Reconstruction with the latissimus dorsi flap after skin-sparing mastectomy.

The latissimus dorsi musculocutaneous island flap was once the standard for breast reconstruction. With the increased use of tissue expanders and the development of the transverse rectus abdominis musculocutaneous flap for autologous tissue breast reconstruction, use of the latissimus dorsi has decreased. To reassess the role of the latissimus dorsi musculocutaneous flap in breast reconstruction, a retrospective review was performed to evaluate women who had skin-sparing mastectomy followed by immediate reconstruction with a latissimus dorsi flap and permanent implants. The postoperative aesthetic results and donor site morbidity, including contour deformity and scarring, were examined. Satisfactory results were obtained in 17 of 18 patients. Complications were noted in 5 patients, and all were minor. Using the latissimus dorsi musculocutaneous flap and a permanent breast prosthesis for immediate reconstruction is successful because it provides sufficient muscular coverage of the implant. In addition, it provides a good aesthetic result using a single-stage procedure. Illustrative cases are presented.

Harvesting the latissimus dorsi muscle for cardiomyoplasty.

The development of cardiomyoplasty over the past several years has provided a surgical alternative for management of patients with severe heart failure. It may be indicated in patients for whom transplant is not indicated or must be delayed. Optimal results can be obtained when the maximum amount of viable muscle is used to wrap the heart. Between May of 1997 and October of 1998, five patients underwent cardiomyoplasty in our institution. All operations were performed using the left latissimus dorsi muscle wrap with postoperative stimulated muscle training. Presented is a review of cardiomyoplasty and our technique for harvesting the muscle flap, which has proven to be successful.

The present status of endoscopy.

Introduced to the field of plastic surgery in the early 1990s, surgical endoscopy has expanded rapidly with applications across the broad range of plastic surgery. Although basic principles and concepts have remained the same, there have been advances in both instrumentation and surgical ingenuity, allowing these broader applications. The numerous applications of the endoscope were reviewed and evaluated. Although some applications such as the endoscopic forehead lift and transaxillary endoscopic augmentation seem to have received general acceptance and are used across a broad spectrum of plastic surgery practices, others such as endoscopic muscle harvest have not gained such widespread acceptance. Also, there are areas such as endoscopic microvascular surgery that await advances in technology and instrumentation.

Skin ultrastructure after CO2 laser resurfacing.

Skin ultrastructure was examined in patients undergoing CO2 laser resurfacing for facial rejuvenation. The lasers used in this study were the Coherent Ultrapulse CO2 laser with computerized pattern generator, the Sharplan Feathertouch laser, and the Laserscope Paragon-70 pulsed CO2 laser with computerized pattern generator. Results showed that the epidermis was totally removed with one pass of the CO2 laser. After one laser pass, there was little compaction of collagen in the dermis, but after two and three passes, there were sequential graded increases in collagen compaction with loss of the intervening extracellular gel matrix. There was no "collagen shrinkage," and the collagen itself was marginally affected, except for occasional losses in striations at the surface of the specimens. Elastin was very much affected by the laser such that with only one pass, the elastin was abnormal, presenting with a mottled heterogeneous structure. This elastin aberrancy was present in both the papillary and reticular dermis. After one laser pass, fibroblast necrosis was present in the papillary dermis and the reticular dermis (depending on which laser was used), and the extent and depth of necrosis increased with multiple laser passes.

Microvascular surgery utilizing the endoscope as the sole source of visual assistance.

With the introduction of endoscopy to surgery, it has become apparent that magnification similar to the magnification provided by the surgical microscope can be achieved with its use. Endoscopic techniques provide both magnification and the ability to operate at a distance, potentially increasing the applications of microsurgery. An endoscopic unit is significantly less expensive than the operating microscope. Furthermore, it enables invasive techniques utilizing smaller incisions. The purpose of this project was to investigate whether the visual assistance provided by the endoscope is sufficient to perform a microvascular anastomosis. An initial experiment with six rats is presented. The right femoral artery was isolated, divided, and reconstructed by standard microanastomosis with the visual assistance provided by a 4-mm endoscope. All anastomoses were patent at 7 days by microangiography and histology. The magnification provided by the endoscope is sufficient for the creation of a microvascular anastomosis.

Ultrastructural study of the skin after facial chemical peels and the effect of moisturization on wound healing.

