Body contouring of the arms and brachioplasty.

Massive weight loss patients suffer severe arm deformity, extending through the axilla and onto the chest. We found current operations inadequate, often with conspicuous scars. The L-brachioplasty was evolved to treat the entire deformity through the excision of two right angle unequal ellipses, leaving natural contours and an unobtrusive L-shaped scar. The upper body deformity consists of loose upper arm skin, oversized axilla, descent of the posterior axillary fold, flattening and elongation of the anterior axillary fold, and lateral chest rolls of skin. By tissue gathering and pinching, a hemi-ellipse is drawn over the lower half of the inner arm, sweeping up to the deltopectoral groove. Then a shorter ellipse is extended through the axilla onto the chest. These ellipses are connected by an inverted V-resection through the axilla. After skin resection the wound margins are closed with a triangular flap advancement of the posterior axillary fold. The result is a properly contoured reduced arm, axilla, and lateral chest with a sweeping inverted L-scar coursing upward along the lower medial arm to cross the dome of the axilla and then drop vertically along the mid lateral chest. Over the past four years more than fifty weight loss patients have been treated with aesthetic reshaping of the upper arm leaving inconspicuous scars and only minor complications. There have been 8 scar revisions, including two Z-plasties for contracture. The rationale and results compare favorably with contemporary techniques. L-brachioplasty is our procedure of choice for the massive weight loss patient and can be selectively applied to the aging arm.

Long-term effects of nasoalveolar molding on three-dimensional nasal shape in unilateral clefts.

OBJECTIVE: This objective of this study was to determine the effect of presurgical nasoalveolar molding on long-term nasal shape in complete unilateral clefts. DESIGN: The study was retrospective, and the subjects were chosen at random. Nasal casts of the subjects were scanned in three dimensions. Each nose was best fit to its mirror image, and a numerical asymmetry score was determined. SETTING: All patients were treated at the Institute of Reconstructive Plastic Surgery, NYU Medical Center, New York, New York. PATIENTS: The study subjects (n = 10) were selected from a group that had undergone presurgical nasal molding in conjunction with alveolar molding. The control subjects (n = 10) were selected from a group that had undergone presurgical alveolar molding alone. INTERVENTIONS: All subjects underwent presurgical orthopedic treatment until the age of approximately 4 months at which time the primary surgery was performed. MAIN OUTCOME MEASURE: The nasal shape following nasal molding should be more symmetrical than if molding had not been done. RESULTS: The mean asymmetry index for the nasoalveolar molding group was 0.74, and the control group was 1.21. This difference was statistically significant (p < .05). CONCLUSIONS: Presurgical nasoalveolar molding significantly increases the symmetry of the nose. The increase in symmetry is maintained long term into early childhood. The limitations of this study include (1) asymmetry alone is not an adequate shape result in most situations, (2) the children evaluated in this study were not fully grown, and (3) the control group was not age matched.

Computer-assisted anthropometry for outcome assessment of cleft lip.

Anthropometry and clinical examination best evaluate the morphology of repaired cleft lip and nose. An original, accurate, and practical image analysis of the lip and nose, which takes advantage of the mathematic, geometric, and organizational capabilities of public domain NIH-Image software (http://rsb.info.nih.gov/nih-image/), has been developed and tested over the past 6 years. A modified structured physical examination form that complements this analysis is under study. Accuracy of NIH-Image-based anthropometry was compared with direct measurements of 22 linear distances on the lip and nose. Twenty-five sets of direct measurements were taken, prospectively, on 15 children with repaired cleft lip over a 6-year period. The results were submitted to regression analysis. Then, relevant lip and nasal tip aesthetics were evaluated by the measuring capabilities of NIH-Image to create a quantitative assessment tool. For each episode, 15 possible faults were weighted, according to aesthetics and deformity, to provide an adverse score. The sum of the 5 lip scores, 10 nose scores, and combination gave respective grades. The analysis was modified to stratify congenital deformity to relate severity of disease to outcome. This analysis was applied to digitized images of 19 consecutive children, immediately prior to repair of complete unilateral cleft lip and nose, at the time of palate repair, and annually from the age of 3 to 6 years. There were 19 NIH-Image-based measurements of the congenital deformity and 35 measurements of surgical results; four children had three sets of records, eight had two sets, and seven had one set Descriptive statistics were applied. Following 556 paired direct and computer-assisted measurements, exceptional linear correlation was shown with a Pearson R coefficient of 0.96. The best correlation was lines within the plane of the camera lens, with the average difference ranging between 0.025 and 0.997 mm. Visual inspection of frontal and submental photographs of excellent, good, and poor results substantiates the ability of this analysis to quantify and grade a spectrum of relevant cleft lip and nasal anatomy. For these 19 patients, there was a broad range of performance scores, approximating a normal distribution. The mean of the NIH-Image-based analysis scores, 16.91, was a (very) good grade. A single standard deviation of 6.88 extended up into excellent and down to fair. The congenital analysis indicated a range of deformity. Comparing deformity with outcome, simple regression analysis had a coefficient of determination (R2) of 0.223, indicative of a weak positive relationship. An accurate and practical morphologic computer-assisted outcome assessment of repaired cleft lip and nasal deformity has been developed. There is a weak direct correlation between severity of deformity and outcome. Testing in multiple clinics is warranted.

