The health care crisis: impact on surgery from a chief executive officer's perspective.

Kaiser Permanente, in conjunction with the surrounding academic institutions, trains 64 surgical residents annually in Northern California. Although the current health care crisis has made resident education increasingly difficult, we are committed to maintaining and expanding our programs. The current health care crisis reflects the effect that for-profit health plans, hospitals, and pharmaceutical groups have had on medicine. Their negative impact has not been simply the extraction of resources from the delivery system to their equity shareholders, but the implementation of an authorization process designed to frustrate and deny. As executive director and chief executive officer of the Permanente Medical Group, I believe that resident training allows us to attract outstanding clinicians, train the physicians of the future, and improve the clinical care of our patients. The multispecialty nature of our medical group and our size allows us to work collaboratively, offer evidence-based approaches, preserve professional independence, and implement innovative programs to increase quality and service. Although it is uncertain how health care will evolve in the future, we at Kaiser Permanente are committed to maintaining and expanding our involvement in the education of the next generation of surgeons.

Dermal thymus. A light microscopic and immunohistochemical study.

Two rare cases of distinctive thymic remnants occurring in the skin are described. The lesions were present at birth, and involved the side of the neck. One child had a complete cleft lip and palate. The other had multiple congenital anomalies consistent with a rare syndrome entitled branchio-oculo-facial syndrome. Microscopically, lobular foci were present in the dermis and consistent with both prethymic and thymic remnants. Immunohistochemical studies using antibodies to T cells and B cells showed a distribution similar to that seen in normal thymus. Dermal thymus appears to be a distinct entity and may be associated with other faciobranchial defects.

Treatment of enophthalmos.

This article has focused on the prevention and treatment of enophthalmos. It has stressed that enophthalmos is both a common complication of orbital fracture and a complication that can be difficult to treat. The cause of these failures of primary and secondary treatment is failure to recognize that orbital fractures have two distinct patterns and that neither is secondary to the anterior orbital floor defect. The zygoma fracture is the more common fracture and the most frequent cause of late enophthalmos. When this bone fractures, it does so at its sutural attachments. It is essential to reposition it at a minimum of three locations to achieve correction in three dimensions. The key to adequate reduction is not only to identify the frontozygomatic and zygomaticomaxillary suture at the infraorbital rim, but also to examine the zygomaticomaxillary suture in the region of the anterior maxillary buttress. Frequently, reduction at the first two sutural areas still leaves persistent lateral rotation of the zygoma and marked intraorbital volumetric expansion behind the axis of the globe. Complete reduction at three points will prevent late enophthalmos. Reosteotomy with repositioning of the zygoma and bone grafting to restore proper orbital volume can correct secondary enophthalmos once it develops. True blow-out fractures do occur, but the cause of the enophthalmos is most commonly the concomitant medial wall fracture and the occasional posterior expansion. The key to treatment is proper diagnosis, which is dependent upon CT scanning. Following definition of the exact fracture spots, restoration of intraorbital volume and sealing of the defects are satisfactory to avoid enophthalmos.(ABSTRACT TRUNCATED AT 250 WORDS)

Acquired ptosis: a reexamination of etiology and treatment.

The etiology of acquired ptosis is almost always disinsertion of the levator aponeurosis from the tarsal plate. As opposed to congenital ptosis, where levator resection is required to compensate for muscle weakness, acquired ptosis can be consistently treated with simple levator reattachment. This study examines both the diagnostic and anatomic etiology of acquired ptosis in 80 consecutive patients. Although dermatochalasis, trauma with orbital hematoma, orbital swelling, anophthalmos, and multiple other diverse clinical etiologies were responsible for this condition, the anatomic etiology was identical in 79 of the patients--levator disinsertion. Cadaver studies demonstrate that the levator aponeurosis inserts into the tarsal plate through multiple flimsy, fibrous attachments. Any condition that results in either excess weight to the eyelids or excess muscular pull can disrupt these fibers. A modification of the external approach is described that allows rapid identification of the levator aponeurosis and permits accurate repair. Complete repair was achieved in the majority of the cases, and there were no instances of overcorrection.

Improved technique for fascial sling reconstruction of severe congenital ptosis.

