Bryan J. Michelow

The natural history of obstetrical brachial plexus palsy.

Obstetrical brachial plexus palsy remains an unfortunate consequence of difficult childbirth. Sixty-six such patients were reviewed. Included were 28 patients (42 percent) with upper plexus involvement and 38 (58 percent) with total plexopathy. The natural history of spontaneous recovery in all of these patients has been determined using an appropriate grading mechanism. Sixty-one patients (92 percent) recovered spontaneously and five patients (8 percent) required primary brachial plexus exploration and reconstruction (median age 12 months), demonstrating that most patients do well. Additional analysis was undertaken to examine ways in which outcome might be predicted. The analysis does not consider whether or not the patient was operated upon. Good or poor recovery was determined by the spontaneous recovery observed. Discriminant analysis revealed that whereas elbow flexion at 3 months correlated well with spontaneous recovery at 12 months, when used as a single parameter it incorrectly predicted recovery in 12.8 percent of cases. Shoulder abduction was not a significant predictor of recovery. Numerous other early parameters correlated well with spontaneous recovery. When elbow flexion and elbow, wrist, thumb, and finger extension at 3 months were combined into a test score, the proportion of patients whose recovery was incorrectly predicted was reduced to 5.2 percent.

Double-pedicle TRAM flap for unilateral breast reconstruction.

Autogenous breast reconstruction with the pedicled TRAM flap has been employed in 500 patients in our series. We have developed and refined indications for use of the single-pedicle TRAM flap and double-pedicle TRAM flap in unilateral breast reconstruction. In our experience with 341 unilateral breast reconstructions, we used a double-pedicle TRAM flap 19 percent of the time; however, in our most recent 50 unilateral modified radical mastectomy reconstructions, the double-pedicle technique has been employed 60 percent of the time. In general, when a TRAM flap is chosen for unilateral reconstruction of a modified radical mastectomy defect, we feel the single-pedicle TRAM flap is the procedure of choice. Carefully selected patients will benefit from the added safety of a double-pedicle TRAM procedure. The indications for the double-pedicle TRAM flap, the technique, and our results are described in detail.

Refinements in endoscopic forehead rejuvenation.

Endoscopic forehead technique provides an effective method for rejuvenation of the upper face. Distinct advantages of this technique over classic methods of forehead rejuvenation such as coronal or subcutaneous approaches include significant reduction of incisional scars. Described here are three refinements related to (1) control of hair, (2) differential release of the periosteum, and (3) advanced fixation methods. Control of hair can be achieved simply by braiding and the use of an Endoscopic Access Device. Extensive release of the periosteum and arcus marginalis is recommended laterally, while elevating the medial periosteum either intact or with conservative release. Different and technologically more advanced fixation methods are described to provide better control of elevated forehead. Incorporation of these refinements strives to optimize aesthetic results while minimizing operative morbidity. These refinements have been implemented during the care of 29 patients and have proven to be of major value in achieving greater patient satisfaction and technical advancement.

The nasolabial fold: A challenge, a solution

A prominent nasolabial fold results from a combination of relaxation and thinning of the facial skin and selective fat deposits lateral to the fold. The surgical approach described herein has been used to correct the pronounced nasolabial fold for the last 3 years. First, the temple incision is positioned at the anterior hairline rather than in the hair-bearing skin. This permits removal of the maximum amount of skin without concern for posterior transposition of the temple hair, and, more important, it transmits a more effective pulling force to the nasolabial fold due to the more advantageous proximity. Second, a strip of fat is added under the fold in the subcutaneous plane (immediately under the fold) after extensive undermining of the skin through a rhytidectomy flap. Third, removal of the fat lateral to the fold reduces the buccal projection and thereby lends an appearance of flatness. This report covers 35 patients (8 males and 27 females) who underwent this problem-oriented approach with an average follow-up of 23 months. Complications included one localized hematoma (managed conservatively) and one expanding hematoma (which required evacuation). Two incidents of graft dislodgment were discovered early in the study, following which all grafts were fixed to the overlying nasolabial groove with a through-and-through 5-0 catgut suture. Partial resorption of the graft was considered the rationale for undercorrection in 6 patients (17.1 percent). The remaining 29 patients (82.9 percent) had good to excellent results.

