Faculty Bibliography

This retrospective study evaluates 11 infections requiring hospital readmission following 6166 consecutive face lifts (0.18 percent). Seven patients had surgical drainage of an abscess, and four patients were treated for severe cellulitis, Staphylococcus was the predominant organism in all abscess cultures. Of three patients admitted 3 weeks after surgery, two cultured gram-negative organisms in addition to Staphylococcus. This suggests that all patients should be treated initially with Staphylococcus coverage. If a patient is readmitted more than 1 week postoperatively, gram-negative coverage should be considered, pending culture results. There was no consistent finding regarding past medical history, the use of perioperative antibiotics, surgical equipment used, complexity of the surgical dissection, drains, or hematoma formation. No patients demonstrated systemic signs or grossly abnormal laboratory results on readmission. Eight patients had no sequelae from the infection. Three patients developed scarring that was considered minor by the affected patients. These data support the conclusion that major infections following a face lift are rare occurrences. Standard medical and surgical care, given in a timely fashion, usually results in a satisfactory outcome with minimal morbidity

The microvascular surgical anastomosis remains one of the most technically sensitive aspects of free-tissue transfers. To facilitate these often time-consuming, difficult anastomoses, various anastomotic coupling systems have been introduced. The 3M microvascular anastomotic coupling device, a polyethylene ring-pin device, was found to be highly successful in numerous animal studies. It has been available for use in human subjects for the last 4 years, but clinical experience remains sparse. Our clinical experience with the 3M coupler is reported in 100 free-tissue transfers. The average anastomotic time was 4 minutes. Mean follow-up was 8.6 months, and flap survival was 100 percent. The overall success rate for 3M (MACD) coupler use in microvascular anastomoses is 98.4 percent (121 of 123). Nine abandoned anastomoses were converted to sutured anastomoses intraoperatively. The over-all failure rate for 3M coupler anastomoses is 1.6 percent (2 of 123). We conclude that the 3M device is best suited for minimally discrepant, soft, pliable venous microvascular anastomoses and is unsuitable for end-to-side anastomoses in clinical situations. When carefully and selectively employed by a trained microvascular surgeon, the 3M coupler can be a safe, fast, and reliable adjunct for free-tissue transfers

Adequate knowledge of perforator location preoperatively will enable the surgeon to achieve optimal flap design and flap survival. Most previous attempts have relied on the use of Doppler ultrasound and earlier anatomic knowledge. With ultrasound, there may at times be signals from overlapping blood vessels. Magnetic resonance imaging (MRI) is sensitive to flowing blood and, on an MRI scan, dark-flow void characterization is used to identify perforators. This study was undertaken to evaluate the anatomic location and the number of perforators in the flap zone, based on inherent blood flow, and to determine information about the dominant perforators for free-flap design, using MRI. The CSMEMP technique allowed the characterization of flow void signals, which appeared in the image as dark spots. This technique also enabled differentiation of the surrounding tissue, with a high degree of accuracy. The relationship of the perforators aided in an 'ideal' flap design. No necrosis was noted in any of these cases. It appears from this study that MRI can be a useful imaging modality, to assess the location and number of perforators in musculocutaneous flaps

A rat model has been devised to study the determinants of microvascular anastomotic patency in the setting of diameter discrepancy. Isogeneic interposition grafts of rat inferior vena cava were used to repair a femoral artery defect (diameter ratio 4.5:1). Three methods for compensating for diameter discrepancy were studied. The anastomoses were explored on postoperative days 3, 7, and 14. By 2 weeks, tapered grafts were shown to result in higher patency rates (p < 0.05) compared with nontapered and spatulated grafts. Hemodynamic, histological, and scanning electron microscopic analysis suggested that turbulence caused by large velocity gradients predisposes to thrombosis. This animal model was shown to be sensitive to experimental hemodynamic alterations and may be useful in elucidating the effect of technical or pharmacological manipulations on patency in the setting of vessel diameter discrepancy

