The patients were under intravenous sedation with a board-certified anesthesiologist in attendance at all times. The preferred solution was 0.3% lidocaine 1/250,000 epinephrine (average volume injected 500 mL). The solution was a mixture of Ringer's lactate 400 mL plus 2% lidocaine 50 mL and 1% lidocaine 50 mL plus 1:1000 epinephrine 2 mL. The average lidocaine dose per patient was 29.4 mg/kg. Serum lidocaine levels demonstrated a 1-hour peak at 2.7 microg/mL (no value exceeded 3.3 microg/mL). The technique began with superficial liposculpture followed by independent skin-lateral superficial musculoaponeurotic system-ectomy/platysmaplasty with wide skin undermining. Average operating time was 1 hour and 48 minutes. No operative complications were encountered. Excellent anesthetization was achieved in all patients without postoperative hematomas or nerve injuries. Tumescent cervicofacial rhytidectomy has been found to be a safe and effective rhytidectomy procedure that offers several advantages when compared with nontumescent techniques: avoidance of general inhalational agents, reduced operative bleeding and operative time, improved technical ease of superficial liposculpture and surgical dissection, and minimal postoperative bruising and swelling.

The role of the cranial base in facial growth: experimental craniofacial synostosis in the rabbit.

Craniofacial synostosis designates premature fusion in sutures of the cranial vault (calvarium). When craniofacial synostosis is associated with a syndrome (e.g., Apert, Crouzon), premature fusion of the cranial base has been postulated to occur as well. This study was designed to determine whether the primary growth disturbance in craniofacial synostosis is located at the cranial base (i.e., spheno-occipital synchondrosis) or the calvarial vault (i.e., coronal and sagittal sutures) or both. Sixty newborn New Zealand White rabbits were randomly assigned to six groups: (I) calvarial control, (II) cranial base control, (III) cranial base immobilization, (IV) coronal suture immobilization, (V) coronal and sagittal suture immobilization, and (VI) cranial base and coronal and sagittal suture immobilization. An anterior cervical microsurgical approach to the cranial base was used, while cranial vault sutures were exposed through a bicoronal scalp incision. All sutures were fused by periosteal abrasion and application of methyl cyanoacrylate. Cephalograms were taken at 30, 60, and 90 days postoperatively to assess craniofacial growth. Linear and angular measurements of facial, calvarial, and basicranial growth were subjected to multivariate analysis. Analysis indicated that (1) craniofacial length was shortened most significantly by cranial base fusion, (2) cranial base fusion and cranial vault fusion had an additive effect on craniofacial length restriction, (3) the anterior cranial base was significantly shortened by cranial base and cranial vault fusion (p < 0.05), (4) the posterior cranial base was shortened by cranial base fusion only (p < 0.05), and (5) cranial base fusion alone significantly flattened the cranial base angle (p < 0.05), whereas cranial vault fusion alone did not. These results suggest that cranial base fusion alone may account for many dysmorphic features seen in craniofacial synostosis. This model is consistent with the findings of other investigators and confirms both a primary directive and translational role of the cranial base in craniofacial growth.

Fragile X syndrome in two siblings with major congenital malformations.

We report on 2 brothers with both fragile X and VACTERL-H syndrome. The first sibling, age 5, had bilateral cleft lip and palate, ventricular septal defect, and a hypoplastic thumb. The second sibling, age 2 1/2, had a trachesophageal fistula, esophageal atresia, and vertebral abnormality. High-resolution chromosome analysis showed a 46, XY chromosome constitution in both siblings. By PCR and Southern blot analysis, the siblings were found to have large triplet repeat expansions in the fragile X gene (FMR 1) and both had methylation mosaicism. Enzyme kinetic studies of iduronate sulfatase demonstrated a two-fold increase in activity in the first sib as compared to the second. Possible mechanisms through which the fragile X mutation can cause down-regulation of adjacent loci are discussed.

Craniofacial injuries resulting from taxicab accidents in New York City.

Taxicab accidents are a common occurrence in New York City. This review was undertaken to characterize the nature of craniofacial injuries that result from taxicab accidents. Data were collected on 16 patients who required admission to trauma or plastic and reconstructive surgery services, after sustaining craniofacial injury as a result of a taxicab accident. Front-end deceleration collisions were the most common mechanism of injury. Fifty-six percent of the patients were thrown against the bulletproof, Plexiglas driver safety divider and sustained an injury most commonly to the anterior midface. Both bony and soft-tissue injuries were common in the entire group. Complex facial fractures were sustained by 56% of patients, with nasal-septal fractures most common, followed by naso-ethmoid-orbital, anterior frontal, anterior maxillary, and Le Fort I and II fractures. Only 1 patient in the group was wearing a seat belt and that patient was a driver. Given the high incidence of craniofacial injury, appropriate safety standards for taxicabs must be initiated, including the reevaluation of the utility of the safety divider and mandatory seat belt use for rear-seat passengers.

