Incidence of cleft palate fistula: an institutional experience with two-stage palatal repair.

The purpose of this study was to determine the incidence of cleft palatal fistula in a series of nonsyndromic children treated at the authors' institution. This retrospective analysis of 103 patients with cleft palate treated by five surgeons between 1982 and 1995 includes 60 boys and 33 girls, whose median age was 18.4 months at the time of surgery. The median length of follow-up was 4.9 years after primary palatoplasty. Cleft palatal fistula was defined as a failure of healing or a breakdown in the primary surgical repair of the palate. Intentionally unrepaired fistulas of the primary and secondary palate were excluded. Extent of clefting was described according to the Veau classification. Statistical examination of multiple variables was performed using contingency table analysis, multivariate logistic regression, and the Wilcoxon rank sum test. The incidence of cleft palatal fistula in this series was 8.7 percent. All of these fistulas were clinically significant. The rate of fistula recurrence was 33 percent. The incidence of cleft palatal fistula when compared by Veau classification was statistically significant, with nine fistulas occurring in patients with Veau 3 and 4 clefts and no fistulas occurring in patients with Veau 1 and 2 clefts (p = 0.0441). No significant differences between patients with and without fistulas were identified with respect to operating surgeon, patient sex, patient age at palatoplasty, type of palatoplasty, and use of presurgical orthopedics or palatal expansion. All three recurrent fistulas occurred in the anterior palate, two in patients with Veau class 3 clefts and one in a patient with a Veau class 4 cleft. The low rate of clinically significant fistula was attributed to early delayed primary closure, with smaller secondary clefts allowing repair with a minimum of dissection and disruption of vascularity.

Microdermabrasion in clinical practice.

Microdermabrasion is the general term applied to the technique of abrading the skin with a high-pressure flow of crystals. Patient selection, equipment, and technique for face, hands, and chest are described. Results of a survey on the efficacy of the treatment are provided.

Comparative lipoplasty analysis of in vivo-treated adipose tissue.

A comparative histologic and chemical analysis was undertaken of adipose tissue treated in vivo with traditional, ultrasound-assisted, and external ultrasound-assisted lipoplasty. A series of six healthy women undergoing elective liposuction according to the superwet technique using a 1:1 infiltration ratio with the estimated quantity of fat to be removed was included in the study. Four separate regions on each patient were treated independently in vivo with traditional liposuction, internal ultrasound-assisted liposuction, or external ultrasound-assisted liposuction for 7 minutes. External massage was used as a control. Four separate specimens of adipose tissue from each patient were assessed for cellular disruption using blinded histologic evaluation. The remainder of tissue was centrifuged to separate the aqueous phase from the cellular components and then spectrophotometrically analyzed for creatinine kinase and glycerol 3-phosphate dehydrogenase activity as markers of cellular disruption. Histologic analysis confirmed 70 to 90 percent cellular disruption with internal ultrasound-assisted liposuction. Suction-assisted and external ultrasound-assisted liposuction showed 5 to 25 percent disruption, whereas massage controls showed only 5 percent. Only internal ultrasound-assisted liposuction showed 5 to 20 percent thermal liquefaction. Absorbance analysis showed creatine kinase activity (sigma units) greatest in ultrasound-exposed tissue. Both external and internal ultrasound-assisted liposuction gave creatine kinase levels 28 to 33 percent greater than suction-assisted liposuction, which varied only 10 percent from controls. Glycerol 3-phosphate dehydrogenase activity was 44 percent greater for internal ultrasound-assisted liposuction than that detected with suction-assisted liposuction. Glycerol 3-phosphate dehydrogenase activity with external ultrasound-assisted liposuction and massage did not vary much from each other, at only 14 percent and 11 percent activity compared with internal ultrasound-assisted liposuction, respectively. Histologic and enzyme analysis of the different types of liposuction and their effect on adipocyte cellular disruption revealed no significant effect of external ultrasound or massage on the adipocytes. Further experimental studies are necessary to evaluate the role and efficacy of alternative techniques for body contouring.

Total soft-tissue reconstruction of the middle and lower face with multiple simultaneous free flaps in a pediatric patient.

A 2-year-old boy sustained a massive facial soft-tissue wound secondary to a dog attack. Essentially all the soft tissues of the face were absent, including innervation and intraoral lining. We describe the reconstruction of this defect with five simultaneous free tissue transfers. To our knowledge, this is the first report of five simultaneous free flaps in any patient.

