Unilateral mydriasis after nasal reconstruction surgery.

PURPOSE: To present a case of iatrogenic, unilateral pupillary dilatation after general anesthesia for nasal surgery. Unilateral pupillary dilatation after general anesthesia has sinister implications, which might prompt further investigations. However, in patients undergoing nasal surgery, it might be caused by the action of drugs injected intranasally. Consideration of iatrogenic causes of pupillary dilatation might help clinicians to avoid time-consuming and costly investigations. CLINICAL FEATURES: A 24-yr-old healthy woman underwent a general anesthetic for septoplasty and bilateral turbinectomy. She was hemodynamically stable and did not suffer any hypoxia intraoperatively. At the end of the operation her right pupil was dilated (8 mm diameter). Her left pupil was normal. No other abnormality was detected. After she woke up, her vision was grossly normal. Neurological examination did not show any other abnormality. Six to eight hours later, both pupils were equal (2 mm in diameter) and reacting normally to light and accommodation. CONCLUSION: The patient was a healthy 24-yr-old who underwent an operation in which there was no incident of hypoxia or hemodynamic instability. Since the patient recovered completely within six to eight hours, the pupillary dilatation was probably caused by epinephrine, which could have entered the eye through the nasolacrimal duct. Although pupillary dilatation after general anesthesia has been described, this is the first case report where the most likely causative agent was epinephrine, injected into the nasal submucosa.

Simultaneous osseous genioplasty and meloplasty.

A review was done of the records of 50 patients who had osseous genioplasty performed at the same sitting as face lifting and, in many cases, submental lipectomy over a 20-year period by the senior author. The types of genioplasties were sliding advancement (40), lengthening with interpositional bone graft (7), and reduction (3). In 9 patients, chin implants were removed, generally because of inadequate chin projection or implant erosion. Three patients were operated on under local anesthesia, the remainder under general anesthesia. Associated procedures, done in 46 patients, included rhinoplasty, forehead lifting, blepharoplasty, lateral canthopexy, excision of buccal fat pads, reduction mammaplasty, and abdominoplasty. In 4 patients, associated maxillofacial procedures were performed, including Le Fort I and III osteotomies, two-jaw surgery, mandibular advancement with sagittal splitting, and orbital expansion. The perceived advantages of osseous genioplasty were greater versatility in dealing with problems in other than the sagittal plane, the possibility of greater chin projection, and a tightening of the submental musculature. Complications occurred in 10 patients. These included two hematomas requiring aspiration in the office, a prolapsed submandibular gland requiring later excision, a transient weakness of the marginal mandibular nerve, a transient numbness of the lower lip on one side, four revisions of scars resulting from the face lifting, and one localized wound infection in the parasymphyseal area that resolved with oral antibiotics. The most common complaint, which came from 8 female patients at some time from 1 month to 3 years postoperatively, was that the chin was "too strong." In 6 of these patients, most of whom were operated on early in the series, some of the chin projection was reduced by burring. Osseous genioplasty can be performed safely along with face lifting and submental lipectomy. The degree of advancement necessary in aesthetic surgical patients is generally less than that required in reconstructive patients. Patient satisfaction is great unless the chin is overly advanced.

The frontonasal flap for increased exposure in posttraumatic nasal deformity: a technical overview.

Nasal reconstruction continues to be a surgical challenge. The prominent location of the nose, the unique quality and texture of its skin, and the intricacies of its cartilaginous and bony infrastructure demand careful attention to fine detail. Attempts to refine reconstructive techniques have resulted in a myriad of local flaps. The frontonasal flap is well-described and reliable, but it is infrequently used. A brief review of the literature is presented. The authors describe a unique case of a 64-year-old woman with posttraumatic nasal tip and dorsal deformity. The frontonasal flap provided soft tissue coverage for the nasal tip and allowed excellent exposure for reconstruction of the hard nasal framework with cartilage and bone grafts. It provides local tissue with excellent contour, color, and texture match, and can be performed in one stage.

The use of the labiocolumellar crease incision in rhinoplasty.

Aurel Rethi, in 1934, first described the transverse upper columellar incision for open rhinoplasty for resection of a portion of columella in cases of overly projecting nasal tip. The mid columellar incision has come to be known as the "Rethi" incision. Numerous variations of this approach have been popularized through the years. Recently, a great debate has raged over the criteria to be used in selecting patients for rhinoplasty. In this paper, we review 100 consecutive rhinoplasties and discuss our technique of labiocolumellar crease incision for open approach, and relate the criteria that we utilize to select patients for open rhinoplasty. There were 37 male and 63 female patients. Of these, 32 primary, 45 secondary, 18 cleft, and 5 reconstructive rhinoplasties were performed. Twenty-eight percent of primary, 62% of secondary, 78% of cleft, and 80% of reconstructive rhinoplasties were performed using the open approach via the labiocolumellar crease incision. There were no cases of circulatory compromise of the columella. The presence of a scar along the columella base (as with the C-flap in cleft patients) should be an indication for open rhinoplasty. Several myths about the labiocolumellar crease incision are dispelled. Adhering to principles of aesthetic subunits should guide the surgeon to place scars in a less noticeable position.