Complete nasal agenesis with bilateral microphthalmia and unilateral duplication of the thumb.

Complete nasal aplasia is an extremely rare clinical entity and most infants are stillborn when this is associated with holoprosencephaly. A viable 3-year-old infant born with frontonasal arrest without holoprosencephaly is presented. The child's main complaint was lack of a nasal airway, which made eating extremely difficult. A method for craniofacial reconstruction of the nasopharynx is presented.

Midline defects of the orofaciodigital syndrome type VI (Váradi syndrome).

The orofaciodigital syndromes (OFDS) represent a spectrum of anomalies of the palate, cranium, hands, and feet. Váradi syndrome, designated OFDS type VI, is a rare disorder that is additionally characterized by cerebellar anomalies. The following report is of a patient with OFDS VI and characteristic multiple midline defects: median cleft lip and palate, lingual cleft with nodules, and midline brain malformation. In addition, this case is uniquely associated with the presence of midline (metopic and sagittal) craniosynostoses as well. It is unusual that deformities which result from premature fusion of cranial vault sutures would appear synchronously in a syndrome based on the concept of failure of fusion or coalescence of facial growth centers. The midline represents an independent developmental field, whereby CNS defects and midline anomalies can present concurrently.

Autoimmune disease and silicone breast implants.

An association between crystalline silica and immune disease has long been recognized. However, despite ongoing case reports of systemic autoimmune disease in silicone implant recipients, the available data has not been sufficient to prove or disprove a causal relationship. Silicone has been shown to "bleed" from the implants and can migrate to distant sites. There is evidence of cellular and humoral immune responses to silicone in vivo, but the role of these responses in the development of connective tissue disorders has not been determined. Further studies are necessary to elucidate the role of silicone, if any, in the pathogenesis of autoimmune connective tissue disease. Meanwhile, the implant population needs to be closely monitored; their clinical management should be based on a case by case evaluation.

Donor leukocyte migration following extremity transplantation in an experimental model.

In an effort to further define the immunologic mechanisms leading to acute composite-tissue allograft rejection, the migratory patterns of donor leukocytes were evaluated. Using a rat model, 52 orthotopic vascularized hindlimb transplants were performed in strains representing major histocompatibility mismatches. In order to evaluate the effect of allogeneic skin on limb rejection, all donor skin was removed in a second group of allografts. Recipient lymphoid organs were examined during the week following transplantation for antigen-presenting cells using a donor-specific class II monoclonal antibody. Donor leukocytes, with dendritic cell morphology, were identified in recipient spleen and lymph nodes draining the allograft. Significantly higher numbers of donor leukocytes were present during postoperative days 1 through 4 for both groups. Association of these important passenger leukocytes with host T-lymphocytes may represent the site of initiation of the immune response.

Variations in digital nerve anatomy.

One hundred digital nerves from 10 cadaver hands were dissected, and branching patterns were analyzed. Contrary to the traditional belief that the digital nerve predictably trifurcates at the distal interphalangeal crease, much variation exists. Terminal branching occurred distal to the crease in 60% of the thumb digital nerves and in 78% of the digital nerves supplying the other four digits. The number of terminal branches also varied from two to seven in the thumb and from two to five in the other four digits. No significant differences were seen in branching patterns between digits or between radial and ulnar sides. These findings are clinically relevant to the surgeon who is contemplating digital nerve repair.

A nasal trumpet orthosis to maintain nares openings and respiratory function for patients with facial burns: a case report.

Management of facial burns is a challenge to the burn team because it may lead to functional and cosmetic compromise. Severe scarring of the nares may lead to nasal occlusion. This article introduces a method of maintaining nasal patency that allows respiratory exchange through the use of a custom-fabricated, semirigid tubular orthosis. The technique for fabrication is reviewed, and the use of the device is addressed through a case report. This inexpensive, readily available device is useful in preventing nasal occlusion that results from scar formation.

Anterior cervical microsurgical approach to the cranial base in the rabbit: technical note.

