Correction of the “Simian” forehead deformity

A procedure for the correction of the simian forehead deformity is described.     

Vertical lengthening of the unilateral cleft lip after a triangular flap repair

Summary A triangular flap repair for unilateral cleft lip is stated to have the potential problem of creating a lip that is too long. Although preoperative measurements were performed with calipers, the gap created in the medial segment was directly measured during the procedure, in order to determine the size of the flap more precisely. Ninety patients with complete unilateral cleft lips underwent a triangular flap repair using this method. The symmetry of the Cupid's bow was evaluated at a follow-up period averaging between six years and three months. Sixty-two lips obtained symmetry and the remaining 28 cases showed a lip which was too long; none of the lips were too short. The comparison between 27 primary palate clefts (UCLA) and 63 primary and secondary palate clefts (UCLP) showed no significant difference in the surgical result. The preoperative shortness of the lip on the cleft side was significantly greater in the too long group (5.01 ± 0.95 mm) than in the symmetry group (4.40 ± 0.87 mm). The width of the flap used was significantly larger in the too long group (3.76 ± 0.79 mm) than in the symmetry group (3.42 ± 0.69 mm). The triangular flap repair with intraoperative measurements is considered to be beneficial, although preoperative measurements provide an optimal design in most cases. It is suggested that the use of a wider triangular flap results in a lip which tends to be too long in spite of the preoperative shortness on the cleft side.     

An interpretation of acute changes in plasma45Ca following parathyroid hormone administration to thyroparathyroidectomized rats

Acute changes in plasma calcium and⁴⁵Ca were studied in young adult male thyroparathyroidectomized (TPTX) rats injected with moderate doses of parathyroid hormone (PTH). For plasma calcium changes, comparison was made between rats fasted or fed prior to PTH injection. For plasma⁴⁵Ca changes, the effect of the time of administration of the radionuclide was also studied; this included rats injected with PTH 1 h after radionuclide (1 h⁴⁵Ca), 18 h later (18 h⁴⁵Ca) and more than 6 days later (6 day⁴⁵Ca). The results can be summarized as follows: (1) Plasma calcium changes were greater when PTH was injected into fed rather than into fasted rats. (2) PTH always produced a relative increase (compared to controls tested concurrently) in plasma⁴⁵Ca concentrations. This increase was the same in the 1 h⁴⁵Ca and the 18 h⁴⁵Ca groups. (3) Plasma⁴⁵Ca rose at least temporarily following PTH injection in the 18 h⁴⁵Ca group. (4) The⁴⁵Ca rise following PTH was always greater in fed than in fasted groups. (5) Plasma⁴⁵Ca specific activities (S.A.) tended to rise in the 6 day⁴⁵Ca group and to fall in the 18 h⁴⁵Ca group, following PTH injection. However, the⁴⁵Ca S.A. was always higher in fed than fasted groups. (6) In a few experiments in which³²P was injected with⁴⁵Ca, specific activity changes in plasma⁴⁵Ca following PTH injection werenot accompanied by similar changes in³²P specific activity.These results could not be adequately explained by PTH effects on bone resorption, but the data supported the postulate that PTH controls plasma calcium concentrations by increasing transport of calcium through the osteocyte-lining cell (osteoblast) bone cell complex from the bone fluid compartment to the ECF.     

Aesthetic surgery as organopsychic therapy

Summary Abnormal anatomic variations have a wide range from small abnormalties to greater defects. Although these cannot be considered pathologic deformations, they may cause psychic problems in patients already on the border of psychic disease. It is therefore necessary to call them organopsychic alterations. In general, the plastic correction is not carried out exclusively because of aesthetic causes, but also to heal the psychic disease. On this basis, it is justifiable to call these aesthetic interventions organopsychic therapy.     

Computer assisted quantification of vasospasm on angiograms

Summary We describe a new computer-based, automated method for the assessment of in vivo cerebral vasospasm. Arterial diameter measurements were performed on post-processed digital substraction angiographic images, using pixel as the unit. Vasospasm which was difficult to detect by visual inspection could be measured by the stenosis quantification program. A computer-assisted method such as we describe might decrease the risk of subjective errors.     