Ultrastructural changes occurring in the skin at early times after chemical peels as well as effects on the wound healing with moisturization after these peels have been examined. This study evaluated the changes seen in the skin 3 days and 5 days after 35% trichloroacetic acid peels, and the effect of moisturization on this healing was evaluated. Biopsies at 3 days showed an outermost layer of necrotic stratum corneum and stratum granulosum and an underlying layer of new stratum corneum. There were increased cytoplasmic vacuoles in the keratinocytes of the stratum spinosum, stratum granulosum, and stratum basale layers. There was extensive intercellular spacing between the basal keratinocytes. At 5 days the necrotic layer of stratum corneum and stratum granulosum was gone. The lower epidermis at 5 days showed less intercellular spacing, and there was less vacuolization within keratinocytes. In seven of eight patients treated with moisturization after the peel (p = 0.0325), the ultrastructural changes at 5 days were consistent with a more advanced state of healing compared with those that were treated dry. Ultrastructural morphology at this time showed less intercellular spacing and fewer cytoplasmic vacuoles, indicative of an advanced state of wound repair. These moisturized skin specimens had returned to an almost normal state of structure compared with the skin that had been treated dry.

Nasal cartilage grafts: more than a decade of experience.

From 1985 to 1995, a total of 311 patients underwent nasoplasties. During this time period, the number of patients receiving grafts increased from 94 percent in 1985-1989 to 100 percent in 1993-1995. The donor grafts averaged 72 percent nasal cartilage, 10 percent conchal cartilage, 9 percent fascia, and 9 percent rib allograft. Graft recipient sites averaged 41 percent in the tip, 31 percent in the dorsum, 17 percent in the columella, and 3 percent in the region of the lower lateral cartilage; 8 percent were spreader grafts. During this time frame, tip grafting increased from 34 percent in 1985-1989 to 54 percent in 1993-1995. Reoperation for complications decreased from 17 percent in 1985-1989 to 2 percent in 1993-1995. During the time span examined, the use of rib allografts declined, the use of autologous cartilage increased, the use of onlay tip grafts increased, and the incidence of reoperations declined. Early in the series, 80 percent of the malplaced tips were shield type grafts. With the use of the onlay tip graft, the complication of a malpositioned tip has been substantially diminished. The increased use of crushed cartilage has resulted in improvement in results and patient satisfaction, as it serves to camouflage slight irregularities in the tip and dorsum of the nose.

Reconstruction of the abdomen and perineum in cancer surgery.

Trunk and perineal defects after tumor resection present a challenge to the reconstructive surgeon. When primary closure is not possible, the use of well-vascularized autogenous tissue is required to achieve adequate soft-tissue coverage. Pedicled muscle or myocutaneous flaps provide excellent sources of vascularized tissue for postradiation defects. When local tissues preclude the use of pedicled flaps, free-tissue transfers can be performed. A thorough understanding of radiation wounds and the reconstructive options is essential for treatment of these challenging defects.

Lidocaine and epinephrine levels in tumescent technique liposuction.

The safety of lidocaine dosing in the tumescent technique has been well documented, but there is little evidence regarding the safety of combining tumescent lidocaine infiltration with subcutaneous lidocaine infiltration required in other aesthetic surgery. The safety of lidocaine and epinephrine dosing was investigated in 10 patients undergoing tumescent technique liposuction alone and in 10 patients undergoing tumescent liposuction with concurrent facial and aesthetic breast surgery by determining serum lidocaine and epinephrine levels at 3, 12, and 23 hours following infiltration of the tumescent solution and the subcutaneous lidocaine. The mean lidocaine dose of all patients was 22.3 mg/kg. All patients demonstrated safe lidocaine levels at all intervals, with the highest levels occurring in patients who received intravenous lidocaine at the induction of anesthesia. The peak epinephrine levels occurred at the 3-hour blood draw and were approximately four times physiologic. No patient demonstrated any subjective or objective signs of lidocaine or epinephrine toxicity.

Subcutaneous approach for elevation of the malar fat pad through a prehairline incision.

In summary, vertical suspension of the malar fat pad has been a safe procedure that results in the creation of a more youthful cheek and a lessening of the prominence of the nasolabial folds. No complications were encountered in this series with the suture suspension of the malar fat pad.

Endoscopy in plastic surgery. An overview.

The advances in endoscopic plastic surgery are exciting. Only with time will the best indications for the endoscope in aesthetic and reconstructive surgery be delineated. In the interim, continued ideas and innovations will push forward the limits of our understanding and allow a fresher look at the rationale for many of the procedures performed.

Endoscopic browlift.

