The lateral osteotomy in rhinoplasty: clinical and radiographic rationale for osteotome selection

A preferred osteotome for endonasal osteotomy would facilitate reliable, complete osteotomies with minimal soft-tissue trauma. In this report, a radiographic evaluation of the bony lateral nasal wall thickness along the track of a high-low-high osteotomy was undertaken to guide the determination of appropriate osteotome size. Bone window axial computed tomographic scans were evaluated in 56 patients with a mean age of 48 years (range, 19 to 86 years). The average thickness along the site of lateral osteotomy was determined to be 2.47 mm (standard deviation, 0.47) in male patients and 2.29 mm (standard deviation, 0.40) in female patients. On the basis of these data, clinical evaluation of prototype 3- and 2.5-mm low-profile guarded osteotomes was undertaken in comparison with a "standard" 4-mm low-profile guarded osteotome to assess both their reliability and the degree of intranasal trauma, as reflected by intranasal mucosal tears. Although 2- and 3-mm unguarded osteotomes are time-tested, they may be reliable only in the hands of the most experienced surgeons. Therefore, a low-profile guard was included in the osteotome design to allow the surgeon to engage the bone securely and minimize the risk of slippage. Forty patients underwent rhinoplasty, for a total of 80 lateral osteotomies; the mean age of the patients was 38 (range, 16 to 75). In all cases, lateral osteotomies were accomplished with one pass. The 4-mm osteotome causes intranasal mucosal tears in 95 percent of osteotomies, the 3-mm osteotome in 34 percent, and the 2.5-mm in 4 percent. Early postoperative edema and ecchymosis were comparable among the groups. One patient, who underwent osteotomies with a 4-mm osteotome, had excessive postoperative narrowing, possibly due to his wearing of eyeglasses earlier than directed. This report suggests that proper selection of osteotome and attention to proper surgical technique results in a reliable, minimally traumatic lateral osteotomy through the endonasal approach. The 2.5-mm osteotome was reliable and the least traumatic to soft tissue of the osteotomes evaluated.     

Modifications in the surgical correction of trigonocephaly

A modified technique for the surgical correction of trigonocephaly is presented. The technical modifications are designed both to increase the stability of fixation of the supraorbital bar and lateral canthal advancements and to increase interorbital distance and anterior cranial fossa volume when utilized in those patients who exhibit the full expression of trigonocephaly, including midline ridging, bifrontal recession, hypotelorbitism, shortened anterior cranial fossa, deficient projection of lateral orbit, and bitemporal narrowing. It is a modification of the supraorbital bar remodeling/advancement procedure as originally described by Marchac with the introduction of a nasofrontal osteotomy and superior osteotomy bone graft and midline miniplate fixation of the supraorbital bar to the nasofrontal junction. Its use in 20 patients has been favorable.     

The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem.Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.     

The use of intraoperative grid pattern markings in lipoplasty

Intraoperative grid pattern markings have been used in the performance of liposuction. Grid pattern markings include series of longitudinal and transverse lines to delineate various anatomical boundaries and landmarks, including the midline, lateral line, and medial line. The markings are superimposed on the customary preoperative markings and divide broad or circumferential body surfaces into smaller subunits for liposuction. Grid pattern markings are applied to areas such as the anterior thighs, medial thighs, entire abdomen, flanks, back, arms, buttocks, calves, and ankles; they are not applied to smaller, less curved areas. Eighty-two consecutive patients underwent lipoplasty in 562 areas of the body. The revision rate for postliposuction contour irregularities was 4.0 percent (nine of 224 areas) where grid pattern markings were used; one area had an indentation type of contour irregularity and required autologous fat grafting. The revision rate was 1.5 percent (five of 328 areas) where grid pattern markings were not used; two areas in one patient had indentation-type contour irregularities and required autologous fat grafting. All remaining areas requiring revision had protuberant-type contour irregularities and responded to additional liposuction only. The use of grid pattern markings is associated with a low incidence of serious contour-related complications.     

Modeling a fibula transplant in mandibular reconstructions: evaluation of the effects of a minimal number of osteotomies on the contour of the jaw.

