Richard A. Pollock

Traumatic aneurysms of the face and temple: a patient report and literature review, 1644 to 1998.

The branches of the external carotid artery are protected from injury in most locations by an adequate buffer of soft tissue. On occasion, the vessels approach the surface to cross bone structures, and in these key areas they become vulnerable to blunt trauma. The facial, superficial temporal, and terminal branches of the internal maxillary arteries are the branches most often affected via this mechanism of injury. In addition, damage to deeper branches of the internal maxillary artery and to the subparotid portion of the superficial temporal artery has been reported secondary to maxillary fractures and craniofacial surgery. A brief patient report illustrates the highlights of clinical examination, diagnostic study, and surgical management of an aneurysm of the facial artery. A review of the world literature since 1644 has revealed 386 patients with traumatic aneurysms of the face and temple.Conner WCH, Rohrich RJ, Pollock RA. Traumatic aneurysms of the face and temple: a case report and literature review.

Inferior turbinate surgery: an adjunct to successful treatment of nasal obstruction in 408 patients.

Septal deviation is often associated with hypertrophy of the contralateral inferior turbinate. Failure to reduce the size of the turbinate at the time of septal reconstruction may result in persistent nasal obstruction. The authors present their experience with 408 patients who underwent one of four turbinate procedures over a 6-year period. Most patients underwent unilateral turbinate surgery, although bilateral procedures were undertaken in 7 percent of patients. A graduated surgical approach was taken that varied according to the amount of turbinate enlargement and the degree to which mucosa and bone were involved. Full-thickness excision of the anterior third to half of the inferior turbinate (turbinectomy) became a favored procedure. Relief of nasal obstruction was obtained in greater than 90 percent of patients. Healing was satisfactory regardless of the method, and complications, including hemorrhage and infection, were few. Long-term follow-up revealed no untoward sequelae, and no patient developed atrophic rhinitis. The authors conclude that turbinate surgery, particularly when unilateral, in the carefully selected patient with nasal obstruction is a useful adjunct to septal surgery.

Reduction mammoplasty with free-nipple transplantation: indications and technical refinements.

Multiple techniques for breast reduction have been proposed. For carefully selected women with macromastia, the technique of choice may be amputation mammoplasty with free nipple-areolar grafting. These select groups include the following: the poor-risk elderly, women with systemic disease that could affect the vascularity of the skin flaps or impair wound healing, women with previous operative procedures in the breast affecting skin flap or pedicle vascularity, and women with indications for removal of tissue in the region of the inferior pedicle. Our experience demonstrates that in these high-risk women, amputation mammoplasty with certain technical refinements provides an aesthetic safe result without significant perioperative surgical or medical complications. A clinical series is presented with an average follow-up of 2.75 years.

The Search for the Ideal Fixation of Palatal Fractures: Innovative Experience with a Mini-Locking Plate

Fractures of the palate have defied conventional management, such that malrotation and disinclination of the palatal shelves occur in a significant number of patients after repair. The fractured palatal shelves of eight patients were first prealigned. To do so, one or more 205-mm ratchet clamps and two intermaxillary fixation (IMF) posts were used. Rigid fixation was then achieved by applying a 2.0-mm mini-locking titanium plate (across the palatal vault) and by applying an adaptation miniplate across the fracture line as it exited the anterior surface of the maxilla. Screws were passed directly through the mucoperiosteum, to engage the palatal shelves and to lock the locking plate into position. Lacerations in the mucoperiosteum were neither used to aid fixation nor used as portals for dissection; incisions and mucoperiosteal flaps in the palatal vault were avoided. Adjuncts, such as intraoral splints, have not been used in cases to date, and early mobilization was allowed. Reconstitution of the craniomaxillofacial buttresses was added in patients with more extensive maxillary injury. The palatal appliance and screws remained rigidly in position in the roof of the mouth, much like an external fixator, until their removal 8 to 12 weeks after the repair. No patient suffered erosion of the mucoperiosteum or other major morbidity, other than a transient fistula of the soft palate. The palatoalveolar segments remained in proper realignment and inclination, and pretraumatic occlusal patterns and the width and depth of the lower face appear to have been restored with one exception. The latter suffered a subtle posterolateral open bite that was corrected orthodontically. Prealignment of fractured palatal shelves with one or more large ratchet clamps and two IMF posts provides several points of forced reduction of the palatal shelves, along the dental arch. In addition, stabilization with mini-locking plate(s) in the palatal vault and an adaptation plate across the fracture line, as it exits the maxilla, appear to have merit, based on this preliminary report (n = 8). Outcomes seen on computed tomography and clinical examination during this 3-year experience have been favorable.

