A simple solution to a complex position in cleft surgery.

Correct positioning of the surgeon and patient in palate surgery is a problem often faced by the craniofacial surgeon. To achieve the best result, it is essential that the surgeon has direct visualization and sufficient access to the field. We describe a simple solution to this complex problem, which has been used by Dr. Ian Jackson for the last 20 years. We believe the Jackson method of positioning offers good visualization of both anterior and posterior parts of the palate, while minimizing the strain associated with neck extension during conventional positioning in cleft surgery.

Endotracheal tube fixation methods for optimal stability: a comparison of adhesive tape, suture, and tape-suture fixation.

Accidental extubation of an intubated patient is a serious consideration in the surgical patient. Adequate fixation in the intubated patient is essential to prevent potentially life-threatening complications. Several methods of endotracheal tube fixation have been described in the literature. In this study, we examine 3 common methods of fixation: adhesive tape alone, suture, and tape-suture. Testing occurred in a laboratory setting with 2 fresh cadavers. Endotracheal tubes were inserted, using the methods of fixation in question. We subjected each fixation technique to progressively increasing weight to determine which technique is most resistant to accidental removal. We found that fixation of the tube by combining tape around the tube with a suture through the tape is the best noninvasive technique of the 3 methods evaluated in cases where movement of the head is anticipated.

Palatal fistulae resulting from cocaine abuse.

Cocaine fistulae require repair with well-vascularized material. In the technique used this is accomplished by closure of the nasal layer by delayed palatal flaps and the oral layer with a tongue flap. Three cases are presented.

Comparison of osteogenic potential of calvarial bone dust, bone fragments, and periosteum.

INTRODUCTION: Bone dust is often used as a control when testing the potential of a new reconstructive graft material. Under microscopic examination, it would be expected to see the fully differentiated cellular components of bone, but instead only fusiform shapes characteristic of fibroblasts are mainly seen. This study aimed to compare the osteogenic potential of cells obtained from calvarial bone dust, bone fragments, and periosteum using 3 assays: collagen, calcium, and alkaline phosphatase. MATERIALS AND METHODS: Bone dust was harvested from the calvaria of 5 euthanized rabbits by drilling burr holes. Small pieces of intact, nondrilled bone, and periosteum were also obtained to serve as controls. The cells obtained from the bone dust, bone fragments, and periosteum were cultured for 5 weeks and then assayed for collagen (type 1), calcium, and alkaline phosphatase. RESULTS: Staining for calcium revealed that the greatest calcium deposition was achieved with periosteum, followed by bone dust and then bone fragments. Staining for alkaline phosphatase was similar for bone dust and periosteum, followed by bone fragments. Collagen assay demonstrated the presence of collagen in similar concentrations in all 3 preparations. CONCLUSIONS: Bone dust has most of the necessary components for osteogenesis, including the presence of osteoprogenitor cells that have the ability to lay down collagen type 1 and deposit calcium and can differentiate to form bone. Further studies that can accurately quantify the percentage of surviving osteoblasts in various bone components are needed.

Evaluation of polymethylmethacrylate adhesion: a comparison of direct onlay versus screw anchoring techniques.

