James R. Sanger

The nasolabial fold ; an anatomic and histologic reappraisal

The nasolabial fold was analyzed by anatomic and histologic evaluation of the tissue planes that create and surround the fold. A fascial-fatty layer exists in the superficial subdermal space extending from the upper lip across the nasolabial fold to the cheek mass. The SMAS is present in the upper lip as the superficial portion of the orbicularis oris muscle. Traction on the SMAS or periosteum lateral to the nasolabial fold can deepen the fold, while traction on the fascial-fatty layer lessens the fold. The fascial-fatty layer and skin of the cheek mass are suggested as the primary ptotic elements responsible for facial aging. (Plast. Reconstr. Surg. 93: 60, 1994.)

THE LATERAL ARM FASCIAL FREE FLAP : ITS ANATOMY AND USE IN RECONSTRUCTION

Free fascial transfer has been used for reconstruction of gliding surfaces of the upper and lower extremities or when thin, pliable coverage is required (hand, heel, nose, and ear). In our experience with the lateral arm fasciocutaneous flap, we have found that the fascia alone is an excellent source of tissue for free flap transfer. A thorough investigation of the microscopic, gross, and radiographic anatomy of the lateral arm fascia was undertaken by the study of 25 fresh cadavers. Vascular pathways were mapped, their locations were analyzed, and then they were correlated with the elevation, design, and transfer of the flap. The lateral arm has a large fascial component located anterior and posterior to the lateral intermuscular septum, which itself lies between the triceps and the brachialis and brachioradialis muscles. It is perfused by the posterior radial collateral artery (PRCA), one of the terminal branches of the profunda brachii. This vessel (PRCA) provides at least four fascial branches from 1 to 15 cm proximal to the lateral epicondyle, the largest of which is located an average of 9.7 cm superior to the lateral epicondyle. Fascia up to 12 x 9 cm may be used with good axial perfusion. The histologic cross sections demonstrate the complex anatomy of the fascia itself, as well as its relation to the nutrient vessels. We have applied the lateral arm fascial flap in five cases of upper extremity reconstruction. We have also found this flap valuable in preservation of underlying anatomic detail for total reconstruction of the ear and nose when local tissue and more conventional flaps were not available.

Psychological adjustment following work-related hand injury : 18-month follow-up

Severe, work-related hand injuries are often accompanied by a significant number of psychological symptoms that are frequently associated with posttraumatic stress disorders. These symptoms occur in the following four domains of psychological functioning: cognitive, affective, physiological, and behavioral. This study examined the incidence of a variety of symptoms occurring with work-injured patients. Interviews were conducted at 1 week, 3 months, 6 months, 12 months, and 18 months after injury. Symptom frequencies were recorded. The results indicate that many of these symptoms were persistent 18 months later and continued to be significantly debilitating. The results support the need for psychological intervention after severe, work-related hand injuries.

Glomus tumor imaging: Use of MRI for localization of occult lesions

Magnetic resonance imaging has been performed in six patients with glomus tumors of the hand and correlated with clinical surgical histopathologic findings and with angiography in one case. Two of the patients had obscure pain without the classic clinical and radiologic findings of glomus tumors. The MRI examinations depicted the tumors in excellent detail and facilitated diagnosis in the two patients with atypical presentation. In all six cases the diagnoses were confirmed at surgery. The MRI proved valuable as a noninvasive and accurate means for the early diagnosis of occult glomus tumors.

The nasolabial fold: a photogrammetric analysis.

The nasolabial fold was analyzed by studying changes with aging in the nasolabial fold and adjacent soft-tissue features. Chronologic photographs were obtained from 19 older subjects, taken approximately every 10 years, from age 20 to their present age. In a separate phase of the study, facial portraits in repose and smiling were taken of young and old adult subjects with a mechanical frame used for setting an objective point of reference. Facial landmarks were identified and depth measurements were made in the anteroposterior direction. Relative lengths of selected points also were determined in the other dimensions (in the coronal plane) from photographs; these distances were normalized by using lower face length (distance from medial canthus to menton) for the vertical orientation and interpupillary distance to normalize horizontal dimensions. It was found that with aging there is anterior, lateral, and inferior displacement of the cheek mass with a resultant deepening of the nasolabial fold, while relationships between the upper lip and the fold itself remain constant.Also with age, the lateral commissure was found to move laterally, while the apparent angle of the nasolabial fold was decreased; this latter dimension was reflected by a decrease in the horizontal component of the fold length. These results support the theory that nasolabial fold deepening with age is caused by changes in the cheek mass and its support. (Plast. Reconstr. Surg. 93: 70, 1994.)

