Arshad R. Muzaffar

Surgical anatomy of the midcheek and malar mounds.

The anatomy of the midcheek has not been satisfactorily described to adequately explain midcheek aging and malar mounds, nor has it suggested a logical approach to their correction or provided sufficient detail for safe surgery in this area. This cadaver study, which was complemented by many operative dissections, located a missing link: a glide plane space overlying the body of the zygoma. The space functions to allow mobility of the orbicularis oculi, where it overlies the zygoma and the origins of the elevator muscles to the upper lip. The space is a cleft between the sub-orbicularis oculi fat and the preperiosteal fat and is lined by a fine membrane. The anatomic boundaries are clearly defined by retaining ligaments, which correlate with the triangularity of the space. Several anatomic features provide the functional characteristics of the prezygomatic space, including the (1) absence of direct attachments between the orbicularis in the roof to the floor, (2) more rigid inferior boundary formed by the zygomatic ligaments, and (3) more mobile upper ligamentous boundary formed by the orbicularis retaining ligament (separating from the preseptal space of the lower lid). These components determine the characteristic aging changes that occur in this region and explain much about malar mounds. An appreciation of this anatomy has several surgical implications. The prezygomatic space is a junction area that can be approached from the temple, lower lid, and cheek. The zygomatic branches of the facial nerve to the orbicularis do not cross the space; rather, they course in the walls and in the sub-orbicularis fat within the roof of the space.

Surgical Anatomy of the Ligamentous Attachments of the Lower Lid and Lateral Canthus

Description of the surgical anatomy of the superficial fascia of the face must include its deep attachments. These attachments have been mapped out for the forehead, temple, and cheek as retaining ligaments. The deep attachments of the orbicularis oculi of the lower lid and lateral canthus have long been recognized in canthopexy surgery but have yet to be properly defined. Six fresh cadavers were dissected with histologic support, and the results were correlated with surgical observations. The fascia of the deep aspect of the orbicularis is attached to the periosteum of the orbital rim by an orbicularis retaining ligament. This attachment is weakest centrally and tightest over the inferolateral orbital rim. The retaining ligament fuses with an expanded fibrous attachment beyond the lateral canthus, the lateral orbital thickening, which extends over the lateral orbital rim onto the adjacent deep temporal fascia. Aging changes are associated with attenuation of the ligamentous support provided by the orbital thickening and the orbicularis retaining ligament, which then allows inferior displacement of the lower boundary of the lid and contributes to the typical effects of age in this region. The superficial fascia of the lateral orbital region has a continuous connective tissue structure linking the temporoparietal fascia and orbicularis fascia to the lateral canthal tendon by means of the tarsal plate connection. Release of the deep ligamentous attachments (lateral orbital thickening and orbicularis retaining ligament) of the orbicularis fascia is important in some canthopexy and in rejuvenation procedures. The release allows effective redraping and upward mobilization of the orbicularis of the lower lid and the premalar soft tissues.

Parameters of Care for Craniosynostosis

Background A multidisciplinary meeting was held from March 4 to 6, 2010, in Atlanta, Georgia, entitled “Craniosynostosis: Developing Parameters for Diagnosis, Treatment, and Management.” The goal of this meeting was to create parameters of care for individuals with craniosynostosis. Methods Fifty-two conference attendees represented a broad range of expertise, including anesthesiology, craniofacial surgery, dentistry, genetics, hand surgery, neurosurgery, nursing, ophthalmology, oral and maxillofacial surgery, orthodontics, otolaryngology, pediatrics, psychology, public health, radiology, and speech-language pathology. These attendees also represented 16 professional societies and peer-reviewed journals. The current state of knowledge related to each discipline was reviewed. Based on areas of expertise, four breakout groups were created to reach a consensus and draft specialty-specific parameters of care based on the literature or, in the absence of literature, broad clinical experience. In an iterative manner, the specialty-specific draft recommendations were presented to all conference attendees. Participants discussed the recommendations in multidisciplinary groups to facilitate exchange and consensus across disciplines. After the conference, a pediatric intensivist and social worker reviewed the recommendations. Results Consensus was reached among the 52 conference attendees and two post hoc reviewers. Longitudinal parameters of care were developed for the diagnosis, treatment, and management of craniosynostosis in each of the 18 specialty areas of care from prenatal evaluation to adulthood. Conclusions To our knowledge, this is the first multidisciplinary effort to develop parameters of care for craniosynostosis. These parameters were designed to help facilitate the development of educational programs for the patient, families, and health-care professionals; stimulate the creation of a national database and registry to promote research, especially in the area of outcome studies; improve credentialing of interdisciplinary craniofacial clinical teams; and improve the availability of health insurance coverage for all individuals with craniosynostosis.

