Giles Toogood MA DM FRCS

• Consultant hepatobiliary and transplantation
• surgeon
• St James? University Hospital
• Honorary senior lecturer, University of Leeds
• Examiner for RCS England, Member of the
• Intercollegiate Board in General Surgery, UK

Telephone Ear Deformity Telephone ear deformity occurs when the root of the helix and the ear lobule remain protruded while the middle half or third of the ear is set back against the head mens health week 2012 uroxatral 10 mg generic. These deformities can be avoided by carefully checking the position of the helical root prostate gland enlarged buy discount uroxatral 10mg, the upper helical rim prostate exam purchase genuine uroxatral on line, and the lobule at the completion of surgery prostate cancer diagnosis buy cheap uroxatral 10 mg. Scapha Buckling Scapha buckling or a transverse fold can develop in the Mustarde technique prostate oncology johnson order uroxatral online pills. This deformity can be avoided by placing the horizontal mattress sutures closer together where the scapha is widest prostate cancer 3 monthly injection purchase on line uroxatral, combined with adequate anterior scoring or weakening. Aesthetic Complications Inadequate correction of the ear deformity is the most common untoward result of otoplasty, often more obvious to the surgeon than to the patient. Calder and Nassan18 described at least one complication or residual deformity in 16. Recurrence of the ear deformity is a more common complication of reduction otoplasty, but is less likely to happen after excising a portion of the cartilage as well as a segment of skin, as described in the Davis method. Narrowed Meatus A constricted external auditory meatus can occur if the conchal bowl is rotated anteriorly in setting the ear back in any technique in which the conchal bowl is not excised. This problem is eliminated in the Davis method in which the floor of the conchal bowl is excised. Care must also be taken in placing the inferior end of the cotton roll bolster dressing into the external auditory canal to avoid stenosis. Accurate preoperative assessment of the individual deformities and the appropriate choice of a surgical correction will minimize unfavorable aesthetic results. The single greatest cause of an unfavorable result in this procedure is inaccurate diagnosis. The surgeon must understand the normal external anatomy of the ear and learn to recognize the pathologic characteristics of the abnormal ear. Having accurately assessed the deformity, the surgeon needs to be familiar with the various surgical approaches available to correct them. Finally, it is important to have a working knowledge of the potential complications of otoplasty and their prevention and treatment. Since the mid-1990s, cosmetic facial surgery has ushered in "lunchtime" procedures such as neurotoxins, facial fillers, fractional lasers, and anatomic facial implants. Advances and refinement of chemical peeling, fat transfer, and skin care have also been made. Another reason for this popularity is the fact that cosmetic facial surgery involves primarily females. Many procedures that promise maximal effect with minimal recovery are often disappointing. Before the mid-1990s, no predictable procedures existed to stop unwanted mimetic muscular movement and associated skin rhytids. When selectively injected into the muscles of the head and neck, various cosmetic and functional changes are predictably achieved. Additional muscles treated for cosmetic or functional reasons include the nasalis, levator labia superioris ala que nasi, orbicularis oculi, orbicularis oris, masseter, mentalis, and platysma. In the upper face, levator palpebrae superioris injection remains the most feared complication. A, the white dots indicate common injection points for glabellar treatment with the respective number of Botox units for each area. Novice injectors should actually measure and mark injection points on the brow and lateral canthal regions to remain 10 mm away from the orbital rim as not to inadvertently affect the levator palpebrae superioris or lateral extraocular musculature. Although variable in some patients, most injection patterns and dosages are similar. For optimum treatment in females, the author recommend 5 Botox units or 15 Dysport units for each glabellar injection point. The frontalis, being a thinner muscle, is generally adequately treated with 3-unit injections, as is the lateral canthus regions. Males and patients older than 65 years old frequently require more units per area and the treatment may have a shorter longevity. The glabellar region includes injection in the procerus muscle, both corrugator supercilii muscles, and the lateral orbicularis oculi regions. Being from an animal source, allergy testing was required and results were very transient, often 2 to 3 months. Our European colleagues during this time had numerous choices of safe and predictable fillers. The dose and position vary from patient to patient, but generally 2 to 3 units per injection point is adequate. Generally, 3 units of Botox is injected at three regions in a semilunar shape with care to stay 1 cm lateral to the lateral orbital rim. Also, allergy testing was not required, which had been a major drawback for impetuous cosmetic patients and the "I want it now" generation. The hyaluronic acid fillers (Juvederm Ultra, Juvederm Ultra Plus, Restylane, and Perlane) are far and away the most commonly injected products. These hyaluronic acid fillers are clear gels and can persist from 6 to 12 months, depending upon the injection site. L-Polylactic acid (Sculprta) and silicone oil (Silikon 1000) are stimulatory fillers in that they induce a foreign body reaction that induces collagen encapsulation and, hence, further augmentation. Artefil is a filler consisting of polymethylmethacrylate microspheres in a collagen matrix and is also considered permanent filler. At the time of this publication, both Evolence and Artefil have closed operations in the United States, but will more than likely reappear under a new company. If the filler appears to be migrating laterally, the needle is removed and placed in a more medial position. It is imperative that the injector see the actual improvement of the wrinkle or fold while injecting. If the wrinkle is not improving as it is being injected, the needle is likely too deep and the filler is lateralizing. Injecting the Lips Lip augmentation is more technique-sensitive and more difficult to learn than treating skin folds or wrinkles. Younger Injecting the Nasolabial Folds this author most frequently injects hyaluronic acid fillers in the nasolabial folds. An intradermal injection of hyaluronic acid filler is shown on the nasolabial fold. Older patients may require "white roll" outline, deep volumization, and