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Background: The technique of facial bipartition has been considered a great advance in achieving a more natural appearance in hypertelorism correction. Methods: Fourteen patients who had undergone hypertelorism correction by facial bipartition were retrospectively studied to analyze the role of three-dimensional computed tomographic reconstruction in the evaluation of the deformity and preoperative planning. The procedure and surgical details that can improve the outcome were described. A reproducible set of three-dimensional measurements that can help in preoperative patient evaluation was determined based on information obtained using the Analyze/AVW 3.1 system (Biomedical Imaging Resource, Mayo Foundation, Rochester, Minn.). Results: In this series, the most common diagnosis was frontonasal dysplasia (64.3 percent). Five patients had seconddegree (35.7 percent) and nine had third-degree hypertelorism (64.3 percent). The three-dimensional scans were shown to be highly accurate in predicting the degree of deformity. There was a significant difference in the preoperative and postoperative interdacryon distance and midface height (p < 0.05) but not in the bitemporal distance (p = 0.08). The simulation correlated significantly with the postoperative result when interdacryon distance and midface height were analyzed (0.736 and 0.999). Conclusions: Facial bipartition provided a three-dimensional correction of hypertelorism. Three-dimensional imaging can definitely be considered an extra tool for accurate surgical planning and helping the family understand the surgical procedure and the end result.

Background: Management of benign chronic frontal sinus disease is difficult. Patients are frequently seen by multiple specialties for medical treatment and endonasal procedures before they seek or require definitive treatment with frontal sinus obliteration. The progression of the disease may lead to serious or life-threatening conditions such as local bone destruction, periorbital abscess, osteomyelitis, meningitis, cranial epidural abscess, or septicemia. This study presents the use of the galeal-frontalis myofascial flap as part of the treatment of this disease. Methods: Thirty-one patients with chronic frontal sinus disease requiring obliteration were included in this study; all were approached through a coronal incision. The anterior wall of the frontal sinus was removed and the frontal sinus disease was evacuated. The sinus mucosa was completely removed, and the frontal sinus and nasofrontal duct were totally obliterated with either a unilateral flap or a bilateral galeal-frontalis flap. Results: All patients had failed medical therapy and many had failed endonasal and endoscopic procedures. The mean follow-up was 43.6 months (range, 1 to 125 months). There were two early complications, a seroma and a hematoma. Sinus infection recurred in one patient 3 months postoperatively. The recurrent infection was treated in the same manner, using the available and viable galeal-frontalis flap to obliterate the frontal sinus, with no recurrence after 40 months. Conclusions: The galeal-frontalis flap has been investigated by angiography and is based on the supratrochlear and supraorbital vessels. Its location and vascularity make it reliable and effective for frontal sinus obliteration. In the head and neck area and elsewhere, filling defects with vascularized tissue prevents infection. A further advantage is that any residual defects are usually well tolerated by patients, and those requesting correction can be easily accommodated. The risks and complications from using exogenous materials and from performing secondary procedures for graft harvest are avoided. Considering that most patients presented with complications from advanced disease and that after one revision no patients have had recurrence of disease, obliterative treatment with the galeal-frontalis myofascial flap should be contemplated earlier in treating patients with chronic frontal sinus disease.

Surgery is accepted as one of the most demanding professions that create both physical and mental strain on the performers. Therefore, the authors aimed to elucidate the mental burden of surgeons, which is dedicated to operative stress. They also tested the hypotheses that participating in surgery creates mental stress on surgeons that leads to cardiovascular changes, and that this stress is more pronounced for actual operators than for first assistants. The method chosen for this purpose was an analysis of heart rate variability. Twelve surgeons (five plastic surgery staff and seven plastic surgery residents) were monitored by a digital ambulatory Holter recorder on at least two occasions. Half of the recordings were carried out on operating days and the other half on office days. Heart rate variability indices (low frequency, high frequency, high frequency/low frequency ratio, and heart rate) were analyzed from those recordings using computerized research tool software. The heart rate variability indices of the operators showed statistically significant differences between operating days and office hours in favor of an increased sympathetic and decreased parasympathetic activity for the former. For first assistants, three of the parameters, with the exception of heart rate, changed in favor of a sympathetic predominance over parasympathetic activity; these changes were also statistically significant. These results showed a sympathetic hyperactivity for both operators and first assistants during the operations. When the sympathovagal balance of the actual operators was compared with that of assistants, the former group showed a more pronounced sympathetic arousal. This difference is accepted as a proof for the mental stress of the surgery being the main factor responsible for the sympathetic hyperactivity that we detected during the operations. Surgeons continuously face a unique mental strain that other professions rarely bring forth, and these psychological stressors are associated with alterations in cardiac autonomic control that may contribute to the development of cardiac disease. Prolonged sympathetic hyperactivity could anticipate cardiac discomfort in more experienced surgeons with marginal cardiac reserve. Such cardiac diseases would be reconsidered as occupation-related illnesses, which might be reimbursed to the physician. In addition, the legal responsibility of surgeons concerning their unfavorable results might be assessed with more understanding with a realization of their undue working conditions.