Diagnostic approach in instability and irritative state of a “lumbar motion segment” following disc surgery—Failed back surgery syndrome

Summary A diagnostic protocol for patients with suspected instability and irritative state of a lumbar motion segment following lumbar disc surgery is presented and the results of internal fixation are analyzed.In this group of patients the clinical picture and physical signs may be quite distinct and suggestive of instability and irritation of a lumbar motion segment, however, in isolation, they do not allow to decide upon surgery. Radiological studies favour a decision for surgery only in cases with an obvious instability of a motion segment. Anaesthethizing the articular nerves permits localization of the irritable segment and non-surgical therapeutic decisions (thermocoagulation) can only be taken in cases of an isolated facet-syndrome when instability has been ruled out. The trial plaster jacket holds the most important position with respect to the indication for internal fixation as demonstrated by the conformity of the results of the plaster jacket and the results of surgery.After internal stabilization excellent, good, satisfactory and moderate results were obtained in 20, 3, 1 and 1 patients, respectively.The German term Bewegungssegment comprises all parts which are involved in the movements of one vertebral segment, i.g. disc, facet joints, ligaments and related muscles.     

Absorptiometry and “osteoporosis”: problems

connecting the dots between diverse clinical and other matters and an updated bone physiology reveals relationships that could modify some ideas about the roles and uses of absorptiometry in osteoporosis work. Herein, absorptiometry means that part of clinical densitometry that depends on X-ray absorption by bone and other tissues, thus excluding ultrasound methods and magnetic resonance imaging. The modifications concern, in part, some limitations of bone mineral density data, the kinds of physiological information that absorptiometry can and cannot provide, the relative importance of bone mass and whole-bone strength, how to define and study bone health and osteoporosis, and two kinds of osteoporotic fractures. As those modifications concern important national health care issues, they deserve answers based on hard evidence. Identifying those modifications might help others to evaluate them.     

Reduction mammoplasty: General approach and basic considerations

Reduction mammoplasties must take into consideration volume, mammary base, and forward projection in establishing criteria for a standard breast. Any reduction procedure involves the mammary gland or mass, the skin, and the nipple-areola complex.Since 1969, we have used a dermal vault technique on over 1,200 patients with satisfactory results. It produces a short, well-situated scar, a pleasing form, ideal residual mammary volume, and good stability.     

A versatile procedure for the closure of small skin defects

The author describes a method for the primary, direct closure of wide skin lesions, combining the lazy S, crown, and the H-advancement flap techniques. The lazy S edges of the flaps permit the satisfactory use of adjacent surrounding skin with good aesthetic results, when the flaps alone would otherwise be placed under too much strain.     

Osteosarcoma with multiple skeletal metastases

Summary Osteosarcoma of the thoracic spine developed in a 15-year-old Japanese boy, After his first admission with paralysis, multiple skeletal metastases were demonstrated in the absence of pulmonary metastasis. This rare condition may possibly be considered as a unicentric osteosarcoma with bone metastases, since there were no precursor lesions or history of exposure to radio-active materials or chemical agents. These multiple lesions may be an example of so-called organ-specific metastasis, although this nonstochastic process is rare.     

The skin aptitude for retraction (SAR) applied on mammareductions

Summary The aptitude of skin for retraction is a well recognized mechanism. What is its application in breast hypertrophy, ptosis or a combination of these? This paper attempts to explore the limits of using this feature of skin in surgery to correct these problems, or more precisely to determine contributions of skin resection and glandular resection in big reductions (in excess of 400 g per breast). Two techniques have been used in these cases: the first in which the final scar is an inverted T takes no advantage of the skin's ability to retract; the second in which the scar is a capital I without a horizontal component takes maximal advantage of this characteristic of skin. The results of each technique are compared by comparison of two groups of 20 patients, each group operated by one technique, and analyzed postoperatively according to eight objective criteria.     

Nasal anatomy: The muscles and tip sensation

The author stresses the importance of columellar sensation, nasal tip sensation, and the role of the nasalis muscles in determining the postoperative results of corrective rhinoplasty, especially as these have an influence on the drooping tip and the columellar base. Specific anatomic details of this area are emphasized in order to help the plastic surgeon understand better the normal anatomy of this region and the effects that operative procedures have on successful results if the surgeon understands especially the role of the nasalis muscles.     