vertical lipstick line fill, which presents a greater challenge. Deep Lip Augmentation for Volume and Pout Many young patients and virtually all females older than 40 can benefit from lip volumization. The lips are first anesthetized with intraoral perisulcular local anesthetic infiltration. Filler is injected as the needle is withdrawn and the treatment is tapered to augment the center of the lip more than the lateral portions. Massage is performed with petroleum jelly to smooth and contour the gel to a smooth and homogenous state. Injection of the white roll involves the augmentation or reconstruction of Cupid `s bow and its angular anatomy in the upper lip. In either lip, this area is injected by placing the needle in the potential space that exists between the mucosa and the orbicularis oris muscle. In the correct plane, the filler will flow freely and the filler is injected while withdrawing the needle. White roll augmentation in younger patients may involve only the central two thirds of the lip and gently tapers laterally. In older patients with loss of vertical dimension, the white roll may require extension to the commissures. In addition to the aforementioned areas, augmentation of the philtral columns, oral commissures, and vertical rhytids is also commonly performed. When performing deep lip volumization, the needle is inserted into the middle of the lip at the level of the wet/ dry line and the filler is injected upon withdrawal. The injection is bilaterally tapered so the center of the lip has more volume than the lateral portions. This patient is shown before and after deep injection volumization of the upper and lower lips. Chemical peeling is safe when performed with adequate training, is inexpensive, and has a moderate recovery of up to 1 week. Chemical peels are performed with a myriad of acids, and deep or aggressive peels can cause problems with burns, scars, and hypopigmentation. The depth of the peel is dependent upon the peeling agent used, the concentration of the agent, the number of coats applied, and the physical properties of the skin. Peels can be classified into superficial, medium, and deep depending on how deeply the acid penetrates the skin. Medium-depth peels are generally considered to be those that penetrate to the level of the papillary dermis; deep peels penetrate into the reticular dermis. Although the author will in some applications use this directly out of the bottle, most frequently the author dilutes it to 20% or 30%. This patient is shown before and after hyaluronic acid augmentation of the deep lip and vermilion/cutaneous junction. All peel patients are covered with an antiviral and antibiotic medication beginning the day before surgery and for the next 5 to 7 days. Superficial peels do not require this premedication unless the patient has a history of recurring herpes simplex infection. The best means of learning chemical peeling is to perform superficial procedures on a patient such as an employee or friend who can be observed every day for the first week. The 4 mL of mixture is applied to the skin using a makeup sponge, cotton ball, Q-tips, or gloved finger. As the 15% solution is applied, the skin will tingle and slightly burn, but the discomfort is tolerable. After the procedure, the patient can apply hypoallergenic moisturizer multiple times a day. There will not be much peeling, only a little flaking, and there will not be a significant visible clinical result. After experience with doing this several times, the same procedure can be performed, but a second coat applied this time. With this treatment, it is advisable to apply Vaseline to the face for the first 48 hours, then moisturizer for the next several days. This patient has been treated with two or three coats of 30%; a homogenous white frost is evident 20 minutes into the procedure. The surgeon must then wait several minutes before the next coat to allow the action to ensue and the frosting to form. The surgeon should not allow ego or desire to overtake common sense in learning these procedures. Begin with very conservative peels and after doing 5 or 6 patients, move on to the next level. Superficial peels will heal in 1 to 2 days, basilar peels in 3 to 4 days, and medium-depth peels to the papillary dermis will heal in about 7 days. In addition, because the neck has far less pilosebaceous units, it is never peeled as aggressively as the face. Patients with pigmented skin are also treated with caution and, therefore, less aggressive peels. Resurfacing pigmented or ethnic skin is an advanced procedure and should not be performed by the novice. Chemical peeling is very technique sensitive and more of an art form than a science; extreme caution must be used with higher concentrations of acid because disfiguring burn and scarring can occur. Purchasing a dedicated text on chemical peeling and observing and mentoring cases is the safest and most effective means of learning chemical peeling. Contemporary cosmetic surgeons realize the importance of volume replacement as an integral part of cosmetic facial surgery. Midface lifting has a reputation for being transient, fat and fillers resorb, but cheek implants are a permanent, three-dimensional means of volumizing the midface. When discussing implants with prospective patients, it is reassuring to tell a patient that the result will be permanent, but if they are unhappy, the implant can be removed in 5 minutes. Older patients undergo fat atrophy as well as skeletal and cutaneous changes and the cheeks at some point become the jowls, leaving an atrophic hollow in their place. Almost any patient older than 45 years can benefit from some type of midface augmentation, and younger patients with developmental midfacial deformities are also excellent candidates. A myriad of implant sizes and shapes are available and this can be confusing for the inexperienced facial surgeon. The author basically categorizes the regions of midfacial volume deficiency to the submalar region, the malar region, or a combination of both. Patients with otherwise normally developed midface features will lose fat in the infraorbital and submalar regions. This is the earliest and most common cosmetic problem, and therefore, the majority of implants (90%) the author places are silicone submalar implants. The implants run a bit small, so the average female will require medium to large submalar implants and males may require extra large submalar implants. For the patient who has adequate submalar fill, but requests solely malar augmentation, the malar shell implant configuration is convenient. This implant lies more superior and lateral and produces the "high cheekbone look. This implant is a hybrid of the submalar implant and the malar shell implant and serves to augment both regions simultaneously.

