Biomedical subjects
Publications and source records attributed to B M Zide.
Prior irradiation and surgery predispose laminectomy wounds to a higher than usual incidence of wound problems. Likewise the tightness or absence of local fascia in the tethered cord patient make wound closure more complicated. To reduce morbidity, i.e., CSF leak or pseudomeningocele formation, specific techniques are required. These methods are outlined below.
Three different options are proposed to cut the flap after expansion of rectangular tissue expanders. Each method, when used effectively, allows the expander to deliver the full punch of the expansion process.
A technique of wound closure following tethered cord correction is presented that significantly reduces the incidence of cerebrospinal fluid collections in the subcutaneous space. In over 60 cases, the described method of fascia and skin closure has lessened wound problems to a minimal level. Patient hospitalization time has also been greatly diminished.
Because the chin, like the nose, occupies a prominent position in the face, it must also be assessed in planning any changes in the facial profile. For example, a large nose associated with a microgenia does not appear as large when the chin is augmented. A chin increased in the vertical dimension confers an excessively long appearance to the face. Finally, a microgenia is associated with the stereotype of a sluggish personality, and a large chin in women connotes a masculine personality. The authors provide guidelines for assessing these variables and including them in surgical plan.
Computerized tomographic scans provide a new means of evaluating the spatial and geometric relationships between the movement of the bony orbit and its soft tissue contents (the globe and extraocular muscles) [1, 12]. Preoperative and postoperative computerized tomographic scans were analyzed in four patients to explore these relationships. Measurement of the changes in distance between the globes correlated most closely with the change in the distance between the lateral orbital walls; resection of medial (inter-orbital) bone provides space into which the globe is translocated. The medial rectus muscle may be bowed across the medial wall osteotomy line, creating a functional shortening of the muscle; this finding may explain the esotropia that is commonly seen after this procedure [2, 3]. These observations should have a direct impact on the understanding and planning of orbital hypertelorism correction.
This series reports on 20 patients who underwent orbital hypertelorism correction under 5.3 years of age (average age 3.9 years). The patients were followed an average of 5 years, and six patients were followed in excess of 7 years with clinical and cephalometric parameters. The study demonstrated that the procedure could be safely performed at this age and was aesthetically desirable. There was minimal clinical or cephalometric evidence of skeletal orbital relapse except in three patients, for whom individual explanations are given. During the period of postoperative study, nasomaxillary growth and development proceeded as expected, except in those patients with associated clefting. All patients demonstrated increased cranial width measurements preoperatively and postoperatively, but bigonial and bimastoid measurements were generally within normal range. Excessive resection of nasoglabellar skin at the time of hypertelorism correction appeared to adversely affect nasal development.
Surgical bending or contouring of the supraorbital bar may cause inadvertent fractures during craniofacial surgery. Wires may be placed in the bony segments themselves to facilitate reshaping with the Tessier rib bender. The wires are especially helpful in stabilizing the more acute curve at the lateral orbital rim.
An autogenous split-thickness calvarial bone graft that was used to correct a marked depression in the frontal region of the forehead resulted in excellent cosmesis. Cancellous bone from the iliac crest, which was applied between the posterior wall of the frontal sinus and the anterior calvarial bone graft, eliminated the dead space and made infection less likely in an area prone to such infections.
The soft-tissue chin may become ptotic following surgery in this area. The mentalis muscles which are responsible for proper central lip motion and chin point position may be affected. The mentalis muscle origin may require resuspension at a proper level. This reattachment may be performed by means of an intraoral approach. Non-absorbable sutures are used to hold the soft-tissue chin upward. The exact method involves placing drill holes through the alveolar bone, into which sutures are passed. These sutures are then placed through the lower mentalis muscles and tightened. Chin and lip position may be corrected in certain cases. Ancillary procedures are required to correct vestibular scarring and submental scars.
The keystone for successful reconstruction of the medial canthal area is adequate positioning of the medial canthal complex to maintain proper intercanthal distance and apposition of the lids to the globe. This requires an understanding of the dynamics of the tripartite insertion of the MCT and its relationship to the medial orbital wall. We have previously described a technique for transnasal wiring based on anatomic studies that is anatomically and physiologically precise and that is applicable to a variety of clinical situations. Soft-tissue problems need to be dealt with on an individual basis with grafts, flaps, or a combination of these modalities.
Fifty-eight patients with previously irradiated intramedullary spinal cord astrocytomas underwent laminectomy for radical excision of their tumors. A high incidence of postoperative cutaneous cerebrospinal fluid fistulas and large pseudomeningoceles following routine closure prompted the development of an alternative method of wound closure using mobilized musculofascial flaps. The authors describe the surgical techniques and pitfalls to be avoided during the closure of complicated laminectomy wounds.
Observed variations in face-life technique prompted an analysis of these techniques to determine whether experience correlated with certain aspects of the surgery. A questionnaire was returned by 565 of 1,750 plastic surgeons, quantifying varying techniques in over 121,000 face lifts. The respondents were placed into three groups according to the number of rhytidectomies performed, and correlations were determined.
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