Plastic surgery: new methods and refinements

Plastic Surgery

New Methods and Refinements

Tord Skoog

MD . FAC.5.(Hon.1

Professor of Plastic Surgery, University of Uppsala, Sweden

w. B. Saunders Philadelphia · London· Toronto

Copyright © 1974 by Tord Sk oog,

AlmQvist & Wik sell International, Stockholm, Sweden.

All Rights Reserved.

No pan of this publication may be reproduced or transmitted

in any form , or by any means, electronic or mechanical,

including photocopy, recording , or any information storage

and retrieval syste m, without permission in writing from the

copyright owner.

First published by

Almqvist & Wiksell International

Stockholm - Sweden

ISBN 91 ·22 00000·3 in Collaboration with W. B. Saunders Company Philadelphia, Penn., USA

ISBN O· 7216·8355·X Library of Congress Catalog Card Number: 74~11 691

Published in Italian by Piccin editore, Padova in Japanese by Igaku Shoin, Ltd., Tokyo in Spanish by Salvat Editores, SA, Barcelona

Drawings: Poul Buckhoj Photography: Per-Erik Barkman, Lars Nystrom and Tord Skoog Bookdesign: Bertil Samuelsson Layout: Bengt Hogstrom

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Contents

7

Foreword

Prefac e

9

Acknowledgements

11

Section One 14 34 II 80 III 94 IV 124 V 144 VI 156 VII 174 198

VIII IX

Congenital Facial Clefts

The Cleft Maxilla

The Cleft Nose

The Cleft Lip

Bilateral Clefts Lateral Clefts Regeneration of Facial Periosteum an d Bone; Experimental Research Cleft Palate 1; Primary Repair Cleft Palate 2; Secondary Repairs

Sectio n Two 224 X 250 XI 284 XII 300 332 382 392 412 428 456 499

The Large Nose Protruding Ears

XI II XIV XV XVI XVII XVIII

Cartilage Regeneration; Experimental Research The Aging Face Breast Hypertrophy Inverted Nipples Axillary Hyperhidrosis Syndactyly Dupuytren' s Contracture 1; Pathology, Pathogenesis

XIX

and Predisposition Dupuytren ' s Contracture 2; Surgical Treatment Biographical data

Foreword

Out of each generation of surgeons two or three "Meister A"zte" seem t o emerge. From such men a specialty derives its standards and direction. Sometimes these men excel in developing and refining in­ novative surgical techniques. Others achieve eminence through their abilities to teach and communicate the specialty, particula r­ ly in writing. Still others are honored and respected for their organizational talents in forming and fostering productive, progressive surgical units which often outlast the career of the founder. It is exceedingly rare, however, to find all of these gifts in a single individual. Such a surgeon is Tord Skoog. Along with scores of others who have traveled from every part of the world to work with him in Uppsala, we find this conclusion inescap­ able. In this text Skoog demonstrates a rare quality of honesty and directness. Although his unit at the University of Uppsala pro­ vides, with outstanding quality, the full spectrum of plastic sur­ gical services, he restricts the material here to philosophies , in­ novations, and surgical techniques which are largely his ow n. While thus limiting the subject matter, the author nonetheless manages a concise presentation of what plastic surgery is large­ ly about. An abundance of meticulously accurate and infor­ mative illustrations complete the instruction. The first section, dealing with clefts, must certainly become a classic description of a superior approach to surgical manage ­ ment of this deformity. While some of the techniques presented demand superior surgical abilities, they are described and illustrated in a way which cannot be misunderstood. The second section is devoted to innovative procedures for cor­ recting the most common aesthetic deformities . The chapters on axillary hyperhidrosis, syndactyly, and Dupuytren's contrac ­ ture are beautifully written and illustrated presentations of Skoog's original work in these areas.

, The book will be most va luable to tho se student s of plastic surgery or related specialities who seek a greater understanding of the deformed anatomy and to those who are w illing to strive to achieve the best possible surgical corrections of these defor­ mities, rather than be content with acceptable standard tech­

7

niques. Books such as thi s, w ith ra re attention to accu racy , editing and illustrations, q ui kly become classi cs and find a special place in the surge on's library. Richard C. Schultz, M.D., F.A.C. S. Head of the Department of Pla stic Surgery University of Illinois, U. SA. Paolo Santoni Rugiu, M .D. Head of the Depa rtment of Plastic Surg ery University of Pisa, Italy

8

Preface

Pla stic surgery is to o b ro ad a field to succ es sfully cover in a single book . I have thus tri ed t o limit this volume to selected topics. Only my personal p rocedures, dev elope d and improved over the years are presen t ed , w ith the early pitfalls and co mp li­ cations essentiall y eliminated . For each con di tion the pathology, surgical anatomy and func­ tional significance of the related structures are an alyzed. The problem is thus defined and a metho d of repair outl ined , g reat emphasis is then placed on the p rinci p le s of re co nstructi o n. The surgery in a typi cal case illust rates each o pera tive t ech · nique. Since pre cise knowl ed g e of all de tail s is a p rerequisite for success in treatment, col o red p hotograp hs hav e been used extensively to gi ve a true prese ntati on and all ow a thorou gh understanding of every phas e of t he procedures . Th ese p i ctures are supplemented with drawi ng s to clarify fin e poi nts and h ig h · light important aspects. With this pi cto rial approa ch , t he ac­ companying descript ions have bee n mad e concise to ex press the f acts merely on a w orking basis. From cu m u lative persona l ex perience it is felt that defi n ite co ncl usions may be drawn i n reg ard to the indications, co mp licatio ns and results of these techniques. Other aspects ent er ing into reconstructi ve t reat­ ment are occasionally entertained . The final goal of all recon str uctive surge ry is to restore no rma l anatomy and phy siology. T his is be st achieved by re con st itut­ ing the structural matrix, not just superfici ally adjusting th e integument. The value of this approach is pa rti cul arly eviden t in the treatment of facial cleft malformations, wh ere biol og ical studies and anatomical anal ysis have led to a better un der­ standing of the deformity and its aberrations, on the basis of which more functional repairs have been devised. These proce· dures co ver the primary treatment of all facets in th ese complex conditions. Many of them are evolutionary in character and modifications of the techniques w ill undou btedly be added , based on the original concepts. The trea tm ent of secondary de­ formities w ith their multitude of anatomic varieties is not w ithin the main focus of this book . An exception has been made f o r correction of velopharyngeal incompetence, persisting after an unsuccessful primary repair. In treating acquired diseases, clinical experience and patho­ logic observations form the basis for new operative methods, and this is particularl y noted in selective aponeurectomy for Dupuytren ' s contracture and in the treatment of ax illary hyper­

9

hidrosis. In aesthetic surgery, the rationale of previously sacro­ sanct techniques has been challenged and more radical proce­ dures have been introduced . The correlation between research and clinical work is apparent throughout the tex t. This interaction has germinated surgical in ­ nova tions which have proved most gratifying w hen the poten­ tials of periosteum and perichondrium were realized for gen­ erating bone and cartilage . These discoveries were here utilized for specific reconstructi ve purposes and promise even wider future developments. An effort has been made not to overburden the text with references or historical reviews. This should , howeve r, not diminish our gratitude to all those who developed the knowledge and standards on which the present work is based. The book itself is basically the culmination of my thirty years of work in plastic surgery. It has been influenced by the brilliant men who taught me the speciality-Professors Richard Faltin and Atso Soivio in Finland, Sir Harold Gillies and Sir Archibald Mcindoe in England, as well as the pioneers and great men of the United States-Sterling Bunnel, Sumner L. Koch and James Barret Brown, to name only a few. In retrospect, however, the most profound stimulus for this work has come from the men who have studied with me in Uppsala. From diverse back ­ grounds and different countries, they brought unique philo­ sophies and approaches-causing me to question, mOdify and eventually refine my methods into the techniques of which this volume is comprised. These fine men have formed a socie­ ty, and the society has done me the honor of taking my name. I am thus indebted to all the members of the Tord Skoog Society, as they were the primary inspiration in my efforts.

Tord Skoog

10

Acknowledgements

The University of Uppsala gave early recognition to the speciali­ ty of Plastic Surgery and at the University Hospital excellent conditions were made available for this new branch of surgery . I am deeply grateful to these two institutions for their continued support. The days of the lone brilliant pioneer have passed and the peripheral approach has been replaced with co-ordinated efforts. The climate of close cooperation within the medical faculty and the access to vast facilities and resources of the highly specialized modern hospital are vital to keep pace with modern developments. My special thanks go to Dr. Stephen Sohn , presently working with me in the clinic. He has been invaluable as a sounding board for my ideas. His quick mind perceived the surgical problems involved, and his considerable literary talents have offered a new dimension to the book. The clarity of the text reflects his tireless efforts. Dr. Leith Douglas embodies the spirit of the men who have come to my Department in Uppsala. He has taken time from his busy work to look over most of the book, analyzing and correct­ ing with the critical eye of an experienced plastic surgeon and talented writer.

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The detailed photographs and drawings are the cornerstone of the book . To help with these illustrations I have had the good fortune to have three most skilled people, medical artist Poul Buckhoj and hospital photographers Per -Erik Barkman and Lars Nystrom. I admire their talents and great patience in so faith ­ fully carrying out my every instruction , even when it involved tedious, repetitious work to improve on minor details. The con­ tribution of Buckhoj is of an obviously exceptional calibe r and should well serve one objective of this book : the creation of surgical illustrations which would meet the needs of the practis­ ing plastic surgeon. Our many hours of working together have been a most pleasant experience. When the writing of the book spread over a longer period than planned my debts increased to the staff of the Plastic Surgery Department. In parti cular, I am grateful to my asso ciates, Dr. Bengt Ponten and Dr. Sune Johansson for their kind and gener­ ous support during this time. My thanks are also due to my secretary, Miss Margareta Gustafsson, who has prepared the

11

final copy from dev iously interlined longhan d man uscri pts that one less familiar with my handwriting could not have man aged into serviceable form.

From the incipience of this work the M an aging Direct or of A lm ­ qvist & Wiksell Boktryckeri AB, Gbran Z. Haegg strb m, has given me the most generous cooperation . A book of this kind involves the aid of many indiv iduals and more people than I ca n name here have helped in extraordinary way s. I ca nnot om it, however, personal acknowledgements to Me. Be rtil Sa mu elsson fo r the final shaping of the book and to Mr. Bengt Hbg strom for his lucid and art istic la y out. In concluding I would like to express my sincere gra tit ude to all the patients who have made th is book po ssi bl e by ki nd ly per ­ mitting the publication of ph otograp hs related to the ir trea t­ ment. It is m y hope that throu g h d ocum e nt ary information of thi s kind we will be better able to hel p th o se affli cted .

Tord Skoog

This publication was sponsored by:

Astra AB , Sweden ;

Dav is+ Geck, Cyanamid International;

Ethicon, Inc., U.S.A.;

Johnson & Johnson, U.S.A.;

Minnesota Mining & Manufacturing Co (3M Company ), U.s.A .;

Societe Steril Catgut (SSC)' Switzerland;

Stille-Werner AB , Sweden ;

VIS Offenburg, West-Germany .