Laser ablation of periosteum and brow fat medial to the nerve is performed to locate this sometimes small muscle for treatment prostate transition zone buy uroxatral australia. A prostate cancer jokes 10mg uroxatral, Because of both brow ptosis and upper eyelid laxity prostate 45 grams buy 10 mg uroxatral with visa, the patient required upper blepharoplasties as well as endoscopic forehead and brow lifting to achieve the results she desired prostate tea buy uroxatral 10 mg line. B prostate cancer pain generic uroxatral 10mg without a prescription, the patient before and after only blepharoplasty and full-face laser skin resurfacing mens health nutrition 10 mg uroxatral with mastercard. She has multiple problems including asymmetry of the brows due to a blepharospasm on the left side, eyelid asymmetry and severe laxity, pseudoelevation of the brows due to frontalis compensation for severe eyelid ptosis, and severe actinic skin damage. She is not a good candidate for simultaneous brow lifting because a change in brow position will likely occur after the removal of the eyelid ptosis. The depressor muscles and their resulting creases in the glabellar region can be adequately treated from a subperiosteal, subgaleal, or subcutaneous plane. However, they are not completely eliminated by brow lifting alone, and the patient must understand that botulinum toxin therapy may be required to treat these particular lines on an ongoing basis. Intrinsic skin and collagen damage from the effects of sun, age, and smoking are not treated by lifting alone. Bony contouring can be performed on a limited basis endoscopically, but a major reduction for significant bone hypertrophy such as a frontal boss is best treated with an open (coronal) approach. The three most classic forms of brow lifting are presented using dashed lines to demonstrate the incision used for each technique. The shaded areas demonstrate the extent of dissection typically required for each technique. Interestingly, the endoscopic brow lift actually requires more undermining to allow tissue redraping because no direct scalp excision is performed compared with the other techniques. As with any surgical procedure, appropriate preoperative laboratory and other indicated tests must be performed. Written instructions are given to the patient regarding pre- and postoperative care, including instructions for shampooing hair with antibacterial soap or other antiseptic shampoo and avoidance of the use of hair spray or other hair products immediately before surgery. The patient should be thoroughly instructed on the critical need to avoid all medications that may cause platelet dysfunction 10 days before surgery (including aspirin and other nonsteroidal anti-inflammatory drugs, vitamin E, and many over-the-counter herbal supplements). Endoscopic techniques require a very dry operating field that necessitates strict avoidance of these medications as well as proper preoperative injection of vasoconstrictive agents. Before induction of anesthesia, photographs are taken and the patient is marked while awake and sitting up. Following the introduction of general anesthesia or intravenous sedation, the patient is prepared and carefully injected with local anesthetic with epinephrine. The author prefers to use a local anesthetic with 1:100,000 epinephrine along the entire orbital rim and a tumescent anesthesia solution (250 mL of normal saline mixed with 1 mL of 1:1,000 epinephrine and 20 mL of 2% lidocaine) in the remaining upper forehead, temple, and posterior scalp. Careful injection in the desired tissue planes helps to avoid the formation of a hematoma during the injection and allows for a nearly bloodless procedure. Minor shaving of hair along the marked incision lines is performed if desired immediately before the final preparation and draping of the area. If performed correctly, the endoscopic technique can be as long-lasting and possibly more precise than open brow lifting techniques. Care must be taken with the coronal lift to avoid elevating the medial brow too much and creating a very high hairline. The amount of tissue excised is not a precise determinant of the amount of brow elevation obtained. Scoring of the underlying fascia and muscle resection can cause the tissue to stretch oddly, making prediction of the exact brow elevation difficult. The benefits of the coronal lift include great exposure and relatively easy dissection. It can also be used to extend the procedure into a deep-plane facelift by dissection over the zygomatic arches and onto the zygoma and masseter. This much more aggressive lift gives excellent elevation of the midface but greatly increases postoperative edema and the potential for motor nerve damage. Comparatively, the basic coronal lift is an easier procedure for the novice surgeon. When selecting this tried-and-true method, one should take into account the disadvantages, including the lengthy scar and possible hair loss, significant scalp anesthesia, and a significantly elevated hairline. With this procedure, hair does not grow anterior to the incision, leaving a visible scar in front of the hairline. In contrast, in the trichophytic lift, although still at the frontal hairline, the incision is placed just behind the hairline. This incision is beveled so that follicles in front of the initial skin incision survive and hair grows anterior to the incision to better camouflage the resulting scar. Even better than the trichophytic lift is the irregular trichophytic hairline, which not only employs a beveled incision but also creates a wavy pattern along the hairline for a more natural postoperative appearance compared with a straight-line scar. Regardless of the specific incision design, the ultimate advantages of the trichophytic forehead and brow lift include great exposure (similar to that with the coronal approach) and the ability to lower a high forehead. In addition, lateral incisions and dissection are usually limited with this technique unless required. Incision design can even improve hair thinning in the temporoparietal areas by excising the area of hair loss and bringing forward areas of dense hair-bearing scalp. This gives great exposure of the entire orbital rims for bony osteoplasty, if required, and treatment of muscles that require resection including the depressors (corrugator and procerus) as well as the frontalis. Heavy horizontal forehead creases can be addressed with this technique by way of either midline myotomies or minor midline thinning of the frontalis. Major resection of the frontalis should be avoided to prevent postoperative irregularities and strange facial expressions during frontalis movement. The lateral frontalis should be avoided to prevent nerve damage, ptosis, and other irregularities. Regrettably, the coronal lift also has the disadvantages of a long incision and a significant elevation of the hairline. Patients with a high hairline are not good candidates for this technique because a significant amount of scalp excision is required. The technique involves several incisions placed strategically behind the hairline to gain access for early blunt dissection and insertion of the endoscope and tissue retractor. Other incisions can be used as ports for dissecting tools such as periosteal elevators, electrocautery, lasers, tissue graspers, and suction instruments. Fixation points are usually placed at these incision sites; therefore, the author prefers five separate 2. One is placed in the midline in the sagittal plane and two in the parasagittal plane tangential to the lateral third of the brow (where maximum lift is typically desired in females). This same incision can be moved slightly