Current trends in research on craniofacial syndromes have led to enhanced interest in the cranial base as a contributory factor in the development of normal and abnormal midfacial structure. Indeed, attention has focused upon one particular growth plate in the posterior cranial base, the spheno-occipital synchondrosis, since it has been shown that alterations in this structure are associated with profound changes in craniofacial growth. In this report we describe a surgical approach to the cranial base of the rabbit that is safe, simple and reliable. It is applicable to neonatal as well as adult rabbits.

The effect of early fronto-orbital advancement on frontal sinus development and forehead aesthetics.

The frontal sinuses make an important contribution to normal forehead and glabellar contour. This study was designed to test our clinical impression that early fronto-orbital ("frontal bone") advancement could have an adverse effect on frontal sinus development and consequently on forehead aesthetics. A retrospective study was conducted on 11 patients who had undergone fronto-orbital advancement and also had a long period of follow-up at the Institute of Reconstructive Plastic Surgery at New York University. The longitudinal cephalometric data were compared with unoperated controls. With one exception, no patient who underwent bilateral fronto-orbital advancement developed a frontal sinus, and all such patients had a flattened brow contour when compared with unoperated patients, of whom 82 percent developed at least one frontal sinus. Of the three patients who underwent unilateral fronto-orbital advancement for plagiocephaly (flattened forehead), two developed a frontal sinus but only on the unoperated side and one developed bilateral frontal sinuses. The two patients with unilateral frontal sinus development had a particularly obvious deformity resulting from normal glabellar projection on the unoperated side and a flattened contour on the operated side. Fronto-orbital advancement affects forehead aesthetics and should be performed only in infant patients with moderate to severe deformities. patients with plagiocephaly whose deformity is sufficiently severe to warrant surgery should preferably undergo bilateral fronto-orbital advancement (by the technique described) rather than unilateral advancement in order to avoid the brow asymmetry that results from unilateral frontal sinus development.

Migration of donor leukocytes from limb allografts into host lymphoid tissues.

This study was undertaken in an initial effort to characterize the immunology of extremity transplantation by examining the pattern and kinetics of leukocyte migration from rat limb transplants. Migration of donor leukocytes was evaluated by examining recipient lymphoid tissues with a donor-specific, anti-major histocompatibility complex, class I monoclonal antibody. Double-antibody, two-color labeling was used to localize donor cells to specific regions within these tissues. Donor leukocytes, with dendritic cell morphology, were found in the T-cell-rich areas of lymph nodes draining the allograft and spleen. The donor cells were present on postoperative days 1 through 3 but were not present on days 5 to 7. Donor leukocytes were not present in distant lymph nodes or liver. These findings indicate a migration of leukocytes, most likely the highly immunogenic dendritic cell, from rat limb transplants to the draining lymphoid tissues. Migration occurs shortly after transplantation and may lead to the sensitization of alloreactive T-cells.

The role of rigid skeletal fixation in bone-graft augmentation of the craniofacial skeleton.

The type of fixation (rigid skeletal vs. wire) was assessed against embryologic origin (membranous vs. endochondral) and recipient site (depository vs. resorptive) as variables affecting inlay and onlay bone-graft survival in 20 mature dogs. Wet weight and volume measurements were made at operation and at sacrifice (16 weeks). The results were as follows: (1) Rigid skeletal fixation increased bone-graft volume survival over wire fixation (p less than 0.05). (2) Fixation (i.e., rigid skeletal) and embryologic origin (i.e., membranous) were equal determinants of bone-graft volume survival (p less than 0.001); the recipient site was not significant for onlay bone graft survival. (3) Embryologic origin was the only significant determinant of weight survival (p less than 0.001). (4) Inlay bone grafts demonstrated greater weight and volume survival than onlay bone grafts (p less than 0.05). (5) Histologic and microradiographic studies demonstrated bony union of bone grafts fixed with rigid skeletal fixation, while fibrous union predominated in bone grafts fixed with wire technique.

The role of the Schirmer's test and orbital morphology in predicting dry-eye syndrome after blepharoplasty.

The Schirmer's test for tear production has been recommended to identify patients with diminished tear production prior to blepharoplasty. The decision to operate may rest with this simple clinical test. This paper reports a prospective clinical evaluation of 100 consecutive blepharoplasty patients to determine the role of preoperative assessment of the orbital and periorbital morphology and the Schirmer's test in predicting the likelihood of the development of the dry-eye syndrome (DES) postoperatively. Our findings indicate that the morphology of the orbital region is a more important and reliable method of evaluating a predisposition to developing dry eyes postoperatively than is the Schirmer's test. The value of the Schirmer's test is to flag patients prior to blepharoplasty, but it should not be relied on as the sole method of screening patients and it is definitely of less importance than the history and physical examination.