12

Section I

Chapter I

A head from ancie nt Corinth 16 Comments

References

Incidence of congenital clefts 20 Embryology and classification 20 The cleft palate team 22 Registration 23 Appearance and oral pathology M axi llary and dental condition Speech Middle ear and hearing Psychosocial adjustment Principles of repair 28 Clefts of the primary palate Clefts of the secondary palate Timing the repair 30 Operative mortality 31 References 32

Title page; This terracotta head of a clown,4th century B.C" was found at the Potters' Quarter in ancient Corinth . In spite of its small dimensions, the accu rat ely scul ptu red head faithfully reprodu ces the cha racterist ic stigmata of a unilateral cleft li p with the as­ sociated nasal deformity. 14

Congenital

Facial Clefts

A head from ancient Corinth

Athens, Sparta, and Corinth held preeminent position s in an­ cient Greece. Athens was the intellectual capital , Sparta, t he pinnacle of military excellence, and Corinthian craftmanship was renowned throughout the classical world . Potter's Quarter, the excavated workshops of ancient Corinth , is a lasting tribute to her well deserved fame. A wealth of material was unearthed there, including a great number of terra cotta figurines. Over twenty-three hundred of them ha ve been inventoried , and an extensive report of the findings was published by Agnes New­ hall Stillwell in 1952.

Many of the terracottas are representative of the finest work from this golden age of Greece and are considered without parallel. The significance of the figurines, according to Stillwell, is not always clear. They seem to have been made for the work­ man's own amusement or as an exercise in ingenuity, rather than as objects for sale. A large proportion of them were dis­ covered along with vases and other material. The period pieces, have thus enabled archeologists to date the figurines with fair accuracy to a time from the first half of the 7th century B.C. to about the third quarter of the 4th century B.C.

In the archeological museum at Corinth, some examples of the findings from the Potters' Quarter are exhibited. The collection includes a grotesque head, representing a comic actor. On a v isit to the museum in 1968, my daughter Gunhild noticed, that the irregular features of this face resembled the general appearance of a person born with a cleft lip. On closer examination, this observation was easily confirmed (Figs. 1-2). Stillwell gives a detailed description of this male head:

1--,2 These illustrations of the ancient figu'ine high­ light the cleft lip and nasal deformity.

16

"Brown clay. Head solid. Back handmade and too flat. Neck, small and tapering, forms projection which was doubtless in­ serted into socket in neck of figurine. Top of head slightly con­ ical. Forehead marked by long wrinkles. Brows heavy, pulled up in points, and outlined with narrow grooves. Eyeball formed by raised boss with depression in center to indicate pupil. Line of strongly marked upper lid continued in wrinkle running from outer corner of eye to ear. Nose projects nearly at right angles to forehead and is bent to right. Wings of nose strongly marked and asymmetrical. Cheek bones and jaw muscles very promi­ nent. Mouth wide open. Upper lip droops in center. Ears ren ­ dered by large shallow depressions with projecting rims.

Congenital Facial Clefts

In a general way we may connect the head with the actor molds from Terracotta Factory deposits of about the third quarter of the 4th century B. c. These also show the round eyes with wrin­ kles at the outer corners, the nose which makes a sharp angle with the forehead and which is bent to one side, the furrowed cheeks, and the wide, open mouth, but the breadth of concep­ tion and the skilful modelling set this head above most actor types. "

Observations an d medical considerations

3 This three month old boy has a congenitally cleft lip. The extent and type of the malformation corresponds .to .1h.P.dew. .•".t1;1,f> u >TFa­ cotta head. An oblique nose and a severely deformed nostril it also present.

On closer examination, particularly in a light which casts a shadow across the left side of the face, it is evident that the sculptor has depicted the classical features of a congenital cleft through the upper lip. The medial lip segment carries a phil . trum and a well developed center portion of a Cupid 's bow, though slightly displaced due to contracture along the cleft border . Thi s constant finding of cleft abnormalities was, until the middle of this century, overlooked by surgeons in their numerous designs for repair. The lateral lip segment appears small, because it is retracted towards the corner of the mouth in a clownish smile. The faithful reproduction of the anatomy justifies the conclusion that the malformation has remained un­ changed since birth. Secondary deformity from scarring or tis­ sue loss, due to unsuccessful attempts at surgical repair, would certainly not have escaped detection by the observant artist. (Compare Fig . 3.) Since the actor is posed smiling , the cleft lip is presented at maximum width, extensively exposing the alveolar processes and the anterior part of the palate. Apparently, in this case, the cleft did not severely affect the maxilla, at least alignment with­ in the alveolar region is good, and there is no obvious pro­ trusion of the premaxilla . The absence of severe maxillary d e­ formity may be explained by the presence of a Simonart's band at the le ve l of the floor of the nose, where the modelling is not distinct enough for identification. The limited lateral dis· placement of the alar base supports this assumption. Unfor· tunately, the missing lower lip and chin do not permit an eval­ uation of the relationship between the upper and lower jaws. Visible parts of the alveolar processes are edentulous. In the adult stage of a non-operated cleft, displacement, malforma­ tion and caries of the teeth bordering cleft often produce an un ­ sightly and eve n beastl y appearance . For this reason , remo val

17

of the teeth has long been considered most desirable . This seems especially indicated in a comedian , whose profession is to amuse . In clefts confined to the lip, the entire m axi lla is asym metric due to underdevelopment of the affected side . As far as th e wri n­ kled face and sty lized modelling of the terra cotta head permits an evaluation in this re spect, the left cheek b one appears to be at a lower leve l and even sma ller than on the right side. 4 This man, born with a right-sided complete cleh of the lip, had surgical re­ pair in early ch il dhood. Apparently this involv ed co nsiderable sacrifice of lip tissue. No att empt was made to correct th e nose. The persistent nasal de­ formity sh ows a str iking resemblance to that of the sculptured he ad of Corinth.

The scu lptured head, in spite of its sma! 1d im ensio ns, ac curate ­ ly repr od uce s the characteristic nasal asy mmet ry associ ated with a complete unilateral cleft lip. On a larger scale , it cou ld be a typical cas t of an un corrected cl ef t. The en tire no se is deviated to the right, away from the cl eft. The two carti lages, forming the tip of the nose, are separated by a sh allow fu rrow. On the affected side, the nasal tip is flat and due t o displace­ ment of the lower nasal ca rtila ge, the ala r rim dro op s ant erior­ ly. The abnormal attachme nt of the a lar base, as well as the buckling and outward rotation of t e lower carti lage. is also we ll dem onstrated. (Compare Fig. 4.) According to Stillwell, the head represe nts a convention al ty pe of comic. actor . They wore a short, long-s lee ved lu nic, long, tigh tly fitting trousers, a chlamys, an d usually a poi nted cap . T hey are usually chara cterized by a p ointe d be ard, open grin ­ ning mouth , wrinkled cheeks and fore head , bulgin g eyes and sharply peaked eyebrows. With minor vari ation, all are of this type . They can be dated about the middle of the 4th centu ry B.C., but canno t be later than the end of the third quarter of the century , when New Comedy replaced Middle Comedy. The occupation of the person w ho posed for th e artist is of great interest. One can easily imagine the social impli ca tions of a cleft lip deformity at a time when sur gical rehabilitatio n could not be provided. Apparently the bearer of the cleft had overcome the psychological burden of his disability and was able to use his disfigurement as an ass et in his professional life. The fa ct that other heads of comic actors had bent no ses, might even indicate the possibility that the cleft lip deformity was frequent in thi s professional group. There may have been a tendency to select people with thi s type of malformation to undertake comic parts, or alternativ ely, the occupation might ha ve been handed down within families that had a high inci­ dence of this hereditary deformity

18

Comments

From a medical point of view this portrait, made 2300 years ago, is a~ astonishing discovery. It is particularly remarkable that the unknown artist had such a complete awareness of the morphological complexity of the cleft lip and in fact accurately depicted some anatomical abnormalities, whi ch ha v e not be­ come widely recognized until recent years. The general sculp­ ture is an inspired creation of great simplicity and superio r artistic quality. The deformity of the lip and the nose has been modelled in great detail, with an almost scientific accuracy . Cleft lip malformations have also been uncovered in the early art of the new world. They were reproduced in pre-Columbian figurines found in Mexico, but compared to the sophisticated work from ancient Corinth , these Indian sculptures appear quite primitive. They express horror and fear, magnifying the grotesque for a spiritual-magical p urpose (Ortiz-Monasterio and Serrano 1971).

I am indebted to Charles Williams, Director of the excavations con­ ducted by the American School of Classical Studies at ancient Corinth, for allowing me to take and reproduce the photographs of the terra­ cotta head.

References

Ortiz-Monasterio F. and Serrano R. A. : Cultural aspects of cleft lip and palate treatment. Cleft Lip and Palate. Ed. W. C. Grabb, A. W. Rosen­ stein and K. R. Bzoch . Little, Brown and Comp., Boston, 1971, p. 130. Skoog T.: A head from ancient Corinth . Scand J Plas/ Reconstr Su rg 3 : 49, 1969. Stillwell A. N.: Corinth, vo l XV, part 2. The Pollers ' Quarter. The Terra co lIa s. Princeton, New Jersey, 1952 , p 143. 19

Incidence of congenital clefts

Cleft lip deformities, with or without an associated palatal'de ­ fect, occur in slightly more than one per thousand live births. Within the geographi cal area served by the University Hospital in Uppsala, the incidence is 1.22 per thousand. The general characteristics and genetics of our material was evaluated by Henriksson (1971). His work substantiated previous studies, that reveal a predominance of males in clefts of the primary palate and a higher incidence of females for clefts affecting the sec­ ondary palate alone. In addition, the left side of the lip was shown to be more frequently and severely affected than the right one. From a hereditary point of view, cleft lip deformities with or without a cleft palate, and isolated cleft palate mal­ formations, represent two distinct entities. For both groups, Henriksson considered polygenic inheritance to be the most ­ likely explanation.

Embryology and classification

A basic knowledge of normal embryology in the maxillo-facial region is necessary to understand the characteristics of the cleft deformity. Although some disagreement still persists as to the exact details of cleft morphogenesis, there is a general con­ sensus of opinion that the most common clefts , those of the primary palate, arise when the maxillary and merged naso­ medial processes fail to meet and unite (Fig. 5) This simple defect is distorted by dynamic factors , and though the eventual appearance demonstrates the wide range of pos­ sib le outcomes, the end result is strictly related to the exten­ siveness of the cleft. The relationship of the nasomedial proc­ esses to the primordial nasal septum is particularly important. If unrestrained by the lateral segments, the powerful, medially placed growth centers act forcefully and cause marked protru­ sion of the premaxilla. When differentiation into muscle and bone occurs, the discontinuity of these mesodermal tissues further d 'stort the cleft. The disturbed balance between inter­ acting growth centers and the asynchrony within functional tis­ sue layers themselves, accounts for the morphologic complex­ ity of clefts of the primary palate. 20

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Congenital Facial Clefts

A cleft of the secondary palate is the result of failure of the palatal shelves to fuse with each other This defect markedly influences the length and function of the soft palate as well as the general dimensions of the pharynx. Even in "submucous clefts", where the palatal halves are united, the defective mus ­ cular portion manifests an altered topographic anatomy, which results in velopharyngeal incompeten ce. In facial clefts, it has proven particularly difficult to standardize findings. Reproducable data are essential for proper clinical ana­ lysis and for initiating effective therapeutic programs. Th~ problem has been to provide an accurate and consistent termi­ nology. A classification based on embryologic patterns is ..ro w recognized as the best available system. This concept was orig­ inally proposed by Kernahan and Stark (1958) and has been ap­ proved by the International Confederation for Plastic and Re­ constructive Surgery. Recognizing clefts of the primary palate as a single entity, af­ fecting the lip, nose, and maxilla , has been particularly useful in defining the related reconstructive problems and planning an integrated program of repair.