The effects of soft-tissue expansion on lip repair and midfacial growth in a rabbit cleft lip model.

Midfacial hypoplasia following primary cleft lip repair is a common clinical correlate. Recent experimental work has suggested that increased lip pressure following an undermined lip repair may contribute to midfacial growth inhibition. Soft-tissue expansion has been used to generate additional soft tissue for reconstruction in the cranial region. The use of this technique in the labial region may allow lip repair to be performed with less tension (pressure) and thus facilitate midfacial growth. To test this hypothesis, 40 4-week-old rabbits were randomly divided into four groups. Two groups had surgically created lip and alveolar defects. Ipsilateral labial tissue expanders were placed in all four groups. One cleft and one normal group underwent expansion. The other two groups served as a control. The expanders were removed at 4 weeks, and an undermined lip repair was performed in both cleft groups. Findings revealed that soft-tissue expansion increased labial surface area significantly by approximately 96% (p < 0.001). Labial soft-tissue expansion alone had no effect on midfacial growth during the observation period. In contrast, cleft animals undergoing tissue expansion exhibited significantly reduced (p < 0.05) postoperative lip pressure and increased midfacial growth compared with cleft animals without expansion through 36 weeks of age. Results suggest that preoperative tissue expansion reduced postoperative lip pressure and improved midfacial growth in a rabbit cleft lip model.

Reducing eyelid retraction following subperiosteal face lift.

The most common complication of lower blepharoplasty is malposition of the lower eyelid. This deformity may present as scleral show, ectropion, entropion, or canthal dystopia, with dry eye or epiphora. These problems occurred frequently in our initial series of patients undergoing blepharoplasty with subperiosteal face lift. The key to prevention lay in avoiding the potential causes of these problems: overresection of eyelid skin, retraction of the orbital septum, orbicularis oculi dysfunction, postoperative swelling, and downward pull from the facial suspension. This article reviews the cases of 14 consecutive patients who underwent a modified subperiosteal face lift with blepharoplasty. Eleven of the patients had a concomitant endoscopically assisted brow lift. This group is compared with a prior series of 16 patients who underwent 12 endoscope-assisted brow lifts without special modifications. The modifications in the second series consisted of the following: (1) Improved patient selection; (2) minimal tissue trauma; (3) intact orbital septum; (4) lengthening of the septum; (5) secure midfacial suspension; (6) three-step lateral canthoplasty; (7) limited resection of skin; and (8) specific postoperative care. Results regarding the incidence of eyelid malposition and reoperations were subjected to Fisher's exact test. In the 14 consecutive patients who underwent the modified procedure, two temporary episodes of lower eyelid malposition occurred (follow-up of 12 to 20 months). In the 16 patients who underwent a nonmodified procedure, five temporary and three permanent episodes of eyelid malposition occurred (follow-up of 20 to 30 months). Fisher's exact test demonstrated a significant difference with a p value of 0.038. Modifications of the subperiosteal face lift and lower blepharoplasty reduced significantly but did not eliminate the incidence of lower eyelid malposition.

Quantitative assessment of results of ultrasound-assisted lipoplasty with dual-energy x-ray absorptiometry: a preliminary report.

