Plastic Surgery最新文献

The present article includes a video designed to show the reader/viewer how to obtain a better lip roll in primary and secondary cleft lips as well as in traumatic cleft lips. The key is to not damage the delicate glands and fat in the lip roll. The actual surgery demonstrated in the video is a cleft lip redo with an effaced lip roll.

Background: Sphincter pharyngoplasty has demonstrated time-tested results as a surgical treatment for velopharyngeal incompetence (VPI). However, controversy surrounding the contractility of the transposed muscles persists. Completely unaddressed in the literature is whether the dynamism of the sphincter affects speech outcomes.

Objective: To determine whether active sphincter contraction following sphincter pharyngoplasty influences velopharyngeal closure, nasal emission and hypernasality.

Methods: A prospective analysis of patients with VPI after cleft palate repair undergoing sphincter pharyngoplasty by a single surgeon was performed. Video nasendoscopy and videofluoroscopy were performed preoperatively and postoperatively at three and 12 months. Eighteen consecutive patients with cleft palate with or without cleft lip and VPI were reviewed. The average age of the patients at initial evaluation was 7.3 years, with a range of three to 19 years. Dynamicity of sphincter pharyngoplasty, velar closing ratio (VCR), and lateral wall movement (LWM) were assessed by nasendoscopy and videofluoroscopy. Nasal emission and hypernasality were assessed by perceptual speech examination.

Results: FOR LONGITUDINAL COMPARISON, THREE GROUPS WERE CREATED: dynamic at three and 12 months (n=12); adynamic at three months and dynamic at 12 months (n=4); and adynamic at three and 12 months (n=2). Perceived hypernasality scores significantly improved at three months (P=0.0001) and showed continued improvement at 12 months (P=0.03), despite no change in VCR and LWM from three to 12 months. There were no significant differences among the three groups at any time point.

Discussion: Sphincter pharyngoplasty effectively treats VPI in appropriately selected patients. Although the VCR and LWM remained stable between three months and one year, four of six adynamic sphincters became dynamic. Considering all patients, hypernasality showed continued improvement from three months to one year.

Conclusions: There were no differences between dynamic and adynamic sphincters in terms of speech outcomes or the mechanical properties of velopharyngeal closure.

Background: Postoperative management of patients after modified radical mastectomy has evolved over the past decades. In the early postoperative period, wound complication rates were reported to be as high as 60%. Flap necrosis after modified radical mastectomy is a common problem encountered by surgeons. Various treatment strategies have been proposed in the literature but none have addressed the use of dextran-40.

Objective: To determine whether dextran-40 infusion improves skin flap viability after modified radical mastectomy.

Methods: Twenty-eight patients who underwent modified radical mastectomy were randomly assigned to receive dextran-40 or no dextran-40 intraoperatively after flap dissection. Patients were followed prospectively over a five-year period in a community hospital. The incidence of postmastectomy skin flap necrosis and prognosis of the necrotic area after dextran-40 infusion was observed.

Results: Flap necrosis was observed in five (17.8%) patients. Hypertension and diabetes mellitus were found to be risk factors for the development of flap necrosis (P<0.05). Flap thickness and tension on the flaps were found to be related to flap necrosis. Six of seven patients with flap perfusion problems (ecchymosis or necrosis) underwent dextran-40 treatment and healed without graft replacement.

Conclusions: Dextran-40 treatment did not affect development of flap necrosis. However, if necrosis had already developed, the necrotic area of the skin flaps improved with dextran-40 treatment.

Acral myxoinflammatory fibroplastic sarcoma is an extremely rare soft-tissue sarcoma. It typically presents as an inflammatory mass in the distal extremities of adult patients. The authors present a review of the available literature as well as a discussion on the surgical management of a patient with acral myxoinflammatory fibroplastic sarcoma who originally requested conservative management but ultimately required a two-digit ray amputation after local recurrence.

Implant-associated anaplastic large cell lymphoma (ALCL) is the subject of much debate in the field of plastic surgery. Only a few published cases have been reported and the rarity of the disease may make proving causality exceedingly difficult. Despite this, it is of utmost importance that full attention be devoted to this subject to ensure the safety and well-being of patients. The authors report one new case of implant-associated ALCL that recently presented to their institution. Implant-associated ALCL is a poorly understood disease. It should likely be considered its own clinical entity and categorized into two subtypes: one presenting as a seroma and the other as a distinct mass or masses. When reported, only textured implants have been associated with ALCL. The United States Food and Drug Administration and American Society of Plastic Surgeons have initiated a registry and have collected critical data to gain further understanding of this disease.