Cle' the,

5 This schematic drawing of a human embryo, during the sixth to seventh week of gestation, is presented to show the proposed mechanism for development of a unilateral cleft lip. On the left side, the paired nasomedial processes, which are destined to form the prolabium and premaxilla, have failed to fuse with the maxillary process. On the non-cleft side , these processes have joined to­ gether and an intact arch has formed .

"""" ;'­

21

The cleft palate team

The manifold problems re lated t o cleft deformities involv e th e domains of many discipline s and logi ca lly requ ire close co­ operation betwee n the va ri o us specialists. This o rganize d, int er­ disciplinary approach ha s markedl y tran sformed the standards of treatment, and more significant results are now achieved than cou ld be expected by a simple arithmetic sum of the in­ dividual con tributions. Koepp -Saker (1971) empha siz ed the distin ct value of group intera ction , which tends to en courage modesty and reduce arbitrarine ss and authoritarian attitude s. In the id ea l setting, where complete surgical correction is p
22

Congenital Facia l Clefts

weekly clinics held by the team . The matron of our Cleft Palate Home is an essential participant. She acts as a social worker in adjusting the environment of the patient. The plastic surgeon is the natural coordinator of the cleft palate team, but any member with a sufficiently wide kn owledge of the whole spectrum of the problems could effect ively serve in this capacity.

.. Registration

Accurate registration, adhering to strict scientific standards, is necessary to establish a preopera tive baseline from wh ich further evaluation can be made at predetermined intervals. In view of the relatively limited experience obtained by each team , every effort should be made to document res ults in such a way, that will permit useful comparisons of the v arious methods employed in different centers.

Appearance and oral patnologv

The original deformity is categorized by use of a chart, where schematic drawings illustrate the possible variations and com­ binations of cleft anomalies. Standardized photographs are taken both in color and in black and white. This includes pic­ tures of the entire face "en face " and in profile. Occasionally, facial casts are made. The exact nature of the cleft is best deter­ mined at surgery, including measurements of cleft width. Simi­ lar registrations are made before and after all subsequent sur­ gery and during the entire growth period. The general appearance, proportions and profile of the face are observed with particular attention given to form and function of the lip, nose and skeletal framework . In the lip, its width and symmetry, the Cupid's bow configuration, orbicularis muscle union , and the continuity of the vermilion border are all evalu­

23

ated . At the same time , the position and shape of the philtrum, the amount of ves tibular lining , and residual scars are assessed . The nose is examined to determine dev iation of the septum , position of the pyramid , airway size , cartilaginous definition of the nasal tip , alar configuration, and depression of the base. Intraoral conditions are also observed , recording the extent of the cleft and estimating the tissue available for repair. The needs are then related not only to the size of the cleft, but also to the dimensions of the pharynx . Secondary deformities present a more complex morphology and require a careful study of the anatomy and speech before-attempting reconstruc­ tion .

Maxillary and dental condition

Recordings of maxillary de ve lopment, at regular intervals, are particularly important to assess the value of various surgical procedures . Evaluations are also made before and after each program of orthopedic and orthodontic treatment. These in­ clude:

Dental examination

A routine examination is performed. Position of the teeth , hy­

giene, and general stage of development are all noted .

Maxillary casts

Generally, the original condition is recorded at the time of primary repair of the lip or palate, at 3 months and 18 months respe ct ively. ImpreSSions are conveniently made prior to sur­ gery, when the child is anesthetized and intubated When preoperative ma xillary orthopedics is required , casts are made before initiating treatment. Similarly, the condition is re­ corded before and 'after orthodontics. Study models are ob­ tained at the age of about 5,16 and 19 years . Intermediate evaluations are made at approximately 8,12 and 14 years of age: a) after eruption of the first permanent molars, lower in ­ cisors and upper medial incisors; b) after eruption of the bi ­ cuspid s; c) after eruption of the permanent canines and second ·molars.

Photographs

, 24

Dia-slides of the full face, profile, and intraoral views are taken

at the <same intervals as the ma xillary casts.

Congenital Facial Clefts

Intraoral roentgenograms

a) Intraoral roentgenography is carried out before any surgery of the cleft region (Fig. 7). Postoperatively, roentgenograms are taken after 3-6 months and 1-2 years. b) Panoramic roentgeno­ grams of the upper and lower jaws are obtained at ages 5, 8 and 12 years.

Cephalometric roentgenograms

Cephalometric studies are made at 5, 8, 12, 14,16 and 19 years of age. These include: a) Profile cephalometric roentgeno­ graphy in the intercuspal position ; in certain cases these pic ­ tures are taken with the mouth wide open . b) Postero-anterror cephalometric roentgenography with the teeth in the inter­ cuspal position. In both the profile and postero-anterior record­ ings, the head is oriented in the cephalostat along the Frank­ fort horizontal plane.

Speech

To evaluate speech disorders and therapeutic effectiveness, careful analysis and registration is essential. Though subjective parental opinion is sought shortly after surgery, it is seldom possible to obtain meaningful information about speech pat ­ terns until the age of four years. At that time all patients are ad­ mined to the Cleft Palate Home, a rehabijitation center spon­ sored by the Swedish Red Cross.

,

Speech is tested by having the children recite standard sen­ tences, and their efforts are recorded on tape and kept as a baseline, from which future progress can be measured. The cri­ teria used to assess speech are intelligibility, open nasality, closed nasality, consonant articulation and glottic and pharyn­ geal sounds. Special attention is given to velophrayngeal func­ tion and nasal air escape. A complete study is made of the intra­ oral anatomy, velopharyngeal topography and nasal passages, and speech effectiveness is interpreted in view of these find­ ings. The magnitude of speech retardation is estimated by means of various language tests. A rough evaluation of the general maturity and receptivity of the child is also made, so that patients requiring therapy can be admitted at a time when they can fully benefit from treatment. Cineradiography is of use for diagnosing functional and anatom­ i'cal defects. This type of analysis should be carried out routine­ ly, so as to evolve an overall understanding of the complex speech mechanisms found in cleft palate patients .

25 r

... Speech is then observed at regular intervals by the pho niatri­ cian and speech therapist, at the same tim e w hen m axi ll ary development is assessed. Children requiring th erapy ar e tested before and after each course of treatment. The therapeu ti c routine is to admit the patients for periods of three weeks , twice a year, until speech is considered to be norm al o r n o further progres s is made. In the latter instance, addi t ional su r­ gical correction is usually implemented. After the second ary procedure, further speech therapy is need ed to fully utili ze the changed anatomy.

"

Middle ea r and hearing

Earl y restoration of normal hearing and a concom itant redu c­ tion and limitation of morphologi cal cha nges in the m id d le ear is part of the therapeuti cal program. Th e f ollow in g tests are used prior to and every sixth month after cl o sur e of the cl eft pal ate . Routine follow-up is made at t he age of 5, 8, 12, 14, 16 and 19 years .

Otomicroscopic examination

The ty mpanic membrane and middle ear are' ex am ined th rough a microscope. If there are signs of middle ea r effus io n a m yr­ ingotomy is performed, and when the canal contai ns thick tenacious secretions, a tympanostom y tube is inserted .

Eustachian tube function test

In patients who hav e a tympanostom y tube or have had a prev ious perforation of the tympani c mem b rane, the Eustachi an tube function is tested by a middle ear aspiration m ethod .

Hearing tes t

Pure tone audiometry is periodicall y used to evaluate hearing and this is occasionally augmented by other hea ring tests.

Middle ear functio n test

Middle ear transmission is studied by impedan ce aUdiometry.

Radiography of the m astoids

Lateral radiograms of the mastoid area are taken before closure of the cleft palate , and again at the age of 5, 12 and 16 years. Planimetric measurements of the mastoid air cell system are simultaneously performed.

26

Congenital Facia l Clefts

PsVchosocial a djustment

In addition to the usual difficulties of chi ldhood and adoles­ cence, the cleft palate patient carries with him an added bur­ den. He must cope with a prominent disfigurement and/o r speech impairment. This psychological trauma is in some cases , quite significant. Total therapy must therefore consider this aspect of the malformation. The psychosocial adjustment of the child is evaluated and an attempt is made to understand the complex family relationships and interactions. The patient is admitted to the Cleft Palate Home, where he is observed and instructed, but also where he and his parents can see how other children , with similar limitations, learn to handle their prob­ lem s. "T he wounded bird syn drome " is particularly prone to occur among families with crippled childre n. These parents have an instincti ve desire to shelter t he ch il d f rom the harsh­ ness and disappointments of life . This often results in ov er­ protection , which is harmful to child and pa ren t alike. Unless both are re-educated , the child's developmental growth may be stunted and he will never learn to "fl y" al o ne. Occasionally the parents neglect their children . This situation must be corrected, if the child is to progress normally. School age ch ildren attend classes at the Cleft Palate Home, and the teacher can thus re cognize any emo tional problems that are present. She can usually discern whether the problems are secondary to hearing or speech deficits, o r whether they are rooted in deeper maladjustments. When necessar\', refer­ rals are made for child psychiatry . Often , only minimai therapy is required. With adults, the st ay at the center is somewhat different. The various problems are discussed and local so cial workers are contacted t o fa ci litate the patient's integration into the com­ munity. Attempts are made to help the patients adapt to the pressures of society and to make them as productive as pos­ sible. Further education is encouraged and made av ailable both in the center and at home. It must be remembered , that apart from the congenital defect, these patients are normal in every respect. Many are extremely intelligent and will contribute a great deal to society. It is thus of crucial importance, that their mental health is as attentively treated as their more obvious and visible afflictions.

27

Pn"ncip/es of repair

Clefts of

the p rimary palate:

maxi lla.

nose and li p

The congenital cleft of the primary palate can be viewed as a tripartite reconstructive problem, involving restoration of the maxillary cleft, correction of the nasal deformity, and repair of the lip (Fig. 6). These three aspects of the cleft deformity are interdependent, and the treatment of one facet of the anomaly affects the out­ come of the other. The corrective techniques are performed simultaneously and are interwoven into a single, integrated procedure. At operation , one aspect is left uncompleted, while another part of the problem is handled. Exposure is thus facili­ tated, and the coincidental reconstruction of one defect com­ pliments the surgery of the associated deformities . The final effect of dealing with the entire problem as a unit results in a more satisfactory approach , than working on each component singly. For purposes of discussion, however, the various re­ constructive measures will be artificially placed into different chapters, to elucidate the individual techniques and eliminate possible confusion. If deemed necessary, each step can be used independently and performed as a separate procedure, but this type of management decreases the total effectiveness of the repair. The ultimate aim of surgery must be complete anatomical restoration. Based on a detailed analysis of the pathophysio­ logy, the advocated methods of correction rely on valid, but somewhat unconventional principles to realize this goal. For reconstruction of the maxilla, the osteogenic potential of the perios teum is utilized to produce new bone within the defect; the nasal deformity is ameliorated by radicall y shifting the alar cartilage into a normal position; a successfu l reconstruction of the lip relies on the restoration of muscle continuity and bal­ ance, as well as meticulous skin approximation using multiple flap closure. The development of these procedures has gradually evolved from experience with a considerable volume of clinical material over the past twenty years. In the la st decade, the complete operation has been utilized with minor modifications, and over one hundred and fifty cases have been successfu lly treated in the described manner.

