Transoral submucosal resection of the inferior turbinate: a novel approach to functional rhinoplasty.

BACKGROUND: In the presence of turbinate dysfunction, an inferior turbinectomy for persistent hypertrophy of bone and/or mucosa may be performed. We sought to explore anatomic feasibility of a transoral turbinectomy. METHODS: After transoral inferior turbinectomy in 12 cadavers, average distances from the external nasal valve to inferior turbinate and from pyriform aperture to inferior turbinate were compared. Average "area of access" was calculated. Preoperative and postoperative nasal length, tip projection, and alar-base width were also compared. RESULTS: Average distance from external nasal valve to inferior turbinate was 32.4 mm. Average distance from aperture to inferior turbinate was 2.4 mm (P < 0.0001). Average "areas of access" to nasal vault through the external nasal valve and mouth were 183.9 mm(2) and 243.6 mm(2) (P = 0.07), respectively. CONCLUSIONS: The transoral approach provides a larger "area of access" to the turbinate, a statistically significant reduction of distance to target, no postoperative changes in nasal soft tissue, and easier instrumentation.

The sentinel fat pads: the relationship of the ROOF and SOOF to the temporal nerve in facial rejuvenation.

BACKGROUND: A great number of studies have reported on the temporal branch anatomy and its relationship to the fascial layers and various fat pads of the temporal region, but no article has included information on the relationship of the temporal nerve to the retro-orbicularis oculi fat (ROOF) and/or the suborbicularis oculi fat (SOOF). OBJECTIVES: The authors report the results of a series of human cadaver temporal nerve dissections, with particular attention paid to its relation to the ROOF and the SOOF. The results of a literature review and a subsequent open browlift are also reported to confirm the results of the cadaver study. METHODS: Dissection was performed on 15 fresh human cadavers, for a total of 29 hemifaces. The course and relationships of the temporal nerve branch to the fascia, fat pads, and landmarks in the temporal region were noted and detailed. A thorough review was also performed for 23 articles, to compare the author's anatomical findings with data in the previous literature. RESULTS: During cadaver dissection, the temporal branch was found to lie on the undersurface of the superficial temporal fascia. In the supraorbital area, the ROOF existed in the loose areolar plane or deep layer of the superficial temporal fascia, with the temporal nerve branch directly superficial to it. The temporal branch passed lateral to the SOOF in its superiomedial course at the level of the zygoma. These findings were later confirmed during an in vivo open browlift as well. CONCLUSIONS: The ROOF was formerly unrecognized as an important sentinel marker for possible injury to the temporal nerve branch during browlift. However, this cadaver study and its accompanying literature comparisons show that browlift dissection, whether endoscopic or open, should aim to keep the ROOF fat in the superficial plane, ensuring that the nerve branch is safe from iatrogenic injury.

Bilateral carotid endarterectomy as treatment of vascular pulsatile tinnitus.

Atherosclerotic carotid artery disease (ACAD) is a rare but recognized cause of pulsatile tinnitus. Existing literature of reported cure for pulsatile tinnitus is reviewed. We found: (1) a male preponderance exists; (2) ipsilateral carotid endarterectomy (CEA) for tinnitus is 92% (12 of 13) effective; (3) proximal lesions lend themselves to CEA whereas distal lesions have been treated by stenting; (4) overall 68% (15 of 22) are cured by intervention; and (5) 89% (17 of 19) can expect immediate relief. We now present a case of bilateral pulsatile tinnitus relieved by bilateral carotid endarterectomy.

Risk factors for compartment syndrome in traumatic brachial artery injuries: an institutional experience in 139 patients.

BACKGROUND: The brachial artery is the most common vascular injury encountered in upper extremity trauma. If not treated promptly, it can result in compartment syndrome (CS) and long-term disability. Here, we report an institutional experience of traumatic brachial artery injuries and establish risk factors for the development of upper extremity CS in this setting. METHODS: A retrospective review of 139 patients with traumatic brachial artery injury from 1985 to 2001 at a single institution. Patients were divided into two cohorts, those with evidence of CS and those without CS (NCS), for comparison. RESULTS: One hundred thirty-nine patients presented with traumatic brachial artery injuries (mean age, 28.4 years). Twenty-nine patients (20.9%) were diagnosed with upper extremity CS, and 28 of these patients underwent fasciotomy on recognition of their CS. Seven patients (6.4%) in the NCS cohort underwent fasciotomy as a result of absent distal pulses on initial examination. Mean follow-up was 51.6 days. Two patients required revision of their arterial repair, and one patient underwent amputation. The risk of CS was increased in the presence of combined arterial injuries (p = 0.03), combined nerve injuries (p = 0.04), motor deficits (p < 0.0001), fractures, and increased intraoperative blood loss (p = 0.001). Multivariate logistic regression performed on these variables revealed that elevated intraoperative blood loss, combined arterial injury, and open fracture were independent risk factors for the development of CS (OR 1.12, 5.79, and 2.68, respectively). CONCLUSION: Prompt evaluation and management of traumatic brachial artery injuries is important to prevent CS, which can lead to functional deficits. In the setting of combined arterial injury, open fracture, and significant intraoperative blood loss, prophylactic fasciotomy should be considered.