medially in male patients to give a more even brow elevation. The midline incision plus the two parasagittal incisions are aligned vertically to avoid unnecessary transection of sensory nerves originating from the supraorbital nerves below. The two parasagittal incisions are placed medial to the temporal crest to gain access to skull bone rather than the more lateral temporalis fascia. Accidental placement of the parasagittal incisions too far laterally over the zone of fixation or temporalis muscle makes pocket development difficult and obscures future endoscopic visualization. Moreover, the parasagittal incisions are located in a thick area of the frontal bone where there is a low density of venous lakes. Placing the incision here helps to prevent accidental intracranial injury during bone tunnel creation or placement of bone screws. Lastly, two temporal incisions are made, one on each side of the head, for direct access to the thick temporal fascia. These incisions are placed perpendicular to the desired be brought forward to lower a high forehead by almost any amount. The more lowering that is desired, the more posterior is the dissection and release. Limited or no posterior dissection can be performed if the hairline is to remain at the same level. A subcutaneous technique has become more popular, particularly when the depressors in the lower brow are less concerning than the horizontal forehead creases. The subcutaneous lift is occasionally combined with deep dissection to treat glabellar lines as well as horizontal lines in the forehead. Overall, the trichophytic technique of forehead and brow lifting is an invaluable tool for any surgeon performing facial cosmetic surgery. When a patient presents with a high forehead and low brow position, the trichophytic approach is the procedure of choice to correct both problems. The main disadvantage is the potential for a visible incision despite best efforts. All prospective patients considering this technique must be informed of the chance that there may be a visible scar at the hairline. Surprisingly, when presented with the potential problems and given the choice, many patients prefer to undergo an endoscopic approach with a slight elevation in hairline rather than risk a visible hairline scar. Still, the patient with an extremely high hairline is often thrilled with the lower hairline obtainable only with the trichophytic approach. Attention to detail and gentle soft tissue management are essential to attaining a natural hairline and hidden scar with this popular technique. A few decades ago, endoscopic surgery progressed through use in upper gastrointestinal examinations and then intraabdominal surgery. However, facial endoscopic cosmetic surgery did not blossom until the early 1990s. Sequential appearance after endoscopic forehead and brow lifting (eyelid and skin resurfacing procedures were also performed). Coincidently, the temporal incision parallels the course of the temporal branch of the facial nerve that is located 2 to 3 cm inferior to this incision. Arranging the three medial incisions on a vertical axis and the two temporal incisions in an oblique position to parallel the nerve and blood supply in each area can reduce interference with sensation and vascular supply to the scalp. Dissection is performed through the above incisions down through periosteum medial to the temporal crest and down to the temporalis fascia lateral to the crest. Some surgeons may elect to use a subgaleal rather than a subperiosteal placement of the incision medially. Blunt and blind dissection can be carried out after reaching the subperiosteal and subtemporoparietal planes through the five incisions. Finger dissection and long curved endoscopic periosteal elevators are used to lift the tissue anteriorly to a point 2 cm above the orbital rims and zygomatic arch. Posteriorly, blunt dissection should elevate the temporal tissues a few centimeters behind the ear, where the temporal fossa becomes self-limiting. The subperiosteal dissection above needs to elevate the scalp at least 10 cm posteriorly but can extend as far back as the lambdoid suture. Blind release of the more inferior portion of the temporal line where the facial nerve crosses should be avoided. Using finger dissection, the upper zone of fixation is broken through, proceeding from the temporal incision toward the medial scalp, rather than vice versa, to prevent creation of a false tunnel in the spongy or foamy temporoparietal fascia. False tunnels along the temporal crest create problems when the endoscope is inserted through the parasagittal port to visualize the lateral forehead; the tunnels force the placement of the endoscope in a more superficial plane within the temporoparietal fascia, which greatly increases the chance of nerve injury. Therefore, it is critical to stay firmly against the periosteum and the temporalis fascia when initially elevating the scalp and forehead. Following blunt elevation of the scalp from each incision for complete flap elevation, the endoscope is normally inserted through one of the three more medial incisions. Poor initial blunt dissection makes the initial endoscopic dissection feel very tight, and care must be taken not to perforate the skin by excessive retraction. Medial dissection over the nasofrontal suture and orbital rims is performed under direct endoscopic vision with a curved and smooth elevator to avoid inadvertent tearing of the periosteum. The periosteum may be thin in some patients in whom a straighter elevator may be used to transect the periosteum at the level of the rim (arcus marginalis). Typically, the periosteum is more precisely incised with a needle tip cautery or laser set at low power. The supraorbital nerves and vessels as described earlier are at a level tangential to the medial limbus and are immediately behind (superficial to) the periosteum from the internal endoscopic view. Suction placed by an assistant from another port is required to maintain a clear view when using cautery or laser. Temporal incisions work well for suction ports during dissection over the rims because the endoscope and cautery take up most of the room through any of the middle three incision sites. With clear and near bloodless dissection at this point, transection can be performed through the corrugator supercilii and procerus. If unwanted bleeding is encountered and cannot be controlled easily with pinpoint accurate cautery, pressure should be applied externally over the rim until improved visualization allows for control of bleeding without nerve damage. Vertical rhytids in the glabella created by the corrugators can be improved greatly by transection through these muscles. Likewise, horizontal glabellar lines are treated by transection of the procerus muscle that creates these particular facial wrinkles. Some surgeons advocate more aggressive surgical avulsion of these muscles with endoscopic biopsy forceps. Blind finger dissection is performed initially, avoiding overzealous dissection inferiorly. Dissection proceeds from the subtemporoparietal plane laterally to the already elevated subperiosteal plane medially. The opposite direction of elevation (medial to lateral) may produce false tunnels in the temporoparietal tissue, which impair future endoscopic vision. A, the orbital rim and local depressor muscle as seen from a transblepharoplasty incision. B, Endoscopic photographs show the rolled border of orbital rim before periosteal release in the first view and the supraorbital nerve and vein in the next view after excising through the periosteum.

Purchase cheap uroxatral online. Scientific Studies: Last Week Tonight with John Oliver (HBO).

