Yousif Nj

A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging : Implications for facial rejuvenation and facial animation surgery

&NA; An anatomic study was performed on living subjects using magnetic resonance imaging (MRI) to distinguish the relative contribution of skin, subcutaneous tissue, and muscle to dynamic changes in the nasolabial fold during facial animation and aging. MRI scans with the face in repose and then holding a full smile were performed in both young and old adult subjects. Anatomic landmarks were identified, and measurements characterizing their position were made on the MRI console. MRI resulted in excellent image resolution of facial tissue planes. Comparison between young and old subjects with the face in repose demonstrated that progressive thickening of the dependent portion of the cheek fat pad and overlying skin, with no appreciable change in the muscle plane comprising the levators of the upper lip, resulted in a deeper and more acute nasolabial fold in older subjects. In both age groups there was significant shortening of the mimetic muscles with smiling, with the lateral mimetic muscles drawn closer to the underlying facial bones. This was accompanied by redistribution of the cheek fat pad, thereby maintaining projection of surface landmarks within the cheek mass in young subjects with smiling. These findings indicate that in order to diminish the nasolabial fold, surgery for facial rejuvenation should be directed to the skin and subcutaneous tissue planes superficial to the mimetic muscles to the upper lip. In order to recreate a natural nasolabial fold during surgery for facial reanimation, contraction of the levator muscles to the upper lip should result in redistribution of the cheek fat pad without change in surface projection of the cheek mass or upper lip; this can only be accomplished if the reconstructed levator muscle is positioned deep to the cheek fat pad, with its insertion toward the deep (mucosal) surface of the upper lip.

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.

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.

The composite lateral arm free flap: Vascular relationship to triceps tendon and muscle

We studied the vascular relationship of the lateral arm flap to triceps tendon and muscle in 16 dissected cadaver arms. We designed composite lateral arm free flaps containing fasciocuta-neous components, triceps muscle, and/or triceps tendon. Vascular communication between the lateral arm fascia and triceps tendon was negligible. In contrast, a mean of 3.6 vessels passed through triceps muscle from the posterior radial collateral artery to the harvested triceps tendon; in each dissection at least 1 vessel entered the proximal 5 cm and 1 vessel entered the distal 5 cm of harvested tendon. Methylene blue injections confirmed that perfusion of the triceps tendon was through triceps muscle and not through lateral arm fascia. We used the composite lateral arm free flap in 6 patients, 3 with triceps muscle and 3 with triceps tendon. Baltimore Therapeutic Evaluation testing in those patients where triceps tendon was harvested showed no deficit in elbow extension. Complete coverage of composite defects was achieved with a single surgical procedure in all patients.

Graded work exposure to promote work return after severe hand trauma: a replicated study

Fifty-one patients with posttraumatic stress disorder after work-related hand injuries were placed on a graded work exposure program to facilitate return to work. These patients consisted of an initial group of 25 patients and a replication group of 26 patients. The program returned 92% of the initial group and 88% of the replicated group to work with their previous employers. At 6-month follow-up, 88% of the initial group and 80.1% of the replication group were still working full-time at the jobs to which they had returned. All of the patients not working with their previous employer at follow-up had appraisal/projected flashbacks, which have previously been associated with a 90% failure to return to work. This intervention was successful with 73% of the patients experiencing such flashbacks. In conclusion, graded work exposure was an effective treatment to promote return to work for patients experiencing significant psychological symptomatology after severe hand injury.

The corkscrew sign in hypothenar hammer syndrome

Arteriography of an adult manual labourer presenting with numbness and cold intolerance in the middle and ring fingers of the right hand demonstrated filling defects in the digital arteries of these two fingers associated with a corkscrew-like configuration of the ulnar artery in Guyon’s canal. This arterial segment was subsequently excised revealing intramural necrosis and fibrosis and non-occlusive intraluminal thrombosis. An arteriogram performed 2 years previously for an unrelated condition revealed a similar but less pronounced corkscrew configuration of the artery, suggesting that this finding could be a marker for arterial injury which may eventually lead to embolization or thrombosis with accompanying ischaemic symptoms.

