Richard P. Jobe

A technique for lid loading in the management of the lagophthalmos of facial palsy.

Weighting of the upper lid with gold, to provide closure and cosmetic improvement in a lagophthalmos due to facial palsy, has found increasing acceptance among plastic surgeons and ophthalmologists since it was described by Smellie9 in 1966. The technique we have developed after a 4-year experience with this procedure has proved to be good, and it can be easily modified as the clinical circumstances change. The availability of a standardized gold weight* will make it possible to extend the usefulness of the procedure. Paralysis of the orbicularis oculi limits the ability of the lids to close. In younger patients, the elasticity of the skin assists in closure. The older the patient, the more lax the skin and the greater the need for therapy. The addition of a gold weight to the upper lid assists in replacing orbicularis function. We have found that variations in the weight and thickness of the eyelid tissues, and in the strength of the levator palpebrae muscle, cause considerable individual variation in the amount of gold necessary to achieve a satisfactory result.

The long-term effects of hard alloplastic implants when put on bone.

The resorption of bone beneath 4 alloplastic materials has been studied for periods up to 18 months in rabbit skulls. When the effects of pressure were negated, there was no significant difference in bone resorption attributable to placement above or below the periosteum. Dacron backing or polyurethane backing were associated with more inflammation and greater bone reaction than were plain silicone or stainless steel. The changes noted at 18 months were essentially the same as those noted at 6 months.

The restrictive pharyngeal flap

Summary Five patients with hypernasal speech resulting from low lying restrictive pharyngeal flaps have been observed in this clinic. Two of these were improved by dividing the flaps and constructing a superiorly based flap in conjunction with the palatal pushback. Normal palatal closure has been discussed and a mechanical explanation of the restrictive flap suggested. An argument is presented to stress the importance of two points of surgical technique to achieve maximum velopharyngeal competence : (1) raising the flap high on the posterior pharyngeal wall and (2) attaching it to the superior aspect of the soft palate near the insertion of the levators.

The combined pharyngeal flap and palate pushback procedure: improvements in technique.

Experience with the combined pharyngeal flap and palate pushback operation (Dibbell et al., 1965; Bucholz et al., 1967; Weber et al., 1970) has confirmed that palate surgery in older children-particularly in children or adults who have had previous palate surgery-is associated with more bleeding than the primary palate repair in infants. A simple reversal of the customary sequence of the procedure (not unique, we are sure, to this centre) has reduced blood loss and simplified the operation. After the mouth gag has been placed, the palate and posterior pharynx are injected

Toward a more natural breast : the interpolated thoracoepigastric pedicle in breast reconstruction

A method of reconstructing the breast mound after mastectomy using a superiorly based thoracoepigastric pedicle is presented. The advantages of the method are its relative simplicity and its definition of the inframammary fold. It often obviates the need for inflatable expanders. The prime disadvantage is the scar left on the abdominal donor site.