Some technical considerations in primary rhinoplasty

Technique in rhinoplasty is discussed in terms of safety, facility, and versatility. Nasal appearance results from the anatomic variation of the component parts. Technique should reflect modifications necessary to correct unpleasant features while respecting anatomic limitations. Techniques are described for dorsal reduction and tip modification by methods that consider surgical exposure and the relation between structural anatomy and external appearance.     

Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions

OBJECTIVE: To demonstrate the flexibility of the endoscopic transsphenoidal approach, with respect to nasal and paranasal anatomic features and the extension of different sellar lesions, for customization of the procedure for specific conditions. METHODS: In 16 of 170 consecutive endoscopic transsphenoidal operations, some modifications of the standard approach were adopted to optimize surgical removal of different lesions. These modifications consisted of a hemisphenoidotomy, a partial ethmoidectomy, extended sellar floor opening toward the planum sphenoidale or the clivus, enlarged opening of the sphenoid ostium area with ipsilateral removal of the superior turbinate, and a bilateral approach. RESULTS: The endoscopic endonasal procedure is easily adaptable to different specific conditions, with slight changes in the standard approach (more or less invasive). Therefore, this surgical procedure is satisfactory for different lesion locations and for the nasal and paranasal sinus anatomic features of individual patients. CONCLUSION: The endoscopic surgical route should be tailored to different sellar lesions, and some modifications of the procedure are recommended in selected cases.     

Methods of safe laparoscopic cholecystectomy for left-sided (sinistroposition) gallbladder: A report of two cases and a review of safe techniques

INTRODUCTION

Left-sided gallbladder is a rare anatomical variation. Usually it is discovered intra-operatively and is accompanied by anatomic variations that can prove quite challenging during laparoscopy.

PRESENTATION OF CASE

From a total of almost 3000 laparoscopic cholecystectomies performed in our institution, two cases of left sided gallbladder were unexpectantly identified intraoperatively. There were no indications for the ectopy preoperatively. In both cases modifications of the standard laparoscopic technique were mandatory. They were performed safely with no post-operative complications. Modifications consisted of transposition of the subxiphoid entry port and alteration in the direction of traction of the rest of the graspers. A review of the literature for methods of safe laparoscopic cholecystectomy was conducted.

DISCUSSION

The surgeon must be aware of the anatomic variances in the rare occasion of a left sided gallbladder, since preoperative diagnosis is very difficult.

CONCLUSION

Knowledge of potential hazards and modifications of laparoscopic technique is mandatory in order to avoid complications.     

Computational bone remodelling simulations and comparisons with DEXA results.

Femoral periprosthetic bone loss following total hip replacement is often associated with stress shielding. Extensive bone resorption may lead to implant or bone failure and complicate revision surgery. In this study, an existing strain-adaptive bone remodelling theory was modified and combined with anatomic three-dimensional finite element models to predict alterations in periprosthetic apparent density. The theory incorporated an equivalent strain stimulus and joint and muscle forces from 45% of the gait cycle. Remodelling was simulated for three femoral components with different design philosophies: cobalt-chrome alloy, two-thirds proximally coated; titanium alloy, one-third proximally coated; and a composite of cobalt-chrome surrounded by polyaryletherketone, fully coated. Theoretical bone density changes correlated significantly with clinical densitometry measurements (DEXA) after 2 years across the Gruen zones (R2>0.67, p<0.02), with average differences of less than 5.4%. The results suggest that a large proportion of adaptive bone remodelling changes seen clinically with these implants may be explained by a consistent theory incorporating a purely mechanical stimulus. This theory could be applied to pre-clinical testing of new implants, investigation of design modifications, and patient-specific implant selection.     

Second Prize: Pelvic neuroanatomy and innovative approaches to minimize nerve damage and maximize cancer control in patients undergoing robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy is an option for surgical management of clinically localized prostate cancer. There have been theoretical concerns, however, regarding lack of anatomic data with specific relevance to robot-assisted prostatectomy, use of thermal or electrical energy during nerve sparing, and lack of tactile feedback. To address these concerns, we have revisited anatomic foundations and have incorporated a few modifications and strategies in the technique of robot-assisted prostatectomy to maximize cancer control, preserve neurovascular tissue, and emulate time-tested steps of anatomic radical prostatectomy. We present our findings about neural anatomy, modified technique, and oncologic and functional outcomes from patients who have undergone this procedure at our institution.     