Early results of vermilion lip augmentation using acellular allogeneic dermis: an adjunct in facial rejuvenation.

The definitive approach to lip augmentation has yet to be defined. Herein is described a technique using acellular allogeneic dermal grafts that is easy, effective, and reproducible. Our results over the past 2 years include 47 patients (94 grafts). Three grafts to the upper lip have exhibited significant resorption, which warranted further augmentation. Early in the series, one graft was malpositioned too superiorly along the vermilion-cutaneous border. There have been no cases of infection, hematoma, or graft exposure. The overall complication rate was 4 percent (4 of 94). Our early results by using acellular allogeneic dermal grafts for lip augmentation are encouraging. Further studies are under way to better objectively define long-term results.

Mersilene suture as a vehicle for delivery of growth factors in tendon repair.

Extensive clinical and laboratory studies have demonstrated that growth factors accelerate and modulate the wound-healing process. The purpose of this experiment was to apply the principles of growth factor-enhanced wound healing to an in vitro rat tendon model. A method was developed for covalently binding a biologically active peptide to nonabsorbable braided polyester suture (Mersilene). Sutures were treated with various growth factors, which included epidermal growth factor, platelet-derived growth factor, and keratinocyte growth factor, and bovine serum albumin was the control. Spectrophotometric assessment was used to verify the peptide's activity. The suture was subsequently placed through individual harvested rat flexor tendons, which were arranged in standard tissue culture conditions. Markedly increased cellular proliferation along the suture was appreciated on the tendons treated with epidermal growth factor-bound suture. Platelet-derived growth factor was shown to have a lesser effect, whereas keratinocyte growth factor had no visible effect on cellular proliferation. This preliminary study describes a new technique of binding growth factors to suture. It also demonstrates that the presence of growth factors may help facilitate flexor tendon healing and allow early postoperative rehabilitation to decrease adhesion formation.

Sensory changes after traditional and ultrasound-assisted liposuction using computer-assisted analysis.

Postoperative sensory changes (i.e., hypesthesias) that occur after suction-assisted lipoplasty (SAL) are expected clinical sequelae. These disturbances usually return to normal within several weeks to months postoperatively. The presumed mechanism of injury is direct trauma to the peripheral nerves from the suction cannula. In addition, the potential for demyelination of peripheral nerves secondary to cavitation during ultrasound-assisted liposuction (UAL) is well known. Quantitative data describing hypesthesia after both procedures are limited. The purpose of this study was to objectively evaluate the severity and duration of postoperative hypesthesia after liposuction to better educate patients preoperatively. Furthermore, the authors use the three-stage UAL technique and wanted to determine whether a clinical difference in sensory return existed between suction- and ultrasound-treated areas. A total of 21 patients underwent liposuction performed by the senior author (RJ.R.). The abdomen, flanks, thighs, and medial knees were tested for objective sensation with the Pressure Specified Sensory Device preoperatively and at 2, 6, and 10 weeks postoperatively. A total of 102 sites were tested. On average, the SAL-treated areas improved to normal sensation by 6 weeks, whereas the UAL-treated areas took, on average, 10 weeks to recover. The severity of the hypesthesia was not correlated with larger aspiration volumes or longer UAL exposure time per site. At 10 weeks, 90 percent of UAL-treated patients and 89 percent of liposuction patients overall had recovered normal sensation. This study provides the body-contouring surgeon with good, objective data with which to educate patients regarding sensory return after liposuction.

Patient evaluation and indications for ultrasound-assisted lipoplasty.

Ultrasound-assisted lipoplasty (UAL) is an important adjunctive technique to traditional lipoplasty that permits true circumferential body contouring of the trunk and thighs. Its effectiveness is realized in those patients demonstrating diminished skin tone, skin irregularities, and fibrous areas of lipodystrophy. Patient evaluation and selection, indications for UAL, and operative strategy beginning with the initial consultation are discussed.

Operative principles for optimizing results in circumferential body contouring with ultrasound-assisted lipoplasty.

The optimization of results in body contouring requires simultaneous visualization of all body regions. This goal is achieved through a circumferential and balanced surgical approach. Adjacent areas must blend together to evoke a smooth contour silhouette. The anatomic differences between men and women, patient selection, markings, access incisions, and technique must all be addressed.

