Biomedical subjects
Publications and source records attributed to W Gubisch.
Ear cartilage is an important source of grafts for rhinoplasty. The majority of cartilage grafts is harvested from the concha of the ear. We describe indications in which the tragal cartilage is a more favorable graft source than conchal cartilage. The technique is fast, simple, and does not require special dressings.
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Even today the difficult septum presents a surgical problem. A severe septum deformity is caused mostly by an accident or is seen in patients with malformation like CLP-deformity. It is characterized by a massive deformation in all levels with a consecutive blocking of one or both airways. Such severe septal deformities cannot be corrected properly by classical septoplasty techniques. Therefore we suggest an extracorporal septoplasty, where the whole septum is taken out and by different techniques a new septal plate is reconstructed and then replanted. From 1981 to 2001 we operated 1855 patients and improved this method constantly, especially the safe septal fixation after replantation. Follow-ups showed that even in severe deformities a revision rate of only 5 % respectively 7 % was found. Therefore we conclude the extracorporal septoplasty with its refinements can also be recommended also to the less experienced rhinosurgeon.
Three cases of advanced ulcerating basal cell carcinoma (terebrant ulcer or ulcus terebrans) of the head are reported. Neglected basaliomas had deeply destroyed larger parts of the skull in three women ages 78, 69, and 65 years when the patients were first admitted for treatment. Death due to meningitis, hemorrhage, or brain damage was imminent. Wide resection and coverage by free latissimus dorsi flaps was carried out in single-stage procedures. The latissimus dorsi, a versatile and very reliable free flap with its constant vascular anatomy and long pedicle, is the ideal flap for the coverage of large defects on the head. The donor site can usually be closed primarily, and the functional deficit is acceptable. All three patients recovered completely. Although only palliative resection could be achieved, the procedures could be justified by the increased survival time and gain in quality of life.
Blepharoplasties are amongst the most commonly performed aesthetic procedures. Various lower blepharoplasty techniques have been described in the literature. Often, value and appropriate indication for each individual technique have not been sufficiently delineated. The recent renaissance of the transconjunctival blepharoplasty allowed the evolution of new and safe procedures for correction of the lower lid. Additionally, the technique of resection of the herniated orbital fat underwent certain improvements. The aim of this article is to describe the currently utilized surgical techniques and to discuss their indications.
The clinical picture, diagnosis, therapy, and theories on the etiology of benign symmetric lipomatosis (Madelung disease) are outlined. Personal experience from 62 operations on 28 patients is compared to the literature. Up to now, there is only palliative surgical treatment for this sporadically appearing disease of unknown etiology. Liposuction--a less traumatic treatment--has considerably facilitated the treatment of the circumscribed fatty hyperplasias. The surgical characteristics of different anatomical regions are pointed out.
Orthotopic cartilage transplantation is a technique frequently used in modern septal surgery. The prerequisite for a stable long-term result is viability of the transplanted cartilage. Therefore, we studied the healing process histologically, angiographically, and histochemically. We found a characteristic picture. Due to chondronal structure of the cartilage, the healing process varied in time and location. Reintegration took place by chondroneogenesis, commencing at the inner perichondrium. Reintegration depended directly on the distance of the cartilage cells to the surrounding vessels. Histochemically, we found an intact respiratory chain in the mitochondria and thus, we were able to demonstrate the preservation of viability in orthotopic transplanted cartilage.
Defects of the lower lid are more common than defects of the upper lid. Various methods for reconstruction of the lower lid have been published; we prefer the method of Tripier. The inner lining is reconstructed using a composite graft from the nose, and the outer defect is covered by a myocutaneous bridge flap from the upper lid. We have used this technique for defects of different sizes and have obtained good functional and aesthetic results.