28

0'

Congenital Facial Clefts

6 This child demonstrates the ~

-'

characteristic features of a com·

plete cleft of the primary palate. If affects the lip, nose and al­ veolar process, back to the in ­ cisor foramen . The projecting

thrust of the premaxilla ex­ aggerates the bony defect. Due to the marked protrusion, as

well as the split in the nostril, the alar cartilage has become severely displaced and dis ­ torted . The lip segments are widely separated by retraction of the nonunited muscles.

Clefts of the secondary palate

Though clefts of the secondary palate may appear less com­ plicated, superficial closure of midline tissues is insufficient to provide adequate function. Complete reconstruction of the dis­ rupted and deranged mesordermal derivates is as necessary for success in working with cle ft s of the secondary palate, as in dealing with primary palate anomalies. Again, the concept of an anatomic and functional restoration is the cornerstone of the repair. The palatal muscles must be released from their ab­ normal, fixed attachments anteriorly, and rearranged to form a muscular sling across the midline at a posterior level. This allows for unrestricted movements. Elongation of the palate is then accomplished by reconstructing the aponeurotic section. The secondary treatment of cleft deformities are not included in this book. An exception has been made for correction of velo­ pharyngeal incompetence, persistent after an unsuccessful primary repair. Since this sizable group of patients is of great practical importance, the principles of treatment will be dis­ cussed and a method of palato-pharyngoplasty described.

29

Timing the repair

At birth, the individual cleft is maximally deformed an d if not surgically altered, the condition in the newborn remains la rgely unchanged throughou t life. There is therefore no urgent ne ed to institute a hasty repair. The optimal time for reconstruction is determined by deve lopmental , biological, patho-physiological and surgical considerations. Surgical intervention in this area will to some exte nt interfe re with growing tissues. Treatment should thus not be carri ed out if tissues will be unduly damaged by the trauma of a repair. This decision must, howev er, be weighed ...vith the desire to utilize growth potentials for co rrective pu rp oses. The restoration of disrupted functional anatomy is obviously of paramount importance, but neither in clefts of the primary palate , nor of the secondary palate, does thi s dicta te an im ­ mediate repair. The diffi culty with di st urbed feeding in a cleft infant has been overcome by numerous techniques, incl ud in g special made nipples or spoons. Complications related to the malformation, such as repeated middle ear and respir ato ry in ­ fections may, howeve r, ne cessitate early surgical interve ntion, but with the present standard of pediatric care, these indica­ tions have become increasingly rare. At surgery, the child should be in good general hea lth, gaining weight , and have normal blood values. In addition, to attai n a proper anatomical repair , tissues must have reached a certain size and stability. With aI/ these factors duly considered, clefts of the primary palate are rarely operated upon before the age o f three months, and in clefts of the secondary palate, reconstruction is post­ poned a t least until the ag e of eighteen months.

It is important to re-emphasize , that the overall rehabilitation of the patient should not be jeopardized by injudicious haste Anxious parents, who may be greatly distressed by the ap ­ pearance of the disfigurement, must be reminded that social considerations cannot be permitted to compromise the child's best interests.

30

Operative mortality

I

Over the past twenty years, in more than 1 500 primary and secondary operations performed on children wi th cl eft l ips and / or palates, there has never been a death. Sev eral factor s ac­ count for this result, but a marked advancement in anest hetic techniques and impro ve d control of fluid balance are th e major reasons for the enjoyed safety of these procedures.

7 Roentgenograms are taken prior to surgery to reco rd the anatomy of the maxillary cleft.

"

The intubated child is maintained on Penthrane ®, or Halothane, and usuall y breathes spontaneously, though he can be ventilated by hand using the modified Magill's attachment. An i.v . cannula is inserted, usually in the foot, and is used during surgery for blood replacament a'n d to maintain fluid and electrolyte balance for the first few hours postoperatively. The small su ction trap, which is at the child's feet, accu rately measures blood loss. To the right of this bottle is placed the electrothermometer, which is connected to a rectal electrode. The thermostatic heater-pump unit of the water mattress maintain s the child's temperatu re between 36 and 37°C. The ECG oscilloscope, at the end of the operating table, is connected to limb or chest elec­ trodes to keep constant surveillance of heart rate and rhythm ,

31

Additional contributing factors are: a thorough examination of the child at birth , where concomitant malformations or diseases are diagnosed, and cured if possible , before the cleft is repaired; adequate preoperative treatment to ensure a satisfactory gen­ eral condition ; proper timing of surgery; and meticulous post ­ operative care. Invaluable contributions in organizing the registration program were

made by members of the Cleft Palate Team: Rune Hellquist, D.D .S.

(orthodonticsl, Hans lindholm, M.L. (phoniatrics) and Carl-Eric lind­ holm, M.D. (ENT).

References

Henriksson T.-G.: Cleft Lip and Palate. A Genetic and Clinicallnvesti­ gation. Pub!. by the Institute for Medical Genetics, University of Upp­

sala, Sweden, 1971. Kernahan D. A. and Stark R. B.: A new classification for cleft lip and cleft palate. Plast Reconstr Surg 22: 435,1958. Koepp-Baker H.: The cleft palate team. Cleft Lip and Palate. Ed . W. C.

Grabb, S. W . Rosenstein and K. R. Bzoch, little, Brown and Camp., Boston, 1971, p 108.

32

,

Maxillary restoration fo r bone formation

utilizing the periosteum

Chapter II

Introduction 36

Surgical treatment 38

Bone graft ing Pe ri o stea l repai r

Age at op eratio n

Preoperative treatment

Operative procedures 42

I. Complete clefts 43

A. Primary periosteoplasty alone 43

Operative technique

Resu lt

Com m ent s

B. Prim ary periosteoplasty with an implant 49

Operative t echnique

Ea rly result

Late res ul t C. Repeate d periosteoplasty 53

t

D. Delayed pe ri osteop lasty 54

Co mments

II. Inco mpl ete clefts 55

Operative t echn ique

Varia ti o n in operativ e techni que

Result

111. Minimal clefts 58

Result

Maxillary orthopedics and orthodontics 60

Early i nfancy

De cid uou s dentition

M ixed dentition

Permanent dentition

Comments

Results of periosteoplasty 65

Bo ne fo rmation

Growth of th e lateral segment

Mig rati on of te eth

Comments 71

Conclusions 74 Reference s 76

34

Title page: In thi s illu stration of a

complete unilateral cleft a drawing of

the underl yi ng maxillary defect has bee n superi mposed over the soft tis ­ sue fe atures of the malform ation.

The Cleft Maxilla

-----

/ ,,, .. , ,

A method o f reconstruction •

Introduction

Nature is often hidden,

sometimes overcome, seldom extingUished.

Francis Bacon: Essays (1625) Early surgical treatment of cleft anomalies focused on the grossly obvious lip deformity. Not until the past few decades has the importance of the associated maxillary defect been fully appreciated. This bony discontinuity disrupts facial harmony detracting from appearance as well as impairing function. 1-2 This complete uni­ lateral cleft demonstrates the characteristic maxillary asymmetry. The premaxil­ la protrudes markedly be­ tween the lip segments and the impaired growth of the disunited lateral segment is reflected in the displaced alor base .

1 With the presence of a maxillary cleft, the septovomeral growth centers cannot exert an equal influence on the disjoined com­ ponents. Medially, this results in deviated protrusion, the pre­ maxilla being propelled excessively forward on the cleft side . Laterally, the dis connected maxilla is not carried along with the medial segment but is left in a posterior position and thus be­ comes partly responsible for the severe asymmetry that char­ acterizes the malformation. In the normal fetus the connected muscles of the lip mold the developing bony structures, but in the cleft child, with this shaping process absent, the unopposed muscles pull in divergent directions, further deforming and twisting the anatomy.

In addition to the displacement of existing structures, there is a substantial tissue deficiency. This deficit reflects stunted bone growth resulting from the entrappment of the lateral maxillary segment in an enclosing periosteal wrapping.

The wedge -shaped maxillary flaw is widest at the nasal floor and tapers to the alveolar ridge, while the superficial defect is greatest at the lip border and narrows as it approaches the nose. These consistent findings are probably the consequence of different embryonic pathways for mesodermal and ecto­ dermal closure.

36

The Cleft Maxilla

The fact that the superficial malformation hallmarks a much more extensive maxillary rent is graphically demonstrated in incom­ plete clefts. Even when the surface cleft is minimal , as in the un­ treated adult shown in Figs. 3-5, there is evident fascial asymmetry .

3-4 When this thirty-two year old man brought his son for treatment of a complete unilateral cleft, his minimal, almost inapparent lip de­ formity was recognized. No surgical correction had been performed . There is characteristically an associated severe malformation of the maxilla, evidenced by pronounced facial asymmetry with dislocation of the alar base . The view from below highlights this deformity. On contraction of the orbicularis muscle incomplete union of that struc­ ture could also be demonstrated. 5 A panoramic roentgenogram shows a wide piriform aperture on the affected side with a depressed nasal floor. The tooth roots are spread apart by the wedge shaped deficiency of bone within the cleft region.

37

Surgical treatment

For many years , reconstruction of the cleft maxilla was essen­ tially ignored. Authorities warned against freeing the perios­ teum from the maxilla for reasons summarized by Holdsworth (1951). It was fe-ared that facial expression might be disturbed by interfering with the bony attachments of the muscles and that maxillary growth in general might be hampered, thus ex­ aggerating two characteristic stigmata of the cleft patient. Furthermore, since underdevelopment of the maxillary seg­ ments was considered to be the result of disturbed growth potentials, the neighboring tissue was felt to be unresponsive, inadequate, and a poor choice for any reconstructive purposes. These views were never substantiated by critical clini cal ana­ lysis, and the extensive research done 0'1 this subject, referred to in Chapter VII, clearly refutes these early assumptions.

~

I

Bone grafting

To restore maxillary continuity bone grafting techniques were implemented at early ages (Nordin and Johanson 1955, and Schmid 1955). Bone positioned in this way, though providing immediate stability, did not develop with the child (Thiland er and Stenstrom 1967, Friede and Johanson 1974, and others). When retardation of facial growth became apparent this method of treatment was widely abandoned.

Periosteal repair

In the last decade new principles were introduced and uncon­ ventional techniques for reconstruction of the cleft maxilla were developed (Skoog 1965, 1967, 1969 and 1971). The periosteal membranes, bordering the cleft, were utilized for bone forming purposes. When rearranged into a pre-designed position, the new bone was molded to fit the defect.

Though Oilier (1867) clearly demonstrated the osteogenic capacity of the periosteum, his work was not completely ac­ cepted. This persistent dissentation is reflected in the extensive literature on the subject. Two separate clinical observations prompted the development of a technique of periosteoplasty. In performing a maxillectomy on a four month old child, suffering from a semi malignant tumor (melanotic progonoma), the periosteum was left in place. Complete bone regeneration fol­ lowed. This was confirmed by an X-ray taken two years later, which showed a normal maxilla, except for the missing teeth. The second case, stimulating the conversion to the current

38

6 In this preoperative photo­ graph of the above mentioned child the premaxilla is bord ered on each side by a complete cl eft. A staged repair was started at the age of three months.