The effects of ultrasonic energy on peripheral nerves: implications for ultrasound-assisted liposuction.

The integration of ultrasound-assisted liposuction with traditional suction-assisted lipoplasty has extended the role of liposuction in body contouring. Although there are ample data regarding the effects of ultrasound on peripheral nerves from studies with the Cavitron ultrasound surgical aspirator, there is little information concerning the effects of modern ultrasound body contouring equipment on neural tissue. This study was designed to evaluate the functional and histologic effects of ultrasound energy on rat peripheral nerves (sciatic nerves) using a commonly-used ultrasound-assisted liposuction generator. After the application of ultrasound to exposed rat sciatic nerves, operative magnification was used to assess any visible injury. The sciatic function index was serially measured to quantify immediate and long-term functional effects on the nerves. Our results showed immediate visible injury using low amplitude settings (level 6), but no functional evidence of injury until much higher settings were used (level 9). All animals in the groups with initial functional impairment had returned to normal or near-normal function at completion of the study (51 days). Histologic examination revealed no evidence of damage in the low amplitude groups. Histologic analysis of the high amplitude groups displayed diffuse infiltration of the nerve, with foamy histiocytes and an increased number of mast cells, consistent with remote neural injury followed by myelin breakdown and repair.

An analysis of silicone gel-filled breast implants: diagnosis and failure rates.

This retrospective review analyzed 180 women who underwent explantation of 357 silicone gel-filled breast implants from September of 1991 to January of 1995. Implant status, including shell integrity and implantation times, was determined at the time of explantation. The age range of the patients was 25 to 75 years, with a mean age of 47 years. The age of the implants ranged from 0.5 to 24 years, with a mean age of 10.5 years. Of the 292 implants with known and documented integrity status, there were 102 intact, 76 unruptured with signs of leakage, and 114 ruptured. The frequency of implant rupture significantly increased with implant age. The average age of rupture was 13.4 years. The average age of signs of leakage was 10.1 years. There were no significant differences in failure rates among the implant types of four manufacturers. Analysis of both mammography and magnetic resonance imaging (MRI) as diagnostic modalities for differentiating intact implants, implant leakage, and implant rupture was performed. Standard mammography was less reliable in diagnosing implant leakage or rupture (sensitivity, 55 percent; specificity, 69 percent) than MRI (sensitivity, 72 percent; specificity, 82 percent). In conclusion, implant rupture occurred at a significantly increasing rate with implant age (10 to 15 years). These findings were independent of implant type or manufacturer. Mammography alone is a below-average diagnostic tool for detecting leakage or rupture, whereas MRI is a more accurate modality.

Safety considerations and fluid resuscitation in liposuction: an analysis of 53 consecutive patients.

There is no agreement as to appropriate fluid resuscitation in patients undergoing liposuction. This has assumed greater significance, as surgeons have undertaken larger volume aspirations (> or = 4 liters) and the potential complications of hypovolemia and fluid overload have materialized. This prospective study of 53 consecutive healthy patients undergoing liposuction using a superwet technique served to develop general guidelines for safe perioperative fluid management, especially in regard to large-volume aspirations. In this context, "aspirate" is defined as the total fat and fluid that is removed during liposuction. All patients were monitored using standard noninvasive hemodynamic monitoring. Thirty-six patients were monitored perioperatively with Foley catheters. The 53 patients underwent liposuction alone. We did not include patients who underwent concurrent aesthetic surgical procedures because our intention was to establish fluid administration guidelines for the liposuction patient. There were no significant complications in our series. The intraoperative fluid ratio, defined as (intravenous fluid + infiltrate)/aspirate, was 2.1 for the small-volume group and 1.4 for the large-volume group. These values were significantly different (p < .001, t test). Average urine output in the operating room and recovery room and on the floor was satisfactory (> 0.5 to 1 cc/kg/hr) and did not relate to volume aspirated (p = 0.21, 0.91, and 0.6, respectively, t test). Four patients who underwent "large-volume" aspirations (> or = 4 liters) had transient hypotension, which was immediately responsive to crystalloid fluid boluses in the first postoperative hours. All other patients required only maintenance intravenous crystalloid postoperatively until oral intake had been resumed. There were no statistically significant differences in postoperative fluid administration between the small- and large-volume groups. Ninety-three percent of patients were discharged within 24 hours of surgery. Our suggested guidelines for fluid resuscitation based on this retrospective study are as follows: (1) small volume (< 4 liters aspirated): maintenance fluid + subcutaneous wetting solution; (2) large volume (> or = 4 liters aspirated): maintenance fluid + subcutaneous wetting solution + 0.25 cc of intravenous crystalloid per cc of aspirate removed after 4 liters. This formula has since been used in the care of 94 patients who have undergone liposuction exclusively. All patients have had unremarkable hospital courses. These guidelines do not replace sound clinical judgment. Good communication between the surgeon and anesthesiologist is critical to optimal patient care and safety.

