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.

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.