Augmentation of the craniomaxillofacial region is required for many aesthetic and reconstructive procedures. A variety of different materials and techniques have been used. Coralline hydroxyapatite has proved to have biocompatible properties as a bone graft substitute. This study further analyzes the use of porous coral-derived hydroxyapatite granules in craniomaxillofacial augmentation for cosmetic and reconstructive purposes and evaluates the long-term clinical result. This retrospective study reviewed the use of porous coral-derived hydroxyapatite granules over a 20-year period, between 1981 and 2001, in 180 patients, in whom 393 procedures were performed. The surgical technique is described and discussed. Statistical significance was evaluated by descriptive statistics and the correlation bivariate Spearman's test (p > 0.05). For 61.6 percent of the procedures, the surgical indication was reconstructive and in 38.4 percent, cosmetic. The maxilla was the most common site of surgery (44.3 percent), followed by the mandible (21.6 percent) and zygoma (15.4 percent). The complication rate was 5.6 percent (n = 22 of 393), with contour irregularities being responsible for 59 percent (n = 13 of 22). Both infection and granule extrusion were responsible for 1.3 percent of the complications. Good results were achieved in 96.4 percent of the procedures. Porous coral-derived hydroxyapatite granules have shown considerable efficacy and versatility in craniofacial contour refinement and augmentation. They are stable, biocompatible, and safe. A sterile technique is advised, with care taken not to tear the periosteum in the pocket design and with subperiosteal placement of the granules, compaction of the granules at the site, overcorrection of 15 percent of the required total volume, watertight closure, and postoperative taping to prevent mobilization. The correct surgical indications and adherence to the principles stated above will result in a very satisfactory long-term outcome.

Lymphangioma circumscriptum of the penis and scrotum is an unusual entity that may be indistinguishable from genital warts. After confirmation of the diagnosis, a treatment plan consisting of wide excision should be outlined. To lower the chance of recurrence, not only the affected skin but all the subjacent subcutaneous tissue, including the deeper components of the lymphatic malformation just above the deep fascia, should be removed.

Reconstruction of the exenterated orbit is a difficult problem with several advantages and disadvantages. Satisfactory reconstructive results for both the physician and the patient may need multistage operations that are time consuming and disfiguring. A simple and effective one-stage technique that combines two regional flaps is described for reconstruction of deformities of orbital exenteration. A temporalis muscle flap is transposed for orbital filling, and a prefabricated frontal island flap based on superficial temporal vessels is used for eye socket and eyelid reconstruction. For patients who oppose living with exenteration deformity and request quicker reconstruction, this new and simple technique may be used successfully.

For the past 15 years, a forehead flap with its pedicle based at or below the medial canthus has been used without any flap loss. This study describes the anatomical vascular relationships allowing this flap design to be successful.Nine fresh frozen cadaver heads were studied in three groups. Six heads were injected with red latex. In group I, the supraorbital, supratrochlear, and facial arteries of four heads were dissected out under the operating microscope. In group II, using two latex-injected heads, the median forehead flap was elevated in the extended fashion and the arteries within the flap were dissected. The distal portion of the flap was elevated supraperiosteally and the proximal portion was elevated subperiosteally. In group III, the arterial systems of three heads were injected with barium solution after the flaps had been elevated. Radiographic assessment was used to demonstrate the vascular pattern within the flap.Group I showed an anastomotic relationship between the supratrochlear and facial arteries and a consistent relationship between the infraorbital and facial arteries. Group II showed that the above-mentioned connections could be protected during the supraperiosteal and subperiosteal flap elevation. This was confirmed by radiographic assessment in group III. The vascular network of the flap was filled through the facial artery by means of the dorsal nasal and supratrochlear arteries.Within the paranasal and medial canthal region, there is an anastomotic relationship between the supratrochlear, infraorbital, and branches of the facial arteries, and branches from the contralateral side, creating a rich vascular arcade. This allows a median forehead flap to be narrowly based at the level of the medial canthus.

Yavuzer, Reha/0000-0002-8549-0875; AYHAN, MEHMET SUHAN/0000-0002-5067-6450; Findikcioglu, Kemal/0000-0002-8276-5730 WOS: 000246032200009 PubMed: 17440343 Background: Research in prevention of partial flap necrosis has recently concentrated on extending the safe length of a flap by ligating vessels of known territories. To advance this approach one step further, the authors decided to reveal the least invasive surgical strategy for transfer of angiosomes. Methods: The study was arranged into three experiments. In the first experiment (n = 17 rabbits), a cutaneous island flap model spanning four adjacent vascular territories was developed. In the second experiment (n = 15 rabbits), the flap model was used to test the possibility of desiccating those vessels supplying the angiosomes to be captured percutaneously with radiofrequency. The delay procedures were performed by means of minimal skin incisions, and the flaps were elevated after a 2-week delay period. In the third experiment, the effectiveness of selective interference of these pedicles was compared to minimize the number of target vessels for successful transfer of angiosomes. Results: The mean surviving area of the new flap model was 63 +/- 2 percent. The mean surviving flap area was 97 +/- 3 percent for the endoscopy equivalent technique and 94 +/- 4 percent for radiofrequency delay. The results were statistically insignificant between these two groups. In experiment 3, comparison of the results yielded a statistically insignificant difference for flap survival area among all four of the groups. Conclusions: An alternative flap model is introduced for future investigation of the vascular delay process. Percutaneous desiccation of the perforators with radiofrequency was found to be a reliable method, and selective desiccation of the perforator(s) was as efficient as destruction of all vascular sources other than the pedicle.