The tissue effects of ultrasound-assisted lipoplasty.

The objective of our study was to investigate the effects of ultrasonic energy on tissues, using a porcine model, performed under various instrumental and procedural parameters. Domestic pigs were anesthetized and prepared for surgery. An incision was made on the side of the hip randomly assigned to the right or left side. Tumescence solution was infiltrated via a blunt tip, small diameter cannula, followed by performance of standard liposuction. On the contralateral side, a similar incision was made. For ultrasonic liposuction experiments without the sheath, a percutaneous introducer was inserted into the incision, which was protected at the entry site from contact with the cannula. Tumescence solution was infiltrated via a blunt tip, small diameter cannula, and then the site was treated with ultrasonic energy at maximum output from the machine with liposuction concurrent through the hollow cannula. The experiments with the sheath did not require a pretreatment with tumescence solution but consisted of tumescence solution pumped through the sheath at a low infusion rate, with concurrent treatment utilizing ultrasonically assisted liposuction through the central lumen of the cannula. In all cases, the lipoaspirate was preserved for biochemical analysis. After treatment, the pigs were euthanized, and samples for histopathology were taken. The pigs were then perfused with a radio-opaque solution through the left ventricle following preperfusion with saline. The groups were ultrasound-assisted liposuction with sheath (n = 3), ultrasound-assisted without sheath (n = 4), and tumescence alone (n = 1), with standard liposuction performed on the contralateral side for all ultrasound-assisted liposuction animals. The lipoaspirates from the ultrasonically assisted liposuction with the sheath showed significantly less blood loss (measured as hemoglobin in the aspirate) than standard liposuction (p = 0.012) at comparable levels of fat (measured as triglycerides in the aspirate). The lipoaspirates from ultrasound-assisted liposuction without the sheath showed blood loss comparable to that experienced with standard liposuction. The ratio of hemoglobin to triglyceride was lowest in the ultrasound-assisted group with (p = 0.01) and without (p = 0.06) the sheath when compared to traditional liposuction. In both of these treated groups, the radiograms of the perfused areas showed significantly less vascular disruption when compared with suction-assisted liposuction. Histopathologic examination of specimens taken from various treated areas showed substantial tissue damage comparable in ultrasound- and suction-assisted liposuction treated groups. This preliminary experimental study showed that ultrasound-assisted lipoplasty is comparable to traditional suction-assisted lipoplasty. Treatment with ultrasound provided more significant hemoglobin/triglyceride ratios, indicative of more lipid aspirated per hemoglobin lost, and better preservation of vascular tissues as demonstrated by our perfusion studies. Treatment with the sheath showed a significantly lower hemoglobin release with a diminished volume infused into the subcutaneous space during the procedure.

Extending the role of liposuction in body contouring with ultrasound-assisted liposuction.

