The art of the trichloroacetic acid chemical peel.

Despite escalating interest in laser resurfacing techniques, chemical peel procedures remain an integral part of the armamentarium for resurfacing aging, sun-damaged, and diseased skin. Like other chemicals, the advantage of the technique of tricholoracetic (TCA) acid application is that the degree and depth of penetration within the skin can be controlled accurately according to specific requirements. This article reviews the preoperative evaluation of skin and the techniques for preconditioning, intraoperative peel, and postoperative management of TCA-treated skin.

The use of expanded polytetrafluoroethylene as a permanent filler and enhancer: an early report of experience.

Plastic and reconstructive surgeons have long sought the ideal material to fill and enhance defects of the head and body. Many of the most widely used materials present problems for the surgeon or the patient, so the search continues. For the past 15 months, we have been using expanded polytetrafluoroethylene (ePTFE) Gore-Tex Soft Tissue Patch to fill in nasolabial and glabellar creases and to augment malar bones and the chin. Early evaluation indicates that ePTFE performs well with very few problems, with a high level of patient and surgeon satisfaction. Histological examination of 3-month explants from the postauricular subcutaneous plane and the antecubital fossa indicate minimal inflammatory response and some collagen penetration into the interstices of the prosthesis.

Succinylcholine increases intraocular pressure in the human eye with the extraocular muscles detached.

BACKGROUND: The increase in intraocular pressure in the human eye that is associated with the use of intravenous succinylcholine has long been ascribed to contraction of the extraocular muscles leading to compression of the globe. This created concern that such contraction would extrude global contents in the patient with an open globe, and led clinicians to avoid the use of succinylcholine in these patients. METHODS: The authors studied 15 patients undergoing elective enucleation, and compared the intraocular pressure change after the administration of succinylcholine in the diseased eye after all the extraocular muscles had been detached to that of the normal eye that had the extraocular muscles attached. RESULTS: The authors found no difference in baseline intraocular pressure (mmHg) between eyes (15.1 vs. 16.1) or at peak intraocular pressure (25.2 vs. 24.7), but did observe a significant difference in pressure in both eyes when baseline was compared with peak pressure. CONCLUSIONS: The authors concluded that extraocular muscle contraction does not contribute to the increase in intraocular pressure after succinylcholine.

Placement of central venous catheters by cut-down with electrocardiogram positioning.

A technique of placement of central venous catheters for hyperalimentation, long term antibiotic treatment or chemotherapy by cut-down and positioning of the catheter tip with intravascular electrocardiography is described. The method was used in 384 patients during a period of four years. The patients varied from premature newborns to adolescents. The external jugular vein was used in 218 patients, the internal jugular vein in 150, the cephalic vein in 11 and the axillary vein in five. Catheters were successfully positioned by electrocardiogram (ECG) control in 95 percent of the patients. In only 5 percent of the patients, the ECG was difficult to interpret because of interference, poor electrode contact or unsatisfactory ECG image or tracing. Roentgenograms to check catheter location did not have to be done in the operating room. Confirmation of catheter position was done in the recovery room or on return to the neonatal intensive care unit. Using the cut-down procedure described, there were no complications, such as bleeding or chest wall infections, along the course of the catheter.

The effect of lumbar disc surgery on postoperative pulmonary function and temperature. A comparison study of microsurgical lumbar discectomy with standard lumbar discectomy.

Preoperative and postoperative pulmonary function and body temperature were measured prospectively in 15 patients undergoing either microlumbar discectomy or standard lumbar laminectomy and discectomy for herniated nucleus pulposus. In these otherwise comparable groups patients undergoing standard lumbar laminectomy and discectomy had significant depression in pulmonary function in the first 20 hours postsurgery and febrile temperatures for as long as 48 hours postsurgery. No alteration in pulmonary function or body temperature was observed in those operated on by the microlumbar discectomy technique. We conclude that patients undergoing microlumbar discectomy for lumbar disc herniation have less postsurgical pulmonary morbidity and temperature elevation than those treated by lumbar laminectomy and discectomy.

