Faculty Bibliography

BACKGROUND: During cleft palate repair, levator sling palatoplasty with tensor veli palatini tendon transection significantly improves speech results. However, the procedure may pose a risk to eustachian tube function. This study assesses the impact of three types of palatoplasty techniques on eustachian tube function: no tensor transection, tensor transection alone, and a new addition to the palatoplasty technique, tensor tenopexy. METHODS: A retrospective review was conducted of all patients undergoing cleft palate repair at two institutions between 1997 and 2001. Three cleft palate repair groups were studied: no tensor transection (n = 64), tensor transection alone (n = 31), and tensor tenopexy (n = 52). The percentages of patients requiring myringotomy tubes at each year of age were compared among the three groups. RESULTS: By 7 years of age, there was a significantly decreased need for myringotomy tubes in patients who underwent no tensor transection compared with patients who underwent tensor transection alone (38 percent versus 61 percent, respectively; p = 0.05), as well as for patients who underwent tensor tenopexy compared with patients who underwent tensor veli palatini tendon transection (23 percent versus 61 percent, respectively; p < 0.001). Also, by the age of 7, there was a trend toward a decreased need for myringotomy tubes in patients who underwent tensor tenopexy compared with patients who underwent no tensor transection (23 percent versus 38 percent, respectively; p = 0.11). CONCLUSIONS: No tensor transection and tensor tenopexy significantly decrease the need for myringotomy tubes compared with tensor transection alone. There is a small decrease in the need for myringotomy tubes when comparing tensor tenopexy with no tensor transection

BACKGROUND:: The authors assessed the safety and efficacy of a novel cleft rhinoplasty procedure that combines an open rhinoplasty with the Dibbell and Tajima techniques. METHODS:: A single-surgeon, 10-year, retrospective review was conducted of all unilateral cleft lip rhinoplasties (n = 157). Nonsyndromic patients undergoing a combined open incision/Dibbell/Tajima procedure and who had follow-up of greater than 8 months were included. Thirty-five patients were identified. Standardized patient photographs were studied in 18 patients who had both preoperative and 1-year postoperative photographs. Farkas normal values were applied to the medial canthal distance; from this value, metric measurements of changes in alar base width, columellar height, and nostril apex height were derived. RESULTS:: There were no complications secondary to skin envelope ischemia or cartilage graft infection. The revision rate was 11 percent for alar base position, 3 percent for depressed lower lateral cartilage, and 3 percent for nostril apex overhang. After the procedure, there was a statistically significant decrease in alar base width (19.9 mm versus 18.2 mm; p < 0.01) and an increase in columellar height (8.37 mm versus 9.59 mm; p = 0.02) and nostril apex height (4.70 mm versus 5.44 mm; p = 0.02) on the affected side. The differences in alar base width, columellar height, and nostril apex height between the affected and nonaffected sides all decreased significantly postoperatively. CONCLUSIONS:: The combined open rhinoplasty/Dibbell/Tajima procedure is safe, has a low revision rate, and is associated with a statistically significant decrease in alar base width, an increase in columellar height and nostril apex height, and a greater symmetry of nasal form

When the editor asked me to write something related to the chin, I (B.M.Z.) told him I would like to concentrate on the soft tissue of the perioral and chin region, something previously not presented before in this Journal specifically or anywhere. Dr. Flores and I have chosen certain soft tissue cases of the lower face, each of which presents certain dilemmas. The reconstructive methods in each case are unique, previously not shown, and represent salvage from prior failures. Case 1 shows how an interior Abbe flap can be used for ipsilateral lip reconstruction. Case 2 shows how a large upper lateral lip elemental loss can be regained from cheek and not the lower lip. Cases 3 and 4 show how to regain proper white roll bulge and symmetry by overcorrection, then exact adjustment in a second stage. Case 5 shows how a failed chin/lip reconstruction can be salvaged to regain sulcus height and aesthetic unit reconstruction. Each case depicts unique reconstructive designs to produce an aesthetic final result