Septal deviations interfere with nasal airflow and contribute to deformities in the external appearance of the nose. An aesthetically and functionally satisfactory correction of severe septal deformities or "crippled" septal plates often requires a temporary intraoperative removal of the septal cartilage for appropriate remodeling. This article describes refinements to the previously described technique of extracorporal septoplasty; these refinements have proven useful and have made the procedure safer in the hands of less experienced surgeons. The refinements simplify the straightening methods for the explanted septal plate, achieving a stable and median fixation of the replanted septum while maintaining a satisfactory contour of the nasal dorsum. A milling cutter is used to straighten the irregularities of the explanted septal plate and to thin broadly based anterior nasal spines. When necessary, microplates are added to stabilize the osteotomized and medialized anterior nasal spine. The final positioning of the replanted septal plate is greatly enhanced by a rein stitch, transosseous sutures, and multiple quilt stitches. Additionally, direct fixation of the replanted septum to the edges of the upper lateral cartilages further improves the stability of the reconstruction. Finally, particular care should be taken to avoid residual irregularities of the nasal dorsum; it they occur, these irregularities can be covered with a thin cartilaginous splint or a layer of dehydrated fascia lata or autologous temporal fascia. A total of 436 patients who underwent rhinoseptoplasties at the authors' department during a 1-year period were reviewed. Of these patients, 108 presented with severe septal deviations and underwent an extracorporal septoplasty using the refined techniques described herein. Despite the complexity of the procedure, the patients' satisfaction rates were high, independent of the operating surgeon.
Since we had the impression that there was an increase in blood loss during mammaplasties after a change in the anesthesiology department responsible, we conducted a study to compare 28 cases from each anesthesiology department. All operations were carried out by the first author in succession using the same operative technique. The two groups did not differ in age, BMI, operative time, weight of resected tissue or preoperative laboratory. Blood loss was calculated from the perioperative drop in hemoglobin and patient's blood volume. Blood pressure, heart rate, medication and intravenous fluid supply were obtained from the anesthetic protocols. RESULTS (MEANS AND STANDARD DEVIATIONS): Group I (n = 28) and [Group II (n = 28)]: total resected tissue 1862 +/- 928 g [1912 +/- 791 g]; Hb-preop. 13.6 +/- 0.9 g/dl [13.8 +/- 0.8 g/dl]; Hb-postop. 10.8 +/- 1.3 g/dl [9.7 +/- 1.3 g/dl] P = 0.006; Blood loss 970 +/- 339 ml [1443 +/- 456 ml] P < 0.001. After exclusion of surgical or biological causes hemodynamic effects of the anesthetic techniques were suspected as the reason for the significant difference in blood loss. MAP was elevated only initially, while the heart rate was considerably elevated throughout the procedures in group II. During anesthesia with nitrous oxide and enflurane, the dose of enflurane in group I could be limited to 0.3-0.5% after initial i.v. administration of 60 to 100 micrograms sufentanil, while in group II without opioids doses of 0.5-2% were required. The well-known dose-dependent effect of enflurane on the peripheral vascular tone was not masked by vasoconstrictors at the operative site. CONCLUSIONS: Blood loss during mammaplasties can be affected considerably by the anaesthetic technique--even without deliberate hypotension. Sufentanil can indirectly reduce the blood loss by lowering the necessary dose of enflurane. Blood transfusions can be avoided at mammaplasties.
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The aim of this paper is to delineate the importance of the correction of the nasal septum when attempting to improve the nasal shape and function in patients with cleft lip and palate (CLP) deformity. The particular problems of the nasal shape in CLP patients are assessed. Various approaches for adequate correction are reviewed and discussed. The method of extracorporeal septoplasty is presented in detail. This method was used between 1982 and 1997 in 141 out of 332 CLP patients who required septoplasties and appears particularly suited for this purpose since it offers the possibility of reconstructing an almost normal septum. This is necessary in order to achieve both a functionally and an aesthetically good result. Our experience over the past 16 years confirms the advantages of this approach.