Posttraumatic thumb reconstruction.

Learning Objectives: After reading this article, the reader should be able to: 1. Discuss the critical anatomic features of the thumb as they affect on reconstructive decision making. 2. Define the goals of reconstruction. 3. Discuss an algorithm for thumb reconstruction according to the level of amputation. 4. Understand the role of prosthetics in thumb reconstruction. Background: The function of the thumb is critical to overall hand function. Uniquely endowed with anatomic features that allow circumduction and opposition, the thumb enables activities of pinch, grasp, and fine manipulation that are essential in daily life. Destruction of the thumb secondary to trauma represents a much more significant loss than would result from loss of any other digit. Therefore, significant effort has been focused on thumb reconstruction. Numerous techniques have been described, ranging from simple osteoplastic techniques to complex microsurgical procedures. With an appreciation of the unique anatomic properties of the thumb, the hand surgeon is better able to understand the goals of thumb reconstruction and to develop an algorithm for thumb reconstruction. With such an understanding, an individualized reconstructive plan can be developed for each patient. Methods: A great many options are available for posttraumatic thumb reconstruction. Optimal results are obtained by pursuing an organized and logical approach to reconstruction based upon the level of tissue loss. Reconstruction methods depend on the location of the amputation and range from homodigital and heterodigital flaps to partial-toe transfer or a great-toe wrap-around flap to first-web-space deepening using Z-plasties, a dorsal rotation flap, or a distant flap, to distraction osteogenesis, lengthening of the thumb ray, spare parts from another injured digit in the acute setting for pollicization or heterotopic replantation, and microvascular toe transfer. Results: Amputations in the distal third of the thumb are generally well-tolerated. The primary reconstructive issues are the restoration of a padded and sensate soft-tissue cover, as well as aesthetic considerations. First-web-space deepening will generally provide excellent results for amputations at the distal half of the middle third. In the proximal half of the middle third, lengthening of the thumb ray is generally required. Distraction lengthening of the first metacarpal is a useful and reliable technique that provides up to 3 cm of length without requiring complex microsurgical methods. Spare parts from another injured digit may be used in the acute setting for pollicization or heterotopic replantation. Microvascular toe transfer is an excellent option for elective reconstruction. However, other options also are available and may be more appropriate in some cases. Less ideal options include the various types of osteoplastic reconstruction. Conclusions: The reconstruction of posttraumatic thumb defects is a challenging and rewarding surgical endeavor. The value of a functioning thumb is immense, and its reconstruction is worthy of considerable effort. Despite the elegant reconstructive options available, the best results are obtained with replantation or revascularization whenever possible. Finally, the treatment plan always must be derived from a careful assessment of each patient’s posttraumatic function and specific reconstructive needs.

Infantile fibrosarcoma of the hand associated with coagulopathy.

Background: Large congenital neoplasms of the extremities may be associated with coagulopathies and significant hemorrhage in the neonatal period. At times, the differences between coagulation derangements can be very subtle, leading to errors in diagnosis. Infants with vascular lesions and coagulopathies are often found to have the Kasabach-Merritt phenomenon, which is a platelet-trapping coagulopathy. However, other neoplasms or vascular malformations can be accompanied by disseminated intravascular coagulation. It is important to obtain accurate diagnoses of the neoplasm and the coagulopathy because the treatments of similar-appearing tumors and coagulopathies can be markedly different. Methods: The authors report the case of a newborn with a congenital tumor of the left hand that was accompanied by a coagulopathy that caused significant bleeding. Results: A presumption was made by the neonatal critical care physicians and hematologists that the infant had a kaposiform hemangioendothelioma along with the Kasabach-Merritt phenomenon. However, steroid treatment did not reduce the size of the mass or correct the coagulopathy. Only after obtaining consultation with a hand surgeon and a tissue diagnosis was it learned that the patient had an infantile fibrosarcoma that was accompanied by disseminated intravascular coagulation. Limb-sparing resection of the lesion along with chemotherapy markedly improved the patient’s condition. Conclusions: Large congenital neoplasms presenting with attendant bleeding diatheses must be rapidly and accurately diagnosed with both a biopsy-proven tissue diagnosis and a hematologic characterization of the nature of the coagulopathy. The differential diagnosis of a vascular-appearing mass in the extremity can be subtle, and presumptive diagnosis, as occurred in this case, can lead to incorrect or delayed treatment. Specifically, kaposiform hemangioendothelioma must be differentiated from infantile fibrosarcoma. The principles of infantile fibrosarcoma treatment are limb-sparing resection and chemotherapy.

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.

Aesthetic management of the nasal component of naso-orbital ethmoid fractures.