BACKGROUND: Breast reduction is one of the most frequently performed plastic surgical procedures in the United States; more than 160,500 patients underwent the procedure in 2005. Many outpatient reduction mammaplasty patients report the greatest postoperative discomfort in the first 48 hours. The authors' investigated the effect of intraoperative topical application of the long-acting local anesthetic agent bupivacaine (Sensorcaine or Marcaine) on postoperative pain, time to postanesthesia care unit discharge, and postoperative use of narcotic medication. METHODS: In a prospective, randomized, single-blind trial, intraoperative use of Sensorcaine versus placebo (normal saline) was compared. Postoperative pain was quantified using the visual analogue scale, and time to discharge from the postanesthesia care unit was recorded. Patients documented their outpatient pain medication usage. RESULTS: Of the 37 patients enrolled in the study, 20 were treated with intraoperative topical Sensorcaine and 17 received placebo. Patients treated with Sensorcaine were discharged home significantly faster (2.9 hours versus 3.8 hours, p = 0.002). The control arm consistently had higher pain scores in the postanesthesia care unit (although not statistically significant) than the Sensorcaine group using the visual analogue scale system. Furthermore, patients receiving Sensorcaine required significantly less narcotic medication while recovering at home (mean, 3.5 tablets of Vicodin) than the control group (mean, 6.4 tablets; p = 0.001).There were no complications resulting from Sensorcaine usage. CONCLUSIONS: This prospective, randomized, single-blind study demonstrates that a single dose of intraoperative Sensorcaine provides a safe, inexpensive, and efficacious way to significantly shorten the length of postanesthesia care unit stay and significantly decrease postoperative opioid analgesic use in patients undergoing ambulatory reduction mammaplasty

Successful nonextremity replantations, particularly of the facial anatomy and testicles, are rare procedures, and only a handful of cases have been reported. This article reviews the current literature in nonextremity replantations and representative cases performed at the authors' institution. Certain underlying themes and problems are consistently encountered in the surgical management of these cases. These are identified and reviewed. Although the replantation of these body parts remains technically challenging, all efforts should be made, when indicated, to repair these injuries microsurgically, because it currently offers the best reconstructive solution for these patients

Intraoperative autotransfusion salvages blood shed during surgery for use in immediate resuscitation of the patient. The purpose of this study was to determine whether such autotransfusion decreases the volume of homologous blood transfused in patients undergoing primary cranial vault remodeling for craniosynostosis. The Cobe-Bret 2 autologous blood recovery system (Hemo Concepts, Union, N.J.) was used in 11 cases, and an equal number of consecutive cases did not receive intraoperative autotransfusion. There were no significant differences between the groups with respect to age, sex, and weight. Mean estimated blood loss was 43.2 ml/kg (range, 20.3 to 65.0 ml/kg) in the intraoperative autotransfusion group and 40.2 ml/kg (range, 6.8 to 72.3 ml/kg) in the control group (not statistically significant; p < 0.05). There was no significant difference in volume of homologous blood transfusion between the two groups. The autotransfusion group received 34.1 ml/kg of homologous blood (range, 0 to 60.7 ml/kg), and the control group received a mean of 32.7 ml/kg (range, 14.5 to 60.2 ml/kg). The autotransfusion group received a mean of 10.4 ml/kg of recovered autologous blood (range, 0 to 21.4 ml/kg). In four of the 11 autotransfusion patients, insufficient autologous blood was recovered intraoperatively to warrant transfusion. Results of this study suggest little benefit for the use of intraoperative autotransfusion in primary cranial vault remodeling for craniosynostosis in the young patient. It was hypothesized that this finding was a result of the following: (1) intraoperative autotransfusion blood was usually available only toward the end of the procedure, after homologous blood had already been administered, and (2) the volume of recovered intraoperative autotransfusion blood is minimal, compared with the homologous transfusion volume requirements during an extensive cranial vault remodeling and fronto-orbital advancement procedure. In the context of unproven cost benefit and increasing similar evidence from other comparative studies, emphasis should be directed to other medical and surgical strategies to minimize the need for perioperative blood transfusion