The fallacy of the conjoined tendon: The etiology and repair of inguinal hernia

Many methods of hernial repair and their modifications have been devised. With some trepidation, the present one is submitted because of its anatomic soundness. This repair takes cognizance of the structural relationships in this part of the body without gross disturbance to their physiology.     

Lateral shoulder graft for microsurgic plasty of hand and foot

The authors have thoroughly studied the versions of anatomic structure, peculiarities of blood circulation and innervation of lateral arm graft at 20 recent cadavers. The graft can be utilized in different modifications; cutaneofascial, subcutaneofascial, musculocutaneous, osteocutaneous. In the clinic were made 8 free microsurgic transplantations of lateral arm graft for plasty of tissues of different genesis in functionally important zones of hand and foot. In long-term post-operative period all patients demonstrated good functional and cosmetic results.     

Uncommon anatomic variations in patients with chronic paranasal sinusitis.

OBJECTIVE: Some uncommon anatomic variations would be encountered with the increasing number of patients with chronic paranasal sinusitis who have undergone functional endoscopic sinus surgery. The correct identification and proper treatment for these variations are important. STUDY DESIGN AND SETTING: A retrospective study of serial computed tomography scan images was conducted in 100 patients collected randomly. Uncommon anatomic variations were recorded and clinical features were analyzed. RESULTS: Five (5%) cases with uncommon anatomic variations were found. These variations included bilateral pneumatization of uncinate process (1%), large uncinate process mimics the middle turbinate (1%), nontraumatic protrusion of orbital contents through dehiscence of lamina papyracea (1%), and nasal septal pneumatization (2%). Two of these 5 cases caused some modifications of routine functional endoscopic sinus surgery procedures and another 2 variants commanded further caution during routine uncinectomy. CONCLUSION AND SIGNIFICANCE: Uncommon anatomic variations, though unusual, are not rare in chronic paranasal sinusitis patients. Procedures should be tailored for most of these special conditions.     

Anatomic repair for chronic lateral ankle instability

Symptomatic ankle instability will develop in upto 20% of patients after inversion injury. Although most patients can be successfully managed with rehabilitation and bracing, some will continue to suffer recurrent ankle instability with activities of daily living, work on uneven terrain, or sports. For this group of patients, we advocate direct anatomic surgical repair with the Brostrom procedure with or without its modifications.     

The area of transposition of the pedicled deep inferior epigastric perforator flap: an anatomical study

The area of transposition of the pedicled deep inferior epigastric perforator (DIEP) flap was assessed in three fresh anatomic specimens. Both horizontal and vertical flap modifications were transposed in anteroposterior and transverse directions as well as in between. The large arc of rotation to the lower thorax, the lateral side of the body, the trochanteric region, upper leg, perineum and contralateral groin enables transposition of viable tissue up to 180° to both sides to areas known to produce reconstructive problems because of lack of sufficient local tissue. Received: 25 September 1998 / Accepted: 4 March 1999     

Histologic Findings in Axillary Hydradenosuction

Liposuction or its modifications have become accepted therapy for hyperhidrosis. During the nearly 20 years since its introduction, the actual anatomic removal of sweat glands has not been investigated. In this study, three patients underwent axillary liposuction and histologic examination of the aspirates. Apocrine sweat glands embedded in adipose tissue were found throughout the crosscuts. These results prove that the therapeutic effects are at least partially attributable to removal of glandular tissue.     

Comparison of mechanical performance among different frame configurations of the Ilizarov external fixator: experimental study

The circular frame of the Ilizarov fixator can be modified to reflect anatomic variations and treatment aims. However, these modifications in the frame system cannot always achieve the mechanical performance of the standard frame system. A standard system has two rings in each bone fragment connected by four longitudinal bars on each side of the ring. In this study, the mechanical performances of one standard and eight modified frame systems were compared. Each system was loaded on a material testing machine, with calculation of axial compression, four-point bending, and torsion. As a result, systems that were modified with drop wires and Schanz screws 45 degrees oblique to the wires on the proximal ring provided a mechanical performance closer to the standard system than systems with other modifications.     