The fibula osteocutaneous free flap has become the preferred method for most cases of mandibular reconstruction after oncologic surgical ablation. To recreate the parabolic form of the mandible, the fibula has to be divided up into segments using a closed wedge osteotomy technique. The number of osteotomies is preferably kept to a minimum so that segmental periosteal circulation is not compromised and also to keep operating time to a minimum. The limited number of osteotomies creates an angular contour. The aim of this study was to establish the degree to which overcorrection or undercorrection would occur when a subtotal reconstruction from ramus to ramus was simulated using five bony segments and four osteotomies. The study was carried out using 30 preserved jaws; the contour lines of the jaws were transferred onto tracing paper using a cardboard template. The contour of the mandible was divided into five sections (ramus, body, symphysis, body, and ramus). Because of the cutting off of the curvature in the original jaw outline, the lateral side of the body will become narrower and the chin broader. This also results in an underprojection (displacement) of the chin. To follow the original contour of the jaw as accurately as possible, all these anomalies must be minimized. The amount of under- and overprojection is calculated for a displacement of 1.0, 1.5, 2.5, 5.0, 7.5, and 10 mm of the chin. The most accurate reconstruction of the mandibular contour is achieved with a displacement of 1.5 or 2.5 mm. To preserve sufficient periosteal circulation, the minimum width of bone segments must be 15 mm or more. This concerns especially the symphysis section. On the basis of a fibula thickness of 14 mm, the internal bone width of the symphysis section is calculated. With a displacement of 1.5 mm, the average internal width of the bone segment is 14.8 mm, with a range of 9.9 to 23.0 mm (95 percent confidence interval, 12.8 to 16.7 mm). Therefore, a displacement of 2.5 mm with an internal bone width of 16.4 mm is preferred (range, 11.9 to 24.8 mm; 95 percent confidence interval, 15.5 to 18.2 mm). The loss of lateral projection is minimal (5.8 mm) and the resulting chin width is acceptable (average, 35.0 mm). In conclusion, we propose that in a subtotal procedure, an acceptable jaw reconstruction can be achieved with a limited number of osteotomies. The bone length of the symphysis section remains within safe limits. If the defect is of limited dimensions, then the resulting jaw contour is even more accurate.     

Reduction malarplasty through an intraoral incision: a new method

Until recently, osteotomies and surgeries to reposition prominent zygoma have been performed by means of a coronal incision or intraoral and preauricular incisions. Such incisions have penalties such as scars, the possibility of facial nerve injury, and long operative times. After reflecting on their past experiences with facial bone surgery, the authors developed an alternative approach. In this method, the cheekbone protrusion is corrected by performing an osteotomy and repositioning through an intraoral incision only. During the past 3 years, the authors have operated on 23 patients with malar prominences. The amount of bone to be removed is determined by preoperative interviews, physical examinations, and x-rays. Intraoral incisions provide access to the zygomatic body and lateral orbital rim. After L-shaped osteotomies (two parallel vertical and one transverse osteotomy at the medial part of the zygomatic body), the midsegment is removed. The posterior portion of the zygomatic arch was approached through the medial aspect and was outfractured using a curved osteotome. After completing the triple osteotomy, the movable zygomatic complex was reduced medially and fixed with miniplates and screws on the zygomaticomaxillary buttress. The patients were followed for 9.5 months, with acceptable results and few complications. The authors conclude that this technique is an effective and safe method of reduction malarplasty.     

Radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late

It is universally acknowledged that correction of a cleft lip nasal deformity continues to be a difficult problem. In developing countries, it is common for patients with cleft lip deformities to present in their early or late teens for correction of severe secondary lip and nasal deformities retained after the initial repairs were carried out in infancy or early childhood. Such patients have never had the benefit of primary nasal correction, orthodontic management, or alveolar bone grafting at an appropriate age. Along with a severe nasal deformity, they present with alveolar arch malalignments and anterior fistulae. In the study presented here, a strategy involving a complete single-stage correction of the nasal and secondary lip deformity was used.In this study, 26 patients (nine male and 17 female) ranging in age from 13 to 24 years presented for the first time between June of 1996 and December of 1999 with unilateral cleft lip nasal deformity. Eight patients had an anterior fistula (diameter, 2 to 4 mm) and 12 patients had a secondary lip deformity. An external rhinoplasty approach was used for all patients. The corrective procedures carried out in a single stage in these patients included lip revision; columellar lengthening; repair of anterior fistula; augmentation along the pyriform margin, nasal floor, and alveolus by bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; fixation of the alar cartilage complex to the septum and the upper lateral cartilages; augmentation of nasal dorsum by bone graft; and alar base wedge resections. Medial and lateral nasal osteotomies were performed only if absolutely indicated. The median follow-up period was 11 months, although it ranged from 5 to 25 months. Overall results have been extremely pleasing, satisfactory, and stable.In this age group (13 years of age or older), it is not fruitful to use a technique for nasal correction that corrects only one facet of the deformity, because no result of nasal correction can be satisfactory until septal deviations and maxillary deficiencies are addressed along with any alar repositioning. The results of complete remodeling of the nasal pyramid are also stable in these patients because the patients' growth was nearly complete, and all the deformities could be corrected at the same time, leaving no active deforming vector. These results would indicate that aesthetically good results are achievable even if no primary nasal correction or orthodontic management had been previously attempted.     

