Microtia- diagnosis and management
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Microtia is a congenital deformity where the external ear is underdeveloped, ranging from small ears to complete absence of the auricular tissues. Treatment options include autologous costal cartilage grafts and prosthetic reconstruction. The Tanzer, Brent, and Nagata techniques use harvested rib cartilage to construct an ear framework, with differences in staging and sculpting of features. Complications can include chest wall deformities, skin necrosis, infection, and resorption of the cartilage graft over time.
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Microtia
This document discusses the anatomy, development, classification and diagnosis of microtia, as well as approaches to total auricular reconstruction for microtia. It covers the nerve supply and embryological development of normal ears. It also describes classifications of microtia, associated deformities, timing of surgery, and factors to consider in patient assessment for ear reconstruction, including facial symmetry, skin envelope, vestige skin and hair.
microtia
1. Reconstruction of ear deformities has evolved over time, starting with flap techniques in the 16th century to use of rib and silicone implants today.
2. Microtia is a congenital deformity of the external ear that occurs in 1 in 500 to 1 in 5000 births and is often associated with other anomalies.
3. Reconstruction of microtia typically uses rib cartilage to form an auricular framework, with the goal of matching the normal ear, and is usually done in stages after age 6.
Auricular reconstruction
1. The document describes techniques for auricular reconstruction, including the Brent and Nagata techniques.
2. The Brent technique is a four stage process using autogenous rib cartilage grafts to reconstruct the ear framework.
3. The Nagata technique is a two stage process using costal cartilage blocks to fabricate a three-dimensional ear framework, which is then used to reconstruct the ear and project it outward.
Weber ferguson incison (poster)
The Weber-Fergusson incision is indicated for access to tumors involving the maxilla extending superiorly to the infraorbital nerve and into or involving the orbit. It provides wide access to all areas of the maxilla. The incision line is drawn through the vermillion border along the filtrum of the lip, extending around the base of the nose along the facial nasal groove. It then extends infraorbitally below the cilium to the lateral canthus. Tarsorrhaphy sutures are placed in the eyelid. The incision is made through the skin and subcutaneous tissue along the nose, and the full thickness upper lip is transsected with ligation of the labial artery
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Nasolabial flap final
The nasolabial flap is used to reconstruct defects of the nose, lower eyelid, cheek, lip, oral commissure and anterior oral cavity. It has a reliable blood supply from the facial and angular arteries. The flap can be raised in a superior or inferior direction and is outlined along the nasolabial fold. The technique involves raising the flap in a supra-muscular plane and transferring it to the defect site through a transoral tunnel. Advantages are a concealed donor site scar and good color and texture match. Complications include infection, necrosis and asymmetry.
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microtia
1. Reconstruction of ear deformities has evolved over time, starting with flap techniques in the 16th century to use of rib and silicone implants today.
2. Microtia is a congenital deformity of the external ear that occurs in 1 in 500 to 1 in 5000 births and is often associated with other anomalies.
3. Reconstruction of microtia typically uses rib cartilage to form an auricular framework, with the goal of matching the normal ear, and is usually done in stages after age 6.
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2. The Brent technique is a four stage process using autogenous rib cartilage grafts to reconstruct the ear framework.
3. The Nagata technique is a two stage process using costal cartilage blocks to fabricate a three-dimensional ear framework, which is then used to reconstruct the ear and project it outward.
Weber ferguson incison (poster)
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This document discusses techniques for reanimating facial paralysis. It begins by outlining general principles, including reinnervating muscles early, separately reanimating the upper and lower face, and tailoring the procedure to the patient's needs and assessment. Surgical techniques are then described, including neural methods like nerve grafting and transfers, musculofacial transpositions, and static procedures. The timing of different techniques depends on whether the paralysis is acute (<3 weeks), intermediate (3 weeks to 2 years), or chronic (>2 years). Assessment involves evaluating the cause and extent of paralysis along with patient factors. The goal is to restore facial symmetry, competence, protection, and dynamic smile.
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The document describes the pectoralis major island flap technique. It can be used for reconstruction of the pharynx, tongue, face, neck, and skullbase defects. The flap has a large arc of rotation from the clavicle to the xiphoid process. It provides a single stage transfer with a muscle carrier but does not match the color and texture of facial skin. The document outlines the surgical technique including flap design, elevation of the vascular pedicle, and closure of the donor site. Variations including osteomyocutaneous flaps with rib bone and use of the flap as a free tissue transfer are also discussed. Complications, risk factors, and modifications to the technique are summarized.