Application and modification of the circular skin excision and pursestring procedures.

The concept of the circular excision is not new. However, it was complicated by excessive postoperative areolar stretching and scar hypertrophy. The Benelli principle of a permanent subdermal pursestring suture overcame these drawbacks. We present our experiences with the circular skin excision for mastopexy procedures and for circular skin incision for total mastectomy and immediate reconstruction.

Ventriculoatrial shunt utilizing the azygos vein.

Long-term ventricular cerebrospinal fluid shunting can prove difficult in the neonatal population, particularly in those neonates who have had previous abdominal and vascular procedures. This article presents a technique of providing vascular access for ventriculoatrial shunting via the azygos vein for patients with limited vascular access and in whom ventriculoperitoneal shunting is not feasible.

Induction and maintenance characteristics of anesthesia with desflurane and nitrous oxide in infants and children.

To determine the induction and maintenance characteristics of desflurane in pediatric patients, the authors anesthetized 206 infants and children aged 1 month to 12 yr with nitrous oxide plus desflurane and/or halothane in oxygen. Patients were assigned to one of four groups: anesthesia was 1) induced and maintained with desflurane after premedication with an oral combination of meperidine, diazepam, and atropine; 2) induced and maintained with desflurane; 3) induced with halothane and maintained with desflurane; or 4) induced and maintained with halothane. An unblinded observer recorded time to loss of consciousness (lid reflex), time to intubation, and clinical characteristics of the induction and maintenance of anesthesia. Moderate-to-severe laryngospasm (49%) and moderate-to-severe coughing (58%) occurred frequently during induction of anesthesia with desflurane; the incidence of these was not altered by premedication. In contrast, laryngospasm and coughing were rare during induction of anesthesia with halothane. In unpremedicated patients, time to loss of lid reflex (mean +/- SD) was similar for desflurane (2.4 +/- 1.2 min) and halothane (2.1 +/- 0.8 min). During induction of anesthesia, before laryngoscopy and intubation, mean arterial pressure less than 80% of baseline was more common with halothane; heart rate and mean arterial pressure greater than 120% of baseline were more common with desflurane. Intraoperatively, heart rate greater than 120% of baseline was more common with desflurane; blood pressures were similar for the two anesthetics. The authors conclude that the high incidence of airway complications during induction of anesthesia with desflurane limits its utility for inhalation induction in pediatric patients. Anesthesia can be safely maintained with desflurane if induced with a different anesthetic.

The "no flap" technique for lower-lid blepharoplasty.

The transconjunctival approach to fat pad excision has gained popularity for use on those patients who require fat excision but not redundant skin excision. For skin excision cases, the pinch technique for raising the cuff of redundant skin of the lower lid has been found helpful, particularly in the older patient with latent senile ectropion. We find that elevating the skin or the skin/muscle flap produces edema of the already weak musculature predisposing it to postoperative senile lid hang. Avoiding lower-lid flaps in a lower-lid blepharoplasty has helped prevent this troublesome problem.

Breast reconstruction utilizing subcutaneous tissue expansion followed by polyurethane-covered silicone implants: a 6-year experience.

Reconstruction of the breast after modified radical mastectomy can be safely and adequately performed in the subcutaneous plane. Placement of a subcutaneous tissue expander (as either an immediate or a delayed procedure), rapid expansion over a 3- to 4-month period, capsulotomy, and placement of a polyurethane-coated implant have led to satisfactory results over a 6-year period. Breast reconstruction methods are well documented; however, the utilization of expanded subcutaneous chest wall skin has not been reported heretofore.

Planning the aesthetic foreheadplasty.

Different approaches to aesthetic foreheadplasty have been thoroughly described and well documented. However, there has been a paucity of information in the literature describing indications for the various approaches. We detail our approach to planning the foreheadplasty; most commonly, we opt for the anterior forehead-hairline approach. We believe that proper patient selection with regard to anatomical, aesthetic, and physiological factors is of the greatest importance in planning an aesthetic foreheadplasty.