Refinements in extracorporal septoplasty

Septal deviations interfere with nasal airflow and contribute to deformities in the external appearance of the nose. An aesthetically and functionally satisfactory correction of severe septal deformities or "crippled" septal plates often requires a temporary intraoperative removal of the septal cartilage for appropriate remodeling. This article describes refinements to the previously described technique of extracorporal septoplasty; these refinements have proven useful and have made the procedure safer in the hands of less experienced surgeons. The refinements simplify the straightening methods for the explanted septal plate, achieving a stable and median fixation of the replanted septum while maintaining a satisfactory contour of the nasal dorsum. A milling cutter is used to straighten the irregularities of the explanted septal plate and to thin broadly based anterior nasal spines. When necessary, microplates are added to stabilize the osteotomized and medialized anterior nasal spine. The final positioning of the replanted septal plate is greatly enhanced by a rein stitch, transosseous sutures, and multiple quilt stitches. Additionally, direct fixation of the replanted septum to the edges of the upper lateral cartilages further improves the stability of the reconstruction. Finally, particular care should be taken to avoid residual irregularities of the nasal dorsum; it they occur, these irregularities can be covered with a thin cartilaginous splint or a layer of dehydrated fascia lata or autologous temporal fascia. A total of 436 patients who underwent rhinoseptoplasties at the authors' department during a 1-year period were reviewed. Of these patients, 108 presented with severe septal deviations and underwent an extracorporal septoplasty using the refined techniques described herein. Despite the complexity of the procedure, the patients' satisfaction rates were high, independent of the operating surgeon.     

Lamellar split osteotomy: a new craniofacial technique

Craniofacial osteotomies have by convention been bilamellar translocations of the entire substance of the dysmorphic bone. This approach limits the surgeon by reducing the stable bone mass available for fixation, creating dependence on concave surfaces. Most important, it changes the bony topography that determines the preoperative plan. This paper presents a new craniofacial concept and technique used in 26 patients with various dysmorphic syndromes who were reconstructed by performing a lamellar split osteotomy. This technique maintains the internal lamella in its native position, thereby allowing it to act as a reference for the bony topography and providing a stable facial framework for rigid fixation. This interlamellar osteotomy has led to improved aesthetic results in the orthomorphic reconstructions of congenital and other deformities. It can be used in any aesthetic patient in whom contour changes or augmentation of form is desired. It is recommended as a preferred method for achieving quantitative contour improvement in patients over 3 years of age.     

Nasal osteotomies: a clinical comparison of the perforating methods versus the continuous technique

