Dennis J. Hurwitz

Long-Term Effects of Nasoalveolar Molding on Three-Dimensional Nasal Shape in Unilateral Clefts

OBJECTIVE This objective of this study was to determine the effect of presurgical nasoalveolar molding on long-term nasal shape in complete unilateral clefts. DESIGN The study was retrospective, and the subjects were chosen at random. Nasal casts of the subjects were scanned in three dimensions. Each nose was best fit to its mirror image, and a numerical asymmetry score was determined. SETTING All patients were treated at the Institute of Reconstructive Plastic Surgery, NYU Medical Center, New York, New York. PATIENTS The study subjects (n = 10) were selected from a group that had undergone presurgical nasal molding in conjunction with alveolar molding. The control subjects (n = 10) were selected from a group that had undergone presurgical alveolar molding alone. INTERVENTIONS All subjects underwent presurgical orthopedic treatment until the age of approximately 4 months at which time the primary surgery was performed. MAIN OUTCOME MEASURE The nasal shape following nasal molding should be more symmetrical than if molding had not been done. RESULTS The mean asymmetry index for the nasoalveolar molding group was 0.74, and the control group was 1.21. This difference was statistically significant (p < .05). CONCLUSIONS Presurgical nasoalveolar molding significantly increases the symmetry of the nose. The increase in symmetry is maintained long term into early childhood. The limitations of this study include (1) asymmetry alone is not an adequate shape result in most situations, (2) the children evaluated in this study were not fully grown, and (3) the control group was not age matched.

The anatomic basis for the platysma skin flap

Meticulous anatomic dissection of the vasculature of the superficial anterolateral neck indicates that the platysma and overlying skin are supplied by direct cutaneous arteries measuring 0.5 mm in diameter. The small arteries are branches of the postauricular and occipital arteries in the upper lateral neck, the facial and submental arteries in the upper medial neck, the superior thyroid artery in the middle of the neck, the subclavian artery in the lower medial neck, and the transverse or superficial cervical arteries in the lateral aspect of the neck. These vessels traverse the undersurface of the platysma muscle to provide blood flow to the overlying skin. As opposed to this direct cutaneous system, the myocutaneous blood supply perforating through the sternocleidomastoid is scant. The platysma skin flap will survive if the blood supply from at least one region is preserved. In addition, it may be beneficial to include the external jugular and/or the communicating veins in the flap. By following these guidelines, the platysma flap has been successfully used for facial reconstruction in 7 of 8 consecutive patients.

Single-staged total body lift after massive weight loss.

This is a retrospective clinical report of a single-staged total body lift in 8 massive weight loss patients. While the combination of circumferential abdominoplasty, a modified lower body lift, and medial thighplasty adequately treats the lower torso and thighs, the residual skin laxity in the upper torso and breasts leaves an incomplete result. Hence, a 2-stage total body lift was designed. The second stage, called the upper body lift, removes epigastric and midback rolls of skin, adjusts the inframammary fold, and reshapes the breast or corrects gynecomastia, leaving behind a near circumferential transverse scar partially hidden by the breasts. In selected patients, a complete torso correction, the total body lift, was done in a single stage. Four to 31 months later, 7 of the 8 patients were satisfied. One male with ultrasonic-assisted lipoplasty and a lateral skin excision found the chest skin too loose. Blood transfusions ranged from none to 4 units. The operations range from 7 to 12 hours of general anesthesia. Hospital stays were from 3 to 4 days. The complications included 3 resolved seromas, 2 minor wound infections due to fat and skin necrosis, and 1 minor skin dehiscence. One patient was readmitted to the hospital due to hypoalbuminemia and generalized edema. Scar revisions and liposuction are scheduled for 2 patients. Single stage total body lift is effective and safe in selected patients after massive weight loss when performed by a plastic surgeon and team experienced in body contouring surgery.

A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale.

Background: Contour deformities after massive weight loss are diverse and often severe in nature. Current progress has necessitated a valid, accessible, and comprehensive rating system that correlates appearance and appropriate surgical treatment. Presently, no existing rating system addresses the breadth and variety of deformities that can occur or allows for adequate postsurgical evaluation. Methods: The authors reviewed full-body photographs of over 300 female patients seen between October of 2002 and May of 2004. The authors targeted body areas most frequently demonstrating skin and soft-tissue laxity and ptosis. A 10-region, four-point grading system was designed to describe the common deformities found in each region of the body. To validate the scale, 12 trained observers applied the rating scale to photographs of 25 patients who showed the 10 regions. Each grading scale ranged from 0, indicating normal, to 3, indicating the most severe deformity. Repeat testing was performed at 2 weeks. Interobserver validity and test-retest reliability were determined using weighted κ analysis. Results: In all 10 categories, the κ value was 0.6 or higher (0.6 = threshold for good validity), with a mean κ value of 0.68 (range, 0.61 to 0.78) and an overall agreement of 69 percent over two sessions. All 12 observers scored an individual mean κ value of greater than 0.6, indicating good interobserver validity. A given observer had a mean 67 percent agreement, indicating reasonable test-retest reliability. Conclusions: The Pittsburgh Rating Scale is a validated measure of contour deformities after bariatric weight loss. This scale may have applications in preoperative planning and evaluating surgical outcomes.

