Bradon J. Wilhelmi

Palatal fistulas : Rare with the two-flap palatoplasty repair

The purpose of this study was to examine the palatal fistula rate after repair with the two‐flap palatoplasty technique. This is a retrospective review of 119 consecutive cleft‐palate repairs performed over a 5‐year interval by a single surgeon. The two‐flap palatoplasty technique was used to provide tension‐free, multilayer repairs. The age of these children at the time of repair ranged from 7 to 84 months (mode, 9 months). The initial follow‐up visit occurred 2 to 12 weeks after the repair operation (mean, 4 weeks). The postoperative follow‐up duration ranged from 7 to 48 months. This review of 119 cleft‐palate repairs revealed a fistula rate of 3.4 percent (four fistulas in 119 repairs). This experience demonstrates the lowest reported palatal fistula complication rate with use of the two‐flap palatoplasty technique. (Plast. Reconstr. Surg. 107: 315, 2001.)

Umbilical reconstruction after repair of omphalocele and gastroschisis.

This article presents our technique of umbilical reconstruction after the repair of omphalocele and gastroschisis. We have treated 8 patients with an average follow-up period of 13 months (range, 6 approximately 24 months). No major complications have occurred; minor complications have included delayed wound healing, decreased umbilical depth, and hematoma. Our procedure is especially useful for patients who have a midline abdominal scar and relatively intact bilateral rectus abdominis muscles. Most of the patients and their parents have been satisfied with the results of umbilical reconstruction.

First successful replantation of face and scalp with single-artery repair: model for face and scalp transplantation.

Successful replantation of the scalp with microanastomosis of a single artery and vein has been reported to produce reliable results. In fact, there have been several reports of scalp replantations based on one-artery and vein repair. There has been a face and scalp replantation reported in the literature, but this was as two separate parts and was based on several arterial and venous repairs. The authors performed the first successful replantation of a face and scalp with repair of a single artery and, of course, two veins. A 21-year-old man presented after his face and scalp were completely severed. The patients long hair was caught in a conveyor belt at work. The face and scalp underwent replantation, with repair of the right superficial temporal artery with an interposition vein graft. A multiteam approach allowed for minimization of overall ischemic time and simultaneous preparation of the vessels on the patient and amputated part as well as vein graft harvest from the arm. Also critical to the success of the procedure, the small portions of the vessels of the amputated part were sent for frozen section to differentiate artery from vein. Initially, only the right superficial temporal vein was repaired. One week after replantation, the patient returned for treatment of venous congestion of an area to the opposite side of the forehead partial transection, with repair of the left superficial temporal vein, also. This saved the entire part that underwent replantation, and the entire part survived. The face and scalp can undergo replantation based on single-artery repair.

Trigger finger release with hand surface landmark ratios: An anatomic and clinical study

The purpose of this study was to identify surface landmark ratios to locate the Al pulley and clarify the controversy of differing anatomic descriptions of the Al, CO, and A2 pulleys. Minimally invasive and percutaneous approaches to Al pulley release may be facilitated with surface landmark ratios, which identify and predict the proximal and distal margins of the Al pulley. Two‐hundred fifty‐sixty fingers were dissected in 64 preserved cadaver hands. Measurements of Al pulley lengths and pulley margins in relation to surface landmarks were obtained. We found that the distance from the palmar digital crease to the proximal interphalangeal crease (mean, 2.42 ± 0.03 cm) corresponds to the distance of the proximal edge of the Al pulley from the palmar digital crease (mean, 2.45 ± 0.03 cm). The mean absolute difference between these two measured distances in each finger was 0.13 cm, with a 95 percent confidence interval of 0.11 to 0.14 cm. Thus, the distance between the palmar digital crease and the proximal interphalangeal crease can be used to predict the distance between the palmar digital crease and the Al pulley proximal edge with reasonable accuracy. Al pulley length averaged 0.98 ± 0.02 cm for the small finger and 1.17 ± 0.02 cm for the index, middle, and ring fingers. The length of the Al pulley was significantly shorter (p < 0.001) for the small finger than for the index, middle, and ring fingers. Additionally, a cruciate (C0) pulley was consistently located between the Al and A2 pulleys, an average of 0.46 cm proximal to the palmar digital crease, which can serve as guide for concluding the release of the Al pulley. Clinically, hand surface landmark ratios were used to release 32 trigger fingers with a minimally invasive technique, without a complication during 4‐ to 30‐week follow‐up. We conclude that hand surface landmark ratios can serve to locate the proximal Al pulley edge, thus facilitating complete trigger finger release by either open or minimally invasive techniques. Additionally, our study clarifies the discrepancy of prior smaller reports of the pulley system anatomy regarding the existence of the CO pulley between the Al and A2 pulleys. The cruciate fibers of this CO pulley can serve as the distal boundary for release of trigger finger. (Plast. Reconstr. Surg. 108: 908, 2001.)