UNLABELLED: Polymethylmethacrylate (PMMA) is still the most frequently used alloplastic material for calvarial reconstruction, especially when dealing with large bony defects. It is strong, provides good protection to the underlying cerebral structures, and is stable and minimally reactive. One of the disadvantages of this material is its tendency to become loose over time because of its poor adherence to bone. Onlay miniscrews in improving PMMA's adhesion to bone have been previously proposed. A series of experiments were conducted to evaluate whether placement of screw anchors will significantly improve the adhesion force between the polymer and bony surface. METHODS: Four fresh-frozen cadaver heads were used for this experiment. The PMMA preparation and setup time strictly followed manufacturer guidelines. Two experimental groups were created: (1) PMMA was placed on the subperiosteal bony surface with increasing surface areas (areas: 1-20 cm2), and (2) a standard area of 16 cm2 PMMA was placed on the bony surface with an increasing number of titanium miniscrews (number of screws: 0-5). The force required to separate the material from the underlying bone was assessed using a digital pull force gauge (Imada DPS-44) through vertical traction. The experiments were undertaken in triplicate; the results were statistically analyzed using Student t test. RESULTS: Experiment 1: increasing forces were required as the surface area of PMMA application increased (1.2-42.3 N). The most consistent measurements with a low SD were obtained on the 16-cm2 implant, which was chosen for experiment 2. A 16-cm2 area would allow for the placement of up to 5 screws without technical difficulty. Experiment 2: higher forces were needed to detach the material, with increasing screw placement (1, 79; 2, 132.5; 3, 194.2; and 4 and 5, >196.1 N). In 73 of 75 experiments, the screws remained attached to the PMMA after separation. When the PMMA alone on a 16-cm2 surface area was compared with the placement of one or more screws, the force of adhesion significantly increased for all groups (P < 0.01). There was a 2.6x increase in this force with 1 screw, 4.4x with 2, 6.4x with 3, and 6.5x with 4 or more screws. Three or more miniscrews provided sufficient stabilization to anchor an implant firmly in place while resisting large traction forces. CONCLUSION: Although greater surface areas of PMMA will increase the adhesion force between the polymer and bone, a clinically and statistically significant increase in this force may only be achieved with the use of miniscrews.

The palatal overlap flap: a modification of the maxillary swing procedure to prevent ascending infection.

The maxillary swing procedure provides an excellent approach to the anterior skull base region and to the clivus. The osteotomy should not be standard; it should vary with the size and position of the central skull base tumor being resected. The main reason for publishing this article is to draw attention to a method of preventing ascending infection from the oral cavity to the intracranial area using the palatal overlap flap. Examples of this approach are provided.

Reinforcement of subcuticular continuous suture closure with surgical adhesive strips and gum mastic: Is there any additional strength provided?

BACKGROUND: This study aimed to compare the burst strength of suture closure versus the use of suture and strip together. METHODS: On cadavers, 50 skin incisions were closed as follows: group 1--subcuticular continuous suture; group 2--same suturing with placement of strips; group 3--same as group 2 except gum mastic was applied prior to strips; group 4--strips alone; and group 5--strips with gum mastic application. The separation forces were measured using a tensilometer. RESULTS: The mean separation forces were as follows: group 1, 14.17 kg; group 2, 14.37 kg; group 3, 15.39 kg; group 4, 1.52 kg; and group 5, 3.85 kg. There were no statistically significant differences between groups 1, 2, and 3. When compared with group 4, group 5 required markedly more force to separate the wound. CONCLUSIONS: Strip reinforcement with/without gum mastic did not provide any additional strength when sutures were used. Gum mastic increased the adherence of strips and this was important when strips were the only means of wound closure.

The freestyle pedicle perforator flap: a new favorite for the reconstruction of moderate-sized defects of the torso and extremities.

BACKGROUND: Perforating vessels are a consistent anatomical finding and well described in the current literature. Any skin flap can be raised on a subcutaneous pedicle as long as it contains at least one supplying perforator. Perforator flaps have been interlinked with microsurgery and generally not widely performed by the general plastic surgeons. The aim of this paper is to present the simplicity of pedicled perforator flap reconstruction of moderate-sized defects of the extremities and torso. METHODS: We retrospectively reviewed the charts of 34 patients reconstructed using 34 freestyle pedicled perforator flaps for moderate-sized defects of the truncus and extremities. We registered indications, flap size and localization, success rate, and complications. Most importantly, we describe a simple approach to the design of freestyle pedicled perforator flaps and elaborate on technical aspects in the context of current literature. RESULTS: The reconstructive goals were achieved in all cases without any total flap loss or major complications. Minor complications occurred in 7/34 (21 %) cases consisting of venous congestion leading to distal tip necrosis or epidermolysis; partial flap loss was significant in 4 cases, however never more than 10 % of the total flap size. Reconstruction was performed on the lower limb in 13 cases, upper limb in 12, and 9 cases were on the truncus. The angle of rotation was 90° in 21 cases and 180° in 13 cases. The most common indication was reconstruction of oncological skin defects; melanoma 19, BCC 6, SCC 2, other 7. The flap size varied from 1.5×3 cm to 12×22 cm. The perforator identification was done by intraoperative exploration in 17 cases and by color Doppler ultrasonography in 17 cases. CONCLUSIONS: Moderate-sized defects of the torso and extremities can be successfully reconstructed by pedicled perforator flaps. The flap dissection is simple, and the complication rates comparable to other reconstructive options. Level of evidence IV, therapeutic study.