Postbariatric surgery breast reshaping: the spiral flap.

Introduction: After massive weight loss, the breasts have poor shape, projection, and skin elasticity. Breast reshaping is recognized as difficult and may require excess nearby tissues. As the senior authors approach evolved over the past 4 years, breast reshaping with the spiral flap became integral to an upper body lift. Materials and Methods: After the weight loss has stabilized, body contouring surgery has been performed on 53 patients over a 3-year period. Six patients had mastopexy and/or augmentation only. Eighteen patients had spiral flap breast reshaping as part of an upper body lift. This lift is a reverse abdominoplasty that ends along the inframammary fold incision of the Wise pattern mastopexy and continues laterally to along the back roll. Excess tissue from the epigastrium and lateral back roll is deepithelialized and used for augmentation. These flap extensions of the central breast pedicle are spiraled around the breast for augmentation, shaping, and suspension. When more tissue is needed, saline-filled silicone implants have been used, preferably during a second stage. Results: Follow up of this initial group ranged from 4 to 28 months with a mean of 11 months. In this initial effort, 14 of the 18 were pleased. In 3 patients, subsequent bilateral saline implants further augmented the breasts. Tip fat necrosis was evident by firmness of the tissues in 3 patients and resolved in all but 1. That 1 patient had operative debridement of the distal 50% of the flaps followed by saline-filled silicone implants. One patient was disappointed with the back scar. Two patients dislike the shape and fill of their breast and have not returned for revision. Conclusion: During 3 years of focused clinical activity, we have evolved the spiral flap reshaping with upper body lift into a comprehensive, effective, satisfying, and safe esthetic contouring of the breast and upper torso after massive weight loss performed with an upper body lift.

The Sliding Gluteus Maximus Myocutaneous Flap: Its Relevance in Ambulatory Patients

Huge sacral defects can be closed reliably with sliding gluteus maximus myocutaneous flaps. In ambulatory patients, this flap is designed to maintain innervation, vascularity, and functional integrity of the muscle.

The L Brachioplasty: An Innovative Approach to Correct Excess Tissue of the Upper Arm, Axilla, and Lateral Chest

Background: Brachioplasty is aesthetic reshaping of the upper arm after removal of excess medial skin and fat. Massive weight loss patients evolve a severe arm deformity that extends through the axilla and onto the chest. Prevalent operations are incomplete and leave conspicuous scars along the bicipital groove that end as Ts or Zs in the axilla. The L brachioplasty starts with a long ellipse centered over the lower half of the inner arm that sweeps up to the deltopectoral groove. A shorter ellipse is connected at right angles through the axilla onto the chest. The V flap formed between the ellipses is advanced across the axilla to raise the posterior axillary fold. An improved arm, axilla, and chest have an L-shaped zigzag crossing the axilla. Methods: L brachioplasty, along with upper body lifting, was applied to 24 female weight loss patients over the last 2 years. Ultrasound-assisted lipoplasty was also performed in five patients. All patients were interviewed. Follow-up ranged from 6 to 28 months. Results: All 22 patients were improved and pleased. One patient requested and received a limited scar revision. Three patients had delayed healing at the tip of the triangular flap. Four seromas near the elbow responded to multiple aspirations. One hypertrophic scar was improved with intense pulsed light. Conclusions: The L-shaped brachioplasty is an innovative, effective, reliable, aesthetic, and safe technique. Integrating the brachioplasty into the upper body lift improves the contours of the axilla, breast, and upper lateral chest, contributing to improved harmonious body contour.

Hemodynamic considerations in the treatment of arteriovenous malformations of the face and scalp.

The fate of angiomas is probably determined by the freeness of their arteriovenous anastomosis and the strains to which they are subjected.

Tobacco Smoking: Impairment of Experimental Flap Survival

The survival rate of experimental flaps as affected by exposure to inhaled tobacco smoke has been investigated in rats subjected to different smoking regimens. A distally based dorsal flap was raised and reattached in each animal. Evaluation of the flaps on postoperative day 8 showed a mean rate of necrosis of 28.5% in 25 control animals, 32.2% in 21 rats postoperatively smoking for 7 days, 41.3% in 18 rats preoperatively smoking for 7 days, and 45.7% in 21 rats smoking for 7 days both before and after the surgical procedure. Histological sections from the lungs of the smoking animals revealed a pattern compatible with mild smoke inhalation injury. Arterial oxygen tensions were lower in the tobacco smoking animals. It is assumed that the multiple effects of tobacco smoking contributed to the impairment of experimental flap survival.

Body Contouring After Massive Weight Loss

The increase in the number of bariatric surgery procedures over the last decade has led to a large number of massive-weight-loss patients seeking improvement in their resultant body contour deformities caused by the process of weight gain and subsequent loss. In this chapter, the reader will become familiar with the typical presentation of the massive-weight-loss patient to the plastic surgeon and the most common body-contouring procedures utilized to improve their deformities.