Do perforating lateral osteotomies cause less ecchymosis and edema compared with the popular continuous method? Many studies have demonstrated that perforated osteotomies cause less trauma and periosteal disruption. Numerous investigators have subjectively perceived less postoperative ecchymosis and edema, but no clinical study has compared the perforated methods versus the continuous technique in the same patient. This prospective, randomized, partially blinded study was designed to test the hypothesis that the perforating method causes less postoperative ecchymosis and edema compared with the continuous lateral osteotomy technique. The questions remain: does the type of perforating osteotomy affect the results? Does a percutaneous approach cause more ecchymosis and edema by the access maneuver of piercing the skin? The two perforating lateral nasal osteotomy techniques require the same 2-mm straight osteotome, so any genuine difference in postoperative ecchymosis or edema could only be attributed to the differing surgical approaches. Accordingly, this study also tests whether the external percutaneous perforating osteotomy causes more ecchymosis and edema than the internal transnasal perforating method. Twenty-five consecutive rhinoplasty patients (group A) requiring bilateral osteotomies (50 total lateral osteotomies) were randomized so that each patient received an internal/transnasal perforating lateral osteotomy (2-mm straight chisel) on one side and an internal/transnasal continuous osteotomy (4-mm curved, guarded osteotome) on the other. The next 25 patients studied (group B) received an external/percutaneous perforating lateral osteotomy (same 2-mm straight chisel as used in group A) on one side and the same internal/transnasal continuous osteotomy on the other. The final 25 consecutive rhinoplasty patients (group C) received an external percutaneous perforating lateral osteotomy on one side and an internal transnasal perforating lateral osteotomy on the other. The entry sites for the perforating osteotomies were either external (groups B and C) with a percutaneous skin puncture or intranasal (groups A and C) at the pyriform aperture. All 75 patients (150 total lateral osteotomies) initialed the surgical plan on the Gunter rhinoplasty worksheet, which has been approved by the Institutional Review Board of Abbott-Northwestern Hospital, Minneapolis, Minnesota (study no. 1341-1 M). All patients were evaluated for ecchymosis and edema on the left versus the right side of the face at 2 to 3, 7, and 21 days after the operation. The clinical evaluation was performed by two blinded examiners (clinic registered nurse and the patient with his or her family) and a partially blinded examiner (the surgeon, who did not refresh his memory about the randomization). To compare the two methods in each study (groups A, B, and C) for the six outcomes (edema and ecchymosis at 2 to 3, 7, and 21 days), the authors used an exact binomial test of the null hypothesis that the treatments do not differ. To compare the two methods in each study (groups A, B, and C) using all six outcomes simultaneously, the authors used a permutation test. By both testing methods, the perforating internal method was superior to the continuous technique (group A; p < 0.01 in both tests). Although the perforating external method gave better results than the continuous technique (group B) and the perforating internal method gave better results than the perforating external method (group C), neither of these differences was significant by either testing method. A lateral osteotomy technique should be precise, reproducible, and safe, and it should minimize ecchymosis and edema. Since edema and ecchymosis are comparable regardless of osteotome size, this prospective randomized study confirms the subjective clinical impression that perforating lateral osteotomies with a 2-mm straight osteotome reduce postoperative ecchymosis and edema in rhinoplasty patients compared with the continuous osteotomy (4-mm curved, guarded osteotome). These findings should encourage te the use of perforating osteotomies rather than continuous osteotomies.     

A problem-oriented and segmental open approach to alar cartilage losses and alar length discrepancies

Alar cartilage losses and alar length discrepancies present problems in nasal tip support, contour, and symmetry. The true extent of the cartilage defect is often not apparent until the time of surgery. This article examines a problem-oriented and segmental open approach to such deformities. It is based on the size of the defect, its location within the dome and lateral crus, and the presence or absence of alar collapse. The defects are classified as major when there is a total or near total loss of the lateral crus, moderate when more than 5 mm is involved, and minor when less than 5 mm is affected. In major defects, a segmental reconstruction of the nasal tip cartilages is undertaken. It consists of a septal graft for columellar support and a conchal shield graft and umbrella graft for nasal tip contour. The whole length of the lateral crus is not reconstructed unless alar collapse is present. In moderate cartilage defects, usually seen laterally in secondary rhinoplasties, the remaining central dome segments are remodeled with shaping sutures. Moderate cartilage length discrepancies, as seen in unilateral cleft lip noses, are equalized through reversed alar rotations. The short crus is rotated laterally, taking length from the medial crus, and the long crus is rotated medially, with the excess advanced into the medial crural footplate. Additional shortening of the long crus can be achieved through cartilage division and advancement. The balanced alar units are then raised with tip projection-vector sutures, and onlay grafts are added if required. In minor cartilage losses, symmetry is usually obtained by shortening the opposite uninjured crus. A total of 33 patients are examined in this review. The average follow-up is 14 months. An improvement in nasal tip shape and support was achieved in all patients.     

Planned angle osteotomy

An improved method for performing angle osteotomies is described. An angle-osteotomy nomogram has been constructed allowing calculation of the width of a wedge osteotomy from the known thickness of the bone and the desired final degree of angulation. Use of the nomogram will speed operating time, improve technical precision, and minimize the chance of inadvertent injury to a vascularized bone graft that might occur in the event of repeated saw cuts.     

How does exercise intensity and type affect equine distal tarsal subchondral bone thickness?