Cranialization in a cohort of 154 consecutive patients with frontal sinus fractures (1987-2007) review and update of a compelling procedure in the selected patient

AbstractRetrospective review of charts of 180 consecutive patients with frontal sinus fractures managed by plastic surgeons at the University of Kentucky between 1987 and 2007 was performed with institutional review board approval. Twenty-six charts did not meet the criteria. The remaining 154 records provided 1-to-20-year follow-up. The study included 34 patients who underwent cranialization and 120 patients who did not. A low-complication rate of 6% after cranialization is ascribed by the authors to meticulous sinus mucosal debridement; thorough obliteration of the frontal sinus outflow tract (with sterile gelatin sponge pledgets and bone chips from the outer cortex of the temporoparietal skull); and avoidance of avascular barriers, such as abdominal fat. As high-resolution computerized tomography with parasaggital views was introduced, an increasing ability to preoperatively define the extent of injury of the medial and lateral sinus floor was observed. The authors conclude selective use of cranialization is indicated.

360-Degree Evaluations of Plastic Surgery Resident Accreditation Council for Graduate Medical Education Competencies: Experience Using a Short Form

Background: The Accreditation Council for Graduate Medical Education has asked training programs to develop methods to evaluate resident performance, using competencies essential for outcomes. Methods: A two-page form was completed by 12 surgeons and 28 nurses and clinical staff directly involved in plastic surgery patient care (n = 40), evaluating University of Kentucky plastic surgery residents at each level of training (n = 6). There were eight groups of health care professionals among the 40. Six Accreditation Council for Graduate Medical Education competencies were rated, with technical/operative skills added as a subset of patient care. Hierarchical cluster analysis was used to determine similarity of rating profiles of the rating groups; Kruskal-Wallis analysis of variance delineated the way in which the participants used the competencies to make their selections by asking them whether they would choose the resident for future surgical care. Results: Rating profiles revealed two clusters of raters. In one cluster were nurses assigned to an ambulatory surgery center, faculty, residents, and an intern (the surgeons’ cluster; n = 15); in the second cluster were other nurses and clinical staff (nurses’ cluster; n = 25). The nurses’ cluster was found to rate residents more positively, and the surgeons’ cluster more often cited areas for improvement. Specific competencies deemed important to each group were identified. Conclusions: Resident performance is rated differently by health care professionals, in two distinct groups. Based on this clustered arrangement, the resident is able quarterly to enjoy two, independent, formative assessments, potentially over 6 years of integrated training.

Management of jaw injuries in the American civil war: the diuturnity of bean in the South, gunning in the north

James Baxter Bean published a series of articles in the Southern Dental Examiner in 1862 describing his work with “plaster and its manipulations.” This early experience included a new way of managing jaw fractures, with customized splints uniquely based on pretraumatic occlusion. Beans oral splints and their method of construction, using an articulator, became the standard of care in the Atlanta region during the American Civil War and, by 1864, throughout The Confederacy. In short course, Beans approach also swept The Union, following in large part the efforts of a colleague in the North, T.B. Gunning. Thus, what began in the early 1860s in a dental laboratory in the southeast swept the continental United States and revolutionized management of jaw-fractures during, and immediately after, the American Civil War.

“oxytocin Hand”: Extravasation and Vascular Compromise after Obstetrical Pitocin

Sir:Oxytocin [produced commercially as oxytocin (Pitocin; Allscripts Healthcare Solutions, Chicago, Ill.) and Syntocinon (Sandoz Pharmaceuticals Corp., East Hanover, N.J.)] and vasopressin are well known for their effects on human reproduction (tetanic uterine contraction) and on sodium excretion (a

Degloving Injuries of the Oral Cavity Change the Operative Approach to Fractures of the Anterior Segment of the Mandible

No report to date describes the added risk traumatic, degloving injuries of the oral cavity may pose when treating fractures of the mandible. The authors describe the oral degloving injury, characterized by separation of periosteum and soft tissue of the anterior floor of the mouth from the inner cortex of the anterior segment. Vascular anatomy of the floor of the mouth is reviewed as a prelude to a description of pathomechanics of the injury and a case report. The higher incidence of oral degloving in youth and in young adulthood and parallels in elective, orthognathic surgery are identified. When this unusual clinical presentation occurs, and when open reduction of fractures of the anterior segment is chosen, a vestibular incision is best avoided. Instead, a submental or upper neck incision is chosen for sufficient exposure to allow reduction and the application of appliances. Meticulous closure of the intraoral void is achieved using one of two techniques, depending on the level of degloving.

Percutaneous Tracheostomy and Percutaneous Angiography: The Diuturnity of Sven-Ivar Seldinger of Mora, Pasquale Ciaglia of Utica

In the latter part of the 20th century, three developments intersected: skin-to-artery catheterization, percutaneous tracheostomy, and market introduction of video-chip camera-tipped endoscopes. By the millennium, every vessel within the body could be visualized radiographically, and percutaneous tracheostomy (with tracheal-ring “dilation,” flawless high-resolution intratracheal video-imagery, and tracheal intubation) could consistently be achieved at the patients bedside. Initiated through the skin and abetted by guide-wire insertion, these procedures are the lasting gifts of Sven-Ivar Seldinger (1921–1998) of Mora, Sweden, and Pasquale Ciaglia (1912–2000) of Utica, New York. Physicians and surgeons managing intracranial, craniofacial, and maxillofacial injury are among those honoring the Seldinger–Ciaglia “collaboration.”