Prefabricated buccal mucosa-lined flap in an animal model that could be used for vaginal reconstruction.

Congenital vaginal aplasia, gynecological tumor excision, and male-to-female sex surgery are three clinical conditions in which the plastic surgeon is involved in vaginal reconstruction. Skin-lined or skin-grafted local flaps are currently used, but for many reasons, keratinized skin is not the ideal lining for such a moist cavity because it leads to dryness, desiccation, maceration of the skin, and even hair growth in the cavity. The purpose of this study was to create a subcutaneous cavity lined with mucosa in an area with a predictable blood supply. The abdominal area supplied by the deep circumflex iliac vessels was chosen. Six minipigs were used. Strips of tongue buccal mucosa formed the lining; if additional tissue was required, it was taken from the mucosal aspect of the cheek. The mucosa was expanded by using multiple stab incisions. The mucosa was sutured onto the fascia supplied by the deep circumflex iliac vessels, and the skin incision was closed over a silicone sheet to prevent adhesion to the underlying mucosa. This was left for 1 week to allow the mucosa to take. The prefabricated fascial flap was rolled over a silicone stent and was closed longitudinally to form a cylindrical shape. The flap was placed in a subcutaneous pocket in the right inguinal area. The caudal end was left open and was sutured to the surrounding skin. The silicone stent was used to keep the cavity patent and to prevent adhesions in the early stage of the healing process. Regular digital examination was performed to assess patency and contour; endoscopy allowed assessment of mucosa viability. This method of producing a mucosa-lined flap may provide a solution to the difficult problem of vaginal reconstruction.

Nasal augmentation with Surgicel-wrapped diced cartilage: a review of 67 consecutive cases.

Cartilage grafting has been used extensively to correct both the functional and aesthetic aspects of the nasal framework. The technique described by Erol ( 105: 2229, 2000) uses Surgicel-wrapped diced cartilage grafts in rhinoplasties. The advantages include its ease of preparation, the large volume of graft substrate available for use, and the avoidance of contour irregularities in the areas of placement. A retrospective case review of 67 consecutive patients who were treated with a Surgicel-wrapped diced cartilage graft as part of an aesthetic and/or functional rhinoplasty, in a 5-year period between 1995 and 2000, was performed in this study. All cases of congenital nasal deformities or deformities caused by trauma or tumors in which the technique was used were excluded. The charts were reviewed to determine demographic variables, the surgical procedures performed, prior operations, the rhinoplasty approach used, and the graft donor and recipient sites. Preoperative and postoperative photographs were examined, and the results were assessed. Data on the donor and recipient sites, complications, and the necessity for revisionary procedures were tabulated. There were two complications, namely, an infection, which resolved with aspiration and oral antibiotic therapy, and a recurrence of a dorsal depression, which necessitated repeated augmentation within 6 months. The technique of using Surgicel-wrapped diced cartilage proved to be effective for the augmentation of various areas of the nose. The complication and revision rates were acceptable and comparable to those of other techniques. Patient satisfaction with the aesthetic results was rated highly, with no reports of graft extrusion or contour irregularities. This technique is recommended for nasal augmentation and contouring for selected rhinoplasty patients.

Augmentation of the craniomaxillofacial region using porous hydroxyapatite granules.

