Helena O. Taylor

Nasal reconstruction after severe facial burns using a local turndown flap.

Reconstruction of the nose after severe burn injury is a challenging problem. There are usually associated facial burns, which limits the availability of local flaps. Reconstruction with unburned distant tissue is often not appropriate because of the resulting mismatch in color and texture. Successful nasal reconstruction can be accomplished in this group of challenging patients using a simple, inferiorly based flap from the nasal dorsum with subsequent skin grafting to the resulting defect. We have used an inferiorly based nasal turndown flap to reconstruct severe nasal deformities after burn injury in 28 patients. The flap tissue consists of the dorsal surface of the nose, which is usually made up of skin graft and scar. The flap base is the scar transition zone between the dorsum of the nose and the lining mucosa. This is turned over to provide nasal length, projection, and to stimulate alar lobules. The resulting defect on the dorsum of the nose is then skin grafted. If further length or refinement is required, the procedure may be repeated. The records of all patients who underwent this procedure were reviewed for demographics, age at burn, percentage of total body surface area burned (%TBSA), availability of the forehead, number of procedures, and complications. Twenty-eight patients underwent nasal reconstruction in our series using this local turndown flap. Most of these patients had severe burns, with an average %TBSA of 46%. The procedure was initially applied to patients with devastating injuries and %TBSA of 80%–95%, with extremely limited donor sites. As the success of the procedure was established, less severely burned patients were included in the series, thereby lowering the mean %TBSA. All patients had partial or complete destruction of their forehead donor site. All patients presented for multiple hospitalizations, with an average of 17 hospital admissions. Using this local turndown flap, adequate nasal length and projection could be achieved. There were few complications. All of the flaps survived, although there were 2 cases of necrosis of the distal edge of the flaps (0.7%). This resulted in decreased length and projection but this problem was successfully addressed with additional staged procedures. Contraction of local scar tissue created bulk and support, eliminating the need for distant tissue transfer or cartilage grafting. Twelve of the 28 patients required repeat turndown flaps to achieve sufficient nasal length and projection. These results were durable over a follow-up period of up to several decades. A simple, multistaged dorsal nasal flap can be used to reconstruct severe nasal deformities after facial burn injury. This can obviate the need for distant tissue transfer. Even in patients with subtotal nasal amputation and complete absence of cartilaginous support, the opportunistic use of scar tissue can restore nasal tip projection and alar lobule architecture without cartilage grafting. The resulting nasal reconstruction blends well into the surrounding facial appearance. This simple technique has been remarkably successful in this selected group of patients with challenging nasal deformities.

Heat injury to cells in perfused systems.

Abstract: Tissue injury in response to excessive heat results in a clinical burn. Burns cause a range of physiologic derangements, including denaturation of macromolecular structures, leakage of cell membranes, activation of cytokines, and cessation of blood flow, all leading to tissue death. The purpose of this paper is to examine the mechanisms and consequences of burn injury and to discuss potential therapies based on these mechanisms. Knowledge of the thermal properties of tissues can predict the time‐temperature relationship necessary to cause a specified thermal insult. Changes in cell membrane biochemistry and the stabilization of proteins through the heat‐shock response can enable biomacromolecules to withstand supraphysiological temperatures. Mechanisms of cellular repair allow recovery of cellular function after thermal insult. An understanding of the response of proteins, cellular organelles, and cells to heat provides the foundation for understanding the pathophysiology and treatment of burn injury. The physics, biochemistry, and cellular biology behind the host response to thermal injury in perfused systems are reviewed.

Quantitative facial asymmetry: using three-dimensional photogrammetry to measure baseline facial surface symmetry.

