Facelift and patterns of lymphatic drainage.

BACKGROUND: It has commonly been assumed that deeper facelift dissection causes greater and more prolonged swelling. OBJECTIVES: In this preliminary report, the authors compare the lymphatic reconstitution after multiple techniques of rhytidectomy by means of dynamic lymphoscintigraphy. METHODS: Three patients were enrolled in this study. All three were female, were similar in age, and exhibited similar signs and degrees of facial aging. Each woman underwent a facelift with a different technique: (1) subcutaneous dissection with superficial musculoaponeurotic system (SMAS) plication, (2) subcutaneous dissection with SMASectomy, and (3) a "high SMAS" composite facelift. Postoperatively, (99m)Tc-sulfur colloid was injected into a standardized infraorbital location in each patient to compare patterns of lymphatic drainage using lymphoscintigraphy. Postoperative scans at two weeks, six weeks, three months, six months, and one year were compared to the preoperative scans taken seven days prior to surgery. RESULTS: All rhytidectomy techniques appeared to temporarily create a significant and similar degree of interruption in lymphatic drainage. There was a subtotal recovery of lymphatic pathways within three months and complete return to baseline drainage pattern after six months, regardless of surgical technique. CONCLUSIONS: Based on the results of this study, it appears that the extent of facial dissection, rather than the depth, is the most significant factor in postoperative edema.

The frontal branch of the facial nerve across the zygomatic arch: anatomical relevance of the high-SMAS technique.

BACKGROUND: The frontal branch has a defined course along the Pitanguy line from tragus to lateral brow, although its depth along this line is controversial. The high-superficial musculoaponeurotic system (SMAS) face-lift technique divides the SMAS above the arch, which conflicts with previous descriptions of the frontal nerve depth. This anatomical study defines the depth and fascial boundaries of the frontal branch of the facial nerve over the zygomatic arch. METHODS: Eight fresh cadaver heads were included in the study, with bilateral facial nerves studied (n = 16). The proximal frontal branches were isolated and then sectioned in full-thickness tissue blocks over a 5-cm distance over the zygomatic arch. The tissue blocks were evaluated histologically for the depth and fascial planes surrounding the frontal nerve. A dissection video accompanies this article. RESULTS: The frontal branch of the facial nerve was identified in each tissue section and its fascial boundaries were easily identified using epidermis and periosteum as reference points. The frontal branch coursed under a separate fascial plane, the parotid-temporal fascia, which was deep to the SMAS as it coursed to the zygomatic arch and remained within this deep fascia over the arch. The frontal branch was intact and protected by the parotid-temporal fascia after a high-SMAS face lift. CONCLUSIONS: The frontal branch of the facial nerve is protected by a deep layer of fascia, termed the parotid-temporal fascia, which is separate from the SMAS as it travels over the zygomatic arch. Division of the SMAS above the arch in a high-SMAS face lift is safe using the technique described in this study.

Using the autospreader flap in primary rhinoplasty.

BACKGROUND: When performing dorsal reduction in primary rhinoplasty, one must pay close attention to the height of the upper lateral cartilages. They are in part responsible for the dorsal aesthetic lines and often require a lower profile. METHODS: The technique the authors describe uses the transverse portion of the upper lateral cartilages rotated medially to function as a local spreader flap while reducing the profile of the dorsum and preserving the aesthetic lines. This is a surgical technique that adjusts the height of the upper lateral cartilages in a precise and safe manner while preserving the function of the internal valve. RESULTS: The authors present two patients seen at 1 and 3 years after undergoing the autospreader flap technique. In the experience of the senior author (H.S.B.) with this procedure over the past decade, preoperative surgical goals were achieved reliably. CONCLUSIONS: The authors review the anatomical indications in which they found this technique to be simple, reproducible, and effective in shaping the dorsal midvault while preserving the function of the internal valve. Autospreader flap rotation should be considered when dorsal reduction is required.

Use of the microvascular free fibula transfer as a salvage reconstruction for failed anterior spine surgery due to chronic osteomyelitis.