7 Following lip closure the late ra l ma xi llary segments hav e shifted medially against the pre­ maxilla. On the left side, which was repaired first, alignment is good . The entire alveolar arch has, howeve r, become too nar­ row and corrective jaw ortho­ pedic therapy was periormed at the age of six years.

8 The lateral segments have been re-expanded, thereby re­ producing the cleft on the pa­ tient's right side. Quite un­ expectedly, new bone was found to have formed w ithin the left cleft , where the arrow indicates a substantial bony bridge that unites the premaxilla and the lateral segment.

techniques for maxillary re con struction , was that of a child with co mplete bilateral cleft (Figs. 6-8). The patient was first operated in 1957, and following soft tissue repair new bone formed spontaneously within one cleft. The interpretation of this find­ ing was, that the periosteal membranes unintentionally were united across the cleft at the primary operation and solid bone had subsequently appeared (Skoog 1966).

39

In this chapter operative procedures are described, which re­ construct the bony deficit in the cleft maxilla. For this purpose periosteal continuity is established across the defect by use of a periosteoplasty. The technique is based on three major pre­ mises. (1) The periosteum covering the maxillary segments possesses normal growth potential. (2) Denuded maxillary bone regenerates normal periosteum similar to other bones. (3) The reestablished interaction between growth centers on the medial and lateral sides, and the biomechanics of the en­ vironment, determine the growth and development of the united maxilla.

L

The original techniques were later refined to obtain a larger volume of bone. The illustrative example of the ossifying frontal bone hematoma in childhood initiated these innova ­ tions. There, the subperiosteal collection of blood lifted the periosteal layer off the bone and thus stimulated rapid bone growth. In the search for a suitable periosteal prop, Surgicel '" was used and found to aid bone formation. It must be em­ phasized, however, that it is not the intrinsic nature of the substance itself that enhances bone production. The material merely acts as a scaffold to create a large pocket and thus artificially stimulates the void induced, in the clinical state , by an expanding hematoma. The blood soaked material can be molded to conform to the defect and thus is effectively used to build up depressed contours. Surgicel is known to be well tolerated , and completely absorbed with minimal tissue reac­ tion (Lebendiger et al 1960, Jantet and Rob 1960) .

Age at operation

The growing bones of the developing face reflect periosteal ac­ tivity . As this dynamic force has little or negligible function in the adult, the mature face retains a relatively static configura ­ tion. Clinical experience has shown that there is little decrease in the osteogenic capacity of the periosteum until five years of age . After this period, substantial bone forming activity still re­ mains, and operations can be considered up to the teenage level, but after this time juvenile adaptability of the periosteum expected Iy lessens. 1 Absorbable hemostat (oxidized regenerated cellu lose), Joh nson & Jo hn so n, New

Brunswick, N.J .. U.S.A.

40

The Cleft Maxilla

For practical purposes it has been found most satisfactory to coordinate the maxillary and lip repairs. This means that the primary procedure is performed at three months in unilateral clefts and in the first side of a bilateral cleft. Maxillary recon­ struction can also be conveniently added to other reconstructive efforts in the total scheme of rehabilitating the cleft patient.

Preoperative treatment

.

Many schools of thought suggest maxillary adjustment prior to surgery. This tedious process involves using cumbersome headgear and various other apparatus in attempts to bend the premaxilla towards the separated lateral segment. The un ­ natural pressure placed on the premaxilla is both harmful a,nd unnecessary. The best way of producing alignment is to repair the lip. The natural forces then provide constant, but not in­ appropriate pressure. Technically, there has never been a case in our series, where any preoperative treatment was required . An exception to this practice is made when the original malfor­ mation presents with collapse of the lateral segment. Expansion of the maxillary arch to a suitable position is then recom­ mended. It is easily accomplished just prior to surgery as de­ scribed on p. 60 .

•

41

Operative procedures

Ge n eral co nsiderations

In maxillary cleft, the bony deficit is directly related to the under­ development of the lateral segment . The reconstructive task is thus precisely defined, and correction has been accordingly planned. A further consideration is the widely different char­ acteristics and surgical requirements of the two sides of the cleft.

Lateral border (1) The bony defect is char­ acteristically quite large.

Medial border (1) The bon y deficit is generally negligible.

(2) Local tissues can be used for repair, since the perios­ teum in the area is of good quality. This primitive tissue vigorously responds to the stimulus of manipulation. Utilizing this mechanism for reconstruction requires ex­ tensive exposure .

(2) The periosteum lining the premaxilla is of poor quality. Thus, freeing it will not provide a substantial osteogenic source. The limited need for mucosal lining and flap attachment requires minimal exposure .

(3) There is no need to fear wide exposure of the bone as no bony sutures or other growth sites are present in this area.

(3) Important growth centers bordering the cleft mediall y, demonstrate their poten­ tials in overgrowth. They should be left undisturbed; fun ctional restoration of the adjacent anatomy will gradually normalize their activity.

Based on these considerations, the principles of surgical re­ construction have been to extensively mobilize and utilize tis­ sues on the lateral aspect and to minimally expose and not interfere with the more vulnerable medial side. Clinical experi­ ence as well as extensive animal experiments by Sarnat and Wexler (1968) and Sarnat (1970) support these views. Their con ­ clusion was, that in cleft repair surgical trauma to the septo­ vomeral region might have an untoward effect upon growth of the upper jaw. Each cleft anomaly has its accompanying set of idiosyncracies. The operative design is thus amended accordingly, to fit the particular clinical setting.

42

I. Complete clefts

A. Primary peristeoplastyalone

In treating the complete cleft the surgica l approach must reo concile the extensive dimensions of the maxillary defect with the limited tissue available for reconstruction. In closure, there will undoubtedly be persistent are as which remain in direct continuity with the mouth; used initially, Surgicel, or other foreign implants, would thus invite infection. Correction is therefore planned in stages, with the primary operation con· sisting of periosteoplasty alone, supplemented at a later stage by rep eated periosteoplasty combined with implantation of Surgicel.

Operative techn ique

Preoperative condition 9-10 These illustrations of a three month old child w ith a complete unilateral cleft show his condition at the time of the primary operation. The palatal view demonstrates a substantial defect within the primary palate and the char ­ acteristic protrusion of the premaxillary segment. A periostepolasty is planned for maxillary re­ construction in accordance with the principles

given on the preceeding page. The repair will involve the alveolar process and the anterior half.of the hard palate.

~""''---''----

Prema xilla

....,...'--~----- Lalera l max illary

segment '---,~-'t.::t-----

Nasal septum

43

Reconstructing the inner periosteal lining 11-12 At the medial border, an incision is made approximately 1.5 cm behind the premaxilla and carried between the palatal and septal mucosa. It is continued over the anterior aspect of the free border of the prema xilla, to the base of the columella. The incision is made through mucosa and peri­ osteum. The mucoperiosteum is raised from the protruding cleft surface of the premaxilla. This thin tissue requires careful dissection in order that the flap can be used to line the defect. It aids in bridging the greatest expanse of the cleft. Care must also be exercised to keep the fragile tooth buds from being injured. In the palate the mucoperichondrium is slightly elevated off the septum.

13 The lateral border of the cleft is incised at a level comparable to the medial side. The incision is extended forward between the upper and lower nasal cartilages.

44

The Cleft Maxilla

14 When the lateral incision is carried down to bare bone the retracted border of the piriform aperture and the edge of the maxillary cleft are exposed . The peri­ osteum can now be separated from the inner aspect of the bone along the entire length of the incision. Wide undermining will permit this substantial flap to be med­ ially advanced and sutured to the contra­ lateral flap.

15 The flaps are approximated with 5/0 in­ terrupted catgut sutures, tied on the nasal side. In this suture line there is always re­ traction of the periosteum, particularly along the lateral side. A second row of 4 / 0 Dexon ' sutures on the oral side, assures periosteal continuity and reinforces the mucosa closure.

16 The anterior periosteal suture is being placed which completes reconstruction of a nasal floor.

I

Poiyglycol ic aci d suture, Davis + Geck, Cyanamid International.

45

Reconstructing the outer periosteal lining I

17 In the final stage of repair a second la ye r of periosteal lining is produced by a flap from the outer aspect of the lateral maxillary segment. This flap is rotated through an arc of more than 90 0 and placed on the anterior aspect of the alveolar cleft. In this manner the creation of a periosteum-lined sleeve between the bony surfaces of the cleft is completed. The flap includes most of the periost eu m over the ant ero -Iateral aspect of the maxilla and is based over the nasal process of the maxilla, on the lateral border of the nasal pyramid.

\

18 In order to raise the periosteal flap from the adjacent maxilla exposu re is gained by extension of the o riginal incision laterally, along the buccal sulcus . The incision is made through mucosa and periosteum down to bone.

19-20 Using a dental elevator the entire cheek, including periosteum, is dissected off the maxilla. In the yo ung infant the perios­ teum in this area forms a su bstantial mem­ brane w hich can ea si ly be stripped off the underlying bone. The outer layer of this membrane is composed of coarse fibrous connective tissue whic h lacks elasticity and, therefore, is not ve ry pliable when tran s­ ferred is a flap. For this reason the fl ap is generously designed, up to the infraorbital foramen, and posteriorly as far back as possible, usually up to the origin of th e, zygomatic process.

46

21 Th e upper border of the flap lies just

22 The perio steal flap is dissected free from

bel ow the infraorbital foramen . As this in­ cision is made, the bu ccal fat protrudes and aids in protecting the infraorbital neuro­ vascular bundle from injury.

the cheek tissues .

23-24 The mobilized periosteal flap is rotated as sh ow n in the previous drawing , into its new position across the cleft, with Its deep periosteal surfa ce still facing in­ wards. It is sutu red to the mucoperiosteal edg e on the anterio r asp ect of the premaxil­ la. The upp er border may also be united to the periosteal fla p s o f th e previously con­ structed nasa l floor. 5/0 catgut is used in this approximati on. W hen the flap is inade­ quate, it is p laced h ig h up at the level of the fl oor of the nose, rather than downwards on th e oral aspect

47

Result

25 This child demonstrates a complete bilateral cleft with marked protrusion of the premaxilla, relative to the lateral seg­ ments, and typical abscence of the colum ella. Periosteoplasty of the alveo lar clefts was carried out with lip closure at th ree and six months respectively.

26 This photograph is taken at eighteen months. The premaxilla has become con ­ solidated into the alveolar arch and approximation of the maxillary segments is most satisfactory .

27 The left alveolar cleft has been ex­ posed at th e time of palate closu re. A bony process extend s from the latera l maxillary segment to the premaxilla and a nasal floor is thus formed. Thi s bridge of new bone is fairly thin and cor­ responds in size to the periosteal flap shifted from the lateral segment during a periosteal repair.

28 Most important, however, the entire lateral border of the cleft has advanced medially by the growth of new bone . The development was almost identical on the right side . In this case there was no pre- or post­ operative maxillary orthodontic treat­ ment. Realignment of the maxillary seg­ ments is en tirely the result o f lip rep air and adjustment of the periosteum.