Benli et al9 presented a retrospective follow-up study of posttraumatic thoracic and lumbar kyphosis after anterior decompression and instrumentation prostate woman proven 10 mg uroxatral. Neurological improvement was achieved in all of the patients with neurological deficits or neural claudication prostate 5k run buy uroxatral 10mg with visa. McBride and Bradford10 treated their population anteriorly with a vascularized rib pedicle graft and femoral neck allograft mens health 8 pack purchase generic uroxatral on-line. All were found to have a solid anterior spine fusion with a 63% mean improvement in preoperative kyphosis prostate 40 gpa scale purchase uroxatral line. All of these are case series prostate cancer stages generic uroxatral 10 mg otc, however androgen hormone and pregnancy order uroxatral 10mg on line, so the quality of this evidence is very low. Been et al11 evaluated radiographic findings, patient satisfaction, and clinical outcome after monosegmental surgical treatment using an anterior procedure alone and compared their results with a combined anterior and posterior procedure after burst fractures. Because their radiographic and surgical outcomes were so similar between the two groups, they concluded that in cases of posttraumatic thoracolumbar kyphosis after burst fractures, monosegmental correction using a single approach (anterior) would be the procedure of choice. This is an observational study with control group, yet retrospective and nonrandomized; the quality of the evidence is low. Correction using the anterior approach, however, may be hindered by ankylosed posterior structures. He suggested a three-stage approach and oligosegmental correction for posttraumatic thoracolumbar angular kyphosis. The first procedure consisted of posterior osteotomy at the lamina of the wedged vertebra or at the facets placing and planting of posterior the pedicle screw. The second procedure consisted of anterior diskectomies, including the contracted anterior longitudinal ligament through the disk above and below the wedged vertebra back to the posterior longitudinal ligament. Roberson and Whitesides15 recommended that the treatment of late posttraumatic thoracolumbar kyphosis should follow basic biomechanical principles, that is, replace the aspect of spinal stability that was compromised, whether anterior, posterior, or both. Using osteotomy techniques, a posterior only approach provides access to both anterior and posterior columns through a single incision. Complications the potential for neurological injury is increased in the surgical management of posttraumatic kyphosis because of the draping of the neural elements over the anterior vertebral elements, the possible presence of a preexisting spinal cord injury, the possibility of scarring with cord tethering, and the combination of subluxation, residual dorsal impingement, and dural buckling at or near the osteotomy site. Neurological deterioration following corrective surgery for thoracolumbar kyphosis has been reported to be as high as 8%. Spinal cord intraoperative monitoring is extremely useful in detecting any change in neurological function during surgical manipulation. A database search was done between the years 1977 and 2007 under "posttraumatic kyphosis," "posttraumatic spinal deformity," "surgery of," "operative treatment of. Additional less cited indications include radicular pain, pseudarthrosis, and development of late spinal stenosis. In the 48 patients reported by Malcolm et al,12 back pain was the most frequent presenting complaint and indication for surgery. All thoracic deformities were larger than 45 degrees, and the deformity at the thoracolumbar junction ranged from 18 to 72 degrees. In the report of Benli et al,9 severe pain refractory to conservative treatment, neurological deficit or neural claudication, and the presence of kyphotic deformity over 30 degrees were considered as the indications for surgery. In the study by Kossmann and Malham,24 indications for surgical correction were incapacitating back pain, progression of kyphotic deformity, persistent neurological deficit, and development of late spinal stenosis. In the report by Chang,13 all 17 patients noted progression of their deformities and all presented with low back pain that was progressive in nature and a feeling of constant fatigue that become worse as the day went on. In the study by Lehmer et al,26 the indications for surgery were severe disabling pain and/or severe deformity. Forty-one consecutive patients were treated with single-stage posterior transvertebral closingwedge osteotomy. Wu et al20 thought that progressive and persistent kyphosis could impede rehabilitation and lead to increasing neurological deficit and increasing local pain; pressure sores also were more likely to occur. Management goals were decreasing local pain, correction of deformity, 429 43 Surgical Management of Posttraumatic Kyphosis the technique as it was originally described results in lengthening of the anterior column and shortening of the posterior column, with the middle column functioning as a pivot point. This maneuver may sometimes result in an anterior column defect requiring anterior column reconstruction. Recently the pedicle subtraction osteotomy has been shown to be very effective for obtaining significant sagittal deformity correction, all from a posterior approach. Thomasen17 first published the description of a transpedicular cortical decancellation osteotomy, which is now more commonly referred to as a pedicle subtraction osteotomy. Gertzbein and Harris18 described a posterior wedge osteotomy, supplemented with compression instrumentation, as being very effective for deformities greater than 30 degrees. Wu et al20 reported 13 patients with posttraumatic kyphosis treated with posterior decompression and a wedge-shaped osteotomy. Lazennec et al21 evaluated the use of a posterior closing wedge osteotomy at the level of injury by comparing thoracolumbar and lumbar spinal levels. They concluded that posterior closing wedge osteotomy was most efficient for thoracolumbar posttraumatic deformities, failing to adequately restore lordosis at the lower lumbar spine. All these publications are case series; hence the quality of the evidence is very low. Although technically demanding, the posterior closing wedge osteotomy procedure demonstrated improved surgical results with significantly less operative time and blood loss. This was an observational study with a control group, but it was nonrandomized, restrospective; hence the quality of the evidence is low. Ahn et al27 performed a prospective clinical trial to study the radiographic parameters and functional outcome in patients undergoing spinal osteotomy to determine whether correction of specific radiographic parameters is associated with improved functional outcome. A significant association was found between outcomes and radiographic correction of coronal and/or sagittal deformity if the postoperative sagittal lordosis (from L1 to S1) was 25 degrees and if postoperative coronal alignment (measuring the horizontal distance from midsacrum to a gravity plumbline dropped from the center of the C7 vertebral body) was within 2. A database search was made between the years 1977 and 2007 under "posttraumatic kyphosis," "posttraumatic spinal deformity," "surgery of," "operative treatment of. Fourteen original articles evaluated the effectiveness of techniques to restore sagittal alignment (Table 43. Surgical methods include anterior only surgery, posterior only, combined anterior and posterior approaches, and posterior