Replacement of the anterior cruciate ligament

Summary Eighty-seven patients have been examined 2 years on average after knee ligament reconstruction for a torn anterior cruciate ligament. The patients were divided into four groups according to the type of operation that had been carried out. In the first group an extra-articular lateral repair (MacIntosh tenodesis) had been performed, in the second group an intra-articular over-the-top repair using the quadriceps and the patellar tendon, in the third group a modified Eriksson procedure using the patellar tendon, and in the fourth group a combined intra- and extra-articular repair using carbon fibres as a graft. The results of the operations in the different groups are compared. The best results were obtained with the Eriksson procedure, closely followed by the over-the-top repair. Limited range of motion and retropatellar pain resulting from changes in the alignment of the patella were the main problems. The results after the use of carbon fibres were less good. In two cases the graft tore without further trauma, and there were also problems because of restricted range of motion and retropatellar pain. The worst results were found after extra-articular lateral repair, due to insufficient stability in many cases. However, the best results with regard to the range of motion were found in this group.

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Zusammenfassung Es wurden 87 Patienten im Durchschnitt 2 Jahre nach Ersatzplastik bei zerrissenem vorderem Kreuzband und chronischer Instabilität nachkontrolliert. Die Patienten wurden in vier Gruppen eingeteilt. In jeder Gruppe war eine andere Art von Ersatzplastik durchgeführt worden. In der ersten Gruppe war es ein extraartikulärer lateral repair (sog. MacIntosh-Plastik), in der zweiten Gruppe eine intraartikuläre over the top geführte Plastik mit der Quadriceps- und der Patellarsehne, in der dritten eine modifizierte Eriksson-Plastik unter Verwendung der Patellarsehne und in der vierten Gruppe eine kombinierte intra- und extraartikuläre Plastik mit Carbon fibres. Die Resultate der Operationen in allen vier Gruppen werden miteinander verglichen. Die besten Ergebnisse zeigte das Vorgehen nach Eriksson, dicht gefolgt vom over the top-repair. Probleme, die in diesen zwei Gruppen auftraten, betrafen eingeschränkte Kniebeweglichkeit und retropatelläre Schmerzen wegen veränderter Führung der Patella. Die Resultate in der Gruppe mit Verwendung der carbon fibres waren weniger gut. In zwei Fällen ist das Transplantat ohne Trauma gerissen, zudem traten auch hier Beschwerden auf wegen eingeschränkter Beweglichkeit und retropatellärer Schmerzen. Am wenigsten gut waren die Resultate nach extraartikulärem lateral repair. In vielen Fällen konnte durch these Methode keine genügende Stabilität erreicht werden. Andererseits war die Beweglichkeit des Kniegelenkes nach dieser Operation kaum je eingeschränkt.

     

Abdominoplasty combined with correction of the flaccidity of the lateral lower abdomen and the flanks

The author describes a surgical technique for correction of adiposity and flaccidity of both the abdominal wall and the flank region. The technique produces a better final outcome with regard to the resultant lateral dog-ears and flaccidity of the flanks that may result after routine abdominoplasty operation.     

Tierexperimentelle Untersuchungen über die Wundheilung unter dem Einfluß von Phenothiazinderivaten

Zusammenfassung Zur Klärung der Frage, ob der Künstliche Winterschlaf in irgendeiner Form Wundheilungsvorgänge beeinflußt, wird die primäre und sekundäre Wundheilung am Meerschweinchen untersucht, die durch Gagen von täglich je 10 mg N-(2-Dimethylaminopropyl)-Phenothiazin (A) und N-(3-Dimethylaminopropyl)-3chlor-Phenothiazin (M) und 20 mg Methylphenylpiperidincarbonyläthylhydrochlorid (D) je Kilogramm bis zu 6 Tagen in den sog. künstlichen Winterschlaf versetzt werden. Die Tiere werden 2,4 und 6 Tage nach den Eingriffen getötet. Das Wundgebiet wird histologisch untersucht und das Ergebnis mit dem an Kontrolltieren gewonnenen verglichen.Die Versuche zeigen, daß in den genannten Zeiträumen bei den Winterschlaftieren gegenüber den Kontrolltieren keinerlei Unterschiede in der Wundheilung auftreten.Während die histologische Untersuchung der Nieren keinen pathologischen Befund ergibt, zeigt der histologische Befund der Leber bei einer großen Zahl der Winterschlaftiere kleinfleckige Massennekrosen im SinneRössles, die bei keinem der Kontrolltiere zu finden sind und deren Genese erörtert wird.     