Safe Treatment of Trigger Finger with Longitudinal and Transverse Landmarks: An Anatomic Study of the Border Fingers for Percutaneous Release

Transverse landmarks have recently been determined to predict the proximal and distal edges of the A1 pulley for trigger finger release. Percutaneous A1 pulley release has been discouraged for the border digits because of the risk of injury to the neurovascular structures of the index and small fingers. The purpose of the study was to identify longitudinal surface landmarks to prevent injury to the neurovascular bundles during percutaneous A1 pulley release of the ulnar and radial border digits. Longitudinal surface landmarks were identified and marked on 29 cadaver hands. Proximal and distal landmarks for the longitudinal vector through which the A1 pulley of the small finger was released include the midline of the proximal digital crease and the scaphoid tubercle. Proximal and distal landmarks for the longitudinal line through which the index finger A1 pulley was released include the midline of proximal digital crease and radial edge of the pisiform. Longitudinal incisions were performed between these landmarks, straight through the skin and deep enough to score the A1 pulley. The distance of the medial edge of the neurovascular structures from the longitudinal incision in the A1 pulley was measured for each small finger and index finger. Using these longitudinal landmarks for the index and small fingers, none of the neurovascular structures was injured while performing these longitudinal incisions through the skin, scoring the A1 pulley. In fact, the average distance for the neurovascular structures from the longitudinal vector of the small finger was 5.4 ± 1.4 mm radially and 6.7 ± 1.9 mm ulnarly. The average distance for the neurovascular structures from the longitudinal line of the index finger was 8.5 ± 1.8 mm radially and 6.2 ± 1.7 mm ulnarly. Based on the findings of this anatomical study, these longitudinal landmarks can be used to avoid injury to neurovascular structures in the management of trigger finger involving the border digits with steroid-injection, open, or percutaneous A1 pulley release.

Local hypothermia during early reperfusion protects skeletal muscle from ischemia-reperfusion injury.

Amputated tissue maintained in a hypothermic environment can endure prolonged ischemia and improve replantation success. The authors hypothesized that local tissue hypothermia during the early reperfusion period may provide a protective effect against ischemia-reperfusion injury similar to that seen when hypothermia is provided during the ischemic period. A rat gracilis muscle flap model was used to assess the protective effects of exposing skeletal muscle to local hypothermia during ischemia only (p = 18), reperfusion only (p = 18), and both ischemia and reperfusion (p = 18). Gracilis muscles were isolated and exposed to hypothermia of 10 degrees C during 4 hours of ischemia, the initial 3 hours of reperfusion, or both periods. Ischemia-reperfusion outcome measures used to evaluate muscle flap injury included muscle viability (percent nitroblue tetrazolium staining), local edema (wet-to-dry weight ratio), neutrophil infiltration (intramuscular neutrophil density per high-power field), neutrophil integrin expression (CD11b mean fluorescence intensity), and neutrophil oxidative potential (dihydro-rhodamine oxidation mean fluorescence intensity) after 24 hours of reperfusion. Nitroblue tetrazolium staining demonstrated improved muscle viability in the experimental groups (ischemia-only: 78.8 +/- 3.5 percent, p < 0.001; reperfusion-only: 80.2 +/- 5.2 percent, p < 0.001; and ischemia-reperfusion: 79.6 +/- 7.6 percent, p < 0.001) when compared with the nonhypothermic control group (50.7 +/- 9.3 percent). The experimental groups demonstrated decreased local muscle edema (4.09 +/- 0.30, 4.10 +/- 0.19, and 4.04 +/- 0.31 wet-to-dry weight ratios, respectively) when compared with the nonhypothermic control group (5.24 +/- 0.31 wet-to-dry weight ratio; p < 0.001, p < 0.001, and p < 0.001, respectively). CD11b expression was significantly decreased in the reperfusion-only (32.65 +/- 8.75 mean fluorescence intensity, p < 0.001) and ischemia-reperfusion groups (25.26 +/- 5.32, p < 0.001) compared with the nonhypothermic control group (62.69 +/- 16.93). There was not a significant decrease in neutrophil CD11b expression in the ischemia-only group (50.72 +/- 11.7 mean fluorescence intensity, p = 0.281). Neutrophil infiltration was significantly decreased in the reperfusion-only (20 +/- 11 counts per high-power field, p = 0.025) and ischemia-reperfusion groups (23 +/- 3 counts, p = 0.041) compared with the nonhypothermic control group (51 +/- 28 counts). No decrease in neutrophil density was observed in the ischemia-only group (40 +/- 15 counts per high-power field, p = 0.672) when compared with the nonhypothermic control group (51 +/- 28 counts). Finally, dihydrorhodamine oxidation was significantly decreased in the reperfusion-only group (45.83 +/- 11.89 mean fluorescence intensity, p = 0.021) and ischemia-reperfusion group (44.30 +/- 11.80, p = 0.018) when compared with the nonhypothermic control group (71.74 +/- 20.83), whereas no decrease in dihydrorhodamine oxidation was observed in the ischemia-only group (65.93 +/- 10.3, p = 0.982). The findings suggest a protective effect of local hypothermia during early reperfusion to skeletal muscle after an ischemic insult. Inhibition of CD11b expression and subsequent neutrophil infiltration and depression of neutrophil oxidative potential may represent independent protective mechanisms isolated to local tissue hypothermia during the early reperfusion period (reperfusion-only and ischemia-reperfusion groups). This study provides evidence for the potential clinical utility of administering local hypothermia to ischemic muscle tissue during the early reperfusion period.