OBJECTIVE: This study was designed to compare the three-point Dixon technique with our present MR protocol incorporating T2-weighted fast spin echo and fast spin echo with water suppression to detect ruptured silicone breast implants. SUBJECTS AND METHODS. Eighty-two symptomatic women with silicone breast implants were examined with both the three-point Dixon technique and fast spin-echo MR sequences. Of these patients, 41 had surgery to remove their implants. Four radiologists reviewed the images from only those patients who had surgery and graded each for rupture by using a scale of 1-5. Receiver-operating-characteristic analysis was performed. RESULTS. Of 81 implants removed, 18 were ruptured. Silicone implant ruptures were identified more frequently on the fast spin-echo sequence than on the three-point Dixon sequence, with areas under the ROC curves of .95 and .84, respectively. Although the difference was not statistically significant, the sensitivity for detecting silicone implant rupture was 89% for the fast spin-echo sequence and 61% for the three-point Dixon sequence. The specificity was 97% for both sequences. CONCLUSION. Silicone implant ruptures were detected more frequently with fast spin-echo MR sequences than with the three-point Dixon technique, although the difference was not significant. The greater spatial resolution used for the fast spin-echo sequence partially accounts for the difference in detection of implant ruptures in this study

BACKGROUND. An alternative to mechanical stapling or hand suturing is needed to permit laparoscopic common bile duct exploration. We evaluated the strength and healing characteristics of canine choledochotomies sealed with a fibrinogen solder and a diode laser. METHODS. After creation of a 0.5 cm longitudinal choledochotomy, the edges were coapted with forceps, and a fibrinogen solder mixed with indocyanine green dye was applied. The solder was sealed in place with an 810 nm diode laser (125 W/cm2). RESULTS. Immediate mean leakage pressure was 264 +/- 7 mm Hg compared with 83 +/- 66 mm Hg in suture controls. This increased to 364 +/- 115 mm Hg at 2 days and was more than 510 mm Hg at 7 days. On histologic examination rapid reabsorption of the solder with no signs of inflammation or stenosis was seen. No episodes of dehiscence or peritonitis occurred. CONCLUSIONS. Laser soldering provides a watertight choledochotomy closure with adequate immediate strength allowing a reliable, technically feasible common bile duct exploration via a laparoscopic approach

Twenty-one consecutive patients who had earlier superiorly based pharyngeal flap surgery and persistent velopharyngeal insufficiency were seen between 1976 and 1991. Patients were divided into two treatment groups, depending on the results of videofluoroscopic and nasopharyngoscopic assessment. The first group consisted of 18 patients who had bilateral port insufficiency and required a complete reconstruction of a new superiorly based pharyngeal flap that was elevated from a scarred posterior pharyngeal wall. After an average follow-up of 6.2 years, 15 patients had normal resonance, 2 patients had improvement but continued hypernasality, and 1 patient was hyponasal. The second group consisted of 3 patients who had 'patch' flaps to a unilateral port insufficiency. Postoperatively, all 3 of those patients had normal resonance. Indications for the decision to 'redo' or patch flaps are described

The effects of unilateral facial nerve ablation on craniofacial development in the rabbit were examined. In this experimental model, 10 newborn rabbits 12 days of age underwent unilateral resection and cautery of the facial nerve. They were allowed to grow to skeletal maturity and were sacrificed at 6 months. Analysis of variance was used to compare direct measurements of prepared skulls in the experimental animals with 3 unoperated control litter mates and with 5 litter mates who underwent a sham procedure (exposure of the facial nerve without section). The animals with facial nerve resection demonstrated an average snout deviation toward the side of injury of 8.3 degrees, apparently due to shortening of the maxilla and mandible on the affected side. This study provides new data regarding the role of the functional matrix in the modulation of craniofacial growth and development

Eighty-six patients with anterior neck burn sequelae underwent scar resection up to the limits of the aesthetic unit of the neck and immediate resurfacing with a scapular-parascapular free flap (the extended scapular flap). The flap was raised in all patients above the deep fascia as a thin skin-subcutaneous tissue flap, providing an initially acceptable aesthetic result. The flap was anastomosed to the facial artery and vein. The donor area was closed directly, or a 4- to 5-cm-wide skin graft was used which could be completely removed in a secondary procedure if the patient requested it. There were four failures early in the series but no losses in the last 70 patients. In order to improve the final aesthetic result, 45 patients underwent complementary defatting procedures (average of three) and Z-plasties initiated 30 days after the initial surgery at intervals of 1 month. Analysis revealed 96 percent good aesthetic results (as determined by the cervicomental angle obtained and the subjective opinion of the patients). There were no recurrences of scar contractures, and good function of the neck was regained in the majority of the patients. Anterior neck burn sequelae thus can be safely treated with en block resection and resurfacing using this flap