Learning Objectives: After studying this article, the participant should be able to: 1. Discuss the critical anatomic structures of the nose that are affected in naso-orbital ethmoid fractures. 2. Discuss the advantages of early, complete nasal reconstruction of these fractures. 3. Apply a clinical algorithm to such nasal reconstruction. 4. List the techniques used in aesthetic reconstruction of the nose in naso-orbital ethmoid fractures. Background: Fractures of the naso-orbital ethmoid complex pose challenging management issues. Although basic treatment principles have been well described, the aesthetic management of the nasal component has not been adequately addressed in the literature. Methods: When secondary nasal deformities occur, they are difficult to correct. Optimal primary correction of the nasal deformity is accomplished using the following four principles: (1) rigid fixation of the nasal pyramid and restoration of nasal height and length; (2) restoration of tip projection; (3) septal reduction/reconstruction; and (4) lateral nasal wall augmentation. Results: Successful management of naso-orbital ethmoid fractures is a complex and challenging task. Both the bony and soft-tissue components must be addressed and the extent of the injury must be adequately diagnosed to avoid omission of critical steps in the reconstruction. Inadequate treatment of naso-orbital ethmoid fractures can produce a severe cosmetic deformity that is very difficult to correct secondarily. Conclusion: The authors discuss the nasal component of naso-orbital ethmoid complex injuries and detail the key principles in their algorithm for aesthetic nasal reconstruction.

Treatment of Kienbock's disease with capitohamate arthrodesis: pain relief with minimal morbidity.

&NA; Despite the large number of procedures available for treatment of Kienbocks disease, no single method has emerged as being clearly superior. Ultimately, the goal of treatment must be the relief of pain and maintaining wrist range of motion. The authors’ experience with 45 consecutive wrists that had undergone capitohamate fusion for treatment of Lichtmans stage 1, 2, or 3 Kienbocks disease is presented. Average follow‐up was 32 months (range, 4 to 107 months). All arthrodeses healed with an average time to fusion of 1.9 months. Postoperatively, 93 percent of patients had either no pain or less pain than they had preoperatively, with preservation of wrist range of motion and improved grip strength (52 percent of normal preoperatively to 72 percent of normal postoperatively). The authors conclude that capitohamate arthrodesis relieves pain in 93 percent of patients with stage 1, 2, or 3 Kienbocks disease and is an effective treatment for this disease. (Plast. Reconstr. Surg. 109: 1293, 2002.)

Pediatric Hand Friction Burns from Treadmill Contact

BackgroundTreadmills have become relatively common in American homes. This machine can be dangerous for children because they can sustain friction burns to the hands when the moving treadmill is touched. With aggressive wound care and physical therapy, most of these burns will heal without surgery. However, some patients will require reconstructive surgery to release contractures. We report our experience with a series of patients who suffered friction burns to the hand from contact with a moving treadmill. The purpose of this study is to further understand the incidence and outcomes of this type of injury.MethodsA retrospective chart review of all patients referred between September 2002 and June 2005 to our hand surgery clinic for treadmill friction burns on the hand(s) was conducted. Pertinent data collected included sex, age, injury distribution, and surgeries performed. An analysis of data maintained by the Consumer Product Safety Commission was used to understand the incidence of exercise equipment-induced injuries.ResultsThirteen pediatric patients were evaluated for friction burns on the hand. Their total injuries included 24 fingers, 1 hand, and 1 forearm. Three patients (23%) required surgery for release of flexion contractures. All wounds of the remaining 10 patients healed, and with the implementation of hand therapy programs did not require subsequent surgery.ConclusionsTreadmill friction burns to the hands of children can lead to limitations of the motion of the hand. Because this problem is completely preventable, parents and treadmill manufacturers are encouraged to be proactive in preventing these injuries. In addition, prompt initiation of wound care and hand therapy is integral to a favorable outcome.

Unilateral Frontosphenoidal Craniosynostosis With Achondroplasia: A Case Report

Isolated, premature fusion of the frontosphenoidal suture is rare. This report describes an unusual combination of frontosphenoidal craniosynostosis and achondroplasia. Although craniosynostosis is known to occur in allelic conditions such as thanatophoric dysplasia, craniosynostosis in individuals with achondroplasia is exceedingly rare. Due to the distracting diagnosis of achondroplasia or inadequate knowledge of craniosynostosis, the abnormal head shape was initially treated by other physicians with helmet molding. Plastic surgery consultation was obtained at 2 years of age and surgical care was provided. An acceptable head shape was obtained, but the delay in appropriate evaluation was disconcerting. To our knowledge this is the first reported case of isolated frontosphenoidal craniosynostosis associated with achondroplasia.