Augmentation of the craniomaxillofacial region is required for many aesthetic and reconstructive procedures. A variety of different materials and techniques have been used. Coralline hydroxyapatite has proved to have biocompatible properties as a bone graft substitute. This study further analyzes the use of porous coral-derived hydroxyapatite granules in craniomaxillofacial augmentation for cosmetic and reconstructive purposes and evaluates the long-term clinical result. This retrospective study reviewed the use of porous coral-derived hydroxyapatite granules over a 20-year period, between 1981 and 2001, in 180 patients, in whom 393 procedures were performed. The surgical technique is described and discussed. Statistical significance was evaluated by descriptive statistics and the correlation bivariate Spearman's test (p > 0.05). For 61.6 percent of the procedures, the surgical indication was reconstructive and in 38.4 percent, cosmetic. The maxilla was the most common site of surgery (44.3 percent), followed by the mandible (21.6 percent) and zygoma (15.4 percent). The complication rate was 5.6 percent (n = 22 of 393), with contour irregularities being responsible for 59 percent (n = 13 of 22). Both infection and granule extrusion were responsible for 1.3 percent of the complications. Good results were achieved in 96.4 percent of the procedures. Porous coral-derived hydroxyapatite granules have shown considerable efficacy and versatility in craniofacial contour refinement and augmentation. They are stable, biocompatible, and safe. A sterile technique is advised, with care taken not to tear the periosteum in the pocket design and with subperiosteal placement of the granules, compaction of the granules at the site, overcorrection of 15 percent of the required total volume, watertight closure, and postoperative taping to prevent mobilization. The correct surgical indications and adherence to the principles stated above will result in a very satisfactory long-term outcome.

The effect of low-molecular-weight heparin in the survival of a rabbit congested skin flap.

Swelling and congestion of flaps are frequently seen postoperatively and can cause unexpected necrosis. According to previous reports, venous thrombosis seems to be a more frequent problem than arterial occlusion in both experimental and clinical surgery. Few satisfactory venous trauma models exist, and reports on experimental venous thrombosis are rare. The object of this study was to create a rabbit venous occlusion flap model and to evaluate the effect of low-molecular-weight heparin on this flap. Eight New Zealand rabbits were used in the pilot study, in which the ideal congested flap was investigated using a flap pedicle based on the central auricular artery with a skin pedicle 0, 1, 2, or 3 cm wide. The flap (3 x 6 cm) was designed on the central part of the left ear, and the central auricular vein and nerve, the former for venous return, were cut out at the base of the flap. The flaps with skin pedicles 0, 1, 2, or 3 cm wide showed mean necrosis length of 60.0, 9.3, 4.2, and 0.0 mm, respectively. The flaps with skin pedicles 0, 1, 2, or 3 cm wide showed mean necrosis of 100, 15.5, 7, and 0 percent, respectively. Therefore, the flap, based on a 1-cm-wide skin pedicle and the central auricular artery, was selected as an optimal congested flap model showing 15.5 percent necrosis. The congested flap was then elevated on the left ear of another 10 rabbits. Subcutaneous low-molecular-weight heparin (320 IU/kg) was administered immediately after surgery to five of the rabbits (the low-molecular-weight heparin group), and the remaining five were used as a control group. Fluorescein was injected 15 minutes after surgery to evaluate the circulatory territory of the flap, and the circulatory territory was measured 5 minutes after injection. The flaps were assessed 7 days after surgery by angiography, histology, and clinical findings. The circulatory territory was significantly greater in the low-molecular-weight heparin group (mean +/- SD, 39.2 +/- 3.0 mm) than the control group (mean +/- SD, 48.0 +/- 1.0 mm) (p < 0.001) assessed 7 days after surgery. The longest flap survival length in group A and group B ranged from 40 to 55 mm (mean +/- SD. 49.4 +/- 5.6 mm) and complete survival (mean +/- SD, 60.0 +/- 0.0 mm). The improvement in survival was statistically significant for group B compared with group A (p < 0.015). Histologic evaluation revealed moderate to severe venous congestion and inflammation in the control group, whereas there were minimal changes in the low-molecular-weight heparin group. Angiography of the flap revealed obvious venous occlusion in the periphery in the control group compared with the low-molecular-weight heparin group. The authors conclude that subcutaneous administration of low-molecular-weight heparin has a great potential to improve the survival length of a congested flap without major complications.

