Norman Waterhouse

Versatility of diced cartilage-fascia grafts in dorsal nasal augmentation.

Background: Augmentation of the nasal dorsum using autologous cartilage remains an exacting task in rhinoplasty. Precise, long-term control over graft contour and alignment can be difficult to achieve. In an attempt to alleviate these problems, the use of diced cartilage wrapped in a supportive sleeve has recently seen a resurgence of interest. The Turkish delight technique uses Surgicel as the sleeve material, whereas Daniel and Calvert have proposed autologous fascia. Methods: The objective of this study was to assess the efficacy and reliability of diced cartilage–fascia grafts in the treatment of dorsal nasal volume deficiencies. Results: Over a 2-year period, 20 adult patients underwent nasal augmentation using diced cartilage–fascia grafts. The indications for dorsal grafting were congenital saddling, racial refinement, or iatrogenic or posttraumatic deformities. Apart from one infection, all of the hybrid grafts retained their original volume and had not undergone resorption by a mean time of 16 months postoperatively. A critical analysis of the radix-dorsum aesthetics led to a minor modification of the original technique. Conclusion: This series supports the use of diced cartilage–fascia grafts for the correction of difficult dorsal nasal defects with grafting in the 3- to 5-mm range in primary and secondary rhinoplasty.

Buckling and hydraulic mechanisms in orbital blowout fractures: fact or fiction?

Since the first description of orbital blowout fractures, there has been much confusion as to their etiology. Two principal mechanisms have been proposed to explain their production, the buckling and the hydraulic mechanisms caused, respectively, by trauma to the orbital rim and the globe of the eye. The aim of this study was to evaluate both mechanisms qualitatively and quantitatively. Our protocol used intact cadavers, quantifiable intraocular pressure, variable and quantifiable force, and quantifiable bone strain distribution with strain gauge analysis. One orbit of each cadaver was used to simulate each of the two mechanisms, allowing direct comparison. Fractures produced by the buckling mechanism were limited to the anterior part of the orbital floor, with strain readings reaching up to 3756 &mgr;&egr;. Posteriorly, strain did not exceed 221 &mgr;&egr;. In contrast, hydraulic-type fractures were much larger, involving anterior and posterior parts of the floor as well as the medial wall of the orbit. Here, strain exceeded 3756 &mgr;&egr; in both parts of the floor. Furthermore, we have demonstrated that the average energy required to fracture the orbital floor by the buckling mechanism is 1.54 J, whereas an average energy of 1.22 J is needed to produce this fracture by the hydraulic mechanism. Our results suggest that efforts to establish one or another mechanism as the primary etiology are misplaced. Both mechanisms produce orbital blowout fractures, with different and specific characteristics. We believe this provides the basis for our reclassification of such fractures.

The clavicular head of pectoralis major musculocutaneous free flap

A new free flap is described based on the deltoid vessels of the acromiothoracic axis. The flap is comprised of the clavicular head of pectoralis major muscle with overlying skin. It is also possible to harvest vascularised clavicular bone with the flap. The vascular anatomy is reviewed and the technique of raising the flap described. Its clinical application is illustrated with five cases. Four of these were intra-oral reconstructions and the fifth a composite osteo-musculocutaneous flap to a lower limb following trauma.

Endoscopic removal of periorbital lesions

In this article, the authors describe the technique, indications and contra-indications for removing various periorbital lesions with an endoscope. The principal reason for using this technique is the excellent postoperative cosmesis. Seven patients in total had lesions removed in this manner. The only complication noted was some leakage of the contents of a dermoid cyst intraoperatively. Cosmesis postoperatively was excellent in all cases. None of the cases had to be converted to an ‘open’ procedure.

The development of a dynamic model for microvascular research and practice using human placenta: a preliminary report

Human placenta has been investigated in an attempt to develop a non-animal model for microvascular research and practice, with a dynamic artificial circulation. Initial work has been encouraging and further development is in progress.

Lengthening of a short traumtic femoral stump

A case is reported in which a severe open injury of the thigh eventually required amputation of the lower limb. Lengthening of the short proximal femoral stump was achieved by turning over a flap comprising bone and soft tissue, with sensation, from the ipsilateral leg.

Lower limb salvage using an extended free radial forearm flap

A case is reported of an unusual double injury, in which a lower limb salvage procedure employed a free radial forearm flap from an amputated upper limb. The use of amputated parts for salvage procedures is well documented but none has previously involved a free forearm flap. This clinical case shows that the entire forearm and hand skin can be adequately perfused on the radial artery along with the superficial palmar arch.

The use of autologous autoclaved bone in orbital reconstruction after exenteration for invasive cutaneous carcinoma.

PURPOSE To describe a technique for reconstructing the orbital bony architecture after invasion by tumour. METHODS Orbital bone invaded by tumour was osteotomized (post-exenteration), autoclaved to remove tumour cells, and then refixated in order to re-establish the normal orbital anatomy. RESULTS Despite some shrinkage of the bone fragment in the autoclaving process, after refixation the contour and topography of the bony orbit was essentially normal. CONCLUSION Autoclaved bone can be used to reconstruct the exenterated orbit; it is a fast and technically simple strategy for maintaining orbital anatomy when faced with bony invasion by tumour.

Free vascularized fibular graft to reconstruct early a traumatic humeral defect

A case is reported in which a free, vascularized fibular graft was used to reconstruct early a traumatic 16-cm defect in a humerus. A description of a cast-brace used postoperatively is included. A brief review is presented of the literature with respect to the use of free vascularized fibular graft for defects in the upper extremity.