Biomedical subjects
Publications and source records attributed to R C Webster.
Blepharoplasty on lower lids frequently results in a downward pull on the free border of the lid and inferomedially on the lateral canthus. Extending the incision in the lower lid upward and lateral to the outer canthus allows most of the excision to occur laterally. Closure then pulls superolaterally, which tends to prevent the commonest complications of blepharoplasty on lower lids.
Excisions from the face are performed to cure diseases and to remove blemishes. Satisfactory cosmetic appearances can be achieved in most cases, even when large defects result from the excisions, if the surgeon employs cosmetic surgical principles and techniques in the repairs. Some esthetic concepts and artful methods are presented to illustrate this feasibility.
Explore the source record for details and available documents.
Many surgeons have difficulty in cutting small split thickness skin grafts of consistent thickness and width. We demonstrate techniques using equipment and supplies almost always available for expeditious cutting and handling of small split thickness skin grafts. The methods suggested should allow surgeons to eliminate some of the problems that they have had with this basic technique of reconstruction.
We have shown the use of two techniques for preventing or treating undesirable sequelae noted so often following the closure of gouging or beveled U- or V-shaped flaps. These simple expedients have prevented "trap door deformities" in many hundreds of repairs carried out over the the years. Other modalities and precautions are mentioned.
Lateral osteotomies performed posteriorly enough to avoid step-like prominences at the sides of the nose may allow medial displacement of bone to impinge on the airways. This obstruction near the floor of the nasal passageway is prevented by leaving a triangular piece of bone at the pyriform aperture intact just superior to the level of the inferior turbinate. A curved lateral osteotomy, as described here, cuts bone posteriorly only where aesthetic narrowing is required in rhinoplasty. Techniques providing the recommended curved or angulated lateral osteotomies with osteotomes are demonstrated in the cadaver and in patients.
Explore the source record for details and available documents.
Photographs, drawings, and examination at consultation have value in rhiniplastic planning. However, the surgeon is not operating on photographs, drawings, or an alert sitting or standing patient; he is operating on a nose with what was forward now facing upward. We find it most helpful to plan and mark almost the entire procedure on the external nose and surrounding structures just before the patient is put supine and sedated or anesthetized. In primary rhinoplasty, it is possible to mark essentially all skeletal anatomy within 1 mm tolerances by palpation, pushing the tip up and back, observing the changes from the outside, and looking at the inside. We believe that the anatomy and planned changes can and should be depicted by appropriate marks put on the skin. There mere act of drawing in the procedure forces us to think it through from beginning to end, a most worthwhile endeavor. Moreover, we learned very shortly after we began forcing ourselves to quantitate the anatomy and proposed changes, that we ran into fewer and fewer surprises as we worked. Photographs taken of the markings become by far the best "operative note" we can have. Comparison of these with the patient or his photographs showing the result allow us to make accurate judgments about long term effects of each surgical maneuver. Much that seemed mysterious before is found to be quite scientifically explainable. We do not propose in this short report to show how we mark every nose. Rather we shall show with drawings and a few examples how we go about marking a nose. The reader may use the suggested marking techniques or may evolve his own. The important thing is that he work out a system meaningful to him. It will be noted that we have used differing techniques for depicting similar concepts from case to case. In other words, we have not settled immutably on one system because we are still searching for the best.
Because of difficulties in making accurate measurements from before and after photographs, we have devised measuring techniques not dependent upon exact reduplication of photographic circumstances before, during, and after surgery. Measuring devices contacting the head of the patient in specified ways are described. They allow simple and exact reduplication so that measurements made at different times can be compared. Lengths of nose and of columella and actual projection of brow, nasofrontal angle, rhinion, supratip region, the tip itself, and of the columella-labial junction can be measured. Tip rotation, cephalic or caudal, can be determined and quantitated. The devices and techniques for using them are described. We believe that employment of the suggested measuring techniques will allow better reporting of rhinoplastic methods and results should significantly increase our understanding of this complex surgical procedure.
Face lift surgery almost always is elective; and, because its purpose is to diminish aging problems, it most often is done in those who are aged. Local and general risks, therefore, should be minimized. Wide undermining dictates flaps dissected more deeply and wounds closed well short of the limits of stretch of skin. Less radical undermining described here produces much smaller total wounds, lessens hazards of hematoma, considerably shortens operative and anesthetic times, reduces risks to nerves and ducts, and allows snugger closures. Details of operative technique, including platysma plication, are demonstrated. Short- and long-term results are shown. They indicate improvement sufficient to justify expanded use of the suggested techniques, particularly in view of diminished morbidity and risks to the general condition of those in the older age group.
Conventional closure of surgical defects in skin may cause unsightly protrusions (dog ears). Fusiform excisions with angles of 30 degrees or less reduce protrusion but may require excision of larger volumes and lengths of healthy skin and subcutaneous tissue than may be desirable. M-plasties reduce these requirements while still allowing use of 30 degrees angles at maximum. Applications and technical details are described and illustrated.
For many years, we have used 6-0 catgut for closure of epithelial and superficial dermal wound edges. Only when absolutely necessary do we use deeper dermal or subcutaneous sutures. The superficial suturing is supplemented with antitension skin taping. Details of the technique are presented and reasons why satisfactory results occur are postulated. The recommended techniques have been used in closure of wounds on the face and body. It is emphasized that only certain catgut and antitension taping products work well.
There is no one technique best for all noses. The sensitive, versatile, and experienced cosmetic surgeon should select from his choices the combination of modalities best tailored to the needs of each patient. Among these modalities should be cartilaginous septal transfixion combined with the three techniques for changing the quantity and shape of the tip cartilages. The most important factor in choosing from the three tip techniques is the decision as to where the rotation points and major thrusts should be. Then come the choices as to tip width and infratip lobule length and the fine points of cartilage incision levels and directions and cartilage excisions or morselization. The decision to detach or not detach the septal strut below the cartilaginous septal transfixion incision is predicated mainly on tip-columella-lip esthetic complex requirements. Proper selection of these methods and attention to the tip-columella-lip esthetic complex should allow the surgeon to construct pleasing, relatively natural looking profiles with fewer radical hump removals and nostril base resections and with rare complications from nostril notching or collapse. No magic is involved in rhinoplasty; the surgeon's incision, removals, and additions, plus scar formation and contraction, produce the results.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Brow modifications are discussed with respect to their role as aids in achieving certain aesthetic effects when rhinoplasty is being performed. If a deep nasofrontal angle should not be brought forward, reduction of the brow may be indicated. If the nasofrontal angle should not be retrodisplaced to deepen a shallow angle, brow augmentation may prove helpful in separating the nose from the forehead or in making the nose appear shorter in the vertical dimension. Augmentation and reduction browplastic techniques are discussed, and selected methods are illustrated. Some involve additional resection of frontal bone or procerus muscle at the time of nasal-hump removal. Others employ grafts of bone and/or cartilage removed from the nose at the time of septorhinoplasty. The versatile aesthetic surgeon should be capable of changing all structures adjacent to the nose. Certain difficult cosmetic problems are best treated by directing appropriate attention to these structures and to the nose rather than by concentrating on the nose alone. That the brow is one of these important abutting landmarks is demonstrated.