Prominent ears and their correction: a forty-year experience.

The technique described in this article correcting the protruding ear deformity has evolved over 40 years. The original procedures and our subsequent modifications are described, including 20-year followup results. The possible pitfalls in carrying out this procedure and how to avoid them are also described. A relatively standardized short procedure with minimal morbidity and maximum long-term results yields an aesthetically satisfactory looking ear.

The use of particulate hydroxyapatite and plaster of Paris in aesthetic and reconstructive surgery.

The authors describe their early investigative results of using a mixture of hydroxyapatite (HA) and plaster of Paris (PP) in skull and frontal sinus defects in a large series of cats. Histologically, bone was found to form and infiltrate the HA-PP implant over a period of months, with gradual resorption of the plaster in 6-8 weeks. Clinically, the HA-PP combination has been used in 24 patients over the past seven years for various skull, zygomatic, and mandibular defects.

The effect of povidone-iodine solutions used as surgical preparations on the bacterial flora of the skin.

One hundred fifty hospitalized patients undergoing elective surgery were enrolled in an open study designed to assess the bactericidal and clinical efficacy of a preoperative skin preparation procedure--application of 7.5% povidone-iodine surgical scrub followed by 10% povidone-iodine antiseptic solution. Of 99 patients with bacterial colonization of the skin prior to surgery, 84 patients (85%) had no detectable levels of bacteria at completion of surgery; bacterial flora persisted after surgery in the remaining 15 patients (15%). The difference between pre- and post-surgical bacterial colonization was statistically significant (p = 0.004). Clinically, none of the 146 patients evaluable for analysis of efficacy developed infections at the incision or suture site and there were no incidents of skin irritation at the surgical site during the postoperative observation period. Thus, preoperative cleansing with povidone-iodine surgical scrub followed by povidone-iodine antiseptic solution is an effective, non-irritating bactericidal regimen for use at surgical incision sites.

The inferior dermal-pyramidal type breast reduction: long-term evaluation.

The evolution of the technique of breast reduction using an inferior dermal pyramidal flap is discussed, including the changes we have found to enhance this procedure. The recommended use of a wide-based pyramidal breast parenchyma with a dermal pedicle nipple-areola flap is based on our 12-year study of 1,001 breast reductions in 519 patients ranging in age from 13 to 73 years; 37 of the patients underwent a unilateral breast reduction. The weight of tissue excised ranged from 207 g to 3,350 g from each breast. Occult carcinomas were found in two of the breast specimens. The longest sternal notch-to-nipple distance was 52 cm. The essential goals of predictability of the result, retainment of nipple sensitivity, excellent aesthetic results, and the possibility of lactation are satisfied by the use of this surgical technique. This technique appears to have continued application in younger women, in whom nipple sensation and lactation are particularly important.

Preoperative positioning of the protruding premaxilla in the bilateral cleft lip patient.

The rationale and technique for preoperative retraction of a protrusive premaxilla in the bilateral complete cleft lip and palate patient are presented. Two types of pinned intraoral appliances are presented that can expand the palatal shelves while retracting the premaxillary segment. Findings from lateral cephalometric x-ray studies of eight appliance patients and six control patients with bilateral clefts but no appliance treatment are presented at age 15. The data indicate that the cephalometric values at age 15 are within the normal range for most patients. Incisor angulation was quite varied among the subjects.

Evaluation in cats of a new material for cranioplasty: a composite of plaster of Paris and hydroxylapatite.

The materials ordinarily used to reconstruct bone defects in the calvaria and facial bones either are difficult to shape, are partially resorbed by the body, or are likely to become infected if used near a contaminated area such as the frontal sinus. Calcium sulfate hemihydrate (plaster of Paris) has been known for years to have excellent reparative qualities in bone defects, but ordinarily it is quickly resorbed. Consequently, a new material, a composite of a dense form of plaster of Paris and hydroxylapatite, was devised to provide nonabsorbable hydroxylapatite particles for bone to form around and within during the phase of plaster absorption. Two types of this material were evaluated in cranial defects in cats. Each of the plaster of Paris/hydroxylapatite mixtures was placed into a surgically unroofed frontal sinus and into a contralateral parietal trephine hole in a group of 32 cats. Two cats in each group succumbed to anesthesia, leaving two sets of 30 cats. During the entire follow-up period there was only one other death, with no evidence of wound infection, wound dehiscence, implant rejection, or cerebral dysfunction among the survivors. The cats in each group were sacrificed at 1, 2, 3, 5, 7, 8, 9, 10, or 12 months after operation. Following sacrifice, both the frontal and parietal defects were exposed and examined visually, histologically, and with histomorphometric analysis for new bone formation. New bone formation was present as early as 1 month after operation and continued to increase during the 12 months of the study. Based upon these osteogenic qualities, the ease of shaping the composite, and the lack of infection in the frontal sinus region, it is concluded that this substance could be a valuable new material for human cranioplasty.

Mammary implants, diving, and altitude exposure.

Mammary implants were exposed to various simulated dive profiles followed by altitude exposures to stimulate aircraft travel and then were observed for bubble formation and volume changes. Minimal volume changes occurred after each dive. Numerous bubbles formed, however, reaching their maximum size in 3 hours. By comparison, when implants were exposed to high altitude following a dive exposure, significant volume changes occurred. This in vitro study showed that bubble formation and volume expansion occur after exposing implants to diving and altitude, but the circumstances required to produce these changes in vivo are extremely unlikely to occur normally.

The orticochea pharyngoplasty and primary palatoplasty: an evaluation.