We have presented the development and current status of endoscopic browlifting from its inception at UAB to the present techniques as they are now practiced by the authors. Endoscopic browlifting was based on sound preclinical research and included thorough training of all investigators in the use and application of endoscopic equipment. We believe that endoscopic browlifting represents clear advantages over the open technique in selected patients. These advantages included avoidance of the long transverse incision and its secondary sequelae. Improved magnification and visualization of small structures are also a secondary advantage. Complications are no greater than the open technique and tend to diminish with experience. We feel that endoscopic browlifting will continue to be refined and will find a permanent place among the armamentarium of all aesthetic plastic surgeons.

The biplanar endoscopically assisted forehead lift.

Our experience with endoscopic forehead lifting and the biplanar forehead lift has been very rewarding, and although the postoperative results are early, the persistent elevation of the brows is encouraging, given that we do not temporarily suspend the forehead to the scalp with external bolsters or to the calvarium with internal anchors to bone, as has been described. The diminution of glabellar wrinkles also is marked. Clearly, the innovation of endoscopy to plastic surgical practice has enhanced our understanding of the goals in forehead lifting; and given our experience and that of others, it is hoped that many more patients will benefit form this continually evolving technique.

Endoscopic abdominoplasty with repair of diastasis recti and abdominal wall hernia.

Endoscopic abdominoplasty is feasible, safe, and effective in the proper surgical candidate. Excellent results can be expected when proper patient selection criteria are followed. With future refinements in technique and equipment, this procedure may be extended safely to those patients with more severe deformities.

Complications in endoscopic plastic surgery.

Owing to the relatively short time endoscopic-assisted plastic surgery procedures have been done, there are few published reports of complications. The experiences of the faculty from the Endoscopy in Plastic Surgery: A consensus Multidisciplinary Symposium as well as the few published reports in the literature have been reviewed. The complications associated with endoscopic techniques are similar to those with open techniques. It is clear, however, that a subset of complications specific to endoscopic procedures exists. As endoscopic techniques and instrumentation are further developed, and as surgeons move higher up on the "learning curve", these complications should be reduced.

Endoscopic techniques in coronal brow lifting.

Laboratory investigations in fresh cadaver heads demonstrated the feasibility of endoscopic techniques applicable to aesthetic surgery of the face, including the cheeks, the forehead, the orbit, the nose, and the nasal septum. Clinical experience with coronal brow lifting in 32 patients using endoscopic techniques is also presented. The elimination of the ear-to-ear coronal incision is an obvious advantage. The endoscopic approach accomplishes division and weakening of the corrugators, procerus, and frontalis muscles, as well as moderate elevation of the eyebrows. Excess skin is accommodated by dissecting the scalp posteriorly toward the occiput.

Treatment of paralytic ectropion with composite chondrocutaneous graft.

We present our experience with correction of paralytic ectropion in 10 patients with a composite chondrocutaneous graft obtained from the scapha of the ear. This large composite graft is sutured to the tarsal plate to support the lower lid. It prevented exposure keratitis in all patients. Two patients needed minor secondary revisions of the corners of the cartilage graft. The donor defect healed satisfactorily without deforming the ear. There were no other complications and no other lid or visual problems. At 3-year follow-up, the results thus far appear long lasting.

Enhanced peripheral nerve regeneration by acidic fibroblast growth factor.

Transection of peripheral nerves may cause permanent denervation with paralysis and disability in humans and represents a challenging problem in microsurgery. Physiologic repair at increasing intervals after the acute phase of injury results in progressively worse recovery, emphasizing the importance of rapid and timely reinnervation to optimize endorgan viability. Despite recent advances in microsurgical techniques, imperfect reinnervation results in partial return of neuromuscular function, even in the mildest neuropraxias. Axonal repair of mature neurons involves a complex interaction of molecular events, suggesting that the presence of specific neuronotropic factors might enhance the regeneration process. Recombinant human fibroblast growth factor (FGF-1) has been shown to induce both rapid angiogenesis and neurogenesis through a synthetic conduit across a 15-mm surgical gap in the peripheral nerve of the rat. Evidence of newly formed neural structures was confirmed postoperatively by histological examination in a temporal fashion over a 24-week interval. Functional motor recovery of regenerated nerves was evaluated by determining the amplitude and latency of compound muscle action potentials in treated animals. Electrophysiology studies demonstrated consistent return of motor function in 43 and 57% of animals harboring an FGF-1 conduit at 8- and 24-week intervals, respectively. None of the control animals exhibited restoration of motor function. Collectively, these data suggest that FGF may serve as an important mediator of controlled growth during peripheral nerve regeneration.