Triage for the neurosurgeon

Triage for the neurosurgeon is a misnomer. The neurosurgeon's role within a mass-casualty situation is one of a subspecialist surgeon instead of a triage officer. Unfortunately because of the events of September 11, 2001, civilian neurosurgeons and other medical specialists have been questioning their role within a mass-casualty situation or, worse, a situation created by biological, chemical, or nuclear weapons. There is no single triage system used exclusively within the United States, and different systems have differing sensitivities, specificities, and labeling methods. The purpose of this article is to discuss varying aspects of triage for both military personnel and civilians and suggest how the neurosurgeon may help shape this process within his or her community. Furthermore, the effects of biological, chemical, and nuclear weapons will be discussed in relation to the triage system.

Fat transfer: current use in practice

The author has used fat transfer, including pearl fat grafts and fat injections, for almost 18 years in practice. Techniques for pearl fat grafting and fat injections are described. Pearls are limited to eyelids and small depressions. Fat injections can be used to augment various facial areas, including chin, cheekbones, nasolabial folds, lips, labiomandibular folds, glabella, forehead, and nose.

Anatomy of the spinal cord in patients with meningomyelocele with and without hypoplasia or hydromyelia

We compared the cross-sectional areas of spinal cords of patients with normal cords to the area of patients with meningomyelocele. The control group consisted of examinations of 27 patients with normal spinal cords providing 1547 axial images at 20 levels, C2-L2. The meningomyelocele group consisted of 67 MRI examinations of 41 patients, providing 4,095 axial images at 23 levels C2 to S1. Thirty-four examinations were of 21 patients with minimal hydromyelia, 7 examinations were of 3 patients with operable hydromyelia, and 26 examinations were of 17 patients without hydromyelia. In an additional analysis, we selected those meningomyelocele patients with cord tethering but without hydromyelia or hypoplasia (53 examinations of 30 patients) and compared them to symptomatic hypoplasia cases (9 examinations of 6 patients). The symptomatic hypoplasia cases were chosen because of progressive loss of muscle strength and worsening spasticity not relieved by surgical adhesiolysis. The test, retest error was 5.6% with differences between the means of repeated readings not being significant. All tests for significance were paired T test. The areas of spine levels C7-L2 for the controls were significantly larger than for the meningomyelocele patients (p = 0.000007). Including all levels C2-S1, the minimal hydromyelia cases were not significantly different from those without hydromyelia (p = 0.5). The areas C2-S1 of operable hydromyelia cases were larger than both non-shunted minimal hydromyelia (p = 0.00009) and of meningomyelocele patients without hydromyelia (p = 0.00003). The areas C7-L2, of hypoplasia cases were significantly smaller compared to the "normal" meningomyelocele cases (p = 0.0004). These data suggest that hydromyelia stimulates overgrowth of the cord, as does hydrocephalus of the brain, and that adhesiolysis procedures are of no value with hypoplasia of the spinal cord.

A 15-year follow-up study of the non-SMAS skin-tightening facelift with midface defatting. Equal or better than deeper plane procedures in result, duration, safety, and patient satisfaction

This article outlines the author's philosophy on facial aging that he uses in a surgical technique that is unique because it requires no SMAS tightening, incision above the auricle, deep-plane dissection, subperiosteal dissection, or stitches in the face above the mandibular border. The fatty nasolabial and labiomandibular prominences are excised using sharp dissection or curette to flatten these areas. Various case studies with extensive follow-up are provided. In the author's experience, this surgical technique has shorter recovery time, higher patient satisfaction, fewer complications, excellent longevity, and a more natural aesthetic result than deeper and more extensive techniques.

Alar rim raising

The relationship of the alar rim to columella visibility and nostril proportion is crucial to a good aesthetic result. The alar rim has been a neglected part of the nose in primary and secondary rhinoplasty procedures for want of a natural contouring operation. Results of directly excising the alar rim and its indications are presented with adequate follow-up. Indications for the procedure include (1) recontouring of the cleft lip nose with anterior webbing, (2) equalizing asymmetrical nostrils, (3) enlarging small nostrils, (4) correcting a hanging (sigmoid) ala, and (5) converting round to oval nostrils.

Avoiding visual tipoffs to face lift surgery. A troubleshooting guide

As aesthetic surgeons we should look more closely at our finished products. A visible scar, distorted ear lobe or tragus, or unnatural hairline says "face lift" to a patient's friends and creates a self-conscious, unhappy patient. The modifications I have adopted of accepted techniques give a more natural look and less conspicuous scarring. They avoid the most dreaded question a patient's associates may ask: "Have you had a face lift?" The text outlines the areas where tipoffs are most prevalent and makes suggestions to minimize them. It is impossible to do inconspicuous surgery all the time, but it is possible by careful observation to minimize visual tipoffs. An unnatural tragus or bad scar should be considered as severe a complication as nerve damage. We should use as proficient avoidance techniques for one as for the other.