Adaptation of osteochondral tissues is based on the strains experienced during exercise at each location within the joint. Different exercise intensities and types may induce particular site-specific strains, influencing osteochondral adaptation and potentially predisposing to injury. Our hypotheses were that patterns of equine distal tarsal subchondral bone (SCB) thickness relate to the type and intensity of exercise, and that high-intensity exercise leads to site-specific increases in thickness. SCB thickness was measured at defined dorsal and plantar locations on magnetic resonance images of cadaver tarsi collected from horses with a history of low [general purpose (n=20) and horse walker (n=6)] or high [elite competition (n=12), race training (n=15), and treadmill training (n=4)] exercise intensity. SCB thickness was compared between sites within each exercise group and between exercise groups. SCB thickness in elite competition and race training, but not treadmill training, was greater than low-intensity exercise. For general purpose horses, lateral SCB thickness was greater than medial throughout. Horse walker exercise led to relatively thicker lateral and medial SCB compared with the midline. Elite competition was associated with increased SCB thickness of the proximal small tarsal bones medially and the distal bones laterally. For race training and treadmill training, there were minimal differences between sites overall, although the lateral aspect was greater than medial, and medial greater than midline at a few sites for race training. In conclusion, different types of high-intensity exercise were associated with different patterns of SCB thickness across the joints from medial to lateral and proximal to distal, indicating that both exercise intensity and type of exercise affect the SCB response at any particular site within the equine distal tarsal joints.     

Rhinoplasty: a CT-scan analysis

In order to assess the postoperative consequences of various rhinoplasty techniques, CT scans were done in 35 patients having a rhinoplasty operation. This series can be subdivided into those having preoperative and postoperative scans at both 2 days and 6 months (15 patients), a postoperative scan only at 48 hours (10), or a long-term postoperative scan at a mean of 12 months (10). Preoperative analysis indicates that a wide variation exists in lateral nasal wall anatomy and angulation. Surgically, the lateral nasal walls undergo limited medial movement, with tilt a significant component. Postoperatively, extensive remodeling can occur, and virtually all osteotomies are healed by osseous union at 6 months. Future application of CT scans in severely deviated noses may be justified.     

The vascularized pig fibula bone flap model: effect of segmental osteotomies and internal fixation on blood flow

The free fibular flap is the flap of choice for reconstruction of complex mandibular defects, although two or more osteotomies may be required to recreate the normal mandibular contour. The effect of these surgical manipulations on the fibula has not been adequately investigated. This study was designed to study the effect of multiple segmental osteotomies and internal fixation techniques on blood flow in the vascularized pig fibula bone flap model. The hindlimbs of 15 Yorkshire pigs were randomized into 1 of 5 groups (n = 6 fibulae per group) consisting of: (1) a nonoperated, in situ fibula; (2) an elevated fibula flap; (3) an elevated fibula flap with two segmental osteotomies; (4) an elevated fibula with two segmental closing osteotomies rigidly fixed with 2-mm miniplates; (5) an elevated fibula with two segmental closing osteotomies rigidly fixed with 2-mm lag screws. Total and gradient blood flow was measured in the bone and soft-tissue components of these flaps using the 15-microm radioactive microsphere technique. The creation of two segmental osteotomies in the vascularized pig fibula bone flap model resulted in a significant decrease (p<0.05) in the gradient blood flow in the segment of bone distal to the second osteotomy. Application of miniplates or lag screws across closing osteotomies resulted in a significant decrease (p<0.05) in total and gradient blood flow to the bone component of the fibulae, as compared with the elevated and osteotomized fibulae groups. An increase in blood flow suggesting a hyperemic response was noted in the bone and soft tissue in the elevated and osteotomized flap groups as compared with the in situ, nonoperated controls. This study established the validity of the pig fibula as a suitable model for investigating the pathophysiology of blood flow changes in the face of standard surgical maneuvers necessary for the restoration of mandibular form and function. The results demonstrated that the creation of multiple segmental osteotomies and the application of internal fixation significantly decreases (p<0.05) blood flow to the distal portion of the flap. The effects of segmental osteotomies and internal fixation on healing and growth of the pig fibula bone flap model are investigated in a separate study.     

Multiple-segment osteotomy in maxillofacial surgery

Multiple-segment osteotomy is defined as an osteotomy that divides the tooth-bearing arch of the maxilla or mandible into three or more segments. Combining large-segment orthognathic surgery and unitooth or small-segment surgery is an effective approach for dealing with a wide range of dentofacial deformities with occlusal problems. The indications for a multiple-segment osteotomy included dentofacial deformities and malocclusions requiring stable correction within a short overall treatment period. From 1991 to 1997, a total of 85 patients had multiple-segment osteotomy orthognathic procedures performed at Chang Gung Memorial Hospital. The indications for surgery were maxillary protrusion/deformity (31 patients), mandibular prognathism (51 patients), and noncleft maxillary retrusion (three patients). The types of osteotomies performed were Le Fort I, anterior segmental osteotomies of the maxilla or the mandible, palatal split, posterior segment, and unitooth or double-tooth segments. Follow-up ranged from 6 months to 7 years; stability was seen in movements, with only three complications (one partial gingival loss and two inferior mental paresthesias). No osteotomized segments were lost. The average overall treatment time was approximately 15 months, including 3 to 6 months of preoperative and 9 to 12 months of postoperative orthodontic treatment. This is at least 6 months shorter than traditional orthognathic surgery. Experience with 85 consecutive patients has shown that the results are good and the procedure is safe, with minimal complications.     