osteotomies. Most of these articles are case series and the quality of the evidence is very low. This should be taken into consideration when reviewing the evidence of the literature. To compare different surgical techniques, validated outcome tools should be developed for these patients. Theirs was a retrospective case series of patients with varying time periods between injury and treatment. High correction rates were obtained in their patients with kyphotic angles between 30 and 50 degrees (96. McBride and Bradford10 described an anterior spine fusion with a vascularized rib pedicle graft and femoral neck allograft providing early stability and maintenance of the kyphosis correction. These are retrospective case series; hence the quality of the evidence would be considered very low. In the patients who underwent an anterior procedure alone, the median kyphosis was corrected from 23 degrees preoperatively to 12 degrees postoperatively and was 11 degrees at follow-up. In the patients who underwent a combined anterior and posterior procedure, median kyphosis was corrected from 21 degrees preoperatively to 12 degrees postoperatively and was 12 degrees at follow-up. Because comparison of surgical correction following anterior only approaches compared with combined one-stage Table 43. This is an observational study with control groups, yet it is retrospective, nonrandomized, and sequential; hence the quality of the evidence is low. Bone union of the osteotomy or diskectomy was obtained at 1-year follow-up in all cases. Bohm et al28 used both segmental posterior transpedicular as well as ventrolateral instrumentation with a 3- to 5-year follow-up period of 40 patients. Percentage correction in the thoracic spine was 62% and 73% in the thoracolumbar and lumbar regions. Atici et al30 and Caceres et al31 also presented reports of a mixture of surgical approaches-anterior, posterior, and combined, without direct comparisons-and corrections of 24 degrees and 27. Lehmer et al26 performed single-stage posterior transvertebral closing-wedge osteotomy for treatment of adult thoracolumbar kyphosis with an average correction of 35 degrees obtained at each osteotomy site. Gertzbein and Harris18 performed closing dorsal wedge osteotomies in three cases with an average correction of 34. Wu et al,20 using a posterior decancellation procedure, achieved solid fusion in all 13 patients, with an average correction of 38. Heary and Bono29 described using pedicle subtraction osteotomy in the treatment of three patients with severe, posttraumatic spinal deformities. A mean of 51 degrees of sagittal plane correction was achieved and maintained at the final follow-up of 2 years. All these are retrospective case series, and the quality of this evidence is very low. Additional acceptable clinical indications are associated neurological deficits and progressive deformity. There seems to be no agreement among authors on the amount of deformity, which should be seen as an indication for surgery. What Is the Most Effective Surgical Method in Restoring Sagittal Alignment in the Treatment of Posttraumatic Kyphosis The evidence is only a weak recommendation that any one technique is superior to the other. By the consensus opinion of the Spine Trauma Study Group, a strong (75% consensus) recommendation can be made that a posterior pedicle subtraction-type osteotomy is superior to other approaches. Post-traumatic syringomyelia: a review of the cases presenting in a regional spinal injuries unit in the north east of England over a 5-year period. Measurement of thoracic and lumbar fracture kyphosis: evaluation of intraobserver, interobserver, and technique variability. Minimum 5-year follow-up surgical results of post-traumatic thoracic and lumbar kyphosis treated with anterior instrumentation: comparison of anterior plate and dual rod systems. The preoperative kyphosis and correction magnitude were significantly larger in posterior closing wedge osteotomy group, and the authors concluded that, although it was technically demanding, the posterior closing wedge osteotomy procedure allowed more reliably restored sagittal alignment. The quality of evidence of this retrospective study must nonetheless still be considered low. Vertebral body replacement with femoral neck allograft and vascularized rib strut graft: a technique for treating post-traumatic kyphosis with neurologic deficit. Clinical outcome and radiographic results after surgical treatment of post-traumatic thoracolumbar kyphosis following simple type A fractures. Management of posttraumatic kyphosis: surgical technique to facilitate a combined approach. Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. Wedge osteotomy for the correction of posttraumatic kyphosis: a new technique and a report of three cases. Closingopening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach. Wedge osteotomy for treating post-traumatic kyphosis at thoracolumbar and lumbar levels. Pedicle subtraction osteotomy in the treatment of chronic, posttraumatic kyphotic deformity. J Bone Joint Surg Br 2006;88(Supplement I):149 44 the Role of Surgery in Traumatic Conus Medullaris and Cauda Equina Injuries Ory Keynan and Marcel F. This is somewhat surprising given not only the unique neurological anatomy at the L1 level, which is often the location of the termination of the spinal cord, but also surprising because there is a predilection for injuries to occur at the junction of the termination of the rib cage and the upper lumbar spine precisely where the distal spinal cord, conus medullaris, and cauda equina coexist. When trying to practice evidence-based medicine in treating traumatic conus medullaris or cauda equina injuries, the clinician has to consider the uniqueness and individual variability of the neuroanatomy of this region of the spine. Within several spinal motion segments lay not only multiple nerve roots, but the lumbosacral enlargement of the spinal cord, the conus medullaris, and the cauda equina, including the filum terminale. At the level of the thoracic spinal cord (generally accepted to be between the T2 and T11 vertebral levels) the nerve roots exit the spinal canal in a generally. This anatomical arrangement changes at the termination of the spinal cord, which most commonly occurs at the middle third of L1 but may occur anywhere from T11 to L3. The conus and cauda also mediate the sacral parasympathetic, lumbar sympathetic, and sacral somatic nerves. The conus medullaris contains all of the sacral motor neurons and interneurons, but adjacent to the conus, at the same segment of the spinal canal, we also find all the lumbar nerve roots. Thus an injury to this region of the spinal column can result in different combinations of injury to upper motor neurons and lower motor neurons. The complex anatomy of this region has not been adequately appreciated in the spinal surgical literature. Specifically, thoracolumbar spinal cord injuries are often described in aggregation, combining thoracic spinal cord and lower lumbar cauda equina injuries. This makes it difficult to uncover the specific evidence applicable to injuries to the variety of neurological structures in this specific region of the spine. The T2 sagittal magnetic resonance imaging scan shows not only the compression of the conus medullaris but also the significant posterior ligament injury. For the reasons stated earlier, we believe that this is a unique region of the spinal neural axis and requires discrete study. Injury Types A variety of injury patterns can lead to neurological injury to the conus medullaris and cauda equina.