The safe face lift with bony anatomic landmarks to elevate the SMAS.

The risk for facial nerve injury has been reported to be increased with the inclusion of superficial musculoaponeurotic system (SMAS) elevation as compared with a skin-only face lift. The facial nerve courses through the parotid gland. The SMAS is elevated superficial to the parotid gland. However, in elevating the SMAS anterior to the parotid gland, the facial nerve is at risk of injury where its branches emerge from the anterior edge of the parotid gland. The purpose of this study was to identify bony anatomic landmarks to predict the location of the anterior edge of the parotid gland to avoid injury to the facial nerve branches as they exit the parotid gland. The authors dissected 20 cadaver face halves to determine bony landmarks-the masseteric tuberosity and the inferior lateral orbital rim-to predict the location of the anterior parotid edge. Then they measured the anterior edge of the parotid gland in relation to the vector formed between these two bony landmarks. They identified and measured the most anterior portion of the parotid gland in relation to this vector. Then the most posterior aspect of the parotid gland in relation to this vector was measured. In the 20 dissections, the authors found the most anterior portion of the parotid gland to be 2.7 +/- 1.0 mm anterior to the vector from the inferior lateral orbital rim to the masseteric tuberosity. The most posterior part of the anterior edge of the parotid gland in relation to this vector was found to be 1.0 +/- 1.5 mm posterior to this vector. The parotid gland measured an average of 38.8 +/- 3.5 mm in width from the tragus to the anterior parotid edge. In elevating the SMAS with a face lift, the facial nerve branches can be predicted to exit the anterior edge of the parotid gland, which can be located 38.8 mm anterior to the tragus and near the vector from the inferior lateral orbital wall to the masseteric tuberosity.

Incidence of earlobe ptosis and pseudoptosis in patients seeking facial rejuvenation surgery and effects of aging.