BACKGROUND: Several factors influence the osseous union of spinal fusions, including the substrate used for arthrodesis, the biology of the fusion bed, as well as local host factors. While cancellous bone grafting is useful in simple cases with no major bony defects, corticocancellous strut grafts are indicated in reconstructions requiring mechanical support. The size and location of the spinal defect to be reconstructed determine what type of vascularized bone graft is indicated. According to the literature, locations suitable for reconstruction using a microvascular free fibula graft include the cervical spine and, less frequently, the cervicothoracic, thoracic, thoracolumbar, and lumbar spine. Using the microvascular free vascularized fibula graft as a salvage procedure for failed anterior spine surgery due to bacterial spinal osteomyelitis has not been reported. METHODS AND RESULTS: Four cases of spinal osteomyelitis after attempted spinal fusion are presented. In all cases, a microvascular free fibula graft was successfully used for secondary spinal fusion and clearance of documented bacterial osteomyelitis. The operative approach is described. CONCLUSIONS: Use of the vascularized free fibula graft for correction of primary and secondary spinal deformities, as well as for reconstruction after excision of malignant spine tumors, has been well documented. On the basis of their experience, the authors also recommend microvascular fibula transplantation as a salvage procedure for failed anterior spine surgery due to chronic osteomyelitis.

Effect of the Veterans Affairs Medical System on plastic surgery residency training.

BACKGROUND: Teaching hospitals within the Veterans Affairs Health System perform the majority of complex and high-risk surgical procedures in the veteran patient population. Residency positions in the Veterans Affairs Medical System are usually part of a rotational educational system within a university-based residency, and plastic surgeons in training are a major work force and health care provider. The purpose of this study was to evaluate the current effect of the Veterans Affairs Medical System on plastic surgery residency training. METHODS: A 6-year (January of 1998 to December of 2003) review was performed of procedures completed at the Durham Veterans Affairs Medical Center, Section of Plastic Surgery. Procedures were divided into the following categories: extremities and trunk; breast and cosmetic; head and neck, including excision of skin lesions; hand surgery; craniomaxillofacial surgery; and other. Only procedures performed in the main operating room were reviewed and analyzed. In addition, a detailed review was performed of major head and neck reconstructions with free tissue transfer. RESULTS: A total of 1655 operative procedures were performed in 1290 patients. The ratio of men to women was 6:1 (1112 men and 178 women). Patients ranged in age from 26 to 97 years (average age, 62.7 years). Procedures in the extremities and trunk (n = 193, 11.7 percent), breast and cosmetic (n = 228, 13.8 percent), hand surgery (n = 155, 9.4 percent), and other (n = 275, 16.6 percent) categories were comparably distributed. Although the head and neck category accounted for the highest number of procedures (n = 766, 46.3 percent), the majority of these procedures were simple excisions of skin tumors (n = 612). There were significantly fewer major craniomaxillofacial cases (n = 38, 2.3 percent). CONCLUSIONS: Data from the retrospective analysis reveal that a broad spectrum of plastic surgical procedures is performed within the Veterans Affairs Health System, serving as a tremendous resource for resident training. The fact that approximately 260 procedures per year are performed demonstrates an active service. Craniomaxillofacial surgery is currently underrepresented compared with other categories at the authors' particular institution. By their definition, nonspecific plastic surgical procedures ("other") account for 275 (16.6 percent) of all 1655 procedures performed. This demonstrates that plastic surgery "overlaps" with other specialties, such as dermatology. The Veterans Affairs Health System will continue to play a significant role in the future training of plastic surgeons. Now, more than ever, a strong Veterans Affairs surgical service, including plastic surgery and its modern techniques, will be needed.

Osteoblastoma of the scaphoid: a case report.

Osteoblastoma is an uncommon primary bone tumor that rarely is found in the hand or wrist. Recurrent osteoblastomas often have a more aggressive appearance than the original tumor, and differential diagnosis from osteosarcoma is difficult. The pain that can accompany this tumor is debilitating. Therefore, successful treatment requires complete removal of the tumor. The purpose of this report is to present an unusual case of osteoblastoma of the carpal scaphoid. This tumor was treated successfully by curettage and bone grafting. At 1 year postoperatively, the patient presented with a stable, painless wrist with full range of motion.

Halofuginone inhibits collagen deposition in fibrous capsules around implants.

Fibrous capsule formation around implants remains a difficult problem that has been studied for decades. The etiology is elusive, but the end result is the deposition of a dense collagenous capsule around implanted materials. The purpose of this study was to determine the effects of a type I collagen synthesis inhibitor, halofuginone, on fibrous capsule formation around implanted materials. Silastic disks were implanted subcutaneously into 4 groups of adult male rats for up to 8 weeks. Group 1 received drug throughout the study, group 2 received drug during the first half only, group 3 received drug during the second half only, and the control group received no drug. Implants were removed and histology of the capsules was examined. A collagen index score was calculated from digital images of trichrome-stained histologic sections, which permitted semiquantitative comparison of collagen content among the 4 groups. The collagen index values clearly indicate that halofuginone effectively inhibited collagen deposition within the capsule around the implanted disks. Halofuginone treatment also resulted in a decrease in the collagen index score in rat skin, indicating that halofuginone may affect preexisting collagenous structures. The ability of halofuginone to inhibit collagen deposition in new and preexisting fibrous capsules suggests that it may be a useful adjunct to minimize the formation of capsules around implantable prostheses.

