Correction of severe facial deformity.

A craniofacial team has been developed to corrdinate the treatment of patients with severe facial deformity and to minimize the surgical risks. Two hundred patients have been evaluated in the last 4 years and more than 100 treated by this team to correct orbital hypertelorism, oxycephaly and plagiocephaly with exophthalmos, features of Crouzon''s disease and Apert''s and Treacher Collins syndromes, hemifacial microsomia, and severe lower facial deformity and malocclusion. Surgical principles include extensive subperiosteal stripping of bone, osteotomy as necessary, and repositioning maintained by bone grafts. Postoperative evaluation is being maintained for 5 years or to maturity in younger children. Although many of the results are less than perfect, there has been sufficient improvement, especially psychologic and functional, to warrant continuation of the surgical program under closely controlled conditions.     

Correction of pincer-nail deformity using dermal grafting

Pincer-nail syndrome has been described as distortion in the shape of the nails with excessive transverse curvature of the plate that increases from proximal to distal, leading to pinching and loss of soft tissue in the affected digit, resulting in severe pain. Many treatments have been recommended, but an effective long-term method that preserves the nail matrix has not been described. A method of dermal grafting under the nail matrix is described, and the results of treatment of six digits are reported. Five women and one man with an average age of 52 were treated. The affected digit was the thumb in four patients and the great toe in two patients. Follow-up averaged 25 1/2 months. The results were good in all cases with only one side of one nail remaining slightly curved. Pain was relieved in all cases, and complete adherence of the new nail plate occurred. Dermal grafting seems to provide excellent long-term treatment of the pincer-nail deformity with preservation of the nail matrix.     

Aesthetic reconstruction of the tuberous breast deformity

The tuberous breast deformity is a rare entity affecting young women bilaterally or unilaterally. The deformity is characterized by a constricting ring at the base of the breast, which leads to deficient horizontal and vertical development of the breast with or without herniation of the breast parenchyma toward the nipple-areola complex and areola enlargement. Several methods have been put forward to correct the deformity, but most of these fail to address the issue of the constricting ring and subsequently yield results that are not aesthetically satisfactory. A new approach to the treatment of the deformity is presented, which consists of a periareolar approach and rearrangement of the inferior part of the breast parenchyma by division of the constricting ring, thus creating two breast pillars. These pillars are allowed to redrape, and in cases of volume deficiency, a silicone breast implant is placed in a subglandular pocket. The procedure is completed by a donut-type excision to address the size of the nipple-areola complex. The technique has used on 11 patients (21 breasts) with excellent aesthetic results.     

Expandable breast implant reconstruction of Tikhoff-Linberg shoulder deformity

Expanding breast implants were used in two patients to reconstruct shoulder contour following a Tikhoff-Linberg resection for cancer. In the first patient, one implant alone was used, and in the second patient, two implants in separate but adjacent pockets. The resulting double contour is more pleasing than that after a single implant, and there also appears to be more flexibility with shoulder motion. This method is suggested as an excellent means of reconstructing the contour of the shoulder area following resection for cancer.     

Chest-wall deformity following soft-tissue expansion for breast reconstruction

We have presented a case in which the presumed pressure effects of tissue expansion caused multiple nondisplaced rib fractures of the anterior thorax in a patient undergoing breast reconstruction. Although the deformity was severe, a satisfactory cosmetic result was obtained and there have been no clinically significant sequelae during a 1-year follow-up period. The degree of bony deformation was most likely enhanced by the combination of this patient's severe osteoporosis, chronic steroid use, and peripheral vascular disease. The fragility and ease of fracture in the bones of osteoporotic postmenopausal females and the long-term effects of steroids on tissues is well known. We believe this observation to be important, since many reconstructed patients are postmenopausal and have variable degrees of osteoporosis. Many undergo adjuvant chemotherapy with steroids and antihormonal agents, and this group of women may therefore be at a greater risk for the occurrence of pressure deformities. The incidence and long-term significance of such deformities are not known. The reconstructive surgeon should be alert to the possibility of this phenomenon occurring as a result of tissue expansion in the patient with severe osteoporosis, peripheral vascular disease, or chronic steroid use.     

Chest-wall deformity after tissue expansion for breast reconstruction

A prospective longitudinal study of chest-wall deformity after tissue expansion for breast reconstruction was performed in 19 women. CT imaging was a sensitive method for detecting occult deformity. Using a semiquantitative scale for measuring deformity, all patients and 94 percent of expanders had some thoracic abnormality after tissue expansion. Rib and chest-wall contour changes were observed under 81 and 68 percent of the expanders, respectively. Routine chest roentgenograms were not a sensitive method for evaluating these deformities. The magnitude of deformity after unilateral expansion was not significantly different from that after bilateral expansion. Linear regression analysis indicated that early periprosthetic capsular contracture was negatively correlated with chest wall deformity. Only one patient experienced a clinically noticeable complication from chest compression--transient postexpansion exertional dyspnea. After removing the expanders and placing permanent implants along with capsulotomy, the mean deformity index decreased by 57 percent after 10.5 months median follow-up, which was highly significant (p less than 0.001). Our findings suggest that chest-wall deformity is a common occurrence after tissue expansion in patients undergoing breast reconstruction and is usually of minor clinical significance.     

Ultrastructural equivalents of postburn anuria

Dystrophic and degenerative disturbances in tubular epithelium are established by electron microscopy. Ultrastructural changes suggested that transport mechanisms in the proximal tubule are enhanced by cytoplasm vesiculation and dilation of intercellular spaces. Transepithelial pinocytosis is the basic process in distal tubules.