Pyriform Costal Cartilage Graft Improves Cleft-Side Alar Asymmetry in Secondary Cleft Rhinoplasty.

OBJECTIVE: The asymmetry of a retrusive cleft-side ala positioned posterior, lateral, and inferior relative to the noncleft ala is exacerbated by ipsilateral deficiency of the pyriform aperture. We describe use of pyriform costal cartilage grafts for enhanced structural foundation and alar symmetry in secondary cleft rhinoplasty. DESIGN: Retrospective case series. PATIENTS: All pyriform aperture paranasal augmentation secondary cleft rhinoplasty cases performed between May 2013 and February 2018 were included. Clinical photos were analyzed, and these results are provided in addition to a detailed description of the augmentation technique. RESULTS: Twelve total cleft patients, 10 (83.3%) unilateral cleft lip and palate, 1 (8.3%) unilateral cleft lip, and 1 cleft palate (8.3%) were included. Age averaged 18.6 ± 6.0 years with 3 (25.0%) males and 9 (75.0%) females. Costal cartilage grafting to the pyriform aperture through the gingivobuccal sulcus was used to reposition the alar base and nasal sill to a more anatomic anterior position, thereby enhancing symmetry in secondary cleft rhinoplasty. Average rib graft donor site incision was 2.5 cm. Follow-up ranged from 3.2 to 48.2 months, average 15.3 ± 14.4 months. No complications related to the pyriform cartilage graft were observed, other than one minor intraoperative breach of parietal pleura. CONCLUSIONS: We observed improvement in the anatomic contour of the cleft-side ala with costal cartilage grafting to the pyriform rim. This resulted in improved cleft-side alar form and thus overall alar symmetry. These results were obtained consistently, without significant complications. This technique is safe and provides a powerful tool to reposition the ala in secondary cleft rhinoplasty. Further studies will quantify the enhancement in nasal base symmetry.

Propranolol for Preoperative Management of a Large Infantile Hemangioma.

Infantile hemangiomas (IHs) are common vascular tumors that typically follow a predictable pattern of rapid proliferation followed by gradual involution. Although most do not require treatment, some large or difficult IHs do, with medical and surgical options available. Prior reports indicate the success of using propranolol, a nonselective ß-blocker, to treat these lesions. This report will demonstrate the use of propranolol preoperatively to manage a large IH followed by surgical excision of the lesion in a collaborative medical and surgical approach.

The reliability and advantages of the sentinel vein as a microsurgical recipient vessel.

Free flaps to the scalp, calvaria, and anterior and middle cranial fossae are typically transferred to the superficial temporal artery and vein. Occasionally the superficial temporal vein is unsuitable for microvascular anastomosis. In such cases, we have had success using the sentinel vein, a perforating vein located in the anterior aspect of the deep temporal fat pad. This article describes the pertinent anatomy, our clinical experience, and the advantages of the sentinel vein as a microsurgical recipient vessel.

Clinical Outcomes of Acellular Dermal Matrix (SimpliDerm and AlloDerm Ready-to-Use) in Immediate Breast Reconstruction.

Background The use of acellular dermal matrix (ADM) for post-mastectomy reconstruction is considered by many surgeons to be an accepted component of surgical technique. Early clinical experience is described for SimpliDerm® - a novel human ADM (Aziyo Biologics, Silver Spring, USA), and AlloDerm® Ready-To-Use (RTU) - an established ADM (Allergan Medical, Irvine, USA). Methods Records were retrospectively reviewed from four sites between 2016 and 2021 of patients who underwent immediate, two-stage reconstruction with either SimpliDerm (n=38) or AlloDerm RTU (n=69) after mastectomy and were followed out to exchange to permanent implant(s), tissue expander(s) explant, or death. Results Immediate breast reconstruction with tissue expanders and ADM was performed on 107 patients (181 breasts). Overall mean patient age was 51.4 ± 12.4 years, and mean BMI was 28.0 ± 5.8 kg/m2. Significantly more patients in the SimpliDerm group were of Hispanic or Latino ethnicity (34.2% vs. 7.2%; P<.001). Reconstructions were predominantly prepectoral (82.3%). A total of 35 adverse events (AEs) occurred in 27 (25.2%) patients, with no difference in AE type, classification, or rates between ADM groups. No AEs were considered related to either ADM. The observed AE profiles and rates are similar to those published for other ADMs in immediate breast reconstruction. Conclusions There continues to be a need for additional clinically equivalent ADMs to provide physicians with more availability and options for their practice. This retrospective, multisite study describes comparable clinical outcomes with SimpliDerm and AlloDerm RTU through a median of 133.5 days (~four months) following immediate two-stage breast reconstruction.

External doppler monitoring of free flaps through negative pressure dressings.

