Temporal facelift and corrugator resection.

On a path analogous to other surgical disciplines, the progression of facial cosmetic surgery has trended toward shorter scars and less invasive techniques. This article outlines an approach to facelifting that limits the scar to the temporal scalp, preauricular area, and retroauricular sulcus. It will enable the reader to identify those patients who are candidates for a less invasive procedure compared with the conventional facelift approach. Specifically, the temporal facelift addresses the lateral brow, the middle one third of the face, and the upper neck. In addition, this article examines the various and current methods for treatment of the glabellar area of the forehead. Medical and surgical options are outlined for the correction of those rhytids induced by corrugator and procerus muscle activity.

Vaginal reconstruction with a rectus abdominis musculoperitoneal flap.

In more than 300 clinical cases, the authors have observed and documented the presence of a branch of the deep inferior epigastric artery that penetrates the posterior rectus sheath near the umbilicus. Their cadaveric anatomic and animal injection studies confirm the vascularity of the peritoneum via the deep inferior epigastric artery. They report 2 patients treated with a new technique of vaginal reconstruction using a thin, pliable flap with a peritoneal-lined rectus abdominis muscle based on the deep inferior epigastric vessels.

Immediate skin expansion: an old concept by a novel and inexpensive technique.

Intraoperative skin expansion is not a new concept. We have developed a technique using readily available inexpensive material to achieve wound closure. In this prospective study, 15 patients (age range, 1-72 years) with melanoma, giant nevi, scars, meningocele, gastroschisis, alopecia, thrombosed renal dialysis fistula, calcified nodule and trauma, with defects on back, limbs, abdomen, scalp, hand, calcaneum, and sole of foot were treated. Only hypodermic needles and dental wire, with an overall cost of less than a dollar, are needed for the immediate skin expansion technique. In contrast, the numerous other commercial devices currently in use are costly and must be ordered in advance. Using our technique, the wound can be gradually approximated and subcutaneous sutures placed with the device in situ. An intradermal or simple running suture is then placed to approximate the skin edges under little or no tension and the device is removed. All patients had a good result with minimal morbidity. The wounds treated by this technique healed by primary intention except in 3 patients, who developed minor dehiscence of the wounds.

Evaluation of intercostal pacing to provide artificial ventilation in quadriplegics.

The purpose of this study was to assess the utility of intercostal muscle pacing by spinal cord stimulation (SCS) to provide artificial ventilation in ventilator-dependent quadriplegic patients. Five ventilator-dependent quadriplegics with phrenic nerve injury (and therefore not candidates for phrenic nerve pacing) were studied. During an initial surgical procedure, a quadripolar epidural disc electrode was positioned on the ventral portion of the upper thoracic spinal cord via a hemilaminectomy and subsequently connected to a radio-frequency receiver implanted subcutaneously over the anterior rib cage. In four of the five patients, initial SCS stimulation resulted in inspired volumes between 150 and 240 ml. Stimulation resulted in no effect in one patient, due to probable cystic degeneration of the thoracic spinal cord. Reconditioning of the intercostal muscles caused substantial increases in inspired volume in three of four patients of 670 to 850 ml. In one patient, reconditioning resulted in a much smaller increase (to 470 ml). The maximum duration that ventilation could be sustained by low-frequency (13 Hz) intercostal pacing ranged between 20 min and 2 3/4 h. Our findings indicate that intercostal pacing via SCS does not result in sufficient inspired volume production to support ventilation for prolonged periods. However, this modality may be a useful adjunct to enhance tidal volume in patients with suboptimal inspired volume by phrenic nerve pacing.

Evaluation of ultrasound as a tool in the follow-up of patients with breast implants: a preliminary, prospective study.

We prospectively reviewed clinical findings in 93 patients with 154 silicone breast implants (SBIs), as well as ultrasound findings in 57 patients with 94 SBIs. Ultrasound findings of implant wall redundancy, combined with abnormal silicone echogenicity, correlated well with predicted and surgically confirmed SBI rupture. Age-related implant findings (i.e., length of time since implant placement) included capsular contracture, a variety of abnormal ultrasound findings, subjective reports of joint pain or fatigue, and a greater probability of rupture. Prospective screening of otherwise satisfied patients with SBIs raises concerns about the need for removal when satisfactory alternatives for maintaining breast size are limited. The ability to predict impending rupture will increase this dilemma.

Ethical and psychosocial considerations of wound management.

Ethical and psychosocial considerations in caring for patients with pressure ulcers are explored in relation to the consequential and the nonconsequential schools of ethical thought. The principles of ethical decision making are related to wound management in terms of beneficence, nonmaleficence, justice, veracity and confidentiality, autonomy and liberty. Allocation of scarce resources and the conduct of research influence ethical decision making in wound management.

Development of a computerized data base to evaluate pressure ulcers.