Current measures for assessing the results of body contouring surgery are limited. The goal of our study was to analyze objectively and quantitatively the results of ultrasound-assisted lipoplasty by use of dual-energy x-ray absorptiometry (DEXA). A prospective study of nine patients who underwent ultrasound-assisted lipoplasty (Lysonics 2000 ( generator) was performed. Each patient underwent preoperative and postoperative DEXA scanning (Lunar). All patients were women, and the average age was 42 years (range 26 to 57 years). The amount of emulsion was recorded, and analysis of the emulsion demonstrated that approximately 40% was infiltration solution, serum, and blood. The average patient follow-up period was 14 weeks (range 8 to 22 weeks). The amount of fat that was measured after aspiration (adjusted for infiltration solution, serum, and blood) was consistently less than the fat reduction demonstrated by DEXA. Fat reduction by DEXA was shown to be 45% and 46% greater than the measured aspirated fat from the right and left thighs, respectively. For both the right and left hips, the difference was 48%, and for the abdomen, DEXA recorded a 30% greater fat reduction than was aspirated. DEXA can be used to assess objectively and quantitatively the results of ultrasound-assisted lipoplasty. Furthermore, DEXA more accurately reflects total fat reduction, including aspirated fat and resorbed emulsion, as well as any prolonged lipolytic effect that may be caused by thermal injury or any regional toxic effect of the emulsion.

A combined frontoorbital and occipital advancement technique for use in total calvarial reconstruction.

The management of infants with bilateral coronal synostosis and resultant brachyturricephaly poses a significant therapeutic challenge. The application of total calvarial reconstruction to the treatment of this problem has represented a major recent innovation that has substantially improved the cosmetic results in this patient population. However, rigid fixation of the reconstructed calvaria is often required to maintain the correction achieved and to provide protection for the underlying brain. The requirement of extensive fixation constitutes a significant disadvantage for the use of this procedure in infants and young children. In this report, the authors describe an approach to the treatment of this problem that incorporates a series of tongue-in-groove osteotomies to provide increased stability to advancements of both the frontal and occipital regions in conjunction with cranial height reduction, while minimizing the need for metallic fixation. With this approach, the reconstructed skull is sturdy enough to resist the compressive force applied by the weight of the child's head immediately after surgery, but retains the ability to expand progressively. The authors have found the cosmetic results to be extremely gratifying. In this article they present their experience with this technique in seven children.

Presurgical orthopedics in the surgical management of unilateral cleft lip and palate.

Forty years after its introduction by McNeil and Burston, presurgical orthopedics remains a controversial subject. Although the more extravagant claims for the technique have been dismissed, assessment of its proper place in cleft rehabilitation has been hampered by the poor design of early studies. Furthermore, although the principles of presurgical orthopedics are derived from the venerable tradition of reducing cleft width to facilitate reconstructive surgery, almost all research has focused on matters of dental alignment, cross bites, and maxillary arch form. Not one research paper has ever been published investigating the possible benefits to cleft surgery resulting from presurgical orthopedic treatment. Although it is now generally accepted that presurgical orthopedics does not give significant orthodontic benefits, there are still numerous opinions indicating that presurgical orthopedics does facilitate primary reconstructive surgery for cleft lip and palate. Furthermore, presurgical alignment of the maxillary skeletal base is considered essential to some of the new techniques of primary rhinoplasty.

Three-dimensional imaging of Poland's syndrome.

Use of a three-dimensional CT scan as an adjunct for planning chest-wall and breast reconstruction in Poland's syndrome is presented with follow-up MRI with three-dimensional reformation to demonstrate the results of the implant reconstruction. The imaging techniques are capable of accurately portraying the three-dimensional tissue deficit and asymmetry. This imaging may assist in the choice of muscle transposition flaps and reconstructive technique.

Long-term results of vascularized cranial bone grafts.

The clinical and radiographic results of 9 consecutive vascularized full-thickness cranial bone grafts to the midface are examined for a period of 3 to 8 years. Satisfactory contour was maintained throughout the follow-up in 5 patients with severe congenital facial deformities. Axial computerized tomography revealed complete survival of a trilaminar bone graft in each case. The complications were limited to a small area of alopecia in the midportion of one temporal scar. This relatively tedious harvest of bone is indicated for severe congenital malar and maxillary midface hypoplasia beginning at 4 years of age.

Pharmacologic manipulation of postoperative labial wound contraction and midfacial growth in rabbits.