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The document discusses techniques for harvesting cartilage grafts for cartilage tympanoplasty. Cartilage can be harvested from the tragus or concha using various surgical approaches and tools. The tragus is often preferred as it is thinner and flatter than conchal cartilage. Cartilage grafts must be thinned to around 500 microns for optimal acoustic transfer properties and stability. Surgical tools described for thinning grafts include scalpels, clamps, knives, and specialized cutting guides.
Fess
This document provides an overview of the steps involved in primary sinus surgery via an endoscopic approach. It begins with a brief history of sinus surgery and then discusses preoperative assessment, including CT scans to evaluate sinus anatomy and disease patterns. The basic techniques of Messerklinger and Wigand are described. The key steps of the surgery are then outlined in detail, including uncinectomy, antrostomy of the maxillary sinus, anterior and posterior ethmoidectomy, sphenoid sinusotomy, and frontal sinusotomy when necessary. Throughout, anatomical landmarks and variations are discussed to guide safe dissection and avoid complications.
Mandibular reconstruction
This document discusses reconstruction of mandibular defects. It begins with an overview of anatomical facts, causes of defects, classifications, historical facts and options for reconstruction. Key options discussed include vascularized bone grafts like the fibula flap, which provides adequate bone stock and contour for reconstruction. Proper planning including templates and osteotomies is important for achieving optimal reconstruction with regard to structure, oral function and cosmesis. Post-operative care including fixation and monitoring for complications is also covered.
Surgical approaches to skull base
1) The skull base surgery approaches discussed allow surgeons to access different regions of the skull base to treat lesions while avoiding harm to intact structures.
2) Key approaches described include the pterional, frontolateral, transsphenoidal, suboccipital lateral, and various transpetrous approaches.
3) Endoscopic skull base surgery has advanced to allow minimally invasive access to regions from the cribriform plate to the foramen magnum and laterally to the infratemporal fossa.
Sinus Lift ppt about maxillary sinus lift
This document discusses the anatomy and surgical procedures related to maxillary sinus lifts. It begins with an introduction describing how maxillary sinus lifts can enable dental implant placement in atrophic maxilla. It then defines the maxillary sinus and describes its anatomy, development, blood supply, nerve supply and functions. It discusses the Schneiderian membrane lining the sinus and various assessment techniques. It provides details on the lateral window and crestal/osteotome approaches to maxillary sinus lifts, including flap design, bone window preparation, membrane elevation, grafting and implant placement. Piezoelectric and Dentium Advanced Sinus Kit techniques are also summarized.
External ear- development
External ear development occurs between weeks 5-8 of gestation. Congenital ear deformities can include malformations of the outer and middle ear, which make up 70-90% of cases. Ear pits and cysts are the most common type of malformation and are often bilateral or multiple. Pinna malformations are classified using the Weerda system. Cup ear deformities involve underdevelopment of the helix, antihelix, or entire upper pinna. Surgical techniques to correct prominent ears include scoring or reshaping cartilage and setting back the concha. Cryptotia involves loss of the upper auricular sulcus and is treated by creating a new sulcus. Secondary procedures may be needed to prevent over
Lower eyelid reconstruction
Lower eyelid reconstruction aims to re-establish a functional eyelid with adequate protection of the eyeball and reasonable cosmesis. Direct closure can be used for up to 30-40% defects in younger patients with eyelid laxity. The Hughes procedure uses a tarso-conjunctival flap to reconstruct large posterior lamella defects but requires a second stage for anterior lamella coverage. The Tenzel slide uses a semicircular musculocutaneous flap to reconstruct large anterior lamella defects but requires posterior lamella coverage. Free tarsal grafts can be used to replace the posterior lamella while the anterior lamella is covered with a myocutaneous advancement flap.
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Eyelid reconstruction
The document discusses eyelid reconstruction, including:
1. It describes the anatomy of the eyelid, including the palpebral fissure size, positions of the canthi and eyelid margins, and layers of the eyelid.
2. Common reasons for eyelid reconstruction include congenital anomalies, tumors, and trauma. Principles of reconstruction include thorough evaluation, debridement of nonviable tissue, and aligning all tissue layers.