Forceful coughing can allow air to pass into the retropharyngeal space and into the mediastinum prostate warmer purchase 10mg uroxatral amex. Alternatively prostate oncology williston discount uroxatral 10mg visa, rupture of a perivascular bleb or traumatic introduction of air through the cervical fascia is also possible prostate oncology kalispell cheap uroxatral 10mg. Subcutaneous emphysema may be managed by observation prostate cancer test purchase uroxatral american express, heat androgen hormone receptor cheap uroxatral 10 mg on line, and systemic antibiotics man health recipe uroxatral 10mg discount. Therapy for pneumomediastinum consists of close observation, cardiac monitoring, intravenous fluids, and antibiotics. Chest tubes or drainage of the mediastinum may be necessary, but supplemental oxygen, as well as pulmonary physiotherapy, should be used. Epiphora Epiphora may be seen after Le Fort osteotomy and is frequently due to edema of the nasal mucosa. Alternatively, the nasolacrimal ductal drainage system may be injured when a concomitant partial inferior turbinectomy is performed with during maxillary osteotomy. Damage to the nasolacrimal appartus may also occur if the bone cut for the Le Fort is placed too far superiorly along the medial wall of the sinus. Meticulous soft tissue dissection and carefully placed osteotomies around the medial aspect of the piriform aperture may decrease the incidence of epiphora. Persistent excessive eye tearing that does not decrease after 3 weeks may need to be addressed with a dacryocystorhinostomy procedure. Also, although the risk of salivary fistula exists through this trocar site, it would represent a rare occurrence. Salivary Gland Injuries Injuries to the parotid gland can occur with extraoral approaches for orthognathic surgical procedures. Painless swelling, parotid sialoceles, and fistulae have been reported in the first week after surgery. Sialography is not recommended in the acute phases of these injuries, because the contrast may extravasate into the soft tissues with inflammation or the procedure may create a larger fistula or increase the size of the current fistula. Resolution of a sialocele should be expected within 4 weeks with the appropriate use of nonsurgical therapies, and failure of these treatment options may require a more invasive surgical procedure. Complications do occur during orthognathic surgery, and the clinician must be aware of the myriad of possible consequences in order to most appropriately manage or prevent these from occurring as well as to be able to adequately perform a detailed informed consent discussion with patients and families before orthognathic surgery. In most cases, complications from orthognathic surgery can be prevented with comprehensive diagnosis and treatment planning including a thorough history, clinical and radiographic examination, dental model and cephalometric analysis, and a meticulous attention to detail in the treatment planning phases for maxillary and mandibular surgery. After an injury to the auriculotemporal nerve, the symptoms are believed to be caused by a misdirected regeneration of parasympathetic fibers to denervated sweat glands, resulting in sweating of the cheek during mastication and salivation; this condition is diagnosed with an iodine-starch test. Mild cases in which the patient may have symptoms only with spicy foods should be observed, because the symptoms may decrease with time. A variety of treatments have been suggested for more severe symptoms, including topical scopolamine patches and insertion of fascia lata or acellular human dermis matrix under the skin. Egyedi and coworkers107 noted 6 undesirable scars in a group of 100 patients with extraoral incisions for orthognathic surgery, although the criteria used to determine what was undesirable are unknown. Percutaneous incisions of 2 to 4 mm seldom leave significant scars, and the more common problem occurs when the epidermis adheres to the underlying fascia and muscle, with puckering or retraction of the skin. Scar revisions can improve the appearance of existing scars, although a scar will always be present. Other options for scar management include massage, injection of corticosteroids, and dermabrasion or laser resurfacing. With the use of intraoral techniques and endoscope-assisted surgery, most skin incisions can be avoided. Whereas the majority of the skin puncture sites on the cheek heal without visible scars, there may be excessive scarring of the site, especially if the metal trocar becomes heated from the rotation of an eccentric drill bit during drilling the holes for the bicortical screws. Incidence of complications and problems related to orthognathic surgery: a review of 655 patients. Management of postoperative hemorrhage following the Le Fort I maxillary osteotomy. Major vascular complications of orthognathic surgery: hemorrhage associated with Le Fort I osteotomies. Major vascular complications of orthognathic surgery: false aneurysms and arteriovenous fistulas following orthognathic surgery. Life threatening, delayed hemorrhage after Le Fort I osteotomy requiring surgical intervention: report of two cases. Prevalence of postoperative complications after orthognathic surgery: A 15 year review. Complications of bicortical screw fixation observed in 482 mandibular sagittal osteotomies. Screw fixation following bilateral sagittal ramus osteotomy for mandibular advancement-complications in 700 consecutive cases. Effects of age, amount of advancement, and genioplasty on neurosensory disturbance after a bilateral sagittal split osteotomy. Neurosensory alterations of the inferior alveolar and mental nerve after genioplasty alone or associated with sagittal osteotomy of the mandibular ramus. Intraoperative recording of trigeminal evoked potential during orthognathic surgery. The anatomic location of the mandibular canal: its relationship to the sagittal ramus osteotomy. A retrospective analysis of lingual nerve sensory changes after mandibular bilateral sagittal split. Accuracy of using the antilingual as a sole determinant of vertical ramus osteotomy position. Blindness as a complication of Le Fort osteotomies: role of atypical fracture patterns and distortion of the optic canal. Postoperative computed tomography scan study of the pterygomaxillary separation during the Le Fort I osteotomy using a micro-oscillating saw. Intraoperative complications of sagittal osteotomy of the mandibular ramus: incidence and management. Further refinement and evaluation of the intraoral vertical sub-condylar osteotomy. A comparative study of bicortical screws and suspension versus bicortical screws in large mandibular advancements. Soft tissue healing after parasagittal palatal incisions in segmental maxillary surgery: a review of 311 patients. Maxillary perfusion during Le Fort I osteotomy after ligation of the descending palatine artery. A modified intraoral sagittal splitting technic for correction of mandibular prognathism. Alterations in nasal respiration and nasal airway size following superior repositioning of the maxilla. Nasal airway changes after Le Fort I impaction and advancement: anatomical and functional findings. Complications of, the mandibular sagittal ramus osteotomy associated with the presence or absence of third molars. Presence of impacted teeth as a determining factor of unfavorable splits in 1256 sagittal split osteotomies. Factors influencing condylar position after the bilateral sagittal split osteotomy fixed with bicortical screws. Mobility of the mandible following mandibular advancement and maxillomandibular or rigid internal fixation: an