Otoplasty: the experience of 100 consecutive patients.

Although prominent ears are the most common congenital deformity in the head and neck region, only approximately 8 percent of patients who present for treatment of this deformity will have some family history of the abnormality. More than 200 techniques have been described for correction of this deformity, indicating that there is no single widely accepted procedure that has been adopted by most surgeons. The authors of this study present their choice of a procedure that combines the most beneficial features of three previously described techniques and that provides consistently satisfactory results. The surgical technique consists of scoring of the antihelical cartilage on its anterior surface in a subcutaneous position (as described by Stenstrom), suturing to recreate the fold of the antihelix (in the fashion of Mustarde), and concha-mastoid suturing applied to the back of the ear to decrease the concha-scaphoid angle (in the manner of Furnas). The last 100 consecutive patients operated on by the senior author (J.A.F.) over a 10-year period were evaluated. Follow-up data were analyzed using the Kaplan-Meier survival method. The postoperative analysis focused on the incidence of postoperative complications and the overall results of the technique.Most operations were performed bilaterally, on women, and with the patient under local anesthesia. There were few complications, and the incidence of complications was much lower than had been noted in previously reported series. All patients were very satisfied with the improvement in the appearance of their ears. The combined technique presented is safe, easy to perform, and has few complications, and its final outcome is reproducible and long-lasting. It can be considered a standard technique to be used for treating patients of any age and with any magnitude of defect.

Skin care and the topical treatment of aging skin.

The desire to maintain or regain a youthful appearance is the main motivation of patients who present themselves to the aesthetic plastic surgeon's office. It has become imperative for the plastic surgeon to know and understand the causes of aging and skin damage and to provide ancillary nonsurgical treatments through which their patients can achieve rejuvenation.

Bowel wall thickening in children: differentiation with US.

PURPOSE: To determine whether vascular, ischemic, and inflammatory causes of bowel wall thickening in children can be differentiated at gray-scale and color Doppler ultrasonography (US). MATERIALS AND METHODS: Thirty-seven children with acute bowel disease underwent graded compression US. Findings of bowel wall thickness, wall echotexture, location of bowel involvement, and presence of color Doppler flow were evaluated. Diagnoses were classified as inflammation (n = 25), vasculitis (n = 7), or ischemia (n = 5) and were confirmed with findings from colonoscopy and biopsy, stool culture analysis, surgery, and cutaneous biopsy, and with a combination of clinical and laboratory data. RESULTS: Patient age (P = .0022), bowel wall thickness (P = .0001), and color Doppler flow (P = .0013) were statistically significantly related to disease type. Wall thickening and absence of visible color Doppler flow suggested ischemia. Older patient age and visible color Doppler flow suggested inflammation, whereas younger patient age and visible color flow suggested vasculitis. Difference in location of bowel disease in patients with ischemic versus those with vascular wall thickening was statistically significant (P = .0185). No difference was found between disease type and wall stratification. CONCLUSION: Gray-scale and color Doppler flow US can aid in differentiating ischemic, vascular, and inflammatory bowel wall thickening.

Safety and efficacy of combined upper blepharoplasties and open coronal browlift: a consecutive series of 600 patients.

Surgical rejuvenation of the upper face involves the correction of excess and lax forehead, eyelid, and periorbital skin. Improving the appearance by correcting the effects of aging involves a combination of blepharoplasty and open coronal foreheadplasty. Many surgeons and several reports question the safety of both procedures being performed concomitantly. The difficulty arises in precisely balancing the skin excision from the frontal forehead and upper eyelid areas. Over-resection of skin may result in incomplete closure of the eyelid and dry-eye syndrome, while an inadequate resection may produce a poor aesthetic result. There is no large series that documents the safety and effectiveness of these two procedures being performed concomitantly. Furthermore, with the recent and rapid development of complex multiplanar endoscopic facial rejuvenation techniques, the basic open foreheadplasty has become increasingly overlooked as a legitimate, efficacious technique for rejuvenation of the upper face. The technique utilized in this series is presented in detail. The consistently excellent results obtained satisfy the aesthetic goals of patients as well as the goals of surgeons, and suggest a renewed interest in the technique based upon its simplicity and easily reproducible results.

Escherichia coli O157:H7-associated hemolytic-uremic syndrome: value of colonic color Doppler sonography.

Hemolytic-uremic syndrome associated with Escherichia coli O157:H7 presents with a gastrointestinal prodrome. During this prodrome the disease may be difficult to differentiate from acute colitis and other hemorrhagic gastrointestinal diseases. We have found that color Doppler sonography in patients with E. coli-associated hemolytic-uremic syndrome of the colon demonstrates a strikingly avascular, thick-walled colon. In the correct clinical setting, this finding should allow a diagnosis during the prodromal phase.

Quantitative analysis of the plain radiographic appearance of eosinophilic granuloma.

RATIONALE AND OBJECTIVES: To quantitate features that distinguish the plain radiographic appearance of eosinophilic granuloma (EG) from other solitary lesions of bone. MATERIALS AND METHODS: Seven hundred nine focal bone lesions, including 26 EGs, were analyzed according to demographic, anatomic, and plain radiographic features. Vector analysis of groups of features was performed to determine those that are most sensitive and specific for the appearance of EG in contrast to other lesions in the data base. RESULTS: The radiographic appearance of EGs was most consistently that of a medullary based lytic lesion (100%) with geographic destruction (76.9%), lobular contour (73.1%), and well-defined edges (73.1%). Long bone lesions showed these features more frequently than EGs in other locations. Periosteal reaction was visible in all long bone lesions but in only one nonlong bone lesion (5.9%). Characterization of EG in long bones as a lytic, medullary-based metaphyseal or diaphyseal lesion with geographic destruction, lobular contours, periosteal reaction, no matrix, and no subarticular extension showed a sensitivity of 55.6% of EG and prevalence of 22.7%. The vector analysis-generated differential diagnoses include unicameral bone cyst, aneurysmal bone cyst, giant cell tumor, Brodie's abscess, enchondroma, chondrosarcoma, and malignant fibrous histiocytoma. CONCLUSIONS: The radiographic appearance of EG is relatively nonspecific but, using vector analysis, can be better elucidated than in current textbook descriptions.