BackgroundAlthough symmetry is hailed as a fundamental goal of aesthetic and reconstructive surgery, our tools for measuring this outcome have been limited and subjective. With the advent of three-dimensional photogrammetry, surface geometry can be captured, manipulated, and measured quantitatively. Until now, few normative data existed with regard to facial surface symmetry. Here, we present a method for reproducibly calculating overall facial symmetry and present normative data on 100 subjects. MethodsWe enrolled 100 volunteers who underwent three-dimensional photogrammetry of their faces in repose. We collected demographic data on age, sex, and race and subjectively scored facial symmetry. We calculated the root mean square deviation (RMSD) between the native and reflected faces, reflecting about a plane of maximum symmetry. We analyzed the interobserver reliability of the subjective assessment of facial asymmetry and the quantitative measurements and compared the subjective and objective values. We also classified areas of greatest asymmetry as localized to the upper, middle, or lower facial thirds. This cluster of normative data was compared with a group of patients with subtle but increasing amounts of facial asymmetry. ResultsWe imaged 100 subjects by three-dimensional photogrammetry. There was a poor interobserver correlation between subjective assessments of asymmetry (r = 0.56). There was a high interobserver reliability for quantitative measurements of facial symmetry RMSD calculations (r = 0.91–0.95). The mean RMSD for this normative population was found to be 0.80 ± 0.24 mm. Areas of greatest asymmetry were distributed as follows: 10% upper facial third, 49% central facial third, and 41% lower facial third. Precise measurement permitted discrimination of subtle facial asymmetry within this normative group and distinguished norms from patients with subtle facial asymmetry, with placement of RMSDs along an asymmetry ruler. ConclusionsFacial surface symmetry, which is poorly assessed subjectively, can be easily and reproducibly measured using three-dimensional photogrammetry. The RMSD for facial asymmetry of healthy volunteers clusters at approximately 0.80 ± 0.24 mm. Patients with facial asymmetry due to a pathologic process can be differentiated from normative facial asymmetry based on their RMSDs. Clinical Question/Level of EvidenceDiagnostic, II.

Utilization of intraoperative 3D navigation for delayed reconstruction of orbitozygomatic complex fractures.

Reconstructive goals for orbitozygomaticomaxillary complex fractures include restoration of orbital volume, facial projection, and facial width. Delayed reconstruction is made more difficult by malunion, nonunion, bony absorption, loss of the soft tissue envelope, and scar. Three-dimensional intraoperative navigation, widely used in neurosurgery and sinus surgery, can improve the accuracy with which bony reduction is performed. This is particularly useful in the setting of bony absorption and comminution. We report a case of delayed reconstruction of an orbitozygomaticomaxillary complex fracture using intraoperative navigation and review this technologys utility in this setting.

Predictive Value of Weight Gain and Airway Obstruction in Isolated Robin Sequence

Objective Treatment of airway obstruction and feeding difficulties among newborns with isolated Robin sequence is challenging. The lack of clear guidelines may lead to prolonged hospital stays and delays in treatment. Appropriate risk stratification can facilitate treatment planning. We aim to identify factors that prognosticate prolonged hospital stay in children with isolated Robin sequence. Setting We used a retrospective multivariate analysis of 46 patients admitted with isolated Robin sequence at the Hospital for Sick Children, in Toronto, between 2000 and 2007. During the initial 4 weeks following admission, data regarding duration of hospital stay, management of airway obstruction, respiratory rate, management of feeding difficulties, and reflux therapy were collected. Results Correlation between length of hospital stay, airway management, and weight gain during the initial 4 weeks was noted. No correlation was found between length of hospital stay and respiratory rate, supplemental oxygen requirement, or reflux therapy. Conclusions Risk stratification is possible in children with isolated Robin sequence. Delayed weight gain in Robin sequence correlates with the degree of airway obstruction. The need for a nasopharyngeal tube and weight gain during the initial 4 weeks of life in newborns with Robin sequence reliably predict length of hospital stay. These prognosticators should contribute to parent and physician expectations, as well as assist in treatment and discharge planning.

Lip replantation and delayed inset after a dog bite: a case report and literature review.

Dog bites to the face are common in children and often involve amputation of the lip or cheek resulting in a devastating facial injury. When feasible, replantation of the amputated lip segment provides the optimal cosmetic outcome. Here, we present the case of a partial upper lip replantation with delayed inset as a new treatment option. Revascularization of the central upper lip segment was enabled by anastomosis to a single labial artery. Inset compression at the time of initial closure caused arterial insufficiency. Therefore, a delayed, sequential inset was performed over the following 2 weeks resulting in an esthetically and functionally successful replantation. A comprehensive review of the literature on published lip replantation techniques is also provided and discussed. We add delayed inset to the armamentarium of the microsurgeon when faced with these difficult injuries.

