Biomedical subjects
Publications and source records attributed to O M Ramirez.
An alternative technique for colorectal or ileorectal anastomosis using the EEA and the TA stapler is presented. This technique overcomes the problem of disproportion in size between the ileum or colon and the rectum. It allows the surgeon to examine the anastomosis directly.
Op-Site is a popular skin-graft donor-site dressing. The formation of hematomas or seromas with their troublesome consequences is effectively prevented by the incorporation of a closed drainage system.
Huge sacral defects can be closed reliably with sliding gluteus maximus myocutaneous flaps. In ambulatory patients, this flap is designed to maintain innervation, vascularity, and functional integrity of the muscle.
The rich vascular network of the gluteal and posterior thigh region provides for a larger range of flaps for reconstructive surgery than previously described. Facility with these flaps requires an appreciation of relevant anatomy, embryology, and anthropology. Structural changes in the gluteus maximus muscle are critical to the evolutionary advance toward an upright stance during walking. The superficial and deep segmentation of the gluteus maximus are best appreciated by phylogenic and ontogenetic study. Femoral arterial and gluteal arterial anastomotic hemodynamics are affected by the relative involution of the gluteal system in late embryogenesis. The gluteal thigh flap should include contributions from the femoral system when the cutaneous branch of the inferior gluteal artery cannot be identified. Huge sacral wounds can be closed with gluteus maximus myocutaneous flaps with maintenance of muscular function by detaching the entire origin, sliding the muscle medially, and reconstructing these attachments. By dissection between the divergent inserting fibers of the gluteus maximus, a long, superficial portion of the muscle can be raised that forms the basis of the extended gluteus maximus flap. The pedicle of the flap is at the level of the piriformis muscle and the skin paddle can be placed over the midportion of the posterior thigh. Finally, the first deep femoral perforating artery forms the basis of a posterolateral fasciae latae flap that is well suited for coverage of defects over the trochanter.
The technique presented is safe and fast. Mobilization and opening of the pouch are avoided. Identification of the ureters are not necessary. Introduction of the end-to-end anastomosis stapler into the rectum without the anvil is made safe. Even though we used the straight end-to-end anastomosis stapler, the curved one would seem to be more suitable for this kind of anastomosis.
Current concepts of total facial rejuvenation involve a comprehensive integrated approach to achieve a balanced youthful appearance. Recently introduced endoscopic-assisted techniques allow us to rejuvenate the face through small, remote incisions. Previously, we have considered only young patients with good skin turgor as candidates for minimally invasive procedures, but the advent of the resurfacing laser has allowed us to expand our indications for single stage minimal access rejuvenation. Full facial immediate laser resurfacing at the time of standard rhytidectomy has been avoided due to risk of flap necrosis. Subperiosteal minimally invasive endoscopic assisted techniques do not substantially interfere with facial blood supply. We can now perform endoscopic-assisted full facelifts combined with immediate laser resurfacing to reposition the tissues in a more youthful position and then tighten the skin envelope. Extended endoscopic-assisted subperiosteal forehead lift is performed through three to five scalp incisions; subperiosteal midface lift is performed through a crow's foot or intraoral incision. Cervicoplasty, if needed, is performed through a small submental incision. Full face laser resurfacing is done using a Coherent Ultrapulse laser. To date we have performed eleven subperiosteal minimally invasive laser endoscopic (SMILE) rhytidectomies. There has been no evidence of flap necrosis with this technique. Postoperative recovery has been no different from patients treated only by full face resurfacing, except perhaps for the slight increase in early facial edema. We believe the SMILE facelift is a viable alternative to standard techniques. The limitations of this procedure still need to be elucidated.