Background: Ideal eyebrow aesthetics give a framework for brow rejuvenation and surgical procedures do not always provide satisfying results. Previous studies have shown elevation of the medial brow with aging; however, they failed to characterize overall shape changes.

Objective: To characterize changes in eyebrow slope with increasing age to better direct brow rejuvenation.

Methods: From standardized anteroposterior facial photographs of 100 women 20 to 80 years of age, eyebrow height was measured at the medial limbus and arch apex from a mid-pupillary horizontal. The slope of the eyebrow was calculated. Using group analysis, mean height and slope were compared using the Mann-Whitney U test. Regression analysis was used to determine the relationship between slope and age.

Results: Mean slope significantly decreased from 20 to 29 years of age to 40 to 49 years of age (0.22 versus 0.12; P=0.03), and then increased between 40 and 49 years of age and ≥60 years of age (0.12 versus 0.21; P=0.05). Medial height did not change significantly, and arch apex significantly decreased between 20 and 29 years of age and 40 and 49 years of age. Regression analysis showed a quadratic relationship between age and slope, with the decrease in slope until the fifth decade of life being directly related to increasing age. After this, age was not a significant contributor to slope changes.

Conclusions: With increasing age, the slope of the eyebrow decreases until the fifth decade dependent on age. After the fifth decade, age no longer plays a significant role. Therefore, choice of brow lift technique should be carefully selected.

Background: Submucous cleft palate is characterized by muscular diastasis of the velum in the presence of intact mucosa with variable combinations of bifid uvula and hard palatal defect. Submucous cleft palate is indicated as a separate entity in most previous classifications but it has never been properly classified on an anatomical basis.

Objectives: To revise the Smith-modified Kernahan 'Y' classification of cleft lip and palate deformities, and to describe the different anatomical subtypes of submucous cleft palate.

Methods: The present study was conducted in Hayatabad Medical Complex, Abasin Hospital and Aman Hospital Peshawar, Pakistan, from November 2010 to December 2011. All patients who presented to the outpatient departments with cleft lip and palate, with the exception of previously operated cases, were included. All cases were described according to the Smith-modified Kernahan 'Y' classification and the authors' revised Smith-modified Kernahan 'Y' classification. All of the data were organized and analyzed using SPSS version 17 (IBM Corporation, USA).

Results: A total of 163 cases of cleft lip and palate deformities were studied, of which 59.5% were male and 40.5% were female. Smith modification of the Kernahan 'Y' classification completely described the cleft deformities in 93.9% of patients. However, while the Kernahan 'Y' classification represented the submucous cleft palate, it did not describe its different anatomical subtypes in 6.13% of patients. The revised Smith-modified Kernahan 'Y' classification completely described the cleft deformities of the entire study population, including the different submucous cleft palate patients.

Discussion: The Smith alphanumeric modification of the Kernahan 'Y' classification of cleft lip and palate came into existence after a long search and a series of modifications over the past century. This classification system describes the cleft region, site of the cleft, degree of the cleft, rare and asymmetrical clefts, and are computer database friendly. However, this classification did not describe the different anatomical subtypes of submucous cleft palate that have variable relationships with velopharyngeal insufficiency.

Conclusion: The revised Smith-modified Kernahan 'Y' classification described in the present study can describe all types of cleft lip and palate deformities in addition to the different types of submucous cleft palate deformities.

Background/objective: Bupivacaine and lidocaine are often used concurrently, in theory, to combine the more rapid onset of lidocaine and the longer duration of bupivacaine. The purpose of this study was to evaluate this concept.

Methods: Twenty-five subjects were enrolled in a double-blinded, randomized block design study to evaluate the onset and duration of four different mixtures of lidocaine and bupivacaine with epinephrine. The study was designed to achieve 80% power to detect an effect size of 0.37 at 5% overall significance. The four mixtures tested were: 0.25% bupivacaine with epinephrine (1:200,000); 1% lidocaine with epinephrine (1:100,000); 0.125% bupivacaine and 0.5% lidocaine with epinephrine (1:150,000); and 0.25% bupivacaine and 1% lidocaine with epinephrine (1:150,000). Four intradermal injections were made in the volar forearms of each participant. Time to effect and duration were measured by sensation of a sharp skin prick.

Results: Mean time to onset ranged from 12 s to 29 s without statistical significance across all tested solutions (P=0.891). Mean duration of effect ranged from 6 h 38 min to 7 h 25 min with a statistically significant difference across the tested solutions (P=0.036).

Conclusions: No statistical benefit was measured when comparing lidocaine with epinephrine, bupivacaine with epinephrine, and mixtures of these local anesthetics with regard to onset of action. While a statistical difference was observed in duration of effect, the clinical benefit measured was narrow.