Neta Adler

Morphometry of the adult human earlobe: a study of 547 subjects and clinical application.

The purpose of this study was to define the factors that influence earlobe length and to establish a standard for adult earlobe length by sex and age. The study sample consisted of 547 adult subjects older than 20 years of age. A randomized, prospective design was used. Patients with malignancies, previous surgery or trauma to the earlobe, or congenital earlobe anomalies were excluded. The following variables were studied: sex; age; ethnic origin; skin complexion; height, weight, and body mass index; and piercing. Pearson’s correlation, analysis of variance, t test, and multiple regression analysis were used for the statistical analysis. There were 383 women (70 percent) and 164 men (30 percent) aged 20 to 80 years. The average length of the left earlobe was 1.97 cm (SD, 0.42 cm), and that of the right earlobe, 2.01 cm (SD, 0.42 cm) (p < 0.0001). A post hoc test revealed a statistically significant difference among the three age groups (20 to 40 years, 40 to 60 years, and >60 years) in both men and women. Pendulous earlobes were significantly longer and less symmetrical than nonpendulous ones by t test. In men, nonpierced left earlobes were longer than pierced lobes; in women, there was no significant difference between pierced and nonpierced ears. Pearson’s correlation tests for weight, height, and body mass index showed that only weight had a significant effect on earlobe length, and only in women. Analysis of variance for ethnic origin and skin color revealed a longer left earlobe in Ashkenazi and Sephardic Jews compared with Ethiopian, Asian, and American Jews and Arabs and a short earlobe in blacks compared with dark and fair-skinned people. On multiple regression analysis, sex and age were the only factors that contributed to earlobe length. A table of average earlobe length by age was formulated on the basis of the authors’ findings. These data, together with the knowledge that earlobe length changes little in women over 40, that earlobes are not symmetrical, and that right and left nonpendulous earlobes are symmetrical in individual patients and shorter than pendulous earlobes, can assist the plastic surgeon in deciding on the proper time for loboplasty. The preferable technique is creating a nonpendulous earlobe to minimize the chances of further elongation with time.

Breast-areola-nipple proportion.

Studies of breast volume and size have failed to take into account the aesthetic value of the nipple–areola–breast proportion. These data are important to plastic surgeons in planning breast reduction, augmentation, and reconstruction. In the current study, the anatomic size of the nipple, areola, and breast was measured in 37 women aged 20 to 64 years, and their proportions were calculated. The areola–breast and nipple–areola proportions were 1:3.4 and 1:3, respectively. The natural nipple–areola–breast proportion is approximately 1:3. This study provides a general guideline for plastic surgeons for planning breast surgery with optimal aesthetic results.

Harvesting the lateral femoral circumflex chimera free flap: Guidelines for elevation

Background: Reconstruction of complex head and neck defects having three-dimensional multiple tissue structural requirements can be a daunting challenge. Although many of these complex defects can be reconstructed with a lateral femoral circumflex chimera flap, elevation of these multiple component flaps can be difficult and confusing. Methods: To simplify harvesting of the lateral femoral circumflex chimera flap, the authors describe a method of freestyle flap elevation concentrating on the anatomy and principles in 12 steps. The initial incision is made medial and proximal to all cutaneous perforators of the lateral femoral circumflex system. It is used primarily for orientation and for defining the anatomy and tissue planes. In contradistinction to freestyle elevation of a simple perforator flap, complex chimera flaps are best dissected from the pedicle to the various tissue components of the chimera flap using a combination of retrograde and antegrade dissection of the perforators. Results: Sixty flaps based on the lateral femoral circumflex vascular system have been elevated using this technique by the senior author (L.J.G.) over the past 4 years. Thirty-seven of these were true chimera flaps. One patient had perforators of inadequate size that precluded using the lateral femoral circumflex flap. Conclusions: The authors describe a straightforward, safe, and versatile 12-step method for freestyle harvesting of complex lateral femoral circumflex chimera free tissue transfers. The flap can be harvested without fear of anatomical inconsistencies and the surgeon is not required to commit to a specific flap design before ensuring that the quality, quantity, and anatomical location of perforating vessels are adequate for the reconstructive plan.

Congenital melanocytic nevi of the eyelids and periorbital region.