Recent experimental work has suggested that increased lip pressure and scar contraction following lip repair with wide soft-tissue undermining may, in part, contribute to midfacial growth inhibition. The present study was designed to test this hypothesis through the application of pharmacologic agents reported to minimize scar contraction. Thirty-six 6-week-old rabbits were divided into six groups: unoperated controls, rabbits with surgically created defects left unrepaired (surgical controls), and four groups of rabbits with surgically created defects with lip repair and wide undermining on the maxillary surface. Animals with lip repair received either no injections or labial subcutaneous injections of distilled water (route-of-injection controls), normal saline, or papaverine hydrochloride for 2 weeks postoperatively. Rabbits with lip repair and saline or papaverine injections showed significantly (p less than 0.05) decreased lip pressure, relatively hypotonic orbicularis oris muscle EMG activity on the cleft lip side, and greater anteroposterior facial growth (assessed radiologically) from 2 to 24 weeks postoperatively compared with rabbits with lip repair and postoperatively compared with rabbits with lip repair and no injections or distilled water injections. Preliminary results suggest that wound contraction following lip repair and soft-tissue undermining may contribute to mid-facial growth inhibition, which may be reduced by pharmacologic manipulations in the rabbit model.

The buccinator myomucosal island pedicle flap: anatomic study and case report.

The buccinator myomucosal island pedicle flap is a useful means of introducing relatively large amounts of vascularized mucosa into the oral cavity. Using cadaver dissections and clinical cases, the anatomy and clinical relevance of this tissue are defined. Emphasis is placed on the technical caveats and pitfalls of the procedure.

Frontal bone advancement and compensatory craniofacial growth changes in rabbits with experimental coronal suture immobilization.

Recent clinical advances in the surgical correction of coronal suture synostosis involve the overcorrection of a frontal bone segment to allow for unrestricted expansion of the developing neurocapsular matrix. However, the effects of such large-scale calvarial repositioning on subsequent brain mass growth trajectories and compensatory cranio-facial growth changes is unclear. This study was designed to investigate this relationship in an experimental rabbit model of bilateral coronal suture synostosis. Amalgam markers were placed across the frontonasal, coronal, and anterior lambdoid sutures in thirty-one 1.5-week-old rabbits. Twenty-one animals underwent bilateral coronal suture immobilization using methyl-methacrylate. Ten animals were left untreated and served as sham controls. At 6 weeks of age, the coronal suture was released by frontal bone craniotomy or frontal bone craniotomy with a 6-mm frontal bone advancement. Lateral head radiographs were taken at 1.5, 6, 7, 9, 12, and 18 weeks of age. Results revealed that by 6 weeks of age, animals with coronal suture immobilization exhibited growth disturbances across the various sutures resulting in altered craniofacial and cranial vault shape compared to control animals. Following coronal suture release, animals that underwent craniotomy showed rapid restenosis, which resulted in significantly altered cranial vault shape and cranial orthocephalization by 18 weeks of age. Animals that underwent frontal bone advancement exhibited normal overall craniofacial growth by 18 weeks of age compared with control animals but did exhibit regional compensatory growth disturbances at the frontonasal and anterior lambdoid sutures, possibly related to neural tissue distension.(ABSTRACT TRUNCATED AT 250 WORDS)

The surgical anatomy of the scalp.

Cadaveric dissections and surgical observations have led to the description and clarification of the boundaries. blood supply, and nomenclature of the layers of the scalp. Special attention was directed to the layer of "loose connective tissue" that lies beneath the entire galea and above the cranial periosteum centrally, and the temporalis fascia laterally. It has been named the subgaleal fascia (SGF). The subgaleal fascia is a trilaminar structure with unusual potential in reconstructive surgery. Histologic study reveals the subgaleal fascia to be composed of a central dense collagenous layer surrounded by vascularized areolar tissue. It is readily dissected from surrounding galeal and periosteal layers. The subgaleal fascia was probably included in previously described "pericranial flaps," which were often based beyond the periosteum. The blood supply of the subgaleal fascia originates from the proximal portion of the peripheral vessels of the scalp and continues within the areolar lamina. The subgaleal fascia is an exceptionally thin, malleable, and well-vascularized flap useful for facial reconstruction.

Clinical applications of the subgaleal fascia.