The initial experience with ultrasound-assisted liposuction in treating difficult fibrous areas, such as gynecomastia, hitherto not uniformly responsive to traditional suction-assisted lipoplasty, has led to the evolution and improvement of ultrasound-assisted liposuction techniques. This prospective study examined 114 consecutive patients treated with ultrasound-assisted liposuction over a 13-month period, from September of 1996 to September of 1997. The means by which this procedure helps achieve fat contouring differs from that of suction-assisted lipoplasty. Ultrasound-assisted liposuction removes fat through a fat emulsification process termed "cavitation," whereas suction-assisted lipoplasty achieves contouring through the mechanical avulsion of fat. The technique for the use of ultrasound-assisted liposuction has changed significantly from our initial series of patients to our current technique. To optimize the benefits of both ultrasound-assisted and traditional suction-assisted lipoplasty, we use a three-stage technique consisting of infiltration, ultrasound-assisted sculpturing, and suction-assisted lipoplasty for evacuation and final contouring. This has decreased our operative time, minimized complications, and optimized our body contouring results. Data were collected intraoperatively, including treatment times, treatment volumes, and treatment areas for both suction-assisted and ultrasound-assisted lipoplasty. A total of 114 patients were treated with ultrasound-assisted liposuction between September of 1996 and September of 1997. There were 23 male patients and 91 female patients. In general, the average total volume removed with this procedure decreased by about 50 percent throughout the series, whereas the suction-assisted lipoplasty volume increased correspondingly by 50 percent. Overall, suction-assisted lipoplasty volume was approximately two times ultrasound-assisted liposuction volume in the same area. Exceptions to this include the dense fibrous areas such as the back and male breast, where aspiration volumes were approximately equal. The total ultrasound-assisted liposuction treatment times were reduced after our initial 30 patients, and suction-assisted lipoplasty times increased. Total aspiration rates in our later patients averaged 36.2 cc/per minute for ultrasound-assisted and 58.4 cc/per minute for suction-assisted lipoplasty, whose rates were approximately 1.5 to 2 times faster than for ultrasound-assisted liposuction in most areas. After using this technology in our initial series of 30 patients, it became apparent that ultrasound was not a substitute for suction-assisted lipoplasty but rather a natural complement. We have found that the marriage of the techniques enhances results and minimizes complications, such as seromas, which have been reported to be 11.4 percent with ultrasound-assisted liposuction alone and are 2.6 percent in our series.

Aesthetic management of the breast following explantation: evaluation and mastopexy options.

This retrospective study reviews 720 patients referred for evaluation of their silicone gel-filled breast implants from December of 1992 to January of 1996. Of the 720 patients evaluated, 282 (39.2 percent) subsequently underwent explantation, and 59 of these patients (20.9 percent) had a breast contouring procedure performed at the time of explantation. Our definition of explantation is the operative removal of the implant as well as the implant capsule. The overall complication rate for explantation was 5 out of 282 patients (1.8 percent), whereas the rate of complication among the patients who underwent simultaneous breast contouring was 2 out of 59 patients (3.4 percent). This article presents the management of the breast following explantation, implant removal, and capsulectomy. We review both the preoperative assessment of patients seeking explantation and our technique of explantation. Additionally, we address the importance of preoperative breast ptosis in technique selection and have developed a practical clinical algorithm for guiding simultaneous explantation and breast contouring. We also identify those patients who should undergo delayed breast contouring due to associated risk factors (smoking, need for > 4 cm of nipple movement, and paucity of breast parenchyma).

Evolving fixation methods in endoscopically assisted forehead rejuvenation: controversies and rationale.

The goals of surgical rejuvenation of the forehead include component brow manipulation, attenuation of transverse forehead rhytids, and reduction of glabellar frown lines. The endoscopic approach has proved successful in achieving these goals in selective patients while minimizing incisions and improving scalp sensation. Efficacy of endoscopic brow manipulation is dependent on (1) complete release of the brow at the supraorbital rim, (2) brow depressor muscle resection/release, and (3) tension-free fixation of the brow position until wound healing has occurred. Fixation of the brow using an endoscopic technique, unlike the open technique, is dependent on skin retraction and tension-free scalp fixation during the process of wound healing to maintain the desired brow position. Techniques for endoscopic fixation are arbitrarily divided into endogenous and exogenous. Endogenous methods include extensive galea-frontalis-occipitalis release, lateral spanning suspension sutures, external bolster fixation, anterior port skin excision, galea-frontalis advancement, cortical tunnels, and tissue adhesives. Exogenous techniques include internal screw or plate fixation, Mitek anchor fixation, external screw fixation, and absorbable K-wires. This article provides a goal-oriented review of these evolving techniques and a rationale for the use of fixation methods in endoscopically assisted forehead rejuvenation.

Recurrent digital ischemia due to thrombosis of the persistent median artery.

A case of recurrent digital ischemia due to thrombosis of the persistent median artery is presented. Diagnosis and treatment are based on accepted principles of therapy for upper extremity vascular disorders.