Background: Congenital melanocytic nevi of the eyelids and periorbital region are unusual. Although their malignant potential can be debated, they present a significant aesthetic concern and also disturb lid function. In this article, the authors present an expanded approach to evaluation and treatment of these patients. Methods: Forty-four consecutive patients, aged 6 months to 18 years, were treated from 1980 to 2008. All patients had congenital nevi involving one or both eyelids, with or without extension into the surrounding periorbital area and face. Follow-up ranged from 6 months to 20 years. Results: All patients were treated successfully with excision and reconstruction of their congenital eyelid and/or periorbital nevi. The involved ciliary border was preserved in all but one case, where the exophytic lesion presented function concerns. Complications included asymptomatic lateral ectropion in three patients. Asymmetry of the palpebral apertures, before treatment, was present in at least half of the patients with extensive facial nevi, and the abnormalities causing these differences may impact efforts to obtain final lid symmetry. A single patient died as a result of extensive metastatic melanoma from an extracutaneous site. Conclusions: Early evaluation and treatment of these nevi may help in preventing the aesthetic, functional, and health-related issues for the patients. Although the current group of infants and young children will not reach full facial growth for more than another decade and a half, and therefore await critical assessment of their long-term outcomes, the authors hope that the experience gained to date will assist surgeons in managing these complex reconstructions.

Refining the intrinsic chimera flap: a review.

Reconstruction of complex tissue deficiencies in which each missing component is in a different spatial relationship to each other can be particularly challenging, especially in patients with limited recipient vessels. The chimera flap design is uniquely suited to reconstruct these deformities.Chimera flaps have been previously defined in many ways with 2 main categories: prefabricated or intrinsic. Herein we attempt to clarify the definition of a true intrinsic chimeric flap and provide examples of how these constructs provide a method for reconstruction of complex defects. The versatility of the intrinsic chimera flap and its procurement from 7 different vascular systems is described.A clarification of the definition of a true intrinsic chimera flap is described. In addition, construction of flaps from the lateral femoral circumflex, deep circumflex iliac, inferior gluteal, peroneal, subscapular, thoracodorsal, and radial arterial systems is described to showcase the versatility of these chimera flaps.A true intrinsic chimera flap must consist of more than a single tissue type. Each of the tissue components receives its blood flow from separate vascular branches or perforators that are connected to a single vascular source. These vascular branches must be of appropriate length to allow for insetting with 3-dimensional spatial freedom. There are a multitude of sites from which true intrinsic chimera flaps may be harvested.

Latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap reconstruction in composite defects of the scalp: case series and review of literature.

Adequate coverage of complex, composite scalp defects in previously radiated, infected, or otherwise compromised tissue represents a challenge in reconstructive surgery. To provide wound closure with bony protection to the brain, improve cranial contour, and prevent or seal cerebrospinal fluid (CSF) leaks, composite free tissue transfer is a reliable and safe option. We report our experience with the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap in the reconstruction of bony and soft tissue defects of the cranium and overlying scalp. The surgical technique, design, and outcomes of the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap reconstruction in five patients with cranial defects between 2003 and 2007 were retrospectively evaluated. Patient characteristics, defect size, underlying cause, reconstructive details, and complications were analyzed. All patients (age 43 to 81) had composite defects ranging from 36 to 750 cm2 (mean size 230 cm2) for the bony component and from 16 to 400 cm2 (mean size 170 cm2) for the soft tissue defect. All patients had a history of prior or current infection of the affected area, and two patients had a CSF leak. Defects were due to malignancy and infection (n = 2), infiltrative cutaneous mucormycosis with osteomyelitis (n = 1), and hemorrhagic stroke requiring craniectomy (n = 2), complicated by infection and failed cranioplasty in one patient and continuous CSF leak in the other. The latissimus dorsi composite free flap consisting of skin, muscle, and vascularized rib can successfully cover large complex cranial defects, provide skeletal support, improve contour, and significantly enhance functional outcome with limited donor site morbidity.

Reconstruction of nonhelical auricular defects with local flaps.