Silicone gel infiltration of a peripheral nerve and constrictive neuropathy following rupture of a breast prosthesis.

Following rupture of a subpectoral breast prosthesis, massive amounts of silicone gel migrated into the arm of a patient. The patient developed painful paresthesias and decreased sensation in the cutaneous distribution of the superficial radial nerve. Nerve conduction studies showed both an increase in distal latency and decreased amplitude in this nerve compared with the normal opposite side. Subsequent neurolysis confirmed dense fibrosis surrounding the nerve. Silicone droplets also were observed within the thickened epineurium of the median nerve, but no electrophysiologic evidence of neuropathy occurred. Multiple debridements of the subcutaneous tissue of the arm were necessary. In one of these specimens, histologic sections demonstrated silicone gel infiltration of a subcutaneous nerve. This is the first reported case of silicone gel infiltration of a nerve and constrictive neuropathy associated with a prosthesis rupture.

Characteristics of prosthetic mesh and autogenous fascia in abdominal wall reconstruction after prolonged implantation

This study evaluated two types of prosthetic mesh and autogenous fascia in long-term abdominal wall reconstruction for rats. Marlex mesh, Gore-Tex patch, and autogenous fascia were Implanted and left in place for 1 year. Materials were removed and evaluated using tensile strength of the material, tensile strength of the suture line, and adhesions. No change in the tensile strength of any of the materials were found at 1 year follow-up. Tensile strengths were significantly greater for Gore-Tex patch and Marlex mesh than the autogenous fascia. The Marlex mesh, however, had a weak and a strong tensile strength direction. These were significantly different (p <0.05). Suture line tensile strength was greater for autogenous fascia and Marlex mesh than it was for the Gore-Tex patch, which was significantly weaker (p <0.05). The greatest number of adhesions were seen in the Marlex mesh group. No significant difference was present in adhesions between Gore-Tex patch and autogenous fascia. In summary, autogenous fascia showed virtually no adhesions and good suture line strength. While it was the weakest of the three materials examined, the strength was still within the normal range and adequate for abdominal wall reconstruction.

Penile replantation after self-inflicted amputation

In 4 men with self-inflicted penile amputation, replantation was successful using microsurgical technique. Postoperative complications were minimal. In 1 man who had amputated his penis and then amputated his scrotum and testicles, a small skin graft was necessary to close a portion of the defect. A mild urethral stricture that developed in this man responded to dilation. Return of sensation was excellent. Normal erections were reported by all men. Microsurgical replantation is the treatment of choice for this injury and is superior to other techniques of penile reattachment, which have a high incidence of distal necrosis, fistula and stricture formation, as well as incomplete or absent sensation and compromised erectile function. Of concern in this group of men is the high incidence of previous or subsequent penile mutilation. Two of the 4 men have a history of recurrent self-mutilation. The follow-up in this series is longer than previously reported and the overall psychiatric pathology appears to be quite severe and persistent.

Temporary ectopic implantation of an amputated penis

A case of temporary ectopic implantation of an amputated penis to the forearm followed by subsequent return to its anatomic position is reported. The penis was amputated by a riding lawnmower, and massive contamination of the perineum and an extensive hematoma precluded immediate replantation. The penile vessels were attached to the radial artery and venae comitantes on the forearm, where it survived completely. After 4 weeks, the edema and hematoma of the perineum had resolved, and the penis was returned to its anatomic position by microsurgical technique. Arteries, veins, and nerves were repaired. The penis survived in its entirety. Return of sensation has been excellent. A urethrocutaneous fistula developed that required secondary closure with local flaps. Temporary ectopic replantation of the penis is a useful salvage procedure when the perineum is heavily contaminated or too extensively damaged for immediate replantation.