Curette fat sculpture in rhytidectomy: improving the nasolabial and labiomandibular folds

The nasolabial and labiomandibular folds develop with facial aging by an anterior caudal descent of the fat prominences of the same name. Young patients with minimal folding can be corrected by substances inserted in the fold; however, this and other techniques have failed satisfactorily to improve the folds naturally and permanently. Identification of the prominences and removal of the fat superficial to the skin by curettes have proven safe and effective and superior to fat suction. Complications include small hematomas and visible depressions in the sculpted areas. There was no nerve or skin injury. Follow-up of this technique (an improvement of a previous technique) is 3 1/2 years.

Achieving standardized photographs in aesthetic surgery

The plastic surgeon who wishes to share clinical experience with colleagues is obligated to produce accurate data in the form of photographs. Moreover, accurate photographs are essential to enable an objective critical appraisal of one's own surgical skill and to display postoperative results to patients in an unbiased fashion. Change should not be a function of either the photograph or the photographer. The use of an acetate screen grid in conjunction with anatomic boundaries is described as a means to achieve accurate, reproducible standard photographs of the face and body in aesthetic surgical patients.

myc gene amplification and expression in primary human neuroblastoma

Although N-myc amplification in neuroblastomas correlates with poor prognosis, not all neuroblastomas which fail to respond to therapy have N-myc amplification. To determine whether other modes of myc gene activation underlie progression of some neuroblastomas, 45 were analyzed for amplification of N-myc, c-myc and L-myc and 26 were studied for transcription of these oncogenes. N-myc amplification was found in 6 of 45 tumors; no tumor had amplification of c-myc or L-myc. Transcription of both N-myc and c-myc occurred in 21 of 26 neuroblastomas. No tumor without N-myc amplification had a level of N-myc expression near that of a tumor or cell line with amplification. One tumor with N-myc amplification was the only specimen with N-myc but not c-myc expression. Five samples had c-myc but not N-myc expression; all had histological features of ganglioneuroma. DNA index did not correlate with myc gene amplification or expression. It is concluded that N-myc and c-myc are commonly expressed in primary untreated neuroblastomas, but in the absence of N-myc amplification, expression of these genes does not appear to correlate with disease progression.

Stereotactic craniotomy: methods and results using the Brown-Roberts-Wells stereotactic frame

Combining the power of stereotactic precision with open craniotomy in a stereotactic craniotomy technique decreases surgical time, morbidity, and postoperative hospitalization. Indications for its use are deep intrinsic masses 3.5 cm or less in diameter; small, superficial lesions otherwise difficult to localize; and lesions associated with motor, visual, or speech areas. Using the standard Brown-Roberts-Wells system allows a) precisely planned cortical entries, b) gross total lesion excisions under direct vision, c) use of probe-guided resection margins, d) small craniotomies through linear incisions, and e) use of local anesthetic alone for resections. The method and results of this universally available and relatively inexpensive technique are discussed in reference to 20 patients.

Stereotactic Craniotomy: Methods and Results Using the Brown-Roberts-Wells Stereotactic Frame

Combining the power of stereotactic precision with open craniotomy in a stereotactic craniotomy technique decreases surgical time, morbidity, and postoperative hospitalization. Indications for its use are deep intrinsic masses 3.5 cm or less in diameter; small, superficial lesions otherwise difficult to localize; and lesions associated with motor, visual, or speech areas. Using the standard Brown-Roberts-Wells system allows a) precisely planned cortical entries, b) gross total lesion excisions under direct vision, c) use of probe-guided resection margins, d) small craniotomies through linear incisions, and e) use of local anesthetic alone for resections. The method and results of this universally available and relatively inexpensive technique are discussed in reference to 20 patients.

Kluver-Bucy syndrome following recovery from transtentorial herniation

Kluver-Bucy syndrome is an uncommon constellation of behavioral abnormalities resulting from bilateral temporal lobe damage. The syndrome is rare in humans. In this paper we present a patient who developed the Kluver-Bucy syndrome following recovery from an intracerebral haemorrhage and transtentorial herniation.

Alar rim lowering

A technique for the lowering of the alar rim is presented. The indications for this technique, originally presented by Meyer and Kesselring, have been expanded to other related nasal deformities, including the high-arched nostril, the asymmetrical nostril, the Mestizo nose, and the hanging columella, in which the surgeon feels that total nasal length should not be sacrificed. The technique consists of an incision parallel to the alar rim and an unfurling of the vestibular mucosa caudally. A cartilage graft from the septum, lowering lateral cartilage, or other source is placed between the two layers at the newly proposed alar height. Through-and-through sutures hold the graft and alar rim in place.