48

The Cleft Maxilla

Com m ents

When a com pletely lined periosteal cavity cannot initially be obtained, incomplete bony restoration is acceptable at the out­ set, for on this matrix a more normal anatomy can be con ­ structed during a further procedure . The anatomical relation­ ships present at th is se condary operation are comparable to the less complicated morphology of an incomplete cleft (see p . 55). Even in complete clefts, it would, however, be possib le to create a closed cavity by utilizing sufficiently large septal flaps or turning a separate mucosal flap from the inside of the lip into the cleft alveolus. These techniques are contraindi ca ted as they depart from the concept of an anatomic repair and concomitant­ ly violate the principle of minimal medial exposure, which serves to safeg uard the important facial growth centers. Furthermore, transferring tissues into unnatural positions would disturb lip symmetry. Used on the outer aspect, the periosteal flap often must be rotated on such a narrow base that its blood supply can hardly be adequate. It then serves as a free graft, providing lining for the cavity and preventing rapid invasion of non-specific con­ nective tissue . In animal experiments, RitsiUi et al. (1972 a) demonstrated co nsistent bone formation from free periosteal grafts. In a limited series of patients they used free grafts of tibial periosteum to form the outer lining of a periosteoplasty. Definite bone formation was observed to overbridge the cleft. It will be of great interest to learn if bone obtained with this technique differs from that produced by maxillary periosteum.

B. Primary periosteoplasty _ __ with an implant (Surgicel®)

When the cleft is li m ited to the primary palate, there is sufficient periosteum to completely line the defect. This permits the sur' gical constr uction of a tight, non-communicatin g pocket. For­ ei gn material can then be successfu lly implan ted when the periosteal membranes are positi oned.

49

Operative techn ique 29 In this three month old chi ld the defect is confined to the primary palate. The maxil­ lary segments are in close approximation at the free border.

31 The well-defined pocket, lined with peri­ osteum and denuded bone, is packed with Surgicel soaked in blood . Since blood provides an ideal medium for bone forma ­ tion and Surgicel mainly serves as a scaf­ fold, the material must be loosely placed in the cavity. The Surgicel extends subperios­ teally across the deficient lateral segment.

50

30 The maxillary defect is exposed , char­ acteristically revealing a large opening in the alveolar process at the floor of the nose, continuing along the retra cted border of the piriform aperture. The mucoperiosteum, raised from the inner aspect of the lateral segment and advanced to meet the cor­ responding flap from the premaxilla, com­ pletely lines the bottom of the cavity.

1 The Cleft Maxi/la

32 A periosteal flap has been raised, as previously described, to cover the implant and form an anterior lid for the pocket.

33 Lip and nose correction have been ac­ complished , using procedures described in the following chapters.

Early result

34 A roentgenogram taken two months postoperatively demonstrates extensive bone formation within the cleft. The arrow points to the thin fissure, which marks the forward edge of growth from the lateral segment. This line may be indicative of the bony suture which normally occupies this site. The premaxilla contribu tes linle to bone regeneration .

51

Late result

•

35 At five years of age permanent tooth buds have migrated into the new bone and occupy the original defect completely .

36 Spontaneous dental arch alignment is well demon­ strated. As often occurs, the decidious teeth are slightly irregu lar in shape and position in the immediate cleft area .

52

37 Genera l facial dev elopment is

normal.

The Cleft Maxilla

C. Repeated periosteoplasty

The periosteum that regenerates over the new bone is of good quality. When raised, this thick, virile tissue rapidly forms ad· ditional bone. Thus, it can be used most effectively in further reconstructive procedures.

•

In the second operation an incision is made along the buccal sulcus and the bone that has developed within the cleft is ex­ posed. The periosteum covering the new bone is incised trans­ versely and elevated to the desired level, where it is maintained by packing the pocket with Surgicel. This maneuvre is generally extended across the maxilla and along the lateral border of the piriform aperture. Relaxing incisions in the periosteum are sometimes required laterally, to allow medial advancement of the periosteal layers; no periosteal flap transfer is required in this procedure. The mucosal incision is accurately closed with catgut mattress sutu res. These subsequent operations have generally been performed three to fifteen months following the initial procedure and can conveniently be carried out in conjunction with some other facet of corrective surgery.

38 This photograph of a three months old boy demonstrates bilateral, complete clefts, the vomero-premaxillary stem thrusts the premaxillary segment into prominent protrusion . The left-sided cleft was closed first. At the same time a periosteoplasty was used to repair the associated cleft of the maxilla. Three months later, du ring su rgery to reconstruct the right side, the area of the left cleft was exposed and a narrow bridge of bone was observed to have formed in this previously open space. The covering periosteum was easily stripped from the new bone, and Surgicel was used as a scaffold to elevate the periosteal layers and thus allow for the production of more bone.

39 One year later, the regenerated bone is exposed in con­ junction with a palate repair. The original, extensive bony defect has been filled with new bone which is almost in­ distinguishable from the neighbouring bony surface. A periosteal elevator marks the reconstructed nasal floor. Just below this instrument, a furrow indicates where the lateral segment has joined the premaxilla. Roentgenograms taken at this time indicate that tooth buds have migrated into the new bone.

53

D. Delayed periosteoplasty

Periosteoplasty as a primary operation may also be successfully performed at later stages. When maxillary reconstruction is not carried out at the primary repair of a cleft, there is, however, a great tendency for maxillary arch collapse . This requires lengthy orthodontic expansion prior to surgery. a nd highlights a major disadvantage in delaying the periosteal repair. Other drawbacks, associated with performing delayed periosteoplasty , are the technical difficulties arising from the presence of fistulae and a generally distorted anatomy.

40 In the primary repair of this three months old boy periosteal continuity was achieved across the deep aspect of the cleft, but no periosteal flap was raised to cover the bony defect an­ teriorly. The resulting new bone was later found to be incomplete.

41 Expansion to correct moderate maxillary collapse at the age of 6 t years revealed the ex· tent of the persistent bony defect. Periosteo ­ plasty was then carried out. This photograph shows a retention lingual arch with splints in position.

42 Six months after surgery roentgenograms demonstrated remarkable bone formation. This panoramic view was taken two years later. A tooth and a tooth bud have moved from the lateral segment towards the new, bridging·bone. It is our experience with these situations, that eruption will Occur within the cleft.

54

The Cleft Max illa

Co mments

The results of delayed periosteoplasty are somewhat unpre­ dictable. This varying response is possibly related to tissue scarring, either from previous surgery , or chronic irritation of the abnormal anatomy that has persisted . When bone forma ­ tion is inadequate, repeated periosteoplasty ilas proved quite effective in adding new bone in spite of the older age of these patients.

II. Incomplete clefts Since the actual extent of the maxillary defect always exceeds clinical expectations,. the bony deficien cy which accompanies incomplete clefts of the lip deserves close attention . Periosteal repair offers new possibilities for reconstruction ; the technique is simple and effective, and should be an integral part of the routine treatment of incomplete clefts, regardless of the degree of deformity. The incisions required for the lip repair generally offer adequate exposure to work on the maxilla. The size and shape of the cleft permits the use of Surgicel along with the periosteoplasty, where the implant is packed away into a well­ confined, closed pocket.

55

43-44 The frontal view of this child w ith an incomplete cleft lip barel y suggests the associated maxillary defect . The vi ew from below, how­ ev er, dem onstrates a depre ssed nasal flo o r and alar base that marks a substantial bony defect .

Operative tec hniqu e 45 The preoperati ve condition of this patient is sh own in Figs . 43-44. A h o rizontal incision has been made through the periosteum at a level with the bottom of the bony defe ct. Throug h this incision , the periosteal layer, cove ring the w idened nasal floor is raised . To correct unde r­ deve lopment laterall y, and to yield enough peri­ osteum, the elevation must be extended across the maxilla as well as along the border of the piriform aperture . If left in this stage, the flat sub­ periosteal po cket, created by the maneuvre, ha s a great tendency to collapse.

46 The new position of the perio stea l membrane is maintained with loosely packed, blood soaked Su rgicel. In minor defects the anterior o pening is small , when compared to the bon y and periosteal sur­ faces , and the cav ity may thus not need a lining anteriorly. Larger openings are covered by ad­ vancing the periosteum from the lateral side, after a relaxing incisi o n has been made . A formal perios teal flap transfer from the cheek region is rarely required .

56

Variation in operative technique

In deeper incomplete clefts of the maxilla, the bordering peri­ osteum appears to be of inferior quality. This deficient tissue is carefully dissected off the bone and is not used for periosteal lining along the nasal floor. Instead, after mobilization, the dense more superiorly placed periosteal mem~ranes are united with catgut or dexon sutures, or as an alternative technique, a periosteal flap is raised lateral to the defect, rotated, and at­ tached to the base of the septum as shown below.

47-48 The incomplete cleft was corrected when this girl was 18 months old. Despite minimal soft tissue deformity, there was a marked bony defect. The diagram depicts the widened piriform aperture on the left side, and the peri­ osteal flap that was rotated to build up the nasal floor.

_/_..:.,:I.......~"

57

Result 4~50

Four years postoperatively symmetry has been attained . The X-ray demonstrates the pres­ ence of a bony nasal floor corresponding to the positi on of me periosteal flap. Tomog rams showed that behind the flap the nasal fl oor re­ mained depressed. The photograph was taken at the age of ten years.

III. Minimal clefts 51 This three month old boy suffers from a bilateral cleft deformity, though minimal on the right side. The depression of the left alar base, due to the con­ comi tant maxillary defect, is quite apparent. When the completely cleft side was repaired a periosteoplasty was included in the procedure.

58

52 Six months postoperatively the maxillary development, which had previously appeared normal o n the right, demonstrates an obvious depression when compared with the restored left side .

., r

53 Exposure of the repaired cleft shows ex­ tensive bone formation with a normally posi­ tioned nasal floor. New bone has formed along the lateral border as well as on the outer aspect of this segment. The result is a united and level maxilla .

54-55 Raising the periosteum on the right side reveals a defect of the nasal floor as well as the retracted lateral border of the piriform aperture. This graphically demonstrates the extensive max­ illary deficien~y associated with even a minimal cleft lip. Correction was then accomplished by subperiosteal implantation of Surgicel.

59 (

Result

56 Panoramic roentgenogram at the age of 7 yea rs shows maxillary continuity and largel y restored symmetry. Teeth and tooth buds hav e migrated into the new bone.

Maxillary orthopedics and orthodontics

Early infancy

When marked maxil lary co ll ap se is present prior to surgery, ex­ pansion of the maxillary arch is indicated. This is particularly important in complete bilateral c lefts, where rea djustment is blocked by en croaching lateral segments that lock behind the protruding premaxilla. Following repositioning subsequent pas­ sive retention is required, while alignment is furnished by the molding forces of the repaired lip. The mechanics of preoperativ e co llapse are such , that there is a need for anterior expansion . A special technique has co n­ sequently been devised to achieve this without unnecessari ly widening the cleft at the level of the tuberosities (Hellquist 1971). Correction is generally comp leted in 4 t08 weeks after which time surgical repair and periosteoplasty can be carried out. Postoperatively, a retention plate maintains the pOSition of the maxillary segments for 3 to 6 months.

57 The appliance used for pre­

surgical co rre ctio n of maxillary co l­ lapse. The acrylic plate acts through a fan expansion sc rew. Lateral rotation of the lateral seg ­ ment widens the cleft anteriorly .

