Biomedical subjects
Publications and source records attributed to D T Gault.
The cauliflower ear presents a challenge to the surgeon. Patients complain of discomfort and appearance. Three patients were treated surgically via a posterior approach to remove the hardened segment and re-sculpture a leaf of cartilage left in place. An acceptable cosmetic result was achieved and all patients are currently pain free.
Laser treatment of pigmented lesions requires melanocytes to lie within the range of penetration of the laser, and to contain melanin in order to absorb and covert light energy into heat by photothermolysis. This study investigated whether these limitations could be tested by immunohistology and used to predict the outcome of treatment. Punch biopsies were taken from 32 patients prior to laser treatment. Immunohistology targeting the S-100 antigen allowed measurement of melanocytic depth and the presence of amelanosis. These parameters provided an accurate method of predicting good results (sensitivity 81%, specificity 93%) and were particularly useful in delineating the likelihood of a poor/very poor outcome (sensitivity 100%), even beyond the predictive capacity of the test patch. No complications were associated with the biopsy technique which reliably provided sufficient material for histological assessment. This study reports the clinical applications of this test to laser treatment.
Laser resurfacing has been reported to have a useful role in the treatment of facial rhytides, however the results of published series have relied on subjective methods of assessment. The aim of this investigation was to develop an accurate method of measuring wrinkle depth and secondly to use this to assess the efficacy of laser rejuvenation. Wrinkle depth was measured in 30 patients with perioral rhytides using a silicone mask to provide a negative replica. Depth was measured using simple light microscopy and the accuracy of this was confirmed with the electron microscope. A highly significant correlation was found between these two methods of measurement (R2 = 0.97, P < 0.0001) with an accuracy of 0.03 mm. Using this method laser rejuvenation was evaluated in a prospective series of 30 patients with perioral rhytides (median follow-up 11.5 months, range 5-20 months). Resurfacing was found to achieve a significant reduction in mean wrinkle depth of 91% (paired t-test, P < 0.00001). The only complication reported was erythema which was always transient. The use of light microscopy on silicone moulds therefore provides a simple and accurate method for assessing the outcome of facial rejuvenation. Using this technique, the carbon dioxide laser was objectively found to provide a safe and effective treatment for facial rhytides.
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Despite the multitude of corrective procedures described, adequate surgical correction of the congenital constricted ear remains a challenge. The maintenance of the shape and elevation of the reconstructed upper neohelix poses a particular problem. In the present series, experiences with lop ear correction utilizing standard techniques and the use of the mastoid hitch as a useful adjunct to these procedures are described. A total of 19 ears were reconstructed. There were three type 1, eight type 2a, seven type 2b, and one type 3 deformities (Tanzer classification). A graded sequence of procedures was adopted. Mild deformities were corrected by cartilage scoring techniques; a V-Y advancement of the helical root was added for moderate deformities. Cartilage expansion by a banner flap was required for more severe deformities. A mastoid hitch, whereby the refashioned upper neohelix is sutured to the mastoid fascia, should be used as an adjunct to these procedures to maintain helical elevation and prevent recurrence. Severe type 3 deformities may require autologous auricular reconstruction. Mean follow-up time was 1 year. There were six excellent, seven good, four fair, and two poor results. Two patients who had not had mastoid hitch procedures developed a recurrence of the lop deformity. Adequate surgical correction of constricted ear deformities requires a variety of surgical techniques. The mastoid hitch being used for constricted ear correction has not been described elsewhere. The mastoid hitch is a useful adjunctive procedure that may be used effectively in combination with other procedures.
The role of tissue expansion in ear reconstruction has not been clearly defined. Tissue expansion was used to reconstruct 16 ears for posttraumatic, burn and congenital defects. Previous surgery or scarring in the region of the reconstruction was not regarded as an absolute contraindication. The overall complication rate was 31.2%. According to the senior author's grading system, the contours were excellent in 4 ears, good in 9 ears and fair in 3 ears.
The use of endoscopy in facial aesthetic surgery, especially the browlift, is becoming well accepted. We report on the use of an endoscopic assisted technique to correct prominent ears in 10 patients. The instruments were inserted through scalp incisions. No skin excision was performed. The posterior (medial) cartilage surface was weakened by abrasion with a custom-made abrader to create a new antihelical fold. Nonabsorbable sutures were inserted through one or two postauricular stab incisions to appose the scaphal cartilage and the mastoid fascia to hold the new fold. Surgical technique, results and advantages of the operation are discussed. A new classification of prominent ears was used in patient selection for the procedure.