A prognostic model for the risk of development of upper extremity compartment syndrome in the setting of brachial artery injury.

A potentially devastating sequela of brachial artery injury in the setting of upper extremity trauma is the development of compartment syndrome (CS). We performed a retrospective review of 139 trauma patients with brachial artery injury from 1985-2001. Objective characteristics of each case were extracted and analyzed using multivariate logistic regression. Three variables were found to be significant in the final model: estimated intraoperative blood loss as a continuous variable, and presence of a multiple arterial injury and presence of an open fracture as categorical variables. Odds ratio were 1.12, 5.79, and 2.68, respectively. We used these variables to create a summative score for the development of CS with weights assigned proportional to the adjusted odds ratio. Odds of having CS for subjects in group 2 and group 3 are 5.3 and 15.1 times the odds for subjects in group 1, respectively. Applying multivariate regression analysis to the largest series of brachial artery injuries to date, we have developed a predictive scoring model of CS.

Flow analysis of left internal thoracic artery in myocardial revascularization surgery using y graft.

In order to evaluate the left internal thoracic artery flow pattern, when the vessel is used as a graft to supply the left coronary artery system, we evaluated flow by Doppler measurement, both at rest and under dobutamine stress. There were 2 groups of 20 patients each: group A patients received only a left internal thoracic artery graft to the left anterior descending artery, and group B patients received a pedicled left internal thoracic artery graft associated with a vein graft, which together supplied the left anterior descending artery and another branch of the left coronary artery. Angiography showed patent grafts in all patients from both groups. The following characteristics were evaluated: systolic flow, diastolic flow, total flow, total flow under stress/total flow at rest ratio, systolic peak velocity, diastolic peak velocity, and systolic peak velocity/diastolic peak velocity ratio. In group A, the total flow was 45.5 +/- 21.6 mL/min at rest and 68.3 +/- 32.9 mL/min under stress. In group B, the total flow was 98.2 +/- 50.4 mL/min at rest and 175.7 +/- 79.2 mL/min under stress. Comparison between groups showed a total flow increase in group B of 115.8% (P=0.0002) at rest and 157.2% (P <0.0001) under stress. The other characteristics were also statistically significant, except systolic flow, total flow under stress/total flow at rest ratio, and systolic peak velocity. Our results showed that the left internal thoracic artery sufficiently supplies regional myocardium at rest and during exercise (stress), demonstrating its great adaptability in response to demand.

Prognostication for body contouring surgery after bariatric surgery.

OBJECTIVE: Body contouring surgery has become a steadily increasing part of weight loss treatment in the population of patients electing to undergo bariatric surgery. This study aims to elicit factors that can be used to prognosticate which bariatric surgery patients will choose to undergo body contouring procedures. METHODS: A database of 381 patients who underwent gastric bypass surgery between August 2002 and December 2005 was retrospectively reviewed. All patients with subsequent body contouring surgery (group I) were identified and compared with those without it (group II). Variables studied were age, gender, preoperative excess body weight, percent excess weight loss at 6 and 12 months, preoperative body mass index, and change in body mass index at 6 and 12 months. RESULTS: We identified 24 patients for group I and 168 patients for group II. Group I was significantly younger with a mean age of 36 ± 9 years than group II with a mean age of 41 ± 10 years (P = .023). Change in body mass index was significantly greater in group I with changes of 16.1 ± 4 and 13.82 ± 3 (P = .001) at 6 months and changes of 21.4 ± 6.6 and 17.39 ± 4.6 (P < .0001) at 12 months in group I and group II, respectively. Lastly, the percent excess weight loss at 12 months was significantly greater in group I with a mean percent excess weight loss of 70.1 ± 13.3 than in group II with a mean percent excess weight loss of 62 ± 16.6 (P = .0052). CONCLUSIONS: Age, change in body mass index at 6 and 12 months, and percent excess weight loss at 12 month follow-up were useful predictive factors to determine which bariatric surgery patients ultimately underwent body contouring procedures.

Z-mammaplasty: a novel concept in mastopexy.