Fascial sling surgery for severe congenital ptosis yields superior results when the operative result is dynamic rather than merely suspensory. The sling itself is attached as in a tendon transfer solely to the frontalis muscle, minimizing adherence to the underlying periosteum and the overlying dermis. The sling is passed behind a pulley created by the superior transverse ligament so as to produce a more normal vector of pull. The dermis of the skin is attached to the sling to create a dynamic supratarsal crease. Postoperative retraining allows the patient to achieve more than one centimeter of levator function. These operative modifications make this procedure more closely parallel the normal eyelid dynamics and yield consistently good results for this difficult problem.

Extensor digiti minimi tendon transfer to prevent recurrent ulnar drift.

Thirty percent of patients with rheumatoid arthritis develop ulnar drift. Although numerous operations have been described, recurrence of the deformity is frequent. We recommend use of the extensor digiti minimi tendon transfer to prevent recurrent ulnar deviation. The tendon insertion is moved from a dorsal location to a dorsal-radial position. In this new location, the tendon produces both extension and radial deviation. Moreover, this transfer is maximally effective in extension when ulnar drift is greatest. We have used this transfer 28 times during the past 6 years. In evaluating patients more than 1 year after surgery, metacarpal phalangeal joint extension averaged 52 degrees and there was no evidence of recurrent ulnar drift of the little finger. The only problem was slight hyperextension of less than 5 degrees in approximately half of the patients. However, in no patient was this functionally a problem. We recommend the use of this tendon transfer in all patients with ulnar drift undergoing metacarpal phalangeal joint replacement for rheumatoid arthritis.

Penile revascularization in the treatment of vasculogenic impotence.

Arterial insufficiency is the most common organic cause of impotence. The diagnosis can be established on a clinical basis through the use of Doppler probe evaluation of the penile pulses, penile blood pressure measuring, and nocturnal penile tumescence monitoring. The diagnosis may be confirmed by internal pudendal arteriography. Through microsurgical arterial revascularization, a 60 percent long-term success rate has been achieved. Two early and two late failures suggest the need for improved patient selection and confirm the progressive nature of the arteriosclerotic process.

Cephalometric study of facial growth in children after combined pushback and pharyngeal flap operations.

Linear and angular cephalometric measurements of children who had had combined palatal pushbacks and superiorly-based pharyngeal flaps do not show later growth retardation of the face. There was an inherent tendency for children with overt clefts of the secondary palate, classic submucous clefts, or occult submucous clefts to demonstrate pre-operatively a narrow SNA and SNB--but the difference between these angles (ANB) was normal.

Breast reconstruction following lumpectomy and irradiation.

The traditional approach to breast cancer has been the surgical mastectomy. The cosmetic deformity resulting from this procedure has led to the development of our current methods of breast reconstruction. The inherent attraction of lumpectomy and radiotherapy has been its equation with improved cosmesis. This procedure may be an effective alternative to surgery from the cancer perspective and does produce, in the majority of patients, an acceptable cosmetic result. However, this paper demonstrates that it may produce a result that is less optimal than mastectomy with postoperative breast reconstruction. The etiology of the increased deformity can either be the localized lumpectomy with marked internal derangement of breast volume or the radiation therapy itself. In addition, those who develop a combination require a solution to both. We describe three patients who illustrate these problems and believe that a greater awareness of these potential complications should be available to aid patients in choosing their cancer treatment.

A congenital orbital defect with periorbital-dural tissue adhesion.

This case demonstrates a previously unreported congenital orbital deformity. The patient was born with a unilateral exophthalmos. The etiology of the defect was demonstrated by CT scan as a convex bowing of the right superomedial orbital wall behind the axis of the eye. At surgery, this convexity was revealed to be a small bony defect through which the periorbital tissue and dura mater adhered. This sort of orbital deformity, although subtle, must be considered in the differential diagnosis of congenital unilateral exophthalmos.

Metastatic cervical teratoma of infancy.

The first case of a documented metastatic cervical teratoma of infancy is presented with a review of diagnostic considerations. Early biopsy of suspicious neonatal head and neck masses is recommended. Complete resection of the teratoma should be considered as soon as clinically possible.