Delayed healing of rhytidectomy flap resurfaced with CO2 laser.

Combining facial rhytidectomy with laser resurfacing, theoretically, provides the best opportunity for achieving an optimal facial rejuvenation result. Previous studies have demonstrated the pernicious effect of a deep peel on a skin flap, but the safety of treating the rhytidectomy flap with laser has not been investigated. This study was conducted to investigate the safety of using these techniques concomitantly. Sixty sites were selected on three Yucatan minipigs, a species of swine chosen because of its hairless nature and opportunity to raise a true skin flap (without the panniculus carnosus). The healing time of 20 laser-treated sites without flap elevation was compared with that of 20 areas treated with laser following flap elevation, shortening (to emulate a more realistic rhytidectomy process), and repair. Twenty flaps were elevated and shortened without laser treatment to serve as a control. The CO2 laser parameters were set at 500 mJ, 50 watts, and a density of 5. Two passes were made to penetrate the upper dermis. The mean healing time for areas treated with laser alone was 12.05 days, ranging from 11 to 14 days. In comparison, the healing time for the laser-treated areas subsequent to flap elevation averaged 17.95 days, with a range of 14 to 24 days (p < 0.05). Two flaps treated with laser (10 percent) failed to heal completely in 24 days. At the time that all 20 of the areas treated solely with laser had re-epithelialized completely, only one of the flaps treated with laser had re-epithelialized completely (p < 0.001). A delay in healing, as well as return of pigment, was demonstrated in the distal portions of all flaps receiving laser treatment. The control flaps all healed normally except for a 5-percent superficial loss on a single flap. It was concluded from this study, and from clinical observation of delayed healing on six of seven patients who underwent concomitant rhytidectomy and laser resurfacing at a conservative laser setting, that laser resurfacing of the rhytidectomy flap is unsafe and results in delayed re-epithelialization. This combination should be avoided altogether or performed with extreme prudence on patients undergoing a deeper plane facial rhytidectomy or by using very low laser settings.

Practical classification of chin deformities

A visually pleasing chin is an important component of facial harmony. This study was undertaken to introduce a practical classification of chin dysmorphology, which can be used to guide the surgeon toward the appropriate surgical approach to chin repair. Analysis of life-size photography, based on standard anthropometric measurements, was completed on 2,879 patients from 1981 to 1991. Six hundred eighty-four patients were noted to have normal occlusion with some form of chin deformity. Analysis of this group of patients identified seven categories of chin dysmorphism: Class I, macrogenia (n = 170, 24.9%); Class II, microgenia (n = 435, 63.6%); Class III, combination of macrogenia in one direction and microgenia in the other direction (n = 54, 7.9%); Class IV, asymmetry (n = 4, 0.6%); Class V, soft tissue ptosis (“witchs chin”) (n = 13, 1.9%); Class VI, pseudomacrogenia (normal skeletal symphysis menti with excess soft tissue covering) (n = 5, 0.73%); and Class VII, pseudomicrogenia (long-face deformity producing clockwise rotation of the normal mandible) (n = 3, 0.4%). Having diagnosed the dysmorphism, logical surgical recommendations for lower face improvement were postulated. Only patients with Class II chin deformity can be corrected with augmentation. Classes I, III, and IV require an osteotomy of the chin. Classes V and VI benefit from soft tissue correction. Class VII deformity can be corrected with a maxillary osteotomy.

The chin: skeletal and soft-tissue components.