BACKGROUND: The inverted-T technique is the most popular skin pattern used for mastopexy, but short scar variations have increased in popularity over recent years. With respect to nipple elevation, superior, superomedial, medial, inferior, lateral, and central pedicle designs have been described. OBJECTIVES: We introduce a novel concept for mastopexy, the glandular Z-mammaplasty, and assess its anatomic and technical feasibility. METHODS: Glandular Z-plasty was performed on 15 human female cadavers. Various parameters were measured pre- and postoperatively to assess degree of ptosis and subsequently compared by student t test. RESULTS: Average pre and postoperative breast width (28.5 ± 4.7 cm, 26.7 ± 3.2 cm, P = .009), breast length (25 ± 6.6 cm and 21.8 ± 4.3 cm P = .005), breast height (10.7 ± 3.7 cm and 9.5 ± 2.9 cm, P = .02), and ptosis degree (1.9 ± 0.9 cm and 0.3 ± 0.5 cm, P < .0001) were determined. Inferior limb transposition moved the nipple closer to the sternal notch and sternum midline an average of 5.3 ± 2.2 cm and 2.4 ± 1.7 cm, respectively. The average Z-plasty degree was 34.5 ± 8.2°. The average central limb length was 8.7 ± 2.1, and the average pedicle width was 5.4 ± 0.8 cm. Buttress support of the nipple was accomplished by caudal transposition of the superior Z-plasty flap and its inset below the nipple. CONCLUSION: We demonstrate that glandular Z-mammaplasty is indeed feasible. The grade of ptosis was statistically significantly improved, with the nipple moving superiorly an average of 5.3 cm in our study group.

Muscle-flap salvage of prosthetic dural repair.

OBJECTIVE: A critical element in the prevention of wound and cerebrospinal fluid (CSF) infections after craniotomies is the prevention of postprocedural CSF leaks. The salvage of infected prosthetic dural material in this milieu is not adequately addressed in the literature and is the subject of this study. METHODS: We performed a 7-year retrospective review of the Yale-New Haven Hospital patient records to identify successful salvage strategies in patients with relentless CSF leaks. Twenty data points were collected, including original diagnosis, nature of the procedure, presence of dural graft, definitive treatment of the leak, culture results and pre- and postoperative antibiotics. RESULTS: Thirteen patients experienced post-craniotomy CSF leaks that required surgical intervention. The most common cause of the original craniotomy (54% of patients) was an oncological aetiology, followed by ruptured aneurysms or haemorrhage in 31% of the patients. Of the 13 patients experiencing CSF leaks, 76% involved the posterior skull base, and therefore a trapezius muscle flap was used in 38% of the cases. The Bovine pericardial graft (10 our of 13), a nonautologous graft, was left intact, and CSF drainage procedures were employed in most patients Growth of gram-positive organisms on cultures was found in 76% of the cases. The most frequent offenders were Staphylococcus aureus (five of the 13), coagulase-negative staphylococcal species (two out of 13), and methicillin-resistant S. aureus (two out of 13). Vancomycin was administered in all cases preoperatively. All 13 patients who underwent open surgery for CSF leak had complete resolution of the leak without need for additional reconstructive surgical intervention. CONCLUSION: Comprehensive method of treating CSF leaks in conjunction with the salvage of bovine pericardial dural grafts may be a viable clinical option.

Right coronary revascularization using the right internal thoracic artery in situ with persisting side branches.

There is a controversy about flow steal when the internal thoracic artery is used, with its remnant branches, to revascularize the coronary system. We report a case of a 64-year-old man who was submitted to revascularization using an in situ right internal thoracic artery, with persisting side branches, to supply the right coronary system. Angiography, Doppler echocardiography, and echocardiography at rest and under stress were performed. We found no evidence of flow steal.

Vineberg's procedure modified technique: flow analysis, immediate postoperative results and angiographic evaluation.

BACKGROUND: The purpose of this study was to evaluate angiographic results of patients subjected to a technique variation of Vineberg's procedure, as well as their morbidity and mortality in immediate postoperative period, and to analyze the flow of grafted left internal thoracic artery (LITA) at rest and under stress. METHODS: Between September 1999 and April 2002 eight patients were operated upon, with implant of the internal thoracic artery (ITA) in the intimal layer of the left ventricle (LV) muscle. After 6 months, they underwent angiographic and Doppler evaluation. According to Doppler study of LITA, the sample was divided in two groups: "Vineberg group," formed by eight patients; and "control group" consisting of 20 patients whose LITA directly revascularize the anterior interventricular artery (AIV). Angiography showed patency of all grafts in both groups. Blood flow and flow velocity in grafts were measured by Doppler echocardiography. T-test for paired and unpaired samples were used for statistical analysis. RESULTS: There were no deaths or complications in immediate postoperative period. Angiography showed 100% patency. The total flow (TF) of Vineberg group was 55% of the flow in the control group. In both groups, the TF increased with the stress. CONCLUSIONS: This Vineberg's technique modification can be successfully used in patients who cannot undergo traditional direct revascularization due to its low rates of morbidity and mortality and a high rate of patency, providing a significant blood flow both at rest and under stress.