3. Various flap techniques are described for reconstructing different areas of the eyelid, including tarsoconjunctival flaps, cheek flaps, forehead flaps, and V-Y flaps. Complications of reconstruction include issues like corneal abrasion
Vascular anomalies
This document discusses vascular anomalies including infantile hemangioma and various types of vascular malformations such as capillary, venous, arteriovenous, and lymphatic malformations. It covers the classification, clinical features, investigations, management, and complications of these conditions. Key points include that infantile hemangiomas have a distinct growth cycle of proliferation, involution, and involuted phases while vascular malformations are present at birth and grow proportionally with the child. Management involves observation, medications like corticosteroids and propranolol, laser therapy, surgery, and embolization depending on the specific anomaly and risk of complications.
Tissue expansion- principles and techniques
Tissue expansion is a surgical technique used to generate additional skin and soft tissue for reconstructive purposes. It involves inserting a temporary implant called a tissue expander under the skin and gradually inflating it with saline over 6-12 weeks to stretch the overlying tissue. This causes mechanical and biological tissue growth. The expander is then removed and the expanded skin is advanced to reconstruct areas of skin loss or defects. Complications can include hematoma, seroma, expander deflation or migration, and skin thinning or necrosis but tissue expansion provides a good source of autologous tissue for reconstruction when other options are limited.
Principles of tendon transfer
Tendon transfers involve rerouting a functioning muscle tendon unit to restore lost function according to established principles. The key principles are having supple joints at the donor and recipient sites, maintaining soft tissue equilibrium, ensuring the donor has adequate excursion and strength, choosing an expendable donor, maintaining a straight line of pull, selecting donors and recipients with synergistic functions, and performing single tendon transfers for single functions. Tendon transfers can restore grasp, pinch and upper extremity motions according to these principles.
Tenosynovitis
This document discusses tenosynovitis, including its definition, etiology, prognosis, pathophysiology, history, physical examination findings, workup, treatment, and postoperative care. Tenosynovitis is inflammation of the tendon sheath that can be caused by overuse, infection, or inflammatory conditions like rheumatoid arthritis. Physical exam may reveal tenderness, swelling, or limited range of motion. Treatment depends on the cause but may include rest, splinting, anti-inflammatories, corticosteroid injections, or surgery. Prognosis is generally good if treated early without comorbidities, while complications can include adhesion formation or tendon rupture if left untreated.
Tendon transfer- principles and techniques
1. Tendon transfers involve rerouting a functioning muscle tendon unit to restore a function lost due to nerve injury or other conditions. Common indications include nerve injuries or trauma.
2. Key principles of tendon transfer include having supple joints, adequate excursion of the donor muscle, and maintaining a straight line of pull. Common procedures restore functions like finger extension, thumb opposition, and wrist extension.
3. Rehabilitation after tendon transfer focuses on immobilization followed by gentle range of motion and strengthening exercises over 8-12 weeks before returning to full activity.
Temporomandibular joint
- The temporomandibular joint (TMJ) is located between the condylar process of the mandible and the mandibular fossa and articular eminence of the temporal bone. It is a bi-arthroidal hinge joint containing synovial fluid that allows for translational and rotational movements.
- Temporomandibular disorders (TMD) is a collective term used for clinical problems involving the masticatory muscles, TMJ, and associated structures. Common signs and symptoms include pain and limited opening of the mouth.
- Disc displacement is the most common TMJ articular disorder and can involve reduction or lack of reduction of the articular disc. Conservative treatments include
Suture techniques, Z-plasty
The document describes various suture techniques including simple interrupted sutures, which are the gold standard, subcuticular sutures which avoid external knots, half-buried horizontal mattress sutures which keep knots on one side, continuous over-and-over sutures which can be placed rapidly but are less precise than interrupted sutures, skin staples which are a timesaving alternative to sutures, skin tapes and adhesives which can be used in low tension areas, and Z-plasties which help prevent or limit scarring and contractures. It also outlines indications, contraindications and potential complications of Z-plasty techniques.
Replantation of the hand and Upper extremity
1. Replantation involves reattaching a completely amputated body part to restore blood flow, while revascularization reattaches incompletely amputated parts.
2. Factors that determine replantation success include patient health, injury details, and surgical team skill.
3. The operative technique prioritizes veins, arteries, bones, tendons, and nerves with the goal of minimizing warm ischemia time.
Skin donation, skin banking, skin culture
1. Skin banking involves procuring skin from donors after death, processing it which may include cryopreservation or lyophilization, and storing it to be used for burn patients or other wounds.