The quantity of soft tissue overlying the symphysis menti affords an important attribute that can aid in determination of the correct surgical approach for optimal facial harmony. Xerograms of the facial profile of 100 patients with normal occlusion were analyzed by accepted radiographic cephalometric techniques. The relative contribution of skeletal structures and soft tissue of the chin was evaluated. All linear measurements were noted to be larger in males than in females, but in both groups, facial features were in proportion. In both males and females, the average thickness of the soft tissue overlying the symphysis menti progressively increased from the B point to midway between the B point and the pogonion. The soft tissue at the pogonion was thinner than at the B point. The soft tissue over the chin in males was significantly thicker than in females in all areas measured. When compared with patients over 60 years of age, the soft tissue at the B point was significantly thinner in patients 50 years of age and younger (p = 0.005), while the soft tissue at the pogonion was significantly thinner in patients 40 years of age and younger (p = 0.04). Pseudomacrogenia was noted in 6 percent of the patients, a diagnosis only possible with cephalometric analysis. An understanding of the relative contribution of the soft tissue to the chin can aid in the diagnosis and appropriate surgical management of chin incongruity. Furthermore, there is significant variation in skin thickness, which will influence the soft-tissue response to skeletal alteration. This has to be considered in planning a predictable surgical result.

The subdomal graft

Dome asymmetry can be an undesirable sequela of both primary and secondary rhinoplasty. Although the malpositioned domes can be corrected using suture techniques, excessive narrowing of the nasal tip and loss of the twopoint light reflection may occur, producing a less desirable aesthetic outcome (Fig. 1). In addition, contemporary suture techniques to reduce a wide boxy tip may lead to excessive narrowing of the interdomal distance and even an overlapping of the domes intraoperatively. Should this be left uncorrected, it would result in an unnatural, pointed tip morphology. Review of the literature reveals a paucity of information pertaining to the correction of the primary pinched nasal tip deformity or prevention of the secondary pinched nasal tip deformity.1–4 The purpose of this report is to introduce a technique that can be used to correct these disharmonious tip configurations.

Management of intraoperative nasal septal tears and perforations.

An organized technique for managing intraoperative septal tears was developed based on 98 patients who endured septal tears. Small nonopposing perforations are allowed to heal spontaneously. Opposing tears, with sizes varying from less than 1 cm to greater than 2 cm, are repaired first on one side of the mucoperichondrium with the reinsertion of a straight piece of septal cartilage; the other side of the mucoperichondrium is then repaired.

Stability after endoscopic forehead surgery using single-point fascia fixation

Background: With endoscopic forehead rejuvenation, most surgeons use at least two points of fixation for each eyebrow, often including some type of bone fixation, to achieve the aesthetic goal of lasting repositioning of the eyebrows and elimination of frown lines. In this prospective study, short-term and 1-year postoperative changes in the position of the eyebrows following extensive release of eyebrow-retaining ligaments and use of single-point fascial suture (without bone fixation) were objectively evaluated. Methods: Front-view, life-size photographs of 48 patients undergoing endoscopic forehead surgery for treatment of migraine headaches were analyzed preoperatively and 1 and 12 months postoperatively. The distance of the caudal portion of each eyebrow from a horizontal line passing through the medial canthi was measured at three levels: (1) the lateral canthus, (2) midpupil on a straight gaze, and (3) medial canthus. Results: Statistical analysis revealed a significant elevation of the eyebrows at each of these three reference points when preoperative and 1-month postoperative data were compared (p = 0.001). Twelve months postoperatively, the eyebrows remained significantly elevated at each of the three reference points on both the left (p = 0.001) and right (p = 0.001) sides. Comparison of data at 1 and 12 months postoperatively did not show any statistically significant difference (p = 0.1 to 0.9 at the three levels), indicating that the eyebrow elevation was maintained. Conclusions: The authors conclude that wide release of the eyebrow-retaining ligaments with single-point fascial fixation is an effective method for elevation of the eyebrows, and that bone fixation should be used when an alteration of eyebrow arch form or correction of eyebrow asymmetry is indicated.