The pedicled reverse-flow lateral arm flap for coverage of complex traumatic elbow injuries.

PurposeThe pedicled reverse-flow lateral arm flap has been described primarily for the reconstruction of nontraumatic elbow wounds. We describe our experience using this flap in staged operations for soft tissue coverage after elbow trauma, including acute coverage of open fractures and salvage of infected hardware. MethodsReview of patients who underwent staged pedicled reverse-flow lateral arm flap transfer for coverage of traumatic elbow defects. ResultsThree patients were identified; all underwent 2-stage repair with flap delay for coverage of traumatic elbow injuries. Each patient had stable wound coverage with this flap. The only complication was 5% distal flap necrosis in 1 patient. ConclusionsThe pedicled reverse-flow lateral arm flap provides reliable soft tissue coverage of traumatic elbow defects with minimal donor-site morbidity.

Infantile digital fibromatosis.

Infantile digital fibromas are rare benign neoplasms that occur principally in children and are usually confined to the digits. These lesions are similar in appearance to several benign and malignant lesions, and biopsy is often required to confirm the diagnosis. The tumor is composed of myofibroblasts, which contain pathognomonic intracellular inclusion bodies. There is a strong tendency for recurrence after excision. We present a 2-year-old who developed extensive involvement of all 4 extremities after syndactyly release. This case is unusual in that the lesions occurred postsurgically and were substantially more extensive than those previously described.

Three-Dimensional Analysis of Nasal Symmetry Following Primary Correction of Unilateral Cleft Lip Nasal Deformity

Objective To evaluate nasal symmetry using three-dimensional photogrammetry following primary tip rhinoplasty with or without an internal splint in patients with unilateral complete cleft lip/palate. Design We captured three-dimensional images of patients with unilateral complete cleft lip/palate who underwent nasolabial repair by rotation-advancement of the lip and primary tip rhinoplasty, either with or without an internal resorbable splint, and normal control subjects. We assessed nasal symmetry by identifying the plane of maximum symmetry and the root-mean-square deviation between native and reflected surfaces. Patients/Participants We imaged 38 controls and 38 subjects with repaired unilateral complete cleft lip/palate (20 with, 18 without an internal splint). Results Nasal asymmetry root-mean-square deviation clustered between 0.19 and 0.50 mm (median = 0.24 ± 0.08 mm) for controls; whereas, those with repaired unilateral complete cleft lip/palate ranged from 0.4 to 1.5 mm (median = 0.75 ± 0.40 mm). Although root-mean-square deviation ranges overlapped, patients with repaired unilateral complete cleft lip/palate had significantly greater asymmetry than controls (P < .001). We found no difference in asymmetry between patients with or without an internal splint (P = .5). Conclusions Three-dimensional photogrammetry was used to successfully compare symmetry among different patient and control groups. Although “normal” nasal symmetry was attained in some patients following cleft lip/nasal repair, most had persistent asymmetry compared with normal controls. Placement of a resorbable internal splint did not improve symmetry in patients with unilateral complete cleft lip/palate.

Interdisciplinary Management of Minimally Displaced Orbital Roof Fractures: Delayed Pulsatile Exophthalmos and Orbital Encephalocele

Traumatic orbital roof fractures are rare and are managed nonoperatively in most cases. They are typically associated with severe mechanisms of injury and may be associated with significant neurologic or ophthalmologic compromise including traumatic brain injury and vision loss. Rarely, traumatic encephalocele or pulsatile exophthalmos may be present at the time of injury or develop in delayed fashion, necessitating close observation of these patients. In this article, we describe two patients with minimally displaced blow-in type orbital roof fractures that were later complicated by orbital encephalocele and pulsatile exophthalmos, prompting urgent surgical intervention. We also suggest a management algorithm for adult patients with orbital roof fractures, emphasizing careful observation and interdisciplinary management involving plastic surgery, neurosurgery, and ophthalmology.