Early psychological aspects of severe hand injury

We investigated the incidence and nature of psychological symptoms occurring during the first two months after severe hand injuries. 94% of patients had significant symptoms at some point early in rehabilitation, including nightmares (92%), flashbacks (88%), affective lability (84%), preoccupation with phantom limb sensations (13%), concentration/attention problems (12%), cosmetic concerns (10%), fear of death (5%), and denial of amputation (3%). Two months later, flashbacks (63%) remained pronounced. Nightmares (13%), affective lability (48%), concentration/attention problems (5%), fear of death (0%), and denial of amputation (0%) declined markedly, while cosmetic concerns (17%) and preoccupation with phantom limb sensations (17%) increased. Based on these findings, we believe that psychological treatment should often be given as part of the rehabilitation process.

Gait analysis in rats with peripheral nerve injury

Rats are commonly used to study peripheral nerve repair and grafting. The traditional footprint method to assess functional recovery is messy, indirect, and not useful when contractures develop in the animal model. The aim of the present study was to establish an accurate, reproducible, but simple, method to assess dynamic limb function. The basic quantitative aspects of a normal gait were characterized from 59 recorded walks in 23 rats. The video was digitized and analyzed frame by frame on a personal computer. Seven parameters of the gait were assessed: (1) walking speed; (2) stance phase, swing phase and right to left stance/swing ratio; (3) step length and step length ratio; (4) ankle angles at terminal stance and midswing; (5) tail height; (6) midline deviation; and (7) tail deviation. These gait parameters were then applied to groups of animals with sciatic (group S), tibial (group T), and peroneal (group P) nerve injuries. A discriminant analysis was performed to analyze each parameter and to compute a functional score. We found that the video gait analysis was superior to the footprint method and believe it will be very useful in future studies on peripheral nerve injury.

Sequential connection of flaps: A logical approach to customized mandibular reconstruction+

Microsurgery has improved the success rate for reconstruction of composite defects in the head and neck. Restoration of mandibular continuity alone is not adequate for reconstruction. Replacement of the oral lining with thin tissue is necessary to improve tongue mobility and to set the stage for later dental restoration. There is currently no ideal osteocutaneous free flap that provides unlimited length of bone, can undergo multiple osteotomies to produce the proper curve to the reconstructed mandible, and provides thin skin for oral lining. Combining free flaps can take advantage of the strengths of the individual donor sites and eliminate some of the problems with current osteocutaneous flaps. In six patients, a fibular osseous free flap was combined with either a radial forearm flap or a lateral arm flap to provide bone and oral lining in reconstruction of mandibular composite defects. In these selected patients, the fibula provided the blood supply for the second free flap, which was placed sequentially. The distal peroneal vessels were used to anastomose to the radial forearm vessels or the lateral arm pedicle. This approach allows the surgeon to customize the defect by improving both the functional and aesthetic aspects of reconstruction and is of use in cases where vascular access is limited, such as following head and neck surgery and radiation.

The comparative strengths of internal fixation techniques

The strengths of internal fixation techniques have been compared by transecting human cadaver metacarpals, reducing and fixing the fractures, and then applying forces to mechanically bend the bone during simulated flexion. Kirschner wires alone, intraosseous wire loops with and without Kirschner wires, and bone plates were tested. Intraosseous loops were tested in three configurations, each with four different wire gauges. Intraosseous loops were stronger than Kirschner wires. Right-angle loops were the best of the intraosseous configurations. The addition of a Kirschner wire strengthened the best dorsopalmar intraosseous loops but not the best right-angle loops. Dorsal bone plates were comparable with the best intraosseous loop configurations of 26-gauge wire.

Condyle Transplantation in Free Flap Mandible Reconstruction

Fourteen patients requiring hemimandible resection were reconstructed with bone free flaps onto which the resected condyle was mounted as a nonvascularized graft. Postoperative mandible function, facial aesthetics, and patient symptoms were reviewed. The follow-up period ranged from 13 to 56 months (average 30.4 months). Interincisal opening ranged from 25 to 52 mm (average 37.10 mm). Opening ability inversely correlated with a need for intraoral soft tissue replacement and with the administration of postoperative radiation therapy. Eight patients were available for late study of the transplanted condyle with lateral tomograms and computed tomographic scans. Condyle volume diminished considerably in some, but this did not correlate with a decrease in function. Dual joint function and preoperative occlusion were maintained long term with this technique. Aesthetic results were enhanced by the contribution of the transplanted condyle to improved accuracy of free flap bone graft fabrication and insetting. There were neither postoperative morbidity nor abnormal symptoms due to the use of the condyle as a nonvascularized graft. This study demonstrates the effectiveness and safety of condyle transplantation in free flap mandible reconstruction.