The anatomic boundaries and vascular supply of the subgaleal fascia have been described previously. The thin and malleable subgaleal fascia was selected for difficult reconstructive problems in seven patients. This flap has been based on either the supraorbital or the superficial temporal vascular leash. The subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and a skin-graftable calvarium. The flap conforms to a cartilage framework for ear reconstruction. It takes a skin graft well. The subgaleal fascia can patch dural defects and fill sinus dead space. It has been used to augment facial contour. Free vascularized transfer of the subgaleal fascia has included the temporoparietal fascia, which was partially split from the subgaleal fascia for bilobed flap resurfacing of the hand. The subgaleal fascial flap should be considered when ultrathin, vascularized coverage is needed.

Frontal bone advancement stability with or without microplate fixation: an experimental study in rabbits.

Recent advancements in surgical correction of coronal suture craniosynostosis involve the overcorrection of a frontal bone segment to allow unrestricted growth of the developing brain. However, problems with segment stability and collapse have been reported. Such problems may be alleviated with microplate fixation of the segments. The present experimental study tests this hypothesis in a growing rabbit frontal bone advancement model. Sixteen 6-week-old rabbits were divided into three groups, consisting of animals with short bone segments advanced with two bone struts and fixed with Vicryl, long bone segments advanced with one bone strut and fixed with Vicryl, or long bone segments advanced with one bone strut and fixed with microplates. Frontal bone advancement collapse was assessed from lateral x-rays through 12 weeks postoperatively. Animals with microplate fixation exhibited significantly (p less than 0.01) less collapse (about 1% height reduction) compared to animals with short segments (about 30%) and long segments (about 45%). These results support, with experimental evidence, the utility of rigid three-dimensional fixation afforded by the microplate system in overcoming the effects of cranial growth and scalp and epicranial musculature closing tensions.

A new approach for repair of oro-antral-nasal fistulae. The anteriorly based buccinator myomucosal island flap.

Oral-antral-nasal fistula (OAN) is a commonly encountered clinical problem. The literature is filled with a plethora of methods described for closing a persistent OAN. Local flaps are available to close minor to moderate defects, however, large fistulae can be a very challenging reconstructive problem. Various areas of the oral cavity have been used for closure of OAN. We describe a technique to reconstruct the oral cavity, in this case an OAN. The anteriorly based buccinator myomuosal island pedicle flap (BMIP) provides an alternative method for reconstructing the oral cavity. An extensive review of the literature as well as the anatomy of the buccinator, its reconstructive capabilities, and two case reports are included.

Extending the reach of island cutaneous flaps.

The advancement of island cutaneous flaps beyond 2 cm is facilitated by an understanding of underlying vascular anatomy. Recent studies demonstrate the perforating cutaneous blood vessels of the body. When extensive mobility is required, an island cutaneous flap should be centered over these vessels. The perforating cutaneous vessels and, if necessary, the axial vessels are identified, which permits vigorous dissection of restraining fascia and muscle. Clinical experience during the past 14 years suggests that the medial face is an ideal location for island cutaneous flaps. Flap design in the trunk and extremities incorporates known septal and subcutaneous fascial perforators. Fourteen of 53 island cutaneous flaps were advanced distances greater than 2 cm without significant complications.

Composite upper lip repair with V-Y advancement flaps.

In two patients, large but superficial partial-thickness resections of lateral upper lip have been repaired by composite island cutaneous flaps. Upper lip and nasolabial fold flaps, along with lateral vermilion, were advanced and closed in a V-Y manner leaving inconspicuous scars and no contour deformity.

Surgical management of difficult wounds of the groin.

Coverage of large defects of the soft tissue of the groin present a challenging problem. Exposure of the femoral vessels or prosthetic grafts requires urgent coverage with well vascularized tissue. The medial and lateral femoral circumflex arteries supply the gracilis, sartorius, vastus lateralis, rectus femoris and tensor fascia lata muscles, permitting the use of these muscles or myocutaneous flaps for coverage of groin defects when the femoral artery is intact. With extensive wounds of the groin resulting from trauma, ablation of carcinoma and vascular reconstruction for atherosclerosis involving the femoral vessels, the aforementioned flaps cannot be used. The external iliac artery supplies the rectus abdominis muscle through the deep inferior epigastric artery and the interal oblique muscle through the deep circumflex iliac artery. These muscle flaps are available when the femoral vessels are not intact. If the ipsilateral iliofemoral vessels are not intact, branches of the contralateral iliac artery through deep inferior epigastric artery and deep circumflex iliac artery provide suitable flaps for covering the groin wound. We review our experience with the management of difficult groin wounds (n = 31) and present a systematic approach to reconstruction of the groin based on these anatomic facts.