The correction of a nasal deformity is a decisive step in the secondary treatment of patients with cleft lip and palate. The complex nasal deformity in these patients is caused partly by the anormaly itself and is partly a result of previous corrective surgery. Correcting the nasal deformity involves solving four complex problems: the septal deformity; the malposition of the exterior nose; the deformity of the nasal tip; and the deviation of the ala on the cleft side. The stigma of the patients with a cleft is sustained mainly by the asymmetry of the nasal entrances. Many operations, some of which cause extensive additional scarring, have been suggested for removing this typical feature in patients with clefts. We developed a triple swinging flap technique which has proved successful when used with an open as well as a closed approach. This also enables us to achieve symmetry of the nostrils.
BACKGROUND: Cleft lips are very common malformation and all patients present a typical feature of the nose. The correction of a cleft nose is the most important step in secondary rehabilitation of CLP patients. Adequate correction of the septum is a must for the functional as well as the aesthetic result. In many cases it will become necessary to take out the whole septum, to build up a straight septum plate and to replant it. To keep the replanted septum in the midline it is necessary to bring the dislocated anterior nasal spine into the correct position. After closure of the lip, the deformity of the nasal tip and the nostrils preserve the stigma of the CLP patient. To achieve symmetry of the cartilagenous structures and the deformed soft tissue, a triple swing flap technique is recommended, which we have up to now used in 261 patients.
We present three cases of mucous cyst as a rare postrhinoplasty complication that were seen in our clinic during the last 16 years. They were located in three different positions of the nose: bony and cartilaginous part of the dorsum of the nose as well as over the alar cartilage part of the nose. We were able to treat all three patients successfully by excision of the cyst through intranasal or open approaches. In reviewing the literature and from our own experience we come to the conclusion that postoperative clearing of all tissue remnants, especially mucous parts, and a careful, atraumatic operation by forming an intact mucoperichondrial tube for intransal osteotomy as well as for hump removal are the best prevention of postrhinoplasty complications such as mucous cysts.
Aesthetic surgery of the lower third of the face is divided up into five clinically relevant problem regions: nasolabial folds, lips, chin, mandibular angle including horizontal ramus and neck. Surgical correction is be described in the international literature. The pathophysiological conditions that lead to aesthetic problems in the lower third of the face are explained. Based on this, the indications for different methods of correction, which include soft and bony tissue of the face, are explained. The results of our own clinical experience, dependent on alloplastic material, are presented with all the advantages and disadvantages.
BACKGROUND. Orthotopic septal cartilage transplants are grafted in numerous rhinosurgical operations. To ensure long-lasting success of surgery, preservation of the vitality of the grafted cartilage is imperative. Although many studies have been conducted on heterotopic cartilage transplants, no studies have been published on a follow-up of the course of orthotopic grafts. METHODS. We performed submucous septal resection in 33 rabbits and then regrafted the cartilage between the laminae of the mucous membrane. Microangiography was performed one, two, six and twelve weeks later and the cartilage was then examined histologically. Cartilage biopsies were performed on humans and compared with the experimental results. RESULTS. Integration of the cartilage presented a characteristic pattern: In the rabbit, the grafted cartilage had healed completely and had been stably integrated in three months' time. Reintegration with the orthotopic cartilage occurred by means of appositional reorganisation of cartilage originating from the inner perichondrium. Microangiography revealed that reintegration took place the faster, the shorter the distance between the cartilage cells and the vessels. We confirmed these experimental results also clinically by means of the cartilage biopsies in man.
The classification of vascular anomalies is controversial since the same terms are applied for different lesions. The biological classification according to Mulliken and Glowacki is based on the correlation of cellular features of vascular lesions during infancy and childhood with the physical examination and natural history. On this basis, two main categories of vascular anomalies can be distinguished: 1. Hemangiomas with endothelial proliferation and clinical course of rapid postnatal growth followed by slow involution. 2. Vascular malformations as developmental anomalies with normal endothelial cell cycles. These are subdivided according to the part of the vascular system involved.