60

The Cleft MaxJJla

Deciduous dentition

•

•

Soft tissue repair sets maxillary growth in a new milieu of changing environmental forces. The subsequent development is therefore checked at regular intervals and should any un­ favourable results occur, they are rectified at the age of 4 to 5, when deciduous dentition can be utilized, Anterior or buccal crossbite with forced bite, and co llapse of the maxillary arch are the recognized indications for maxillary Or1hopedics. In our series the latter group is mainly comprised of patients, who initially presented with some degree of collapse that was not corrected before surgery . Since periosteoplasty became part of the primary treatment, the postoperative complication of max­ illary co llapse has been reduced (Hellquist and Skoog 1973) Correction of unilateral cross bite with forced bite prevents the development of mandibular dysplastic asymmetry , Or1hodontic treatment at this stage also serves to establish good anatomic conditions for the emergence of permanent teeth and the de­ velopment of proper patterns of speech .

, When the cleft maxilla collapses the lateral segment is dis­ placed medially, behind the overriding premaxilla, This is apt to disturb normal development, since membranous ossification does not take place under pressure. Early correction is thus im­ por1ant and can successfully be accomplished during deciduous dentition, The lateral segment is brought into a fairly normal position in 2 to 4 months, Bone, supplied by periosteoplasty, is then needed within the widened cleft to maintain and stabi­ lize the segments. For 12 to 15 months after surgery, maxillary arch alignment is suppOr1ed by a retention lingual arch,

The early observation (Skoog 1966) that new'bone, induced by local periosteum, will enlarge during expansion treatment has been confirmed repeatedly in our late series. When a broad bony union has been established, separation of the ma x illary segments is, however, sometimes met with con siderable resist­ ance. For this reason we advice that clefts with primary collapse of the maxillary arch should be expanded prior to periosteo­ plasty.

The technique and results of maxillary expansion combined with repeated periosteoplasty are shown in the following case; or1hodontically treated by Hellquist. who developed the fixed or1hopedic appliance used for this expansion, 61

58 This incomplete cleft of the lip is associated with a complete cleft of the ma xilla and palate.

59 This illustration depicts the orig i nal bony defect. In conj unction with lip repair, when the child was three months old, a periosteo­ pia sty was performed to the alveo lar cleft .

60-61 Two years later, lip tissues have healed without tension and moderate preoperative collapse of the lateral segment has remained unchanged . Re­ exposure of the alveolar process demonstrates considerable new bone forma­ tion extending from the lateral segment, but a narrow cleft still persists. After removal of all scar tissue from thi s area a periosteoplasty was performed wi th implantation of Surgicel.

62

62 Maxillary expansion was carried out at the age of 5 years. The posterior teeth are lo cked to the splints and thereby immobilize the apparatus. The spring is held in place by vertical tubes and by means of triangular locks in the premolar and molar regions. By activating th e spring the lateral segment will be rotated or expanded . To ensure stability in unilateral cases, the spli nt on the non cleft side is often extended to cover all the teeth in that segment, whereas in bilateral cases anchorage is re ciprocal.

63 Expan sion was completed in 2 months . As a result, the distance between the canines has increased 7 mm. A retention lingual arch with cap splints was kept in place for 12 months.

64 At the age of 7 years the deg ree of expa ns ion is shown in the positions of + 1 and +3 as compared with the pictures above. No appliances have been used for the last 1 ~ years . The exposed cleft area demonstrates the forma­ tion of a large amount of new bone, which completely restores a normal configuration. It is evident that bony continuity was achieved by repeated periosteoplasty and that the new bone has expanded during treatment. X-rays co nfirm that permanent tooth buds lie within the new bon e.

63

Mixed dentition

Since presurgical collapse of the lateral segment is eliminated in early infancy or in the deciduous dentition period , it is reaso nable to find permanent teeth erupting in normal posi ­ tions. However, as a direct result of the original malformation, the permanent teeth bordering the cleft are often rotated, tip pe d or inverted. The first molars may grow in crossbite arrange m ent or diso cc lusion. As a rule, in the mixed dentition period , simple appliances can intersept a developing malocclusion.

Permanent dentition

In the earlier ages, whole maxillary segments are moved by orthopedic procedures. With permanent dentition , it is more a question of individual tooth positioning. For this purpose the edgewise appliances are used almost exclusively. When in­ dicated the dentition is prepared for bridge therapy.

Comments

The nature and magnitude of the cleft deformity requires ex­ tensive maxillary orthopedic and orthodonti c treatment. Even with marked improvements in reconstructive techniques, pro ­ longed dental therapy is still usually required. The work of Hell ­ quist, often referred to in this chapter, has added much to the total rehabilitation of the cleft palate patient. I am especially in­ debted to Dr . Hellquist for his close cooperation , and wish to acknowledge his kindness in allowing me to use his material to illustrate part of this chapter. His skill in expanding the co l­ lapsed lateral segment. complemented by the use of periosteal flaps to regenerate new bone, has radically transformed pre­ vious methods of co rrecting maxillary defe cts .

~

I

64

•

Results of periosteoplasty

Bone formation

Periosteoplasty dep osits needed bo ne to the cle ft area. The newly developing bone aris es almo st excl usively fr om the lateral maxillary segment. Separated fr om the m edial growth centers and consequently dwarfed by co m pari son w ith the normal sized premaxilla , this lateral ti ssue u nde rgoes an osteo­ genic renaissan ce, when its pe rio steum is freed to li ne t he cleft. This initiates a rapid proliferation of new bone . Th e thickened , heavier periosteum that forms the posterior asp ect of the created pocket reflects its most vigorous activity, as does the substantial output of bone that it p rodu ces. There is often a slight malunion between th e p remaxilla and the regenerated bone . During bone develo p m ent in sta bi lity of the maxillary segments may acc o unt for th is ph en omenon . Po s­ sibly this fissure-like line is the rep roduction of a bony suture. In any event, approx imation of th e two ends is cl o se en ough t o assure good function and stab il ity, ev en in co mp lete b il ateral clefts. B~oad bony continuity is general ly only achieved after a second stage p rocedure . In some cases, the regenerated perio steu m has an ad ded vi ta l­ ity and in subsequen t p rocedures has pro ved to be pa rti cu larly osteogenic, and more bone has form ed than follo w i ng the primary o peration. Overcorrection is in fact possi ble with staged repairs . The nasal floor can be made too hi gh and ad­ vancement of the lateral bord er of the piriform apert ure can narrow the nasal o pening too much . Th is is, however, easily rectified. The new bo ne has a soft, cancellous character a nd is covered with its own, normally appearing periosteum. It has a rich blood supp ly, and is more susceptible t o bleeding . Thi s in itial hyper­ vascularity gradually subsides and the regenerated b on e be­ comes indistinguishable from the adjacent bon e. Ca lcification and total os sifi cation take several months to occur and often this process is even more prolonged . Therefore , bone forma­ tion cannot always be studied or well documented in early roentgenograms. Generally the degree of reg eneration is inversel y pro portional to the w idth of the cleft. Broad defect s require longer periosteal flaps to bridge the gap . The blood supply is corres pondin gly more tenuous and the osteogenic activity is thus expectedly less . Conversel y, in narrow clefts there is impressive bone forma­ tion following primary periosteoplasty. This massive generation of ne w tissue effectiv el y prevents fistulae from dev eloping within the vestibular and alveolar regions .

65

65-68 These autopsy photomicrog raphs are from a six months old child with multiple congenital malformations; the patient finally suc­ cumbed to cardiac insufficiency . Three months prior to death , the left side of the lip was closed and the maxillary defect was repaired with a Surgicel filled periosteal pocket. At postmortem, the entire maxilla was removed with the surrounding layer of soft tissues. The specimen was prepared by histologic tech­ niques and transverse serial sections were cut in the plane of the alveolar arch . The diagram depicts a section through the maxilla, about one cm above the free borde r of the alveolar arch. Cancellous bone, marked in blue, has joined the left lateral segment to the separated premaxilla, whereas the unoperated side has remained disconn ected . The areas marked a, band c in the diagram correspond to similarly labelled microphotographs on the next page .

a

c __

~

b

•• I Prem axilla

66

L Maxillary segment

1­

(a) Within the cleft, the new bony trab eculae show an orderly longitud inal architecture. The original border is dif­ ficult to distinguish . ( x 15)

(b) The cancellous bone, formed as an appositional layer over the lateral seg­ ment, displays irregular ly arranged trabeculae. This micro-structu re reflects a lack of any functional demands, which would serve to establish order in the newly fo rmed ti ssue. ( x 100)

(e) The well defined, laminated char ­

acter of the original bone on the non­ operated side is offered for a com parison . ( x 100) ,.

lo~·· •

;".,..c. j

. .

~ 67

Growth of the lateral segment

The periosteum , stripped from the lateral segment to furnish tissue for the flaps, regenerates over the denuded bone, thick­ ened at first but then assuming a normal character . Under­ neath this hypertrophied periosteum a layer of new bone gradually matures as was demonstrated in the previous case. Thus , contrary to what had been anticipated , surgical interfer­ ence stimulates bone formation and appositional growth . This is in an area , where the bone surface is usually resorptive . Factors contributing to this rapid bone development include the release of the lateral segment from a firm , inelastic periosteal capsule , the stimulus of an existing bony deficiency, and the reestablishment of continuity between growth centers on the medial and lateral sides. This development of the lateral seg­ ment tends to restore symmetry .

..

69 The general growth of the lateral segment has been well documented . This incomplete cleft lip was closed at th ree months. A large periosteal flap , raised from the outer aspect of the left maxilla, was utilized to bridge the maxillary defect.

70 At four years facial develop­ ment and bone growth hav e con­ tinued without any impairment

In particular the left side, de­ prived of its covering perio s­ teum , shows no evidence of retardation.

The normal pattern of development of the lateral segment is also demonstrated by alveolar arch restoration. In the un­ operated state the separation is associated with an upward slope of the segments, tangential to the normal plane of the alveolar arch . After periosteoplasty and subsequent union of the maxilla , the undisturbed action of posterior maxillary growth centers elongates the alveolar process and aligns it with the repositioned premaxilla . Simultaneously, there is marked

68 I

The Cleft Maxilla

downward growth or rotation anteriorly, and the entire segment shifts into a normal masticatory plane . The repa ired lip , with its restored muscle function, aids in this adjustment, and the rapid proliferation of new bone within the cleft prevents co l­ lapse. This all permits a more exact approximation as shown in the following case .

71 Periosteoplasty, in conj unctio n with a lip repair, wa s performed in this three month o ld boy with an exceptiona ll y wide unilateral cleft, ranging from 12 mm at its nar­ rowest point to 18 mm at the estimated level of the fl oo r of the nose. When the palate was closed, eighteen m on ths later, the maxi l­ lary defe ct was in spected and found to be compl et ely obliterated.

72-73 These photog raph s, taken at three years of age, show a sy m­ metrica l dental arch and an even bite with good occlusio n. Note the normal appearance of the lower border of th e former cleft. A slight gap, corresponding to a missing tooth (+ 2) persists. This tooth, ab­ normally lo cated to the lateral seg­ ment, has erupted ectopically into the palate . The patient required no jaw orthopedic treatment, either before or after surgery .