Epidemiology of cleft lip and cleft palate in Pakistan.

Clinical and epidemiologic studies of defined geographic populations can serve as a means of establishing data important for the diagnosis, treatment, and counseling of patients with cleft lip and cleft palate. Several descriptive epidemiologic studies have been carried out in many countries worldwide; however, no such study has ever been performed in Pakistan. Population-based data on the incidence of cleft lip and palate were obtained from birth registry information in northern Pakistan. A total of 117 cases from 61,156 live births reported were identified. The incidence for cleft lip and/or cleft palate was 1.91 per 1000 births (one per 523 births). Cleft lip alone (42 percent) was noted more frequently than isolated cleft palate (24 percent) and combined cleft lip and palate deformities (34 percent). Boys were more commonly affected by cleft lip and cleft lip with cleft palate, whereas girls predominated in the isolated cleft palate cases. Consanguineous marriages were observed in 32 percent of parents versus 18 percent in matched controls. Only 32 percent of cleft mothers received formal prenatal counseling, monthly examinations, and regular laboratory testing during the entirety of the pregnancy. Nutritional and vitamin supplements were given to only 28 percent of mothers of cleft children versus 59 percent in matched controls. Descriptive statistics were used to assess pertinent risk factors associated with cleft lip and palate. The acquisition of incidence and associated data has generated baseline information on the magnitude of cleft lip and cleft palate in Pakistan. It is hoped that this information can be used for appropriate resource use, cleft lip and cleft palate prevention programs, and counseling programs with Pakistan-specific data.

Easy tissue expansion of prelaminated mucosa-lined flaps for cheek reconstruction in a canine model.

In head and neck reconstruction, there is sometimes the need for a skin flap lined with mucosa. The object of this study was to determine whether small pieces of mucosa grafted onto the undersurface of a skin flap can be expanded in a reasonable time to provide the material required to reconstruct a full-thickness cheek defect as a free flap. The study consisted of two phases: prelamination and expansion of the flap, and vascularized free-tissue transfer of the flap. Six adult mongrel dogs were used. First, a 5 x 10-cm flap based on the saphenous vessels was elevated on the lower leg, and then four 1 x 2-cm pieces of mucosa harvested from the tongue were grafted onto the undersurface of the flap. A tissue expander (5 x 10 cm) was then placed under the flap, and the incision was closed primarily. The expanders were initially filled with just enough normal saline to obliterate dead space immediately after surgery. The expansion was continued twice weekly for 3 weeks until sufficient expansion was obtained. Two of six flaps were followed for an additional 6 weeks after the 3-week expansion period to observe whether additional mucosa could be obtained. After measurement of the mucosal area, each flap was transferred as free flap to reconstruct an iatrogenic cheek defect. The increase of mucosal surface area was compared with the original graft, and differences were analyzed using the paired t test. All flaps were successfully expanded without any complications. Histologic evaluation revealed that grafted mucosa took well without evidence of graft necrosis, and the intergraft area was covered with histiocytes. Angiography revealed well-defined vascular structures covering the entire area of the flap. The new mucosal area (23.5 +/- 2.4 cm2) was significantly larger than the original mucosal graft (8.7 +/- 0.9 cm2) (p < 0.001). The net increase of the mucosal area was 172.9 +/- 32.4 percent. The increase of mucosal area in two flaps, following a 6-week consolidation period after 3 weeks of expansion, was only slightly greater (25.9 +/- 1.3 cm2) than those without the consolidation period (22.3 +/- 1.8 cm2). This increase of the mucosal area appears to be related to the amount of expansion, and not to the length of the consolidation period. The flaps were successfully transferred as free flaps to reconstruct the full-thickness cheek defects without major complications. Although a staged operation to allow flaps to mature is needed, the present procedure has the advantages of providing a mucosa-lined flap and allowing primary closure of the donor site. The authors conclude that expansion of this flap has great potential in reconstructive surgery.