Frontal muscular balance and botulinum toxin

A good knowledge of the anatomy of the muscles of upper third of the face and their function, a good understanding of the famous Frontal Muscular Balance, to consider the anatomic and histological modifications induced by ageing in the cutaneous layer and the muscular function of the underlying "peaucier muscles", are essential for a better approach and for an easy and safe use of botulinum toxin, remarkable product, and for avoiding its operator-dependent risks.     

Classification of groin hernia: Milestones

Do we have true “milestones” along the hernia-classification route? I am not certain; modifications have been presented along the way, and each presentation (partially discussed herein) should be studied by every student of herniology and personal decisions made. In developing classifications, we should beware of too many hernia types. We must focus our attention and decisions upon each abdominal wall defect. These defects have been nicely described in readily available anatomic texts. Following this route, each surgeon may determine with ease and minimal complexity the appropriate approach and repair with confidence of cure.     

Aging changes in the male face

Discrete anatomic differences exist between the male and female face that are relevant in surgical planning. Although the aging process of male and female faces share many common features, attention to the particular differences in the aging man is warranted. Gender differences in the male face include the presence of facial hair, increased facial vascularity, increased thickness, increased sebaceous content, hormonal influences, and potentially differing rates of fat and bone absorption during the life cycle. This article describes the anatomic characteristics of the male face that require attention as the facial plastic surgeon constructs a treatment plan for the aging face Further investigation is required to describe in more detail the anatomic and biologic differences in male and female facial aging.     

Modified posterior interosseous flap in hand reconstruction

Hand reconstruction methods using posterior interosseous flaps have the merits of being thin and pliable, they do not require sacrifice of any major hand arteries, and closure of the donor site is readily performed. Drawbacks include unreliability of blood flow due to the presence of posterior interosseous artery anatomic variants or damage to the venous circulation. We present some modifications to methods for the preparation of posterior interosseous flaps with which we have achieved some favorable results.     

Technical advances with newer aortic endografts provide additional support to withhold the early endovascular repair of small abdominal aortic aneurysms until it is really needed

The idea of early endovascular aortic repair (EVAR) of "small" abdominal aortic aneurysms (AAAs) has gained attention over "watchful waiting," mostly due to the concern for losing the anatomic suitability for endovascular repair over time. Generally, small AAAs have longer, smaller, less angulated necks, and less tortuous iliac arteries than larger ones. Though the borderline anatomic characteristics were assumed to be contraindications for older generation endografts, the modifications of modern devices seem promising to overcome those limitations, in order to treat the small AAAs when reaching the 5.5 cm threshold. Moreover, early endovascular intervention has been proven neither cost effective nor beneficial for the patients' quality of life. This article evaluates the technical progress that could overcome the difficulties of those small AAAs that present technically demanding anatomies, thus advocating endovascular intervention when they reach the diameter threshold.     

Anatomic examination of a case of open trigeminal nucleotomy (nucleus caudalis dorsal root entry zone lesions) for facial pain.

Nucleus caudalis dorsal root entry zone lesions (open trigeminal nucleotomy) are a surgical procedure which can achieve pain control without major complications in the difficult clinical setting of deafferentation-type facial pain. Two patients are reported, who had relief of pain, but also experienced neurological complications. One patient succumbed to pulmonary complications, which provided the opportunity for anatomic analysis of the lesioned area, which is discussed in detail. Potential modifications of the surgical technique are suggested.     

Indications and technique of Nuss procedure for pectus excavatum

Pectus excavatum most frequently involves the lower sternum and chest wall. Because the morphology varies, preoperative imaging for anatomic assessment and documentation of dimensions of the chest are important. Many modifications have been made to the minimally invasive procedure since it was first performed in 1987. As a result, there has been an increase in the number of patients seeking surgical correction. This article discusses the clinical features of pectus excavatum and reviews the preoperative considerations and the steps involved in the repair of the deformity.