Endoscopically assisted facial suspension for treatment of facial palsy.

Static suspension remains an option for certain patients with facial paralysis. Endoscopically assisted facial suspension obviates the need for a counter-incision at the oral commissure to distally inset the fascia lata graft as described in the standard technique. The endoscopic technique is simple, allows secure placement of perioral fascial strips, and can be performed as an outpatient.

Arterial vascular anatomy of the umbilicus.

The rare occurrence of umbilical necrosis after performance of a transverse rectus abdominis muscle (TRAM) flap prompted this investigation into the specific arterial anatomy of the umbilicus using multiple anatomic techniques. Sixteen fresh cadavers were studied by using dissection of blue latex-injected specimens, radiography of barium latex-injected specimens, and selective ink injection of individual perforators. It was discovered that the umbilicus receives arterial inflow by means of three distinct deep sources in addition to the subdermal plexus. These deep sources are (1) the right and left deep inferior epigastric arteries that each give off several small branches, and a large ascending branch, which courses between the muscle and the posterior rectus sheath passing directly to the umbilicus; (2) the ligamentum teres hepaticum; and (3) the median umbilical ligament. The clinical implications of this study are that the umbilicus should have robust arterial inflow if only one rectus muscle is removed, such as during a unilateral TRAM flap, because the contralateral side should still provide large direct vessels from the deep inferior epigastric arteries to the umbilicus. During bilateral TRAM elevation, all of the large arterial sources are removed from the umbilical inflow and circulation must depend on small vessels from the ligamentum teres and median umbilical ligament. Care should be taken in this latter clinical situation to preserve these sources of blood flow during umbilical flap creation.

Percutaneous diagnostic peritoneal lavage using a Veress needle versus an open technique: a prospective randomized trial.

OBJECTIVE: To prospectively compare the speed, sensitivity, complications, and technical failures of percutaneous diagnostic peritoneal lavage (DPL) using a Veress needle versus open DPL. METHODS: One hundred seventy-six blunt trauma patients requiring DPL were prospectively randomized to undergo either open DPL using a standard technique or percutaneous DPL using an 18-gauge Veress needle to penetrate the peritoneal cavity, with the lavage catheter then being inserted over a guide wire. RESULTS: Mean time to successful placement of the lavage catheter for the percutaneous Veress needle technique was 2.73 minutes versus 7.28 minutes for the open DPL technique (p < 0.001). Sixteen percent of open lavage procedures took more than 11 minutes; the majority (60%) of Veress needle lavage procedures took less than 2 minutes. There were no false-negative findings in either group, and there was one false-positive result in each group. A wound infection after an open DPL was the only complication. Poor return of lavage fluid (<200 mL) accounted for most technical failures; this was more prevalent with the percutaneous method (11.2%) than with the open technique (3.8%) (p < 0.05). CONCLUSION: The percutaneous DPL method using a Veress needle is significantly faster than the open DPL method. The Veress needle lavage was as safe and as sensitive as the open lavage; however, technical failure occurred more frequently with the Veress needle lavage than with the open DPL.

Arterial fasciocutaneous vascular territories of the lower leg.

The purpose of this study was to analyze the fasciocutaneous arterial circulation of the lower extremity to provide a quantitative guide to design reliable fasciocutaneous flaps. Thirty-one fresh cadaver limbs were studied using the techniques of dissection of latex injected specimens, selective ink injections, and barium latex radiographs. Fasciocutaneous perforator locations were recorded according to fascial septum of origin and distance relative to bony landmarks between the knee and the ankle. Selective ink injections of the trifurcation vessels identified four anterior tibial, three peroneal, and three posterior tibial fasciocutaneous territories. Although perforator site locations were randomly distributed along the trifurcation vessel within any vascular territory, the separate cutaneous regions that make up the fasciocutaneous territories occur in predictable locations with a measurable standard deviation. The transverse section radiographs confirmed the transverse dimensions of the vascular territories. Additionally, the summation of any two vascular territories calculated from the anatomical data conforms to the clinically observed 2.5:1 to 3:1 length-to-width ratios for fasciocutaneous flap viability as reported by Ponten and by Barclay et al. This study provides a quantitative anatomical framework using primary fasciocutaneous vascular territories to design potentially reliable fasciocutaneous flaps in the lower extremity.

Transantral endoscopic orbital floor exploration: a cadaver and clinical study.

A cadaver and clinical study was performed to determine the value of transantral endoscopy in diagnosis and treatment of orbital floor fractures. Six fresh cadaver heads were dissected using a 30 degree, 4-mm endoscope through a 1 cm2 antrotomy. In the cadaver, the orbital floor and the course of the infraorbital nerve were easily identified. The infraorbital nerve serves as a reference point for evaluation of fracture size; three zones of the floor are described that are oriented relative to the infraorbital nerve. In the clinical study, nine patients with orbital floor fracture initially underwent endoscopy at the time of fracture repair: three patients had comminuted zygomatico-orbital fractures, five had monofragmented tetrapod fractures, and one had an isolated orbital blowout fracture. Endoscopic dissection of the orbital fractures revealed seven fractures with an area > 2 cm2 and two fractures with an area of < 2 cm2. The isolated orbital floor blowout fracture had entrapped periorbital tissue, which was completely reduced endoscopically. A separate patient with a < 2 cm2 displaced fracture also had stable endoscopic reduction. In the remaining seven patients, the endoscopic technique assisted with the floor reconstruction by identifying the precise fracture configuration as well as identifying the stable posterior ledge of the orbital floor fracture. There have been no complications in any of our patients to date. We conclude: (1) Transantral orbital floor exploration allows precise determination of orbital floor fracture size, location, and the presence of entrapped periorbita. The information obtained through endoscopic techniques may be used to select patients who would not benefit from lid approaches to the orbital floor and may possibly eliminate nontherapeutic exploration. (2) Transantral endoscopic orbital floor exploration assists the reduction of complex orbital floor fractures and allows precise identification of the posterior shelf for implant placement. (3) Transantral endoscopic techniques can completely reduce entrapped periorbital tissue caught in a trapdoor type of fracture.

Reconstruction of the toddler diaphragm in severe anterolateral congenital diaphragmatic hernia with the reverse latissimus dorsi flap.

The management of infants with severe congenital diaphragmatic hernia (CDH) continues to evolve. When a prosthetic patch is placed in the neonatal period for pleuroperitoneal separation, it ultimately will require a subsequent reconstruction for progressive pulmonary or abdominal symptomatology. The reverse latissimus dorsi (RLD) flap has been used for reconstruction in only several reports in the last 12 years. In this paper, a patient with severe anterolateral CDH is reconstructed with the RLD flap on an elective basis at 2 years of age. Elective repair was performed for the particular indication of chest wall restriction imposed by the nonpliable Gore-Tex patch. In this case, use of the RLD flap alone without the use of synthetic mesh has resulted in satisfactory results with 17 months of follow up.

Bregmatic masses in children.

Bregmatic masses often present a challenging diagnostic dilemma. We present two illustrative cases to demonstrate this clinical problem and present our recommendations for evaluation and treatment.

Bregmatic epidermoid inclusion cyst eroding both calvarial tables.

Dermoid and epidermoid cysts are uncommon masses in the head and neck region of children. Although the most common location of inclusion cysts in the head and neck is the bregma, masses in this region must be differentiated from midline hemangiomas, lipomas, hematomas, or encephaloceles. Inclusion cysts should be considered in the differential diagnosis of all midline cystic lesions in infants, because, if left untreated, it may lead to devastating complications. We present the case of a slowly enlarging midline mass in a female infant to illustrate the potential for serious sequelae from inclusion cysts.