Hugh G. Thomson

Residual Problems in Chest Donor Sites after Microtia Reconstruction: A Long-Term Study

The rib cartilage has been the most popular autogenous tissue for microtia reconstruction. In this study, 88 chest donor sites were evaluated in 80 patients examined in the outpatient clinic at least 1 year after tissue removal. Microtia reconstruction usually was initiated between the ages of 2 and 3 years (42 percent), at which time an axial half of the sixth rib was harvested along with all of the seventh and eighth rib cartilages with their attached perichondrium. During this procedure, there were 19 uneventful pleural perforations (22 percent), and early in the series, 2 patients (2 percent) required a chest tube. Postoperative atelectasis without evidence of pneumothorax occurred in 7 patients (8 percent). Chest scars were classified by impartial observers as excellent (25 percent), good (33 percent), acceptable (28 percent), and poor (14 percent). Better scars were experienced in the cold-knife group than in incision by electrocutting. The younger group and the longer postoperative interval group showed better chest scars. Chest topography deformities were rated as normal (75 percent), mild retrusion (19 percent), and severe retrusion (6 percent). Costal margin contours improved as the postoperative interval lengthened. (Plast. Reconstr. Surg. 95: 961, 1995.)

The excised preauricular sinus in 14 years of experience : Is there a problem?

&NA; The congenital preauricular sinus is usually asymptomatic. However, if recurrent infection occurs, complete surgical excision of the sinus is required. If the sinus tracts are not entirely removed, recurrence is likely to follow. A retrospective study of the surgical results at The Hospital for Sick Children in Toronto, Ontario, was completed. One‐hundred sixty‐five primary preauricular excision procedures, performed in 146 patients between the years 1982 and 1996, were reviewed. All clinical, operative, and postoperative data were gathered. Patient outcome and epidemiologic issues were addressed. The overall recurrence rate of this series was 9.09 percent (15 of 165 sinuses). For the group of patients with active infection present at surgery, the recurrence rate was 15.79 percent, and when no infection was present, recurrence rate was 8.22 percent (p value = 0.32, odds ratio = 2.09). Moreover, in patients who underwent surgical drainage of an abscess before the procedure, 16.7 percent of the sinuses recurred, whereas in the patients who did not have an abscess, only 8.16 percent recurred (p value = 0.25, odds ratio = 2.25). In the group of patients in whom auricular cartilage was not excised from the base of the tract, 18.52 percent of the sinuses recurred; when cartilage was excised, the recurrence rate was 4.5 percent (p value = 0.006). A very high recurrence rate of 21.95 percent was found in the group of patients in whom no modality was used to demonstrate the sinus tract at surgery. A high recurrence rate of 10.87 percent was found in the group for whom probing with a cannula was used to identify the tract (p value = 0.17); a low recurrence rate of 2 percent was found in a group with dye injection only (p value = 0.015). In those patients in whom sinus probing and dye injection were used simultaneously, there were no recurrences (0 percent, p value < 0.05). In conclusion, a patient with an actively infected preauricular sinus or one with a previous abscess may have a tendency to experience a higher recurrence rate after excisional surgery. Excising a cartilage piece at the base of the tract and demonstrating the sinus with dye injection or with dye injection and probing at the time of surgery will reduce recurrence rates. In conclusion, we advise the excision of cartilage in the base of the tract as well as the use of methylene blue injection and probing of the sinus at surgery. (Plast. Reconstr. Surg. 102: 1405, 1998.)

Is pharyngoplasty a risk in velocardiofacial syndrome ? An assessment of medially displaced carotid arteries

&NA; The association of medially positioned internal carotid arteries and velocardiofacial (Shprintzen) syndrome was first made in 1987. This is also the most common syndrome associated with facial clefting. The potentially dangerous implications in children with this syndrome requiring pharyngoplasty for velopharyngeal incompetence and stigmatized hypernasal speech involve potential damage to these vessels. This three‐part study was undertaken to analyze this anatomic variant. First, a group of 25 children with velocardiofacial syndrome, velopharyngeal incompetence, and obvious posterior pharyngeal pulsations seen on nasendoscopy was studied by CT angiography to determine the degree of this abnormal vascular pattern. This technique, together with three‐dimensional reconstructions, made it possible to determine the precise location of these abnormally positioned vessels. Second, our routine superiorly based pharyngeal flap was measured by lateral cervical x‐ray to show the distal tip of the flap. The variance was minimal and demonstrated the tip of most flaps to be at the disk between the C2 and C3 vertebrae. By correlating this information with the CT angiography, the risk of surgery can be determined on strict anatomic grounds, allowing customized flap design in some unilateral cases. In this series of children, routine superiorly based pharyngoplasty would be safe in 52 percent, while in 28 percent a pharyngeal flap would be safe if custom designed, and in the remaining 20 percent surgery should not be attempted because the risk of damage to the carotid arteries is too great. Third, in a double‐blind study, velocardiofacial children with obvious pulsations seen on nasendoscopy were grouped with other children with palatal dysfunction. When only endoral examination was performed by plastic surgeons and plastic surgical residents, no vascular pulsations were ever seen. This indicates another important role of nasendoscopy in the preoperative assessment of children for palatopharyngoplasty.

Hemangiomas of the eyelid: visual complications and prophylactic concepts.

We describe a late survey of 51 patients who had hemangiomas of the eyelid in infancy, together with the visual complications found and a program designed for prevention of the latter.

A long-term appraisal of the unilateral complete cleft lip repair: one surgeon's experience.