Traditional facial rejuvenation techniques address the face by lifting the soft tissues in one or two dimensions. The face is a tri-dimensional structure and aging occurs in three dimensions, therefore, facial rejuvenation should be done in three dimensions. Sagging of facial soft tissues occurs inferiorly and inferomedially. The ideal reorientation during rejuvenation is in the opposite direction: vertically and supero-laterally. Two other elements not routinely addressed by traditional rejuvenative operations are reduction of skeletal framework and atrophy of soft tissues, particularly subcutaneous fat layer. These are the third dimension of facial aging. By principle, any technique that unfolds, pulls, or lifts produces a flattening effect of the structure being treated. They may give a false impression of augmentation if these tissues are advanced over bony prominences. These stretched out tissues also have a tendency to recoil. For that reason, the author suggests use of structures or methods less susceptible to a stretch relaxation or recoil. A prerequisite to 3-D facial rejuvenation is to perform a 2-D-(bi-dimensional) lift. A third dimension is integrated into it. There are four methods to provide the third dimension: (1) augmentation of the skeletal framework; (2) augmentation of subcutaneous layer with fat injection; (3) imbrication of soft tissues; (4) mobilization and repositioning of fat pockets as pedicle flaps. These methods are not exclusive to each other. One, a few, or all methods could be integrated according to the patient's needs and aesthetic goals. Tridimensional changes in facial rejuvenation can be assessed by a standard photographic comparison, using tools for in-vivo measurements or 3-D digital imaging. 3-D facial rejuvenation is an advanced concept in our pursuit to provide superior results with the more aesthetic, natural, and harmonious youthful look to our patients.
Recent technological advances in our specialty have made us reappraise the way we approach facial rejuvenation. Some of these technological interfaces have made it possible, in the author's experience, to improve results and to tackle difficult aesthetic problems. The purpose of this paper is to report how we combine these technological advances in an effort to improve the aesthetic outcomes. These technological advances are: laser skin resurfacing, endoscopy, newer fat grafting procedures, and new alloplastic materials for bone augmentation. Other technological advances are consultations via the Internet, computer imaging for simulation of possible outcomes, etc. Endoscopy is routinely used in our facial rejuvenative procedures, almost always for the forehead, often for the midface and less often for the neck. Fat grafting procedures using newly adapted concepts are used for the brow, glabella, tear trough deformity, cheeks, lips, chin, nasolabial folds, marionette lines, and other areas of soft tissue depressions apparent before or after the lifting procedures. This has allowed us to restore the tridimensional volume and treat the soft tissue atrophy. Patients with significant skeletal soft tissue disproportion due to aging, loss of dentition, prior trauma or congenital defects may receive one or more of the following implants: glabella, cheek, piriformis, angle of the mandible, mandibular body glove type of implant, prejawl implant, chin overlay or a glove type of implant. Our preference is for a porous polyethylene material because of its tissue ingrowth inductiveness. Individuals who have damaged skin due to solar exposure, aging, smoking, etc., may receive Ultrapulse CO2 laser resurfacing at the same operative setting (more often) or in a delayed fashion. The Versapulse laser is also needed for the treatment of some skin changes secondary to aging such as telangiectasias (Variable Pulse Green) and brown spots (Q-Switch 532). The high-tech facelift has allowed us to treat the severely damaged skin, fat atrophy, bone atrophy in many patients, at the same time that the lifting procedure is performed. This provides a more comprehensive approach to facial rejuvenation. The combination of different techniques and technologies maximizes the effectiveness and minimizes the potential side effects of each one. Scars in the forehead and scalp are avoided. Incision and fat removal in the lower eyelid are often unnecessary. It provides a more precise vertical lifting with correction of the tear trough deformity and gives a tridimensional restoration of the facial volume. The facial disharmony is treated at every level starting from the facial skeletal support to the most external envelope (skin). Over 200 patients have been treated this way with a minimal rate of complications. The high-tech facial rejuvenation has allowed us to improve the surgical results of our patients compared with previous isolated techniques. The combination of each one of the techniques require a precise understanding of the limits and benefits of each. Case examples of the different combinations will be shown.