Operative management of skull base malignancies: choosing the appropriate approach.

Malignant tumors of the skull base are complex lesions. Identifying the indications and contraindications for resection is essential for the successful treatment of these lesions. This requires an understanding of the pathology, principles of resection, and nonsurgical therapeutic modalities. Choosing the appropriate surgical approach requires an understanding of the tumor and its association with the anatomy of the skull base. Preoperative assessment and preparation of the patient for the postoperative course, including functional and cosmetic deficits, are reviewed in the context of the specific approach. Anatomical variations encountered in the preoperative planning are discussed. A review of reconstructive alternatives is presented that is specific to the approach and anatomical violation. Finally, the use of a multidisciplinary team both in and out of the operating room is recommended, emphasizing a team approach during the resection itself.

Buccal fat pad removal.

According to the author, buccal fat pad removal is a minor procedure that adds relative prominence to the cheek area. For optimal results, he suggests augmenting the malar area with hydroxylapatite granules. Here, he describes his technique. (Aesthetic Surg J 2003;23:484-485.).

Fronto-orbital fibrous dysplasia.

Fibrous dysplasia, which is characterized by a disorganized mixture of fibrous and osseous elements in the affected bones, is a non-neoplastic developmental anomaly caused by an activating mutation. Despite an identical histological pattern, the clinical behavior varies according to the site of involvement. Fronto-orbital lesions behave more aggressively and generally continue to grow during adulthood. During the last 20 years, 32 cases of fronto-orbital fibrous dysplasia have been treated and the results of treatment have been assessed. The indications for surgery were mainly visual deterioration due to optic nerve compression, globe malposition and widespread disease causing gross facial deformity. The treatment of these patients consisted of radical resection of the fibro-osseous tissue, decompression of the optic nerve canal and reconstruction of the resected fronto-orbital areas with either noninvolved bone grafts or with dysplastic bone which was contoured down or, in one case, heated in the sterilizer. Recently, Pamidronate, a bone resorption inhibitor, has been added to the treatment protocol. During follow-up there have been two recurrences, repeat optic nerve decompression has not been required and overall the esthetic results are satisfactory. Fronto-orbital fibrous dysplasia can have a devastating outcome with high recurrence rates and blindness, especially following incomplete resection. A radical and extensive approach to treatment is recommended; this seems to be the best choice as witnessed by the good results achieved in this series.

A new design of a dorsal flap in the rat to study skin necrosis and its prevention.

BACKGROUND: The Mcfarlane flap or dorsal pedicled flap has become the standard model for pedicled rat skin flap study but its reliability has been called to question. In the past, there were possible confounding variable with the McFarlane flap and various methods were used to adjust these variables. We have developed a new model for studying skin flap necrosis and its prevention that eliminates these confounding variables. METHODS: The flap is a significant modification of the McFarlane flap where we form a blind ended pedicled tube using a 3 cm x 9 cm dorsal flap. Survival area is measured using digital photography and computer assisted analysis. This new flap is compared with the standard McFarlane flap with n=25 in each group. RESULTS: The mean survival area of the new flap (15.673 cm(2)+SD3.37) is comparable with the McFarlane flap (18.904 cm(2)+SD3.79). The relative merit lies in the elimination of the confounding variable of the graft bed influence on our flap without a significant reduction in the survival area. CONCLUSION: A new rat model is presented that may be used in studying the effect of various treatment modalities on pedicled skin flaps. This model has the benefit of eliminating graft bed effect without the risk of flap and wound infection or desiccation that have been encountered using other models. The new flap also has better demarcation of necrosis area in this study.