The treatment of multiple basal cell carcinomas in patients with Gorlin's syndrome presents a therapeutic challenge. The carbon dioxide laser presents a unique treatment option due to increased surgical speed, a bloodless operating field, reduced postoperative pain and discomfort, and acceptable scars. Six patients with Gorlin's syndrome have been treated with the carbon dioxide laser. Between 14 and 110 lesions were treated in one session under local anesthesia. Pre- and postlaser biopsies of the lesions confirm complete eradication of the tumors. Mean follow-up is 20 months. No local recurrence has been observed.
An unusual case of severe vascular proliferation presenting in the form of haemorrhaging cutaneous lesions on the leg is reported. The similarity between these benign lesions and various malignancies is outlined. The patient healed well when the lesions were excised using a laser under local anaesthetic.
Four cases of ear reduction for congenital macrotia and ear asymmetry are presented. To minimize the visible scarring the technique of helical advancement was used. The indications for this uncommon procedure are discussed with a review of the literature. This simple technique has been effective in achieving the desired reduction, leaving the scar hidden in the eaves of the helix, and we endorse its wider use.
Non-hypoplastic congenital ear deformities are amenable to non-surgical treatment with splinting in the neonatal period. It is therefore important to determine when the deformity occurs. 100 postal questionnaires were sent to parents to study, retrospectively, the evolution of the prominent ear deformity in their children. 79 questionnaires were returned. As remembered by parents, the deformity was first noted at birth in 48 (61%) children, in 68 (86%) by 6 months and in all cases by 5 years. Therefore a large number of patients with prominent ears could be treated effectively, non surgically, early in life, without anaesthetic and with minimal cost.
Fourteen non-hypoplastic congenitally deformed ears were treated with a simple splint with satisfactory results in all but one. These deformities can be treated non-surgically in the early neonatal period, effectively, without anaesthetic, and with minimal cost. We confirm other reports that better results are obtained and a shorter duration of splintage is needed if treatment is started early in the neonatal period. Our neonatal paediatric colleagues and midwives should be encouraged to manage these deformities in this way, and the need for surgical correction may be largely avoided in the future.
The leakage of cytotoxic drugs, intravenous nutrition, solutions of calcium, potassium, bicarbonate and even 10% dextrose outside the vein into which they are delivered is known not only to cause skin necrosis but also to precipitate significant scarring around tendons, nerves and joints. In this review of 96 patients with extravasation injuries seen between 1987 and 1992 at St Thomas' Hospital, Mount Vernon Hospital and The Hospital for Sick Children, Great Ormond Street, several patients required extensive reconstruction and in some, despite this, extravasation injury has rendered a limb virtually useless. Two techniques, liposuction and saline flushout, are described to remove extravasated material while conserving the overlying skin. Analysis of flushout material confirmed that the extravasated material was actually being removed. Forty four of the study group in whom noxious materials were known to have extravasated underwent such early treatment. The results in this group were quite striking--the majority (86%) healed without any soft tissue loss at all. The early referral and treatment of extravasation injuries is, therefore, recommended.
Intracranial volume and intracranial pressure have been measured in 66 children with craniosynostosis, 48 boys and 18 girls. The premature fusion of skull sutures is assumed to restrict skull growth and predispose to elevated intracranial pressure. Thirteen children (20 percent) had raised intracranial pressure and demonstrated a significant restriction of skull growth. In this series, volume measurement alone, however, did not serve as a reliable predictor that the intracranial pressure was raised.
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Tissue expansion of the forehead by intermittent bolus injection in three patients was noted to be extremely painful. This stimulated a prospective study in four patients whose discomfort was found to be related to a sharp rise in intraluminal pressure after bolus inflation. Tolerable infusion volumes were small (mean 6.25 cc) and associated with high pain scores (mean 7/10). Adequate expansion was protracted (mean 45 1/2 days) and was limited by pain. To eliminate the sharp rises in pressure associated with expansion by bolus injection, a syringe pump was used in two further inpatients. Adequate expansion was both quicker (mean 8.5 days) and less painful (mean pain score 2.6/10).
Poor perineal healing is a major complication of total or partial pelvic exenteration especially when the pelvis and perineum have previously been irradiated. Perineal, vulval or vaginoperineal reconstruction was performed in five women using the inferiorly based rectus abdominis myocutaneous flap. Primary perineal wound healing occurred in all patients and no flap-related complications developed. Primary healing of abdominal wall wounds occurred in all patients without incisional hernia. Three of the patients had an anterior or total pelvic exenteration with continent urinary diversion by the Mitrofanoff technique. Two of the patients had complete vaginal reconstruction and one patient had after-loading catheters inserted for postoperative interstitial irradiation. The patients were in hospital for 42, 28, 21, 17 and 15 days respectively. The longest stays were associated with training for self-catheterization of the continent urinary diversion. Median follow-up was 9 months. One patient developed two perineal recurrences at 16 months which were resected, and she remains disease-free 6 months later.