BACKGROUND The integrity of each of the components of the auricle is important for its overall aesthetic appearance. Cartilage-exposing nonhelical defects that are too large to be closed primarily without distorting the auricle may be reconstructed with local flaps. OBJECTIVE The objective was to present our experience with the reconstruction of nonhelical medium-sized defects using a variety of simple, one-stage local flaps. PATIENTS AND METHODS Eighteen patients who underwent reconstruction of nonhelical auricular defects with local flaps at our center from 2003 to 2006. Defect size ranged from about 10 to 20 mm. Various methods were used for reconstruction as follows: conchal defect (n=11)—pull-through postauricular flap or cutaneous rotation flap from the concha itself; triangular fossa defect (n=3)—transposition-rotation flap from the concha or cutaneous periauricular pull-through flap via the root of the helix; antihelical defect (n=2)—V-Y advancement flap from the skin of the antihelix; and tragus defect (n=2)—periauricular cutaneous flap. RESULTS All flaps survived. Transient congestion was noted in four patients. The aesthetic results were good, with no auricular deformation. CONCLUSION It is important that reconstructive surgeons be familiar with a variety of basic flaps for reconstruction of nonhelical defects. An algorithm for nonhelical flap reconstruction is suggested.

Cyclooxygenase-2 expression in dermatofibroma and dermatofibrosarcoma protuberans

Background:  Dermatofibroma (DF) and dermatofibrosarcoma protuberans (DFSP) occasionally resemble each other histologically but differ in histogenesis and biological behavior. This study sought to determine if these lesions can be differentiated by the quantity or quality of expression of cyclooxygenase‐2 (COX‐2), an enzyme associated with both reactive and neoplastic processes.

Exploding microwaved eggs—revisited

Different types of injuries are described as caused by the use of microwave ovens. Four of 41 burns from microwave ovens, presented by an international survey in 1986, were due to exploding microwave-heated eggs. Careful review of the English language literature through a Medline search from 1966 to 2000 was performed, in search of burns caused by exploding eggs. Clinical information from the published articles was reviewed and missing information was completed by e-mail correspondence with authors. Our own case was added to the collected data, and a total of 13 cases were analyzed. The average age of patients was 24.3 years (range, 7-49 years). All patients suffered from superficial burns of the mid and upper face, namely the forehead, periorbital region, dorsum of nose and malar areas. All patients with information available complained of ocular disturbances, and three suffered long-term decrease in visual acuity. Long-term skin complications were not reported. In summary, the clinical presentation of a facial injury from an exploding microwave-heated egg is relatively constant and mild. Favorable outcome can be expected but a meticulous ophthalmologic evaluation and a close follow-up are mandatory for prevention of long-term sequelae.

Periorbital reconstruction with the expanded pedicled forehead flap.

BackgroundThe complexity of structures within the periorbital region makes reconstruction of this area particularly a challenging endeavor. Within the literature, different techniques have been described for reconstruction of the external lamellae of the upper and lower eyelids as well as the medial and lateral canthal regions.Herein, we present the expanded pedicled forehead flap as a versatile and useful surgical option for reconstruction of various defects around the eye globe. Patients and MethodsA tissue expander is inserted underneath the forehead skin and serially expanded. The pedicle of the expanded pedicled flap is designed either from the superior portion of the expanded skin and interpolated to reconstruct the upper and lower eyelids, and the medial or lateral canthal areas; or from the inferior portion of the expanded skin and interpolated over the eyebrow to reconstruct the area between the upper eyelid crease and eyebrow.Fifteen patients with periorbital nevi or severe scarring were treated using the expanded forehead flap between the years 2003 and 2012. Thirteen patients had complex periorbital defects involving multiple anatomic areas, and 2 patients had defects confined to the upper eyelid area only. ResultsOperative and postoperative course for 13 patients was uneventful. One patient had a late infection of the tissue expander but nonetheless continued with the reconstructive process. In 1 patient, the tissue expander was removed due to infection, and subsequent reconstruction was not carried out. The aesthetic and functional results of reconstruction were very good, and with excellent skin color and thickness match. In 1 patient, the flap was defattened in an ancillary procedure. No partial or complete flap loss was observed in this study. SummaryWe conclude that the expanded pedicled forehead flap is a safe and reliable method for reconstruction of different segments of the periorbital region, while providing good aesthetic and functional reconstructive results with minimal donor-site morbidity.