Spinous process-plasty following lumbar laminectomy as a contributing factor to spine stability

A 10-year retrospective study of 41 consecutive patients who underwent spinous process-plasty is presented. We carried out laminectomy of the lumbar spine in cases of spinal stenosis, dorsomedial herniated disc and recurrent disc herniation with firm scars (traumatic and tumour cases are not included). To forestall the development of laminectomy's negative effects on spine stability, we initiated the spinous processes' reconstruction. Two groups of patients who underwent laminectomy form the basis of this presentation, one group with spinous process-plasty (41 patients) and the other (11 patients) without it. On postoperative neutral and dynamic X-ray films we paid attention to horizontal displacements larger than 3 mm and to negative intervertebral angular displacement. Considering such criteria, only 3.8% of those with spinous process-plasty developed a radiographic instability in contrast to 25% of patients without spinous process-plasty. These results support the use of this technique, which provides postlaminectomy lumbar spine stability.     

110. Management der Verletzungen am distalen Unterschenkel und Fuß

Summary The complex injury of the foot requires immediate decisions. At first the question of vital danger and amputation should be ruled out. The criteria for the conservation of the extremity will be shown. For the most severely injured, primary amputation is indicated, since all attempts of preservation in this group hardly survived. The two-step amputation is recommended: i.e. Guillotine -amputation in the acute phase and muscle plastic stump formation in the regeneration phase. Important principles of treatment are: immediate anatomic reduction and retention of fractures and unstable joints, open wound treatment, delayed closure and reconstructive plastic intervention. A planned second-look-operation is obligatory.     

Premature craniosynostosis a retrospective analysis of a series of 52 cases

Summary A retrospective analysis of a consecutive series of 52 cases with premature craniosynostosis is presented.Excellent functional, cosmetic, and social results could be achieved by resection of prematurely fused sutures and the creation of artificial growth sutures. Pronounced skull deformities have been corrected using the basket handle, the visor plasty, and the T-bone techniques or a combination of several of these skull form correction techniques. The surgical correction of the skull base by the frontal advancement technique in combination with orbitotomy was only necessary in 2 of our cases and could have been considered in 2 additional cases viewed retrospectively.Our results support the hypothesis that the primary cause of skull deformity is the premature closure of vault sutures and not a primary deformity of the skull base.     

Urethro-vesical function during spinal shock

Summary Twenty spinal shock patients were investigated with simultaneous urethrovesical, anal and rectal pressure recordings and EMG of the external urethral and anal sphincters. Dynamic and static urethral pressure profiles (UPP) were carried out with empty and full bladder. Baldder filling was accompanied by an increased resistance in the internal sphincter zone, which in turn was paralleled in the majority of cases by an elevation of pressure in the membranous urethra without concomitant increase of its EMG activity. This is suggestive of an increased sympathetic activity in the bladder neck area and in the smooth muscle component of the external urethral sphincter. Dynamic pullthrough UPP's displayed higher resistances in the membranous urethra than static interrupted UPP's pointing to the role played by the urethral muscosal receptors in eliciting artefactual results. Higher pressures were recorded in the juxtabulbar portion of the membranous urethra than in its mid portion pointing to a gradient of pressure within the external urethral sphincter itself. The amount of EMG activity recorded in the anal and urethral sphincters at rest was somewhat decreased; high pressures and distinct reflex activity were recorded in both sphincters showing that they escape spinal shock characterized primarily by areflexia. After defining spinal shock a rational explanation based upon neuroanatomical and neurophysiological findings is offered as to why somatic activity of the sacral segments escapes it as evidenced by clincial, urodynamic, and electromyographic recordings.     

Masking of physicians in the Growth Failure in Children with Renal Diseases Clinical Trial

Masking — hiding identities of treatments from the patient, physician and/or statistician — is a critical element in clinical trials. Wherever possible, masking is implemented to eliminate observational bias or systematic error. In this paper, general concepts of masking in clinical trials are examined. Specific masking procedures used in the Growth Failure in Children with Renal Diseases (GFRD) Clinical Trial are described. A method to evaluate the success of this masking procedure for physicians is introduced. For each randomized patient at each clinical center, the clinic director was asked to predict which treatment (1,25-dihydroxyvitamin D₃ or dihydrotachysterol) was assigned. Results showed that 72% of responses initially indicated absolutely no idea of treatment. Additional analyses revealed that the number and percentage of correct guesses were essentially equal for the two treatment groups and that a patient's time on treatment did not affect the mask. We conclude that the mask of physicians in the GFRD Clinical Trial was well maintained.