A total of 18 patients with massive vascular malformations of the head and neck region were treated with compartmentalization using nonabsorbable sutures followed by injection of a sclerosant agent into each compartment. The indication for compartmentalization was either to stop potentially uncontrollable, life-threatening hemorrhage during the dissection of the lesion or to reduce its vascularity to allow a less dangerous subsequent resection. Compartmentalization was used in both high-flow and low-flow vascular malformations. In this technique, large nonabsorbable sutures are placed deeply in multiple areas within the lesion. The aim is to divide the malformation into multiple compartments by changing the direction of the suturing; in this way the sclerosing agent is provided with a more effective environment. The sclerosant used was either sodium tetradecyl sulfate 3%, absolute alcohol, or both. The total amount of infiltrate varied from 3 to 35 cc, according to the size of malformation. After compartmentalization, swelling was the most noticeable complication. With this technique, it was possible to treat what were considered untreatable malformations using standard techniques and to control the inevitable serious bleeding.

Malfunction of the marginal mandibular nerve, either in combination with a generalized facial palsy or in isolation, can cause an unpleasant and disturbing appearance around the mouth. In total palsy, a cross-facial nerve graft combined with a free vascularized muscle transplant will usually deal with this problem successfully; however, all older procedures used in this situation are unpredictable. For the isolated palsy, procedures such as digastric muscle transfer or sling suspension are not uniformly successful. A method using the contralateral, nonaffected lower lip orbicularis muscle is described. A wedge is removed from the paralyzed lower lip and the orbicularis is advanced to the modiolus to provide a functional orbicularis all the way across the lower lip up to the angle of the mouth. This is a simple outpatient procedure that has produced satisfactory results in most cases.

Various measurements are still considered to be important for making decisions regarding the approach in reduction mammaplasty, even though the vast majority of techniques used are based on an inferior pedicle. This study was performed to analyze the variability of the suprasternal notch-to-nipple and nipple-to-inframammary fold distance measurements when using the inferior pedicle technique. In 92 patients, 184 breasts having various volumes were measured preoperatively, and the variability of the measurements of the suprasternal notch-to-nipple and nipple-to-inframammary fold distance was analyzed. The values of the distance from the suprasternal notch to nipple were dispersed over a wide range with a trimodal distribution, with peaks at the intervals of 23 to 27 cm, 28 to 33 cm, and 34 to 45 cm. In contrast, the values of the nipple-to-inframammary fold distance showed a normal distribution pattern, with the peak at 14 cm. The distance from the suprasternal notch to nipple has a fair relationship to the inframammary fold-to-nipple distance, the latter being concentrated in a smaller range (r = 0.51). The former is often used to decide whether a free-nipple graft should be performed. However, the relative consistency of the latter measurement has led to the conclusion that the free-nipple graft technique need never be considered.

The combination of chemical peeling and dermabrasion for the improvement of facial wrinkles, acne, posttraumatic scars, and abnormal pigmentation was first described by Dupont in 1972 and Horton in 1984. We have been using the combined technique since 1972, and we have obtained more satisfying results than by using these techniques independently. The purpose of this paper is to summarize the results obtained using the combined technique of chemical peeling and dermabrasion and to emphasize a simple method of postoperative care that can be applied after any physical or chemical rejuvenation technique. Whereas the combined technique takes advantage of depth-controlled surgery, less bleeding, less postoperative pain, less risk of local and systemic complications, and longer lasting results, the covering of the wound with one layer of fine mesh gauze is another advantage that provides easy postoperative care.

Hypospadias surgery is one of the most challenging surgical interventions that still need further refinements for increased success rates. During the last 5 years, we operated on 26 mid-penile or proximal hypospadias cases by using vascularized double-sided preputial island flap and W flap glanuloplasty to achieve superior functional and aesthetic results. Follow-up period of the patients revealed a 92.3 percent success rate with a single operation. Two cases developed fistula, which was located at the proximal anastomosis site. However, they were repaired in a second sitting without any additional problem. The basic aim in hypospadias surgery is the correction of chordee, reconstruction of urethra, and sufficient ventral penile skin coverage in one stage with minimal complication. The use of vascularized tissue for urethral reconstruction and ventral coverage is believed to have a superior healing capacity with better functional and cosmetic outcome. On the other hand, adding W flap glanuloplasty to this technique avoids the risk of meatal stenosis. We conclude that by combining the two above-mentioned techniques, it is possible to cope better with this devastating congenital deformity.