Achieving consistency in the lateral nasal osteotomy during rhinoplasty: an external perforated technique.

The lateral nasal osteotomy is an integral element in rhinoplasty. A reproducible and predictable technique for the lateral nasal osteotomy (when indicated) is a significant contributor to operative success. A variety of methods and instrumentation are used to produce lateral osteotomies; currently, the two different modes used most frequently are the internal continuous and external perforated techniques. A previously published study by the senior author detailed the benefits of the external perforated osteotomy after comparing the two different methods. This article describes the role of the external perforated osteotomy technique in reproducing consistent results in rhinoplasty with minimal postoperative complications.     

Evaluation of abdominal sensibility after TRAM flap breast reconstruction

One commonly expressed concern regarding transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction surgery is the return of sensation to the abdomen. Although many studies have focused on abdominal wall muscle incompetence or herniation, there is limited literature discussing postoperative abdominal sensation. The purpose of this study was to assess abdominal sensation a minimum of 1 year after pedicled TRAM flap surgery for breast reconstruction. Twenty-five female patients who underwent TRAM flap breast reconstruction a minimum of 1 year before the study were compared with 10 female volunteer controls. Subject and control abdomens were specifically divided into 12 zones, then assessed for superficial touch, superficial pain, temperature, and vibration using various techniques. Fischer's exact test was used for analysis with the p value set at p = 0.05. The degree to which superficial touch was affected was then tested using Semmes-Weinstein monofilaments. Student's t test was used for analysis with the p value set at p = 0.05. For all four sensory modalities, subjects were found to have decreased sensation in zones 5 and 8, the supraumbilical and infraumbilical regions. This was statistically significant. When assessed with Semmes-Weinstein monofilaments, the sensation of the subjects' abdomens was significantly decreased compared with controls. Significance was found in all zones. This study clearly demonstrates that there is a significant and persistent reduction in abdominal sensibility following TRAM flap surgery. The distribution of the deficits is consistent and involves the midline supraumbilical and infraumbilical regions. The TRAM flap has become the procedure of choice for postmastectomy autogenous breast reconstruction. It provides the plastic surgeon with a relatively safe, reliable, and aesthetically pleasing method of breast reconstruction. Since its inception, the TRAM flap and its abdominal closure have undergone numerous modifications designed to minimize donor-site morbidity and create a natural-looking breast. In addition to creating an aesthetically pleasing breast, the TRAM flap has the potential advantage of postoperative improvement in abdominal contour.     

A new surgical technique for phalloplasty in patients with exstrophy of the bladder

Posterior pelvic osteotomy has not been a satisfactory operation to provide penile length in the repair of defects associated with bladder exstrophy. The authors are proposing a new technique based on the movement of the halves of the symphysis and pubic rami (en bloc with the attached corpora cavernosa) to the midline. This is accomplished by osteotomies of the superior and inferior rami and bone grafting of the resulting defects in the superior rami only. The hip joints are not disturbed, risk of complications appears to be reduced, and increased effective penile length is obtained. Cadaver dissections confirmed the practicality of this operation and a successful case is reported. The anatomy and physiology of penile function that is important to surgeons is reviewed.     

The evaluation of knee bone mineral density following open-wedge high tibial osteotomy

Examinations of bone density changes in selected knee bone ends were evaluated prospectively in a randomized group of 28 patients, aged from 41 to 65 (mean: 55.3 years), who had varus deformations of their mechanic limb axes, mean 8 degrees. The examinations were conducted during the preoperative period, 10 days, 3, 6, and 12 weeks, as well as 6 and 12 months after the procedure. A statistically significant increase in bone density was observed in the medial tibial condyle area, while a statistically insignificant decrease of bone density was noted in the medial femoral condyles. Bone density increased in the lateral tibial condyle area, whereas there were no density changes in the area of the lateral femoral condyles. The research results demonstrate that the relief achieved in ailments after high tibial osteotomies does not directly correspond to the bone density of the affected areas.