A computerized data base for collecting information on patients with pressure ulcers was developed following a review of selected literature including Allman (1986), Bergstrom (1987), Barbenel (1977), Reichert (1986), Black (1987) and others. The data base was piloted, revised, and used for data collection on 103 patients admitted to two hospitals. Standardized data allowed for correlations of spinal cord injury (SCI) and location of pressure ulcers. Sacral ulcers were more prevalent with patients who had SCI at C4-T1 while ischial ulcers were more common with SCI at T11-L1. Some of the other correlations differ from prior research and warrant further investigation with a larger sample size from multiple institutions.

The expanded myocutaneous flap for reconstruction of the difficult pressure sore.

This paper presents the use of the expanded myocutaneous flap for the reconstruction of the difficult pressure ulcer. The results of expanded myocutaneous flaps on 10 patients with a variety of locations of pressure ulcers showed few complications. A review of the literature on the use of expanded flaps indicates the potential for this technique to be more frequently used.

The perioperative antimicrobial management of pressure ulcers.

No clear data exist as to the efficacious use of antibiotics during the perioperative period for repair of pressure ulcers. Results of a survey from 50 university departments of plastic surgery and spinal cord injury centers revealed that 58% reported routine use of antibiotics for flap surgery with cephalosporins as the choice at 69% of the centers. Clinical experience with 35 patients perioperatively showed good results with a third generation cephalosporin.

Ethical dilemmas of pressure ulcers.

Provocative questions regarding ethical dilemmas surrounding care of patients with pressure ulcers are discussed under the aspects of etiology, epidemiology, prevention, malnutrition, anemia, incontinence, pressure, medical and surgical management and socio-economic factors. Two sometimes conflicting moral schools, that of "Beneficence" and "Utilitarian," form the framework for posing ethical dilemmas.

Burn accidents and the elderly: what is happening and how to prevent it.

Individuals over 60 and children under 2 form the two most burn-prone age groups in the United States. These figures are confirmed in other western cultures. The majority of injuries sustained in these two groups are preventable and relate to inadvertent scalding from hot water at the tap or spilled liquids in the kitchen and ignition of fabrics by faulty heaters or cigarettes. These injuries among the elderly lead to permanent change in health care status in over 40% of such accidents, and their prevention could significantly reduce morbidity associated with aging. Recommendations to promote burn prevention include reducing the temperature of hot water at the tap, introducing self-extinguishing cigarettes, and placing smoke detectors in all residences.

Evidence for the nonmuscle nature of the "myofibroblast" of granulation tissue and hypertropic scar. An immunofluorescence study.

Contraction is an important phenomenon in wound repair and hypertrophic scarring. Studies indicate that wound contraction involves a specialized cell known as the myofibroblast, which has morphologic characteristics of both smooth muscle and fibroblastic cells. In order to better characterize the myofibroblast, the authors have examined its cytoskeleton and surrounding extracellular matrix (ECM) in human burn granulation tissue, human hypertrophic scar, and rat granulation tissue by indirect immunofluorescence. Primary antibodies used in this study were directed against 1) smooth muscle myosin and 2) nonmuscle myosin, components of the cytoskeleton in smooth muscle and nonmuscle cells, respectively, and 3) laminin and 4) fibronectin, extracellular glycoproteins mediating cell-matrix attachment in smooth muscle and nonmuscle cells, respectively. Myofibroblasts can be identified by their intense staining of actin bundles with either anti-actin antibody or NBD-phallacidin. Myofibroblasts in all tissues stained for nonmuscle but not smooth muscle myosin. In addition, nonmuscle myosin was localized as intracellular fibrils, which suggests their similarity to stress fibers in cultured fibroblasts. The ECM around myofibroblasts stains intensely for fibronectin but lacks laminin, which suggests that a true basal lamina is not present. The immunocytochemical findings suggest that the myofibroblast is a specialized nonmuscle type of cell, not a smooth muscle cell.

Rehabilitation of the burn patient.

A successful outcome to the management of the significantly burned patient requires a team approach. Although at one time survival alone was considered a sufficient indicator of success, the quality of that survival now must be closely assessed prior to self-congratulations. The burn team, in addition to the usual medical personnel, requires occupational and physical therapy, as well as rehabilitation medical specialists, whose goals are to preserve function and restore independence. Burn care that does not emphasize these goals from the first day of injury, and extended well beyond initial discharge from the hospital, does not match contemporary standards of excellent care.

Postmentoplasty hemorrhage from pseudoaneurysm of the inferior labial artery.

A 29-year-old woman underwent rhinoplasty and augmentation mentoplasty. She subsequently developed a pseudoaneurysm of the inferior labial artery. This was responsible for three episodes of delayed, major postoperative bleeding before the lesion was identified and the aneurysm ligated. She has had no further episodes of bleeding.