The negative pressure dressing is a highly effective modality for coverage and bolstering of skin grafts in the early postoperative period. In the situation of a skin graft over a free flap, the surgeon might be inclined to avoid this modality out of concern that the dressing would deleteriously effect flap survival or impede flap monitoring. This case series supports the safety of the negative pressure dressing and demonstrates a technical modification that permits external Doppler monitoring of the flap through the dressing. Thus, this technique provides an ideal environment for skin graft healing while maintaining the ability to monitor the flap in a straightforward manner and also simplifies nursing care.

"Universal" and ethnic ideals of beautiful buttocks are best obtained by autologous micro fat grafting and liposuction.

Recently there has been a dramatic increase in the number of patients seeking buttocks enhancement and in the degree of augmentation requested. To fulfill these requests,aesthetic plastic surgeons must understand the patient's personal requests and ethnic identity, as well as any universal ideal of proportions and contours that create the impression of beautiful buttocks. "Universally" perceived ideal buttocks are 1.4 times the circumference of the waist, which is consistent cross-culturally and throughout history. Beyond this are important ethnic differences in the image of perfect buttocks shape. The combination of autologous micro fat grafting and liposuction is the best and possibly only way to obtain various ideal shapes, and offers a lower incidence of complications compared with buttock implants.

International trends in the treatment of cleft lip and palate.

This article presents a contemporary (2004) survey of the methods and timing used in the care of cleft patients. The results are compared, when possible, with those of a similar study published by the lead author in 1998 and with those of the Eurocleft Project that took place from 1996 to 2000. Although very little uniformity is seen in the care of cleft patients, this comparison demonstrates a significant degree of agreement on many aspects of cleft care and a continuing process of adaptation and evolution in the field of cleft lip and palate surgery.

Topographic mapping of the superior transverse scapular ligament: a cadaver study to facilitate suprascapular nerve decompression.

Division of the superior transverse scapular ligament for decompression of suprascapular nerve entrapment can be curative. However, the superior transverse scapular ligament can be difficult to locate, and large incisions are often required. This study was designed to determine the topographic coordinates of the superior transverse scapular ligament to permit reproducible surgical localization and reduce incision size. In 20 cadavers, the superior transverse scapular ligament was identified through a superior approach. Measurements were obtained from the superior transverse scapular ligament to external landmarks. The superior transverse scapular ligament was located 1.3 +/- 0.3 cm (+/- SD) posterior to the posterior border of the clavicle and 2.9 +/- 0.8 cm from the acromioclavicular joint in a two-dimensional surface plane. The depth of the superior transverse scapular ligament from the skin surface was 3.9 +/- 0.7 cm. An incision (mean length, 6.3 +/- 0.7 cm) derived from a novel system of planning marks facilitated access to the superior transverse scapular ligament. The authors conclude that the superior transverse scapular ligament can be located consistently through an incision located on the superior aspect of the shoulder on the basis of palpable topographic landmarks. The superior approach permits small incision size and the maintenance of local muscle anatomic integrity.

The comprehensive management of chemosis following cosmetic lower blepharoplasty.

BACKGROUND: Chemosis can cause persistent discomfort and aggravation in the postoperative period following surgery of the eyelids. This article focuses on chemosis associated with cosmetic lower blepharoplasty. The cause is multifactorial and includes exposure, periorbital edema, and postoperative lymphatic dysfunction. METHODS: A chart review of 312 primary bilateral lower transcutaneous blepharoplasties was performed. Data were collected to identify the incidence of chemosis, define associated etiologic factors, develop a chemosis classification system, and outline a successful treatment algorithm. RESULTS: The incidence of chemosis was 11.5 percent in this population of lower lid blepharoplasty patients. Chemosis presented intraoperatively or up to 1 week postoperatively. The median duration was 4 weeks, with a range from 1 to 12 weeks. Associated etiologic factors included conjunctival exposure, periorbital and facial edema, and lymphatic dysfunction. The four general patterns of presentation were classified as type 1, acute mild chemosis with complete lid closure; type 2, acute severe chemosis that prohibits complete lid closure (chemosis-induced lagophthalmos); type 3, subchronic chemosis that persists longer than 3 weeks; and type 4, chemosis associated with lower lid malposition. Successful treatment existed along a continuum from liberal lubrication to ophthalmic steroid preparations and ocular decongestants to eye-patching to minor surgical procedures such as drainage conjunctivotomy and temporary tarsorrhaphy. In all cases, chemosis ultimately resolved. CONCLUSIONS: Chemosis is a common complication of lower blepharoplasty. Pharmacologic, mechanical, and surgical therapies may be used alone or in combination for the successful management of chemosis. Prevention by minimization of triggering factors intraoperatively and immediately postoperatively is important.