The authors reviewed 85 patients with unilateral complete cleft lip repaired with a low triangular flap technique. Clefts were classified into four categories, depending on the degree of deformity. The clinical results, as evidenced in standardized slides, were assessed by a professional panel using a weighted formula adapted from that devised by Williams. The Farkas-Lindsay anthropometric technique was also used to measure all dimensions of the lip and nose, with the results calculated as a ratio of the cleft to normal side. The findings demonstrated that the method of classification was consistent and reliable. As expected, the panel gave the postoperative results of the Simonarts and mild-degree clefts the highest ratings, with the severe clefts having the lowest. The consultant surgeons awarded the highest marks and the clinical fellows, the lowest. The residual nasal deformity continues to be the challenge rather than the lip defect, as evidenced by an average of 1.7 revisionary procedures on the nose compared with 0.7 on the lip. A combination of subjective and objective methods of evaluation has been incorporated into a critical clinical review of these patients.

Nasal glioma: is dermis involvement significant?

Nasal gliomas are rare, benign, congenital masses more accurately referred to as sequestered glial tissue. Seven patients with nasal glioma treated by Hugh G. Thomson over the last 28 years are presented with special reference to tumor recurrence after excision and associated naso-ocular cleft. Three of our patients had an associated ipsilateral naso-ocular cleft, and three similar cases have been reported. This association is probably more frequent because a naso-ocular cleft can exist as a forme fruste and be easily overlooked. The first two tumors resected in our series recurred within 10 months; however, no recurrences were seen after a new treatment protocol was initiated in 1972. This consisted of total excision of the skin overlying the tumor if the skin adhered to the mass or if glial elements were seen within the dermis on frozen section. Deep resection margin was also assessed by frozen section of the nasal mucosa or fibrous stalk of the tumor. Accordingly, unnecessary intracranial procedures were avoided without increasing the risk of recurrence.

Congenital giant pigmented nevi: Clinical features and risk of malignancy

MJ Weinberg, M Al-Qattan, RM Zuker, HG Thomson, WK Lindsay. Can J Plast Surg 1996;4(2):94-98. There is general agreement that congenital giant pigmented nevi (CGPN) are precursors to malignant melanoma; however, the magnitude of the risk of malignant transformation is the subject of wide controversy. The goal of this study was to present the authors’ experience with CGPN and more specifically their experience with the risk of malignancy. To identify the general features of CGPN a detailed retrospective chart review was performed at The Hospital for Sick Children in Toronto (1979 to 1994, n=84). There were 39 boys and 45 girls. The average size at presentation was 5.24% of the body surface area, and 36.9% of the nevus were located on the head and neck. An important finding was the high percentage of associated extra cutaneous disorders in patients with CGPN (23%) including a case of leptomeningeal melanocytosis. Tissue expansion was the most commonly used treatment modality. One case of malignant melanoma arising from CGPN was identified. To ensure that all cases of malignant melanoma were identified in this cohort, a questionnaire was sent to all plastic surgeons in Ontario (n=118), and data from the Ontario Cancer Registry were reviewed using the diagnostic codes for malignant melanoma and for pigmented nevus. One case of malignant melanoma was identified in all records. Thus CGPN poses a significant management challenge to the plastic surgeon and the risk of malignancy is low.

Microtia Reconstruction: Does the Cartilage Framework Grow?

The use of free rib cartilage ear frameworks in unilateral microtia reconstruction has prompted much discussion about their potential for growth. The senior author has reconstructed ear frameworks in 132 microtia patients, most of whom were under 3 years of age when surgery was initiated. Of this group, 29 were assessed for ear growth through comparison of the lead-plate model of the original normal ear to the normal ear growth and the reconstructed ear framework after a period of at least 2 years. Similarly, 14 reconstructed ears were compared to 14 normal ears at least 2 years after reconstruction. The perimeters of tracings made from the original lead plates and of tracings of normal and reconstructed ears were determined by image analysis techniques. The results demonstrated no significant difference in growth between normal ears and reconstructed ear frameworks after an interval of at least 2.5 years. Therefore, the reconstructed ear is growing at a rate similar to that of the normal ear.

The role of episcleral venous pressure in glaucoma associated with Sturge-Weber syndrome

PURPOSE To evaluate the role of episcleral venous pressure (EVP) in the pathogenesis of glaucoma associated with Sturge-Weber syndrome (SWS). METHODS EVPs were determined prospectively using an episcleral venomanometer in 22 eyes of 11 patients aged 8-18 years with SWS with or without glaucoma. Pressure measurements in the glaucomatous eyes of patients with SWS were compared to those of patients with facial port wine marks but no glaucoma and to the contralateral uninvolved eye in both groups. RESULTS EVP in eyes with glaucoma (mean, 20.9 mm Hg) was significantly higher (P < 0.01) than EVP in contralateral uninvolved eyes (mean, 9.6 mm Hg). In patients with unilateral port wine mark and no glaucoma, EVP was normal for ipsilateral and contralateral eyes (mean, 8.6 mm Hg and 9.6 mm Hg, respectively). CONCLUSIONS Our data support the hypothesis that elevated EVP plays an important role in eyes with SWS glaucoma.

Ocular manifestations of the Johanson-Blizzard syndrome.

Johanson-Blizzard syndrome is a rare autosomal-recessive congenital disorder characterized by hypoplastic nasal alae, midline scalp defects, deafness, microcephaly, hypothyroidism, absent permanent teeth, malabsorption, and failure to thrive. The literature was reviewed to define the reported spectrum of ocular manifestations, which are not well documented. We found that nasolacrimal system malformations are a common feature of Johanson-Blizzard, whereas intraocular malformations are rare. This report describes the ophthalmologic findings and management of 2 affected children.