Activity of antimicrobial-impregnated silicone tissue expanders.

Because bacterial colonization of medical devices may result in clinical infection, it is conceivable that antimicrobial impregnation of tissue expanders may reduce the rate of infection. The objective of this in vitro study was to examine the spectrum, durability, and shelf-life antimicrobial activity of minocycline/rifampin-impregnated silicone tissue expander shells. The impregnated devices exhibited zones of inhibition at baseline against Staphylococcus epidermidis, Staphylococcus aureus, and Escherichia coli. The impregnated devices exhibited strong residual activity against S. epidermidis and S. aureus after suspension in serum at 37 degrees C for 4 weeks. There was no significant decrease in the size of zones of inhibition after storing the impregnated devices at room temperature for 1 year. These results indicate that minocycline/rifampin-impregnated tissue expander shells provide broad-spectrum and durable antimicrobial activity and that the shelf-life antimicrobial activity exceeds 1 year. These findings prompt future exploration of the anti-infective efficacy of these antimicrobial-impregnated devices.

In vivo efficacy of antimicrobe-impregnated saline-filled silicone implants.

Bacterial colonization of mammary implants is a prelude to clinical infection and has been implicated in the etiology of capsular contracture. Antimicrobial impregnation of a variety of medical devices with the combination of minocycline and rifampin has recently emerged as a potentially effective method for preventing device colonization and device-related infection. The objective of this animal study was to examine in vivo the antimicrobial efficacy of minocycline/rifampin-impregnated, saline-filled silicone implants. A rabbit model of Staphylococcus aureus colonization and infection of subcutaneously placed implants was used. A total of 48 saline-filled silicone implants (24 antimicrobe-impregnated and 24 control unimpregnated implants) were suspended in a 106 colony-forming units/ml bacterial suspension of S. aureus for 30 minutes at room temperature, allowed to dry for 60 minutes, and then implanted subcutaneously in the back of 12 rabbits (two antimicrobe-impregnated and two control implants were placed in each rabbit). Rabbits were monitored daily, then killed either at 2 weeks (10 rabbits) or at 4 weeks (two rabbits) and cultured. The antimicrobe-impregnated implants were 12 times less likely to be colonized than control unimpregnated implants (two of 24 versus 23 of 24; p < 0.001), and they were a significantly less likely cause of implant-related infection (0 of 24 versus 22 of 24; p < 0.001) and implant-related abscess (0 of 24 versus 21 of 24; p < 0.001) than control implants. The minocycline/rifampin-impregnated implants routinely demonstrated zones of inhibition against S. aureus at the time of explantation. These results indicate that minocycline/rifampin-impregnated implants can significantly decrease the rate of bacterial colonization, implant-related infection, and implant-related abscess. Antimicrobe-impregnated implants also have the potential of reducing the likelihood of capsular contracture.

In-vitro and in-vivo activity of antimicrobial-coated prosthetic heart valve sewing cuffs.

BACKGROUND AND AIM OF THE STUDY: Prosthetic valve endocarditis (PVE) is a relatively uncommon but very serious condition. As bacterial colonization of the prosthetic heart valve sewing cuff can be a prelude to the clinical occurrence of PVE, antimicrobial coating of the sewing cuff may be beneficial. The study aims were to examine the antimicrobial activity in vitro and anti-infective efficacy in vivo of prosthetic heart valve sewing cuffs coated with minocycline and rifampin. METHODS: Zones of inhibition by antimicrobial-coated sewing cuffs were assessed in vitro against Staphylococcus epidermidis, S. aureus, Enterococcus faecalis, Pseudomonas aeruginosa and Candida albicans. The ability of subcutaneously implanted devices coated with minocycline and rifampin to resist colonization and infection by P. aeruginosa was also examined in a rabbit model. RESULTS: Antimicrobial-coated sewing cuffs produced zones of inhibition against all tested organisms. Coated devices were significantly less likely than uncoated devices to become colonized (2/24; 8% versus 20/24; 83%; p <0.001) or to cause device-related infection (0/24; 0% versus 18/24; 75%; p <0.001) and device-related abscess (0/24; 0% versus 10/24; 42%; p <0.001) due to P. aeruginosa. CONCLUSION: Prosthetic heart valve sewing cuffs coated with minocycline and rifampin provide broad-spectrum antimicrobial activity in vitro, and are anti-infective in vivo against P. aeruginosa. These results encourage the clinical evaluation of these sewing cuffs.