2. The first skin bank was established in 1971 and they continue to improve techniques like reducing immunogenicity and potential for disease transmission.
3. Skin culture techniques also allow creating skin substitutes using fibroblasts, keratinocytes and endothelial cells grown on collagen gels or cadaver dermis in organotypic culture.
Nerves of hand
The document summarizes the anatomy and branches of the ulnar, radial, and median nerves in the upper limb. It describes the course and branches of each nerve in the axilla, arm, and forearm. It also discusses the separation of motor and sensory components within the nerves and provides diagrams of fascicular patterns. Key points include that the ulnar nerve supplies medial forearm muscles and skin of the little and half of the ring finger, the radial nerve innervates posterior forearm muscles and skin of the dorsal hand, and the median nerve gives branches in the forearm and palm.
Neck lift, forehead and thread lift
This document discusses various surgical approaches for forehead and brow lifting as well as neck lifting. For forehead lifts, it describes techniques like the coronal approach and its disadvantages like scalp numbness. It also covers other approaches like the temple approach and endoscopic approach. For neck lifts, it discusses factors to consider like skin elasticity and platysma muscle treatment. It provides details on the surgical process for different grades of neck laxity and describes techniques like subcutaneous lipectomy and platysma plication. Post-operative care is also outlined for both forehead and neck procedures.
Mandibular fracture- diagnosis
This document discusses the classification, diagnosis, and treatment of mandibular fractures. Key points include:
- Mandibular fractures are classified based on location and examined clinically and radiographically.
- Treatment options include closed or open reduction, with closed reduction used for minimally displaced fractures and open reduction for more complex cases.
- Internal fixation methods like miniplates are used to achieve rigid stabilization during open reduction, while intermaxillary fixation can be used short-term for closed reduction.
- Potential complications include hemorrhage, infection, nonunion, and neurosensory changes. Proper treatment aims to restore occlusion and minimize complications.
Skin healing and repair
This document discusses the stages of skin graft take, including plasmatic imbibition, inosculation and capillary ingrowth, and revascularization. It describes graft fixation, contraction, reinnervation, pigmentation, and factors that can lead to graft failure. The stages of graft take typically involve serum imbibition for 24-48 hours, development of fine vasculature in a fibrin layer, and eventual blood flow as the graft becomes pink. Revascularization may occur through direct vessel anastomoses, new vascular channel formation, or a combination. Proper fixation and aftercare are important for successful graft take.
Liposuction- techniques and indications
Liposuction is a surgical procedure to remove unwanted fat deposits from beneath the skin. It was originally introduced in the 1980s and involves using suction to aspirate fat through small incisions. There are several techniques including traditional suction-assisted liposuction, ultrasound-assisted, power-assisted, vaser-assisted, and laser-assisted liposuction. Patient selection, pre-operative evaluation and planning, anesthesia technique, and post-operative care are important considerations to achieve optimal results and avoid complications from liposuction.
Local flaps classifications
This document describes different types of local flaps that can be used in skin grafting and reconstructive procedures. It outlines pivotal flaps, advancement flaps, and hinge flaps. Pivotal flaps involve rotation, transposition, or interpolation of skin and come in various shapes. Advancement flaps can be unipedicled, bipedicled, or in a V-Y or Y-V configuration. They take advantage of skin elasticity or use Burrow triangles to advance the skin. Pantographic expansion is another advancement technique but carries more risk.
Flexor tendon repair
Flexor tendon repair requires protecting the tendon repair while allowing early controlled motion to minimize adhesions. This involves splinting the fingers in flexion after primary repair or tendon grafting, followed by progressive range of motion exercises. Complications can include infection, scarring and joint contractures, but good outcomes are achieved with protocols emphasizing early motion like Duran or Kleinert methods.
Parascapular and free fibula flaps
The parascapular flap uses skin and bone from the back to reconstruct large cheek defects. It provides reliable reconstruction with appropriate bulk and contour for the cheek. The flap has the disadvantages of a tedious dissection due to numerous branches that must be divided and no possibility for a sensate flap.
The free fibula osteocutaneous flap uses the fibula and overlying skin to reconstruct mandibular, maxillary and other bone defects. It has advantages of large vessels, long vascular pedicle, well-vascularized bone that can be shaped. Disadvantages include donor site morbidity such as delayed wound healing and nerve injury. Preoperative vascular problems and poor skin quality can also be issues.