A primary Orticochea pharyngoplasty with a primary palatoplasty was studied in 15 children with cleft palates. Although all children demonstrated velopharyngeal competence, radiographic, endoscopic, and oral examinations suggested that 54% of the children studied would not have needed a pharyngoplasty. In addition, 27% of the children demonstrated aberrant speech patterns associated with velopharyngeal incompetence. Emphasis is placed on the difficulty in identifying which cleft palate patients will have residual velopharyngeal incompetence and the need for continued study and development of techniques for more accurate prediction of which patients would benefit from a primary pharyngoplasty.

An aesthetic approach for nasal tumors.

An elongated columella flap has been found to give excellent exposure to the nasal dorsum, allowing satisfactory removal of soft tissue nasal masses such as dermoid cysts or hemangiomas. This approach provides a more acceptable scar than the standard vertical dorsal nasal incision.

Long-term clinical outcome of immediate reconstruction after mastectomy.

Immediate reconstruction of a breast removed for treatment of carcinoma can be accomplished without altering the cancer-ablative surgical procedure. The theoretical possibility that reconstruction might compromise the cure rate has tempered enthusiasm for this approach. To test this issue, the relapse-free survival of 101 patients who underwent breast reconstruction in the immediate postmastectomy period was compared with that of 377 patients with breast cancer who underwent mastectomy without immediate reconstruction. This comparison was accomplished using multivariable statistical techniques to correct for baseline inequalities between the patient groups. After adjustment for the relevant prognostic factors, no significant difference remained between the two groups. We conclude that immediate reconstruction has no discernible adverse influence on the natural history of surgically treated breast carcinoma.

To share or not to share.

We describe our extensive experience in nipple reconstruction on breasts formed by subpectoral implants, latissimus dorsi musculocutaneous flaps, or rectus abdominis musculocutaneous flaps.

Cherubism.

Cherubism is a rare, hereditary fibroosseous lesion of the jaws that is thought to undergo spontaneous involution after puberty. Treatment is unnecessary unless functional or emotional disturbances develop. This article describes the 21-year follow-up of a patient with cherubism and briefly reviews the pertinent literature.

The meaning of concepts related to breast reconstruction.

Information is presented from a psychometric study using a semantic differential to measure the meaning of concepts related to breast reconstruction. One hundred five women participated. All were experiencing breast reconstruction subsequent to mastectomy. The average woman was married, middle-aged, and had 11/2 years of education beyond high school. Results from the semantic differential demonstrated that the women viewed themselves, their bodies, and their femininity positively. They valued themselves, and their self-concepts were closer in meaning to health than to mastectomy, death, or cancer.

A rationale for modifying the site of insertion of the orticochea pharyngoplasty.

A modification of the insertion level of Orticochea flaps is proposed. The purpose of the modification is to place the pharyngoplasty at a higher site, in the area of attempted velopharyngeal contact. The site of velopharyngeal contact can be identified using lateral radiographic techniques. A success rate of 93 percent was achieved in improved oral-nasal resonance balance when the pharyngoplasty was placed at a site in the nasopharynx.

Masseter muscle hypertrophy.

Benign hypertrophy of the masseter muscle is an uncommon entity important in the differential diagnosis of head and neck masses, particularly a unilateral mass located in the cheek. Ten cases of benign masseteric hypertrophy are reviewed, current surgical treatment is described, and the pertinent literature is summarized.

Rhinophyma: a thirty-five-year experience.

We have treated rhinophyma by a variety of methods during the past 35 years. We describe our current management, which has given the most satisfactory results and fewest problems.

Microsurgical composite tissue transplantation: indications and technical considerations in breast reconstruction following mastectomy.

Twenty-six patients are presented who underwent reconstruction of the breast and thorax following mastectomy. A successful result ensued in 96 percent of the patients. Indications for the use of microsurgical composite tissue transplantation in breast reconstruction following mastectomy include. 1. Inability to employ an island latissimus dorsi musculocutaneous flap 2. Previous failure of an island latissimus dorsi musculocutaneous flap 3. The restoration of form and contour with minimal secondary donor deformity The present series includes 12 patients who underwent reconstruction utilizing the vascularized groin flap and 14 utilizing the contralateral latissimus dorsi musculocutaneous flap. The advantages and disadvantages of the different donor tissues are presented and contrasted with other vascularized donor tissue also employed in breast reconstruction following mastectomy. Technical modifications correlating the limitations of the donor tissue to the complexities of the recipient site and contributing to successful transplantation are detailed. The authors wish to emphasize that microsurgical composite tissue transplantation for reconstruction of the breast following mastectomy has applicability in only a small carefully selected subgroup of patients--approximately 9 percent.

The correlation of histologic changes in the human breast with the menstrual cycle.

Histologic changes in the normal human mammary gland associated with the menstrual cycle were sought in tissues derived from a defined population of patients undergoing subcutaneous mastectomy or reduction mammoplasty for reasons other than neoplasia. Ninety patients were selected for their regular menstrual cycling, abstinence from hormone use, and absence of disease which might influence pituitary-ovarian cycling. Morphologic changes in the mammary stromal and epithelial components were identified as they related to specific pituitary-ovarian events, and histologic criteria were identified that allowed reproducible morphologic categorization of the mammary gland into five specific phases: proliferative (Days 3-7); follicular phase of differentiation (Days 8-14); luteal phase of differentiation (Days 15-20); secretory (Days 21-27); and menstrual (Days 28-2). Double-blind reviews of tissues confirmed the validity and the reproducibility of these histologic criteria in identifying the menstrual phase. The findings further characterize the morphologic correlates of hormone responsiveness of the normal human mammary gland. The recognition of menstrual-cycle-dependent histologic changes may be expected to provide a basis for extending the interpretation of the morphologic characteristics of the breast in surgically acquired specimens that may be associated with hormonal aberrations.