Internal brain herniation in a patient with Apert's syndrome.

Patients with Apert's syndrome typically exhibit craniosynostosis, exorbitism, midface hypoplasia, and symmetric syndactyly. There have also been occasional descriptions of the variable dysmorphology of the inner surface of the calvarium. We present a patient with Apert's syndrome who had an intracranial herniation of a portion of the frontal lobe through a ridge of ossified dura. The ridge and the gliotic cortical tissue were removed when the patient underwent repair of the hypertelorism at age six. Bone grafts for this repair were fashioned in part from the resected ridge. We believe this finding may be the result of a small dural tear that occurred during prior surgery.

Frey's syndrome: prevention with temporoparietal fascial flap interposition.

The recent trend in management of Frey's syndrome has been the use of prophylactic procedures performed at the time of parotidectomy to prevent its symptoms postoperatively. An additional benefit of this approach is the prevention of the typical cheek contour deformity after parotidectomy. We reviewed our experience with interposition of a vascularized temporoparietal fascial flap between the parotid bed and overlying skin immediately after complete superficial parotidectomies to prevent Frey's syndrome and contour defects. The results of seven consecutive attempts revealed it to be an effective technique, achieving both goals in all patients with minimal morbidity.

The inhibition of fibroblast-populated collagen lattice contraction by human amniotic fluid: a chronologic examination.

The effect of human amniotic fluid on fetal wound healing remains to be fully elucidated and may lead to the isolation of factors that could modulate adult wound healing. This study uses an in vitro model of wound contraction, the fibroblast-populated collagen lattice, to examine the effects of chronologically sampled human amniotic fluid on contraction of lattices composed of either human adult or fetal fibroblasts. This chronology has not been reported previously. Human amniotic fluid was obtained in a sterile fashion via amniocentesis from 120 different women at different time points in gestation, ranging from 13 to 24 weeks. At each time point of gestation, three to five samples were individually examined in duplicate sets. Only fluid from pregnancies deemed normal by amniocentesis was included. Contaminated specimens were discarded. Using Bell's protocol, lattices were constructed of acid-soluble rat tail collagen, growth medium, and either human adult fibroblasts or human fetal fibroblasts. Lattices contained 20% v/v human amniotic fluid. In the control lattices, phosphate-buffered saline replaced amniotic fluid in equal volumes. Area was measured at 24-hour intervals, and all tests were run in duplicate for each specimen. The mean area at each interval was computed for each gestational week examined. Data were analyzed for significance with ANOVA and Dunnett's t test against control.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of fibrin glue on skin grafts in infected sites.

Fibrin bonding of skin grafts to wounds is an essential part of the graft-adherence process. Bacteria, in concentrations greater than 10(5)/gm of tissue, are associated with graft failure. Sixty-five rats were randomly divided into three groups, dorsal split-thickness skin grafts were harvested, and the sites were inoculated with Staphylococcus aureus. After incubation, each wound was quantitatively biopsied and treated with saline, fibrin glue with aprotinin, or fibrin glue alone. We found that the addition of commercially available fibrin glue with or without the antifibrinolytic agent aprotinin is capable of restoring graft adherence to normal levels in graft sites infected with greater than 10(5) bacteria/gm of tissue. Fibrin glue may have potential for increasing skin-graft take in the clinical situation where the graft bed is infected.

Skin closure with dye-enhanced laser welding and fibrinogen.

The topical application of wavelength-specific dye and fibrinogen has been used to enhance laser closure of vascular anastomoses. We compared the closure of skin incisions by two different dye-enhanced, fibrinogen-based laser welding systems [argon laser (power density 4.78 W/cm2) with fluorescein isothiocyanate dye (n = 32) and diode laser (power density 9.55 W/cm2) with indocyanine green dye (n = 32)] with closure by interrupted 5-0 nylon suture (n = 64) and examined tensile strength, hydroxyproline production, histology, and cosmesis. Two 3-cm full-thickness incisions were made on the shaved backs of 64 rats. One incision was closed with suture, whereas the other, after treatment with the appropriate dye, was welded with either argon- or diode-lasered fibrinogen. At postoperative days 5, 10, 15, and 28, the closure sites were harvested and sectioned for analysis. Initially, wounds closed with argon-lasered fibrinogen showed less inflammatory response, greater collagen production (34.61 +/- 0.74 mg/gm), and greater mean peak stress at rupture (64.85 lbs/in2) than those closed with suture (16.42 +/- 3.20 mg/gm, 26.68 lbs/in2) (p less than 0.05). By 15 days, both argon and diode laser closures are superior in strength and collagen production to suture closure (p less than 0.05). At 28 days, diode laser closures (1315.60 lbs/in2) are stronger than suture closures (998.09 lbs/in2), whereas both are stronger than argon laser closures (813.16 lbs/in2) (p less than 0.05). Cosmetically, argon-welded wounds consistently appeared finer and lacked cross-hatched suture scars.(ABSTRACT TRUNCATED AT 250 WORDS)