The thin cross finger skin flap.

The cross-finger flap has been used successfully for decades. Traditionally, the flap is elevated in the plane lying superficial to the extensor tendon. This damages the delicate subcutaneous tissues, which are important for the lengthening capacity of the skin of the dorsum of the fingers during flexion and extension. In this report, we present a modification of elevation of the cross-finger flap in a plane superficial to the dorsal veins of the fingers. This modification prevents donor finger complications such as poor graft take, extensor tendon adhesion to the graft and reduced range of finger joint movement and contour deformities. We have used this technique in six digits in four patients with successful results.

Carpal tunnel syndrome: comparison of intraoperative structural changes with clinical and electrodiagnostic severity.

The aim of this study is to grade the intraoperative findings seen in carpal tunnel syndrome (CTS) based on severity, and compare it with clinical and electrodiagnostic severity. Thirty-one hands surgically treated for CTS were graded according to the severity of clinical signs, and electrodiagnostic tests. Oedema, vascularisation, and fibrosis were graded on a scale of 1-3. Pseudoneuroma or 'hour-glass' formation were graded as either 0 or 1. The hands were allocated by an observer into an assumptive severity group, from grade 1 to 3. Clinical severity and electrodiagnostic severity were statistically compared with each other, and with each intraoperative severity criteria. A high statistical correlation (p < 0.01) was found between clinical severity and vascularisation, fibrosis, and the assumptive intraoperative severity. No correlation could be demonstrated between electrodiagnostic severity and the intraoperative criteria. Intraoperative grading should be regarded as a supportive measure to the clinical evaluation in order to obtain a sound base for surgical intervention and internal neurolysis.

Single staged, z-plasty supported, wedge excision modification for treatment of auricular lesions under local anesthesia: a technical note.

Following wedge-excision of auricular lesions, a triangular-cartilage only-excision is planned at the tip of the wedge. The dimensions and the angles of this cartilage can be modified as much as the required helical rotation. After approximating the cartilage edges a notching deformity may be observed which can be improved using single or multiple z-plasties.

An unusual hand injury caused by powered woodsplitter--split fingers.

We present a case of very unusual injury to the right hand of a 14-year-old boy who had an accident with a powered woodsplitter. The trauma produced a unique hand injury pattern. All fingers except the thumb were split into dorsal and volar sections without any bone fractures, mimicking surgically elevated volar flaps. We achieved satisfactory hand function using simple surgical and conservative management in this unique hand injury case.

Open rhinoplasty through a forked flap incision.

Surgical elongation of the short columella is a challenging problem for the surgeon. Although some flaps from the upper lip are successfully used to correct this deformity on cleft lip patients with a scarred upper lip, these methods cannot be applied to noncleft patients with a smooth upper lip. Distant flaps and composite grafts do not give the best aesthetic results. The use of an external approach for rhinoplasty is preferred by many surgeons, especially for difficult or secondary cases. Most incisions for open rhinoplasty are placed on the columella. This report describes a new incision for open rhinoplasty to be used on patients with a short columella. The incision is a standard forked flap with a columellar base but the legs of the flap extend to the nostril bases instead of to the upper lip. This method was used on eight aesthetic rhinoplasty patients with a short columella between March 1995 and March 1998. The results of the method are discussed.

Spontaneous autoinflation of saline-filled mammary implants: postoperative volume determination by magnetic resonance imaging.

Autoinflation of saline-filled mammary implants has recently been reported in the literature. Except for a few controversial hypotheses, the cause of autoinflation has not been clarified. The need to remove implants for accurate measurement of fill volume has been a deterrent to studies of autoinflation. To measure in situ volumes of saline-filled mammary implants, a noninvasive technique using magnetic resonance imaging (MRI) was developed. Measurements were performed manually on every MRI slice by tracing the outline of the implant with a hand-driven cursor. The accuracy of this MRI technique was assessed by measurements of tissue expanders containing known volumes of saline. To evaluate for autoinflation in mammary implants, a prospective clinical study to compare initial fill volumes of saline-filled mammary implants with 3- and 18-month postoperative volumes, calculated from magnetic resonance imaging (MRI) studies, was designed. A total of 12 patients (23 breast implants) implanted between 1994 and 1996 was included in the study. Volume data were compared by statistical analysis. MRI-determined volumes 3 months postoperatively were significantly larger than reported initial fill volumes, indicating that most saline-filled mammary implants included in the study autoinflated to some extent. Comparison of MRI-determined volumes 3 and 18 months postoperatively revealed no significant differences, indicating that saline-filled mammary implants remain stable and inflated between 3 and 18 months postoperatively. As a result of this study we believe that autoinflation of saline-filled mammary implants occurs more frequently than previously thought.