experimental investigation in Macaca mulatto. Long-term effects of orthognathic surgery on the temporomandibular joint: comparison of rigid and non-rigid fixation methods. Condylar torque as a possible cause of hypomobility after sagittal split osteotomy. Signs of temporomandibular disorders in patients with horizontal mandibular deficiency. Condylar remodeling and resorption after Le Fort I and bimaxillary osteotomies in patients with anterior open bite. Stability after vertical subcondylar ramus osteotomy for correction of mandibular prognathism. Auriculotemporal syndrome secondary to vertical sliding osteotomy of the mandibular rami: report of a case. Modified external reference measurement technique for vertical positioning of the maxilla. Rigid versus wire fixation for mandibular advancement skeletal and dental changes after 5 years. Comparison of relapse in bilateral sagittal split osteotomies for mandibular advancement: rigid internal fixation (screws) versus inferior border wires with anterior skeletal fixation. The coordination of care between restorative dentistry, surgery, orthodontics, and prosthodontics is critically important during this phase of reconstruction of the cleft lip and palate patient. These minimum requirements may be inadequate if the team does not provide a consultation for the other members who are truly important in the care of cleft lip and palate patients, specifically restorative dentistry and psychological counseling. Many children with cleft lip and palate have malformed teeth, dental crowding, missing teeth, supernumerary teeth, and ectopic eruption that frequently require careful evaluation and treatment by pediatric or general dentists during the phases of mixed dentition and into the early permanent dentition. Many children have underdeveloped, or missing, maxillary lateral incisors and may be candidates for dental implants and/or other prosthetic reconstruction. Sometimes overlooked in interdisciplinary care of these patients is psychological counseling. A significant number of these children have self-esteem issues associated with their facial deformities, especially during the formative preteen years, and families need to maintain an open mind and discuss these social issues associated with their cleft lip and palate child. A thorough team discussion about the consultations that can be obtained, and the services that can be provided, must take place to ensure that each team member has access to all aspects of care and to ensure that patient expectations are reasonable and appropriate. On occasion, families become very complacent with follow-up and recall to the interdisciplinary cleft palate clinic owing to the fact that they have had their immediate I needs met once the cleft lip and cleft palate have been repaired surgically. If speech problems have been addressed, or do not exist, the family may be satisfied with the progress, and it is critical that the interdisciplinary team review the patient records to ensure that patients who have been noncompliant with regular team meetings attempt to reenter the regular team meetings, especially during late transitional dentition and early permanent dentition, to alleviate significant problems in treatment who may present late for treatment. Orthognathic care in the cleft lip and palate patient begins with development of the maxilla in the transitional dentition, and during this time, the orthodontist should take every opportunity to develop the transverse dimension of the maxilla. Occlusal view of an 18-year-old who had inappropriate management of cleft dentofacial anomaly. The surgeon will have a difficult enough time manipulating the maxilla without having additional problems associated with poorly bonded orthodontic appliances with small arch wires and without adequate surgical lugs for intraoperative intermaxillary fixation. These small issues can provide an increasingly frustrating surgical procedure that may result in inadequate treatment in fixation. Maxillary hypoplasia in three planes of space is a common problem encountered in children with cleft lip and palate, and there is controversy regarding what degree of this restricted growth is surgically induced and what degree of hypoplasia is intrinsic. Discussions about early orthognathic surgery must include an understanding by the family and patient that, in most situations, the patient will require secondary surgery after the cessation of facial growth. Early in the history of orthognathic surgery, the application to children with cleft lip and palate dentofacial anomalies proved to be difficult. There is typically adjunctive bone grafting and some form of additional fixation utilized in these cases of large maxillary advancements in the cleft patient to prevent relapse. Subsequently, the mandible was then repositioned posteriorly to achieve a class I canine and molar relationship with the maxilla. In many patient situations, the projection of the mandible may be in a relatively normal position, and essentially, the technique of treating to the deformity was employed. Maxillary advancement does not correct the lip scarring or retraction or compensate for an unaesthetic lip repair, and it does not normalize anatomic landmarks. The patient was followed by a "cleft" surgeon, but without interaction from other cleft team members. The patient and family may initially think that the patient will not be a candidate for surgery, and this may have negative effects on the orthodontistpatient relationship if a surgery is recommended later. Statistically, the number of children who need to have orthognathic surgery and have had unilateral cleft lip and palate is approximately 25%. Lateral cephalogram of a cleft patient presenting for correction of a severe dentofacial anomaly. Lateral cephalogram of a 12-year-old bilateral cleft lip and palate patient before orthognathic surgery. Lateral cephalogram of the same 12-year-old with early intervention maxillary advancement. The increased support provided by maxillary advancement for the nose and lip changes the cosmetic appearance without direct surgery on these structures. The judgment of the surgeon who performs the definitive lip and nasal surgery may be hindered if the skeletal deformity is not addressed before the final aesthetic soft tissue procedures. Other presurgical orthognathic considerations for patients with bilateral cleft lip and palate include the use of palatal splints, especially in situations in which the bone graft is less than adequate in the alveolar cleft to help prevent fracture of the bone graft in this area and after the down-fracture and manipulation of the maxilla. A palatal splint will help stabilize the bone of the lateral segments as well as the premaxilla so that the intersegment bone does not fracture and will allow stabilization of the entire complex so that additional bone grafting can be accomplished during the orthognathic procedure, if indicated. Occlusal splints must be fabricated before surgery with consideration of whether overcorrection of the jaw movements will be planned. Posnick and Ewing7 showed that 24 patients without pharyngoplasty with mean maxillary advancements of 6. The patient asked the orthodontist for camouflage and did not want a second surgery. Note recurrent maxillary hypoplasia, not secondary to relapse, but continued mandibular growth. Lateral cephalogram of a 17-year-old patient who had had early surgery for correction of maxillary hypoplasia. The anesthesiologist should be made aware of the presence of the pharyngeal flap and that plans for alteration from the usual intubation protocol may be necessary.