Free autogenous pearl fat grafts in the face--a preliminary report of a rediscovered technique

Free autogenous fat grafts between 4 and 6 mm (the size of a pearl) have been used successfully to correct pitting acne, nasolabial folds, eyelid depressions, facial atrophy, facial wrinkles, depressed scars, and in chin augmentation. Theoretical measures taken to ensure the maximum amount of survival of donor fat include exogenous vitamin E, treatment with insulin, small size of grafts, and atraumatic antiseptic technique. Numerous supportive clinical, historical, and laboratory references are cited, dating from 1893. Considering the abundance of fat tissue available and the prolific amounts discarded during blepharoplasty, liposuction, lipectomy, and platysma cervical lift, fat should be reconsidered as the soft tissue substitute. This is a preliminary report and further study is needed.

Male baldness: immediate single-stage rotation of very long arterialized temporo-parieto-occipital flaps

Over a period of 5 years we have performed 62 rotations of long temporo-parieto-occipital flaps in a single stage without delay for both frontal and occipital male baldness. The technique and indications are reported and discussed. The good results obtained permit us to affirm that this surgical technique is safe, simple to perform, and rapidly effective. It has clear advantages over techniques involving delay, including guaranteed survival and vitality of the rotated flap, speedier execution, and few, if not minimal, complications.

The improvement of the gummy smile using the implant spacer technique

A simple technique for correction of a gummy smile by partially transecting the levator labii superioris, the major lip elevator, and decreasing its cephalic excursion using an implant spacer is presented. Results are given for 21 patients, and 3 representative patients are discussed, in whom a silicone implant with maxillary augmentation with concomitant rhinoplasty; cartilage from the nasal septum with concomitant rhinoplasty; and a silicone implant independent of rhinoplasty without maxillary augmentation were utilized.

A technique for the closure of small septal perforations

The small septal perforation has been a particular problem with regard to its symptoms. One author even recommended its conversion into a large septal perforation to decrease the symptoms. A simple technique using autologous nasal cartilage is presented in 4 cases with follow-up for one year.

Transcoronal eyebrow lift with concomitant upper blepharoplasty

A technique for eyebrow lift is presented which employs the eyebrow arch used by makeup artists to add subjectively to the operation and prevent the aesthetically displeasing result of a too highly arched brow. The marking technique to achieve the proper life is outlined. A concomitant blepharoplasty technique and its indications are presented.

Regrowth of platysma following platysma cervical lift: etiology and methodology of prevention

Platysma regrowth after platysma cervical lift is a new complication. We postulate that the platysma reestablishes itself by hypertrophy of muscle fibers contained in its posterior SMAS sheath as well as by muscle regrowth along the posterior sheath. We now routinely cut both platysma and posterior sheath. We also recommend excision of anterior platysma not connected to the posterior sheath. Closure of platysma should be from the mentum to the upper thyroid cartilage utilizing nonabsorbable sutures.

Visual criteria for success in restoring the youthful neck

We have suggested visual criteria for achieving and assessing success in platysma cervical lift. We believe it is now possible to satisfy these criteria in most patients, even those with a low-lying hyoid. Anterior adjustment of the platysma is more important for desirable results than posterior adjustment or posterior closure alone. If present in a heavy neck, the subplatysma fat pocket must be excised. A posterior submental incision as well as a more radical submental lipectomy with platysma sling (submental neck lift) is helpful for patients who are not yet candidates for an upward lift. The cutting of the platysma and fashioning of the sling, as well as defatting, may possibly add to the longevity of the lift, but this can be ascertained only by long-term follow-up.

Partial trisomy 21

This report presents and 18 1/2-year-old patient with clinical features of Down syndrome and severe mental retardation due to partial trisomy 21. Cytogenetic studies using Giemsa banding chromosomes revealed translocation of the 21q21 qter segment onto the short arms of chromosome #8 (46,XY,--8, + t(8qter 8p23::21q21 21 qter)). It is recommended that patients with features of Down syndrome whose chromosome analysis was done prior to introduction of banding studies undergo repeat karyotyping.

Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal face-lift operation

With the increasing popularity of platysmal face lifts, the anatomy of the cervical branch of the facial nerve should be noted. The postoperative appearance of lack of ability to retrude the corner of the mouth, in someone who had a "full denture" smile preoperatively, could possibly be due to severance or stretching of the rami of the cervical branch of the facial nerve--rather than an injury of the facial nerve of the marginal mandibular branch.

A new device to assist in sizing breasts

There is a gray zone in specific communication about what size a woman's breasts will be after surgery. I have devised a clear plastic shell which accurately simulates a bra cup size of a breast in the upright position. This can be used for preoperative demonstration under clothes, intraoperatively with inflatable implants, preoperatively with gel implants, and in pexis. I have used these with great success for two years in my practice.

Injectable fluid silicone therapy. Human morbidity and mortality

Four patients who had received silicone injections had the following complications: migration, hepatic disease manifested as granulomatous hepatitis (previously undescribed, to our knowledge), hypopigmentation, and death. Silicone should now be considered as a possible cause of hepatic granulomas in an appropriate host.