Life satisfaction, self-esteem, and body image: a psychosocial evaluation of aesthetic and reconstructive surgery candidates.

Psychology should be an important part of a plastic surgery procedure in order to buoy up the patient so that he gains a consequent relief of psychiatric and social problems. It is a fact that reconstructive surgery patients also seek psychological stability and a better appearance that is acceptable to society. While the life satisfaction, self-esteem, and body image of the individual who seeks aesthetic plastic surgery has been a special concern in the plastic surgery literature, data about reconstructive surgery patients are usually lacking. To understand the factors influencing the aim of an individual seeking plastic surgery, this prospective controlled clinical study was designed. We hypothesized that they should have lower life satisfaction and self-esteem and more distorted body images than the "normal" population. Three hundred individuals were included in the study. Both the aesthetic surgery group (AG) and the reconstructive surgery group (RG) consist of 100 (n = 100) subjects. Individuals chosen randomly from the total population seen in the 12-month period were included regardless of the type of procedure, body region, or type of trauma as well as whether or not their wish for surgery was justified by the staff. The third group, the control group (CG), also consists of 100 (n = 100) subjects and was chosen from the "normal" population. All 300 subjects were asked to complete four scales: the Socio-Demographic Questionnaire, Life-Satisfaction Index (LSI), Self-Esteem Inventory (SEI), and Body-Image Inventory (BII). Results were collected and compared. The LSI results for the two surgical groups were found to be similar to those for the CG, with the RG demonstrating the lowest level. For the SEI there was a significant difference between the two surgical groups, being in favor of the AG, and a greater difference was noted between the CG and the RG. BII results showed no significant difference among the three groups. As a result, although there may be some, a regular person who seeks an aesthetic procedure should not be considered a psychologically disturbed individual at face value and each case should be evaluated individually in the preoperative consultation. Similarly, individuals who present for reconstructive procedures and wish further aesthetic refinements should be evaluated and treated exactly as pure aesthetic candidates.

Progressive gangrene of the hand following extravasation of antibiotics associated with hereditary resistance to activated protein C.

Protein C, a vitamin K-dependent potent anticoagulant, is synthesized in the liver. Hereditary resistance to activated protein C is a condition that increases the risk of thrombosis as a result of mutation in factor V gene (factor V Leiden). It is generally accepted to be associated with venous thrombosis. We present a patient who was given antibiotics via the dorsal hand veins. Venous thrombosis in the hand that ensued from the extravasation of antibiotics resulted in the formation of arterial thrombosis that eventually lead to necrosis. Factor V gene analysis showed that the patient was heterozygous for the common factor V arginine506 to glutamine mutation. To the best of our knowledge, hand necrosis due to antibiotic extravasation associated with hereditary resistance to activated protein C has not been reported previously.

A case of popliteal pterygium treated along with nerve expansion.

The presence of a short sciatic nerve in the free edge of a popliteal pterygium makes this syndrome a surgical challenge. We present a case of popliteal pterygium that was treated by nerve expansion. The range of motion of the patient's knee joint was between 30 and 120 degrees. A 75-cc tissue expander was placed under the sciatic nerve and filled with 5 cc of saline solution weekly. When a total of 60 cc was reached, wound dehiscence was observed, and the procedure had to be stopped. The maximum extension obtained was 160 degrees. Since the expansion process had to be stopped early, the elongation attained by expansion was less than expected. We conclude that the nerve expansion method can be used as a good alternative treatment modality for patients with popliteal pterygium.

A technique for the repair of simple congenital earlobe clefts.

Congenital cleft of the earlobes is rarely seen among congenital ear anomalies. These clefts show a wide range of severity and localization, from simple notching to extensive tissue deficiencies. We developed a new technique that can be used in simple cases of earlobe cleft. For this technique, we use the anterior and posterior parts of the cleft as Y-V advancement flaps and achieve a three-dimensional construction of the lobe that is symmetrical with the opposite lobe.

An unusual origin for the accessory head of biceps brachii muscle.

During the superficial dissection of the pectoral region and the arm, an abnormal biceps brachii muscle was observed unilaterally. This muscle had three heads. Whereas the short and long heads had their normal origin, the accessory head originated from the anterior surface of the distal part of the pectoralis major muscle, which formed the anterior axillary fold. To our knowledge, this variation has not been previously described. Innervation and vascular supply of this accessory head was from the musculocutaneous nerve and the brachial artery, respectively.