Treatment of exophthalmos.

Current procedures for Graves' exophthalmos fail to achieve complete correction. The standard orbital decompressions were therefore modified to maximize the degree of volumetric increase behind the axis of the globe. In 15 orbits, the preoperative exophthalmos averaged 9.5 mm, whereas the postoperative exophthalmos was 4.1 mm. Postoperative CT study demonstrated that the remaining posterior orbital wall, combined with the persistently increased intraocular muscle volume, blocked retrodisplacement of the globe, despite adequate total volumetric increase. The increased muscle volume varied from 2 to 5 cc. Despite this residual exophthalmos, the modified four-wall expansion provides excellent aesthetic results with visual improvement and resolution of chemosis and exposure keratitis.

Uses of the rectus femoris myocutaneous flap.

The rectus femoris myocutaneous flap is quite useful for definitive immediate coverage of complex wounds within its territorial arc. We describe 4 cases to illustrate the capabilities of this flap. The indications for, the anatomy of, and the surgical technique for transfer, as well as the functional sequelae in two nonparaplegic patients are discussed.

Pathophysiology of cleft lip muscle.

Although attention has been focused for decades on the correction of cleft lip deformities, our knowledge about the etiology of such deformities has remained presumptive. Sixty-six muscle biopsy specimens from cleft lip infants were obtained at the time of primary closure. Histochemical stains, histographic analysis, and electron microscopy were performed. A nonneurogenic muscle atrophy was seen that varied in severity, with muscle fibers near the cleft being the most atrophic and disorganized. Muscle fibers stained with the modified Gomori trichrome technique also demonstrated "ragged red" fibers typical of a mitochondrial myopathy. Electron microscopy confirmed large accumulations of mitochondria distorting the fibrils. These mitochondria also were increased in size and densely packed with cristae. This study thus demonstrates that the muscles in cleft lip deformities are not normal. Instead, they reflect either myopathy in the facial mesenchymal mitochondrion or at least a delay in maturation. We hypothesize that some of the morphologic deformities associated with cleft lip may cause a failure of mesenchymal reinforcement of the facial processes at a critical time in development.

Pathophysiology of cleft lip muscles following the initial surgical repair.

Muscle biopsy specimens taken from the upper lip and perialar area during the time of secondary lip revision and studied by histochemical techniques demonstrate persistent connective-tissue and muscle abnormalities even at a distance from the cleft margins. Some of these changes are consistent with surgically induced denervation-reinnervation of muscle groups in the surgical field. Increased amounts of connective tissue also were found, most likely secondary to the original deformity and the subsequent surgical procedures. Both these changes may be important factors in subsequent abnormal growth and development of the underlying midfacial structures. This study also demonstrated the resolution of previously noted mitochondrial abnormalities found in the primary cleft lip patient.

Complications following silicone injections for augmentation of the contours of the face.

We report 5 patients who have had severe inflammatory reactions following the injection of liquid silicone for augmentation of the facial contour. We offer an approach to the treatment of this complication which, although not resulting in complete resolution, has at least markedly ameliorated these patients' signs and symptoms.

Experience with the temporoparietal fascial free flap.

The temporoparietal fascia is an ideal tissue source for free transfer to distant sites where ultrathin coverage is either desirable or mandatory. The fascia's dependable vascular anatomy facilitates the technical aspects of microvascular transfer by means of its large vessels, ample pedicle, and ability to be grafted on either side. Furthermore, this highly vascular tissue is available in surprisingly large quantities, and its donor scar is hidden in the hair. The authors have found this flap useful (1) in covering exposed bone and tendon without adding unwanted bulk, (2) in providing thin flap coverage or lining in major facial reconstruction, (3) in covering vital structures such as exposed nerves and vessels, (4) in providing neovascularity both as a recipient graft bed and for control of chronic infection, and (5) in reestablishing gliding-tendon mechanisms. The authors have successfully employed this free flap in 15 cases which involved deformities of the ankle, foot, Achilles tendon, forearm, hand, nose, and contralateral ear and scalp. Seven cases are utilized to illustrate the broad application of this unique and versatile free flap.