Quantitative analysis of the plain radiographic appearance of nonossifying fibroma.

RATIONAL AND OBJECTIVES: To quantitate radiographic features that distinguish the plain radiographic appearance of nonossifying fibroma (NOF) from other solitary lesions of bone. MATERIALS AND METHODS: Seven hundred nine cases of focal bone lesions, including 34 NOFs, were analyzed according to demographic, anatomic, and plain radiographic features. Vector analysis of groups of features was performed to determine those that are most sensitive and specific for the appearance of NOF in contrast to other lesions in the data base. RESULTS: The radiographic appearance of NOFs was most consistently a medullary based (97%), lytic lesion (100%) with geographic bone destruction (100%), marginal sclerosis (97%), and well-defined edges (94%). A statistically significant number of lesions were located in the distal aspect of long bones. Unicameral bone cyst shared the most radiographic features with the NOF. Vector analysis showed a large degree of overlap between NOF and other lesions such as aneurysmal bone cyst, chondromyxoid fibroma, and eosinophilic granuloma. The description that optimized sensitivity and prevalence for detection of NOF is a medullary based, ovoid lesion in the distal or proximal portions of a long bone with well-defined edges, a partial or complete rind of sclerosis, and absence of fallen fragment, periosteal reaction, and cortical disruption. CONCLUSION: The radiographic appearance of NOF is relatively nonspecific but, using vector analysis, can be better elucidated over current textbook descriptions.

The superficial-plane rhytidectomy revisited.

Complex procedures for aesthetic facial rejuvenation, such as the deep-plane, extended SMAS, subperiosteal, and composite rhytidectomies, have received significant attention in the literature and at recent symposia. Young plastic surgeons striving to achieve excellent results may be intimidated by these procedures and find them difficult to perform. We suggest a renewed interest in the superficial plane approach for facial rejuvenation. On the basis of our experience with a synthesis of result-oriented technical modifications in 750 patients, we present a procedure to offer not only the beginning but also the more experienced surgeon a safe and satisfactory surgical alternative that will provide both predictable and lasting results while limiting risks and avoiding complications.

The association between residents' work-rounds styles and the process and outcome of medical care.

OBJECTIVE: To determine whether the manner in which residents conduct work rounds is associated with the adequacy of their care processes and the outcomes of their patients. METHODS: Two types of data were collected: time and motion data for residents (n = 12) during work rounds, and clinical and outcome data for the patients they cared for during the observation period (n = 211). Five residents were classified as data gatherers because they spent twice as much time gathering clinical data about their patients as they spent engaging in other activities. Three physicians blinded to the resident's identity rated the quality of the care process and assessed the frequency of undesirable events occurring during the stay and after discharge. RESULTS: A data-gathering style was associated with higher quality of care as judged by both process and outcomes. The data gatherers were more likely to comply with the "stability of medications before discharge" criterion (86% of the data gatherers' cases vs 73% of others', p = 0.07), and their patients were less likely to have unanticipated problems, in that fewer required calls from nurses (20% vs 37%, p < 0.01) and visits by on-call housestaff (33% vs 50%, p = 0.01). The data gatherers' patients were less likely to be readmitted within 30 days (14% vs 38%, p < 0.01). CONCLUSIONS: A data-gathering work-rounds style is associated with better process and outcome. Residency programs should provide formal instruction to trainees in the conduct of work rounds.

Mercury poisoning from intravenous injection: treatment by granuloma resection.

Intravenous injection of mercury is a rare event. Mercury administered by this route may have several different consequences. In addition to elevated serum mercury levels, the diagnosis may be made by radiographic detection of metallic densities in the chest and at the sites of injection. Death due to mercury intoxication is unusual. Impairment of renal and hepatic function may occur. Our patient presented with gingivitis and a dentoalveolar abscess. Dense granulomas occur at the sites of injection. Treatment for these patients should include granuloma excision as the benefit of chelating agents, for chronic mercury intoxication is questionable. Skin and granuloma resection may leave vital structures exposed, necessitating flap coverage.

Characteristics of house staff work rounds on two academic general medicine services.

In this study, the authors determined how residents in internal medicine allotted their time during patient management rounds (work rounds). Fourteen house staff teams were observed for four days each, and the time spent on all activities was recorded. Of the 56 days studied, work rounds were not conducted on nine days. On the 47 days during which work rounds occurred, only 502 (76.4 percent) of a possible 657 visits to patients were made. Daily time spent on work rounds by each team averaged 49.4 minutes (range: 23.9 to 73.1), or 4.6 minutes (range: 2.3 to 6.6) per patient evaluated. Some part of a physical examination was performed on only 44 percent of the patients. For those patients examined, the average time of an examination was approximately one minute per patient. Vital signs sheets and medication sheets were reviewed infrequently. This study suggests that medical educators should be concerned about the thoroughness of house staff work rounds.