The authors have previously described a classification system for earlobe ptosis and have established a criterion for earlobe pseudoptosis. Earlobe heights were characterized based on anatomic landmarks, including the intertragal notch, the otobasion inferius (the most caudal anterior attachment of the earlobe to the cheek skin), and the subaurale (the most caudal extension of the earlobe free margin). The classification system was derived from earlobe height preferences as determined by a survey of North American Caucasians, and it identified the ideal free caudal lobule height range to measure 1 to 5 mm from otobasion inferius to subaurale (grade I ptosis). Also, earlobe pseudoptosis was defined by the attached cephalic lobule height measuring an intertragal notch to otobasion inferius distance greater than 15 mm. In this study, the preoperative earlobe height measurements of 44 patients seeking facial rejuvenation were evaluated. The average attached cephalic segment (intertragal notch to otobasion inferius distance) of patient earlobes measured 11.10 ± 0.46 mm, and the average free caudal segment (otobasion inferius to subaurale distance) of patient earlobes measured 7.15 ± 0.49 mm. Assessment of patient groups based on single-decade age differences demonstrated an increase in the free caudal segment (otobasion inferius to subaurale distance) with increasing age (p = 0.003). Assessment of patient groups based on single-decade age differences demonstrated no increase in the attached cephalic segment (intertragal notch to otobasion inferius distances) with increasing age (p = 0.281). When evaluating for the ideal otobasion inferius to subaurale distance, only 22.2 percent of earlobes demonstrated an ideal free caudal earlobe height (grade I ptosis). Moreover, pseudoptosis was detected in 12.3 percent of earlobes. Finally, a majority of earlobes demonstrated intrapatient variability, with only 16.2 percent of patients demonstrating identical attached cephalic segment (intertragal notch to otobasion inferius distances) and 37.8 percent demonstrating identical free caudal segment (otobasion inferius to subaurale distances) when compared with their contralateral ear. Plastic surgeons should be aware that a significant number of patients (77.8 percent of earlobes) may not possess an ideal free caudal segment and that 12.3 percent of earlobes may present with pseudoptosis. Therefore, earlobe height assessment should be an essential aspect of evaluation in patients desiring facial rejuvenation surgery. Evaluation of both ears should be performed independently due to intrapatient earlobe height variations. Finally, patients should be counseled with regard to the ideal earlobe parameters and aging patterns (stable attached cephalic segment versus increasing free caudal segment). With the natural progression of both facial rhytides and caudal segment earlobe ptosis (increasing free lobule segment) with increasing age, independent and accurate assessment of earlobe height is indicated so that the aging ear may be addressed concurrently with the aging face.

A rare case of pneumosinus dilatans of the frontal sinus and review of the literature.

Pneumosinus dilatans is a rare condition of unknown etiology in which there is enlargement of the paranasal sinuses by air, with extension beyond the normal boundaries of bone. The authors present a case of pneumosinus dilatans of the frontal sinus and review the literature.

The aesthetic earlobe: classification of lobule ptosis on the basis of a survey of North American Caucasians.

North American Caucasian male subjects (n = 59) and female subjects (n = 72) were surveyed, to investigate earlobe height preferences that could serve as guidelines for aesthetic earlobe surgical procedures and reconstructions. Subjects were asked to rank their preferences for variously shaped earlobes in life-size-scaled sketched male and female profiles. Earlobe heights were varied on the basis of previously established anatomical landmarks, including the intertragal notch, the most caudal anterior attachment of the earlobe to the cheek skin (the otobasion inferius), and the most caudal extension of the earlobe-free margin (the subaurale). While the intertragal notch-to-otobasion inferius distance (range, 5 to 20 mm) and otobasion inferius-to-subaurale distance (range, 0 to 20 mm) varied, all other facial and ear anthropometric measurements were held constant. Each of the rank orders for the female and male facial profiles completed by the female and male subjects demonstrated statistical significance, as determined by one-way analysis of variance analysis of ranks (p < 0.001 for all four groups). No difference was noted between the two sexes’ rank orders for either sex (p > 0.05). Therefore, analysis of the combined male and female preferences for each sex was completed with one-way analysis of variance analysis of ranks (p < 0.001 and p < 0.001) and a post hoc Dunn’s test, to delineate significant preference differences between subgroups with respect to the intertragal notch-to-otobasion inferius and otobasion inferius-to-subaurale distances. Both female and male earlobe intertragal notch-to-otobasion inferius distances were preferred at either 5, 10, or 15 mm, more so than at 20 mm (p < 0.05 for all female and male comparisons). Furthermore, both female and male earlobe otobasion inferius-to-subaurale distances were preferred, in descending order, at 5 mm > 10 mm > 0 mm > 15 mm > 20 mm (p < 0.05 for all female and male comparisons). On the basis of the findings of this survey, the first classification of earlobe ptosis (based on otobasion inferius-to-subaurale distances), as well as a criterion for earlobe pseudoptosis (intertragal notch-to-otobasion inferius distance of greater than 15 mm), is presented. These findings suggest a role for independent assessment of the lobule length with respect to its anteriorly attached cephalad component (intertragal notch-to-otobasion inferius distance) and its free-margin caudal component (otobasion inferius-to-subaurale distance).