Gracilis and Latissimus Dorsi flap
The gracilis muscle is a thin muscle in the thigh that can be used as a free flap for reconstruction. It is 25-30 cm in length with a 10-12 cm tendon. The muscle is innervated by the obturator nerve and receives its blood supply from the gracilis vessels of the medial femoral circumflex artery system. It is commonly used in head and neck reconstruction or to repair soft tissue defects. The latissimus dorsi muscle is one of the largest muscles in the body and can be harvested as a pedicled or free flap, often with a skin paddle. It is innervated by the thoracodorsal nerve and receives its blood supply from the thoracod
Gastrocnemius and Forehead flap
This document describes two types of flaps: the gastrocnemius flap and the forehead flap. The gastrocnemius flap uses the medial or lateral head of the gastrocnemius muscle and surrounding tissue to cover defects of the proximal or anterior leg. The forehead flap uses skin and tissue from the forehead, supplied by the supratrochlear artery, to reconstruct nasal or periorbital defects. Key details about the vascular anatomy, dimensions, and applications of each flap are provided.
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Microtia- diagnosis and management
- 1. Microtia
- 2. • Microtia varies from the complete absence of auricular tissues (anotia) to a somewhat normal but small ear with an atretic canal
- 9. Timing • body image concept usually begins forming around age of 4 or 5 years • Enough rib cartilage to serve as the sculpting medium by age 6 • At age 6, the normal ear has grown to within 6 or 7 mm of its full vertical height
- 10. Treatment options 1. Autologous Costal Cartilage Graft 2. Tissue expansion and Autologous Costal Cartilage Graft park technique) 3. Implant reconstruction (Reinisch and Lewin) 4. Prosthetic reconstruction (Wilkes technique)
- 11. Autologous cartilage graft 1. Tanzer 2. Brent 3. Nagata
- 12. Tanzer • Stage 1: – Lobule transposed • Stage 2: – costal cartilage, harvested sub-perichondrially from sixth, seventh, and eighth contralateral ribs, implanted beneath mastoid skin, using a V-shaped postlobule incision
- 13. • Stage 3: – construct was elevated from head • Stage 4: – concha and tragus created with composite contralateral ear and skin/cartilage grafts
- 14. Brent technique Stage 1: harvesting costal cartilage
- 18. • Stage 2. lobule reconstruction
- 20. • Stage 3: elevation of the construct
- 21. • Stage 4: tragus, antitragus construction, conchal excavation, and symmetry adjustment
- 23. • Disadvantages: 1. 4 stages. 2. lack of definition of the conchal bowl, intertragic notch, and contour of antitragus 3. Effacement of postauricular sulcus, result in decreased projection of reconstructed ear. due to contraction of the skin grafts. 4. composite skin/cartilage grafts may contract, diminishing the retrotragal hollow everting tragus itself
- 24. Nagata • two stages. • first introduced in 1993 • Several possible technical refinements, depending on the type of microtia present (i.e., lobular, small concha, conchal, anotia, low hairline)
- 25. • First Stage: – base frame – seventh and sixth ipsilateral costal cartilages – helix and crus helicis - ninth costal cartilage – superior crus, inferior crus, and antihelix- eigth costal cartilage
- 30. • Second Stage: – Six months – Skin incised 5mm posterior to the construct – Elevated – crescent-shaped piece of cartilage harvested from the fifth rib – Temporoparietal fascia flap – ultra-delicate splitthickness skin graft
- 32. • Advantages: 1. Excellent blood supply and minimal risk of resorption of grafted cartilage. 2. high-definition framework of auricle. 3. Symmetrical projection of ear. 4. The possibility of ear reconstruction in anotia, low hairline and secondary cases.
- 33. • Disadvantages: 1. Long learning curve. 2. Surgeon must have great artistic talent 3. high (8 percent) extrusion rate of wire sutures 4. risks of scalp scarring, temporal hair thinning, and the sullying of a potential reconstructive lifeboat. 5. significant chest wall deformity 6. not specifically addressed the issue of frontal symmetry
- 34. Complications • Chest Wall Donor-Site Complications – pneumothorax and atelectasis – chest wall deformity and scarring • Complications at the Ear Reconstruction Site – Exposure of the cartilage – Skin necrosis – Infection (0.5%) – Hematoma (0.3%) – extrusion of suture material – resorption of cartilage framework