69

Migration of teeth

Several cases reported in this chapter demonstrate that peri os ­ teoplasty of the cleft maxilla permits the permanent teeth to erupt normally through the newly formed bone. With more space available, the dislocated crowded tooth buds within the lateral segment gradually take their intended positions within the repaired cleft. In complete clefts, the most anterior tooth bud usually moves into the bony thickening produced on the oral aspect and will consequently arise ectopically in the palate, as was described in the previous case. This is easily corrected by orthodontics. Delayed eruption commonly occurs in the cleft area, particularly in the presence of supernumerary teeth as demonstrated in the patient shown in Figs. 74-76.

74 This patient, born with a left-sided cleft, was treated by periosteo­ plasty at the age of three months. In this radiograph, taken two years after surgery, tooth buds of the permanent dentition have mig rated into · the new bone, which has filled the former cleft . The site of the original bony defect is delineated by a gap in the deciduous dentition. 75 This is a detail radiograph of the cleft area at the age of two and a half years.

70

76 At 8 years of age, general dental development is satisfactory, but on the cleft side the medial and lateral incisors, as well as a super­ numerary tooth, are still impacted. The can ines lie at the same level. Considerable autonomous adjustment may be expected following removal of the supernumerary to oth and as the ca nine erupts.

Comments

Criticism of this technique of maxillary reconstruction has re­ fle cted anxiety about ope rating on the juvenile maxilla. Fear of endangering future development has engendered this feeling . Recent investigations and detailed postnatal craniofacial growth studies have blunted these major objections. Maxillary growth does not occur anterior to the zygomatic pro­ cess. Th is outer surface is in fact normally resorptive . Growth proceeds by new bone deposition on posterior areas, thus moving the maxilla forward and downward as illustrated in the diagram in Fig. 77.

71

I I

~

77 This schematic drawing, based on Enlow' s (1966) cephalographic analysis of facial growth , shows how elongation of the maxilla and downward mov ement of the dental arch is a result of progressive bone deposition on the posterior surfaces of the ma x illary bone. The nasa l portion of the maxilla and the distal half of the nasal bones are ori­ ented in such a way that periosteal bone deposits carry this region in a forward, lateral and superior direction. In marked contrast, during development the outer surface of the maxilla is resorptiv e. Thi s is the area from whi ch the periosteum is raised and transferred in the peri­ osteoplasty procedure.

In a study, using implant techniques, Bjork (1966) confirmed that the anterior portion of the ma x illa was never a growth site. There is thus little to suggest that maxillary development would be iatrogenically impaired when performing a periosteoplasty . At no site do the employed techniques interfere with bony sutures. Furthermore, in animal experiments the removal of periosteum from facial bones has not harmed growth (Hell­ quist 1972). In full y evaluating max illary growth and development in cleft conditions the principles and techniques of soft tissue repair are of paramount importance as an integra l part of any maxil­ lary restoration. The basic requirement of any soft tissue clo­ sure is that the full width of the lip be maintained, since even a moderately tight lip will hamper max illary growth and produce deformity or collapse with subsequent malocclusion of per ­ manent dentition . In the normal individual cheek muscles also playa role in determining the size and form of the dental arches. In this respect the importance of the buccinator was recently emphasized by Brodie (1971). Special attention should therefore be taken to restore the muscular anatomy, for normal 72

The Cleft Max illa

function and balance. In clefts, lip and cheek muscles have ab ­ normal insertions onto the malformed skeletal framework . These irregularities are for the most part corrected when th e periosteum is raised off the bone and a periosteoplasty per­ formed. In this chapter several selected examples, illustrating the effect of maxillary periosteal reconstruction , are presented . The results of the initial lip repair are shown in some of these cases to emphasize the importance of a supple lip, with a re­ stored muscle matrix for molding the maxillary arch without restricting growth. The preferred method of lip management is discussed in Chapter IV. The described treatment of maxillary clefts is based extensively on clinical experience, consisting of more than 150 cases treated over a ten year period. In a study from infancy to the age of five, a series of 36 complete unilateral cleft lip and palate patients treated with primary periosteoplasty was compared to a series of 30 patients, born with the same deformity and treated in an identical manner, except that no periosteal repair was carried out (Hellquist and Skoog 1973). Recordings in­ cluded photographs, X-rays and impressions, taken at the time of lip and palate repair, as well as in the deciduous dentition period. After this stage, cephalograms were also made. Al­ together 28 variables were studied. The results showed that periosteoplasty did not retard or impair the antero-posterior growth of the lateral maxillary segment, furthermore, there was an increased frequency of anterior positioning of this segment following periosteal reconstruction (69.4 %), as compared to the control series (56.7 %). In addition, there was no higher in­ cidence of anterior crossbite, even after repeated periosteo­ pia sty. This investigation demonstrates that neither periosteo­ plasty nor new bone formed by the procedure distorts maxil­ lary growth in any way. Long term follow-ups have been most satisfying and support an unreserved recommendation for peri­ osteoplasty as an integral part of any program to repair cleft deformities.

1

The clinical results have been confirmed by extensive inves­ tigative projects. This research had four principal aims . It tried to acquire an understanding of the reciprocal relationship of periosteal osteogenic potential to environmental factors; it at­ tempted to determine the effect of periosteal resection on grow­ ing facial bones; the influence of Surgicel® on the bone forming process was evaluated; and lastly, explanations were sought as to the difference in behavior of grafted bone, and new bone 73

formed from local periosteum alone. In the former instance, there was a marked retardation of bone growth , w hile there was no disturbance of facial development in the latter group. The results of these studies are summarized in Chapter VII. In recent years there hav e been an increasing number of favor­ able reports on the use of periosteoplasty . Such observations were made by Santoni -Rugiu 1966, 1971 , 1972 ; O'Brien 1970; Bruck 1970; Joss 1972; Jackson 1972, 1973; Ritsilii et al 1972 b, Tortil 1973; Robbe 1973; and others.

Conclusions

• The periosteum covering the maxillary segments in cleft de­ formities possesses a remarkable growth potential , but this force remains inactive until the periosteum bordering the bony defe ct is surgically manipulated. • When the periosteum is shifted across a cleft, its osteogenic capacity is harnessed to rebuild the bony defect. The cambium layer, separated from the bone and placed in contact with a hematoma, induces the characteristic tissue reactions of bone repair . • Properly arranged , the periosteum will lay down more bone than conventional bone grafting procedures. In fact, the skeletal anatomy can be restored extensively, including the hypoplastic piriform border and the underdeveloped portion of the lateral segment. This segment is the best source of bone forming peri­ osteum, the thick membrane on the inner aspect being partic­ ularly potent. Also, extensive mobilization of the periosteum of the lateral maxillary segment can be carried out without inter­ fering with bony sutures or other growth centers. • Periosteoplasty is most effective at an early age and is pre-· ferably performed in conjunction with the primary lip repair. The operation has, however, proved to be quite effective up to the age of five and in a few cases up to eleven years of age. • Following periosteoplasty the tendency for maxillary col­ lapse is reduced by the rapid formation of new bone within the cleft.

74

The Cleft Maxilla

• Periosteum induced new bone grows with the individual, un­ like the static transplanted bone. • In addition to growing with the individual, this bone re­ sponds to maxillary orthopedics. If maxillary collapse should occur in cases of major deficiency, up to 9 mm extension of the bone bridge has been achieved by expansion treatment. Bony substitution of the original defect will thus be completed. • Bone formed by the local periosteum is of " dento-alveolar character.

•

• The tooth buds, compressed within the reduced volume of the lateral segment, will regularly migrate into a more normal position when new bone has formed , and in the cleft area they will erupt through this bone. • Periosteoplasty is useful to correct the extensive bony de­ ficiency associated with even a minimal cleft lip. The technique is recommended as an integral part of repair in clefts of all degrees. • Surgicel ® can be used advantageously as a scaffold to sup­ port the raised periosteum at the desired level , thereby regulat­ ing the volume and shape of the newly formed bone. • Bone surfaces deprived of periosteum in the flap transfer will regenerate a new periosteal layer, which will be thickened and hyperactive at first, but will gradually acquire a normal appear­ ance. • The regenerated periosteum has good osteogenic quali­ ties, which permit repeated periosteoplasties to be performed , resulting in additional bone formation. • Experimental studies on maxillary bone and periosteal re­ generation substantiate the empirical basis for periosteoplasty and firmly support the recommended procedures. These tech­ niques have now been used over a ten year period. • By mobilizing the periosteum over the lateral maxillary seg­ ment, lip and cheek muscles are detached from their abnormal insertions along the piriform aperture. This aids soft tissue re­ construction.

75

References

Bjork A. : Sutural growth of the upper face studied by the implant method. Acta Odont Scand 24: 109, 1966. Brodie A. G.: Emerging concepts of facial growth. Angle Orthodont 41: 103, 1971. Bruck H.: In the discussion of Skoog T.: Cleft lirr--a plastic surgical problem. Read at the First Meeting of the Association of German Plastic Surgeons, Munich, September 29,1970. Enlow D. H.: A morphogenetic analysis of facial growth . Amer J Orthodont 52: 283, 1966. Friede H . and Johanson B.: A follow-up study of c left children treated with primary bone grafting . Scand J Plast Reconstr Surg 8: 1, 1974. Hellquist R. : Early max illary orthopedics in relation to maxillary cleft and palate patients in the Uppsala region of Sweden. Scand J Plast Reconstr Surg 4 : 11, 1970. Hellquist R.: Early maxillary orthopedics in relation to maxillary cleft repair by periosteoplasty. Cleft Palate J 8: 36.1971. Hellquist R.: Facial skeleton growth after periosteal resection. An osteometric, roentgenographic and histologic study in the rabbit and guinea pig. Scand J Plas! Reconstr Surg, Suppl 10, 1972 . Hellquist R. and Skoog T. : The influence of primary periosteoplasty on maxillary growth and deciduous occlusion. Reported at the 2nd Internat Congr Cleft Palate, Copenhagen, August 28, 1973. To be published. Holdsworth W. G.: Cleft p 36.

Lip and Palate. W.

Heinemann, Lond on. 1951,

Jackson I. T.: A functional reappraisal of cleft lip repair. Read at the meeting of Societe Francaise de Chirurgie Plastique et Reconstructive, Deauville, June. 1972. Jackson I. T.: Maxillary deficiencies in partial lip clefts. Abstracts 2nd Internat Congr Cleft Palate, Copenhagen, August 2&-31 , 1973, P 186 Jantet G . H. and Rob C. : An experimental and clinical investigation of a new haemostatic absorbable gauze . Brit J Su rg 48, 270, 1960. Joss G.: (Norwich , Norfolk, England) Personal communication, 1972.

76

The Cleft Maxilla

Lebendiger A., Gitlitz G . F., Hurwitt E. S ., Lord G . H. and Henderson J.: Laboratory and clinical eva lu ation of a new absorbable hemostatic material prepared from oxidized regenerated cellulose. Surg Forum 10: 440, 1960. Nord in K.-E. and Joh anson B.: Freie Knochentranspla ntation bei De­ fekten im Alveolarkamm nach kieferorthopadischer Einstellung der Maxilla bei Lippen-Kiefer-Gaumenspalten. Fortschr Kiefer-Gesichtschir 1.168,1955. O'Obri en B ,MeC. : The maxillary periosteal flap in primary palate sur­ gery. Austral New Zeal J Surg 40: 65,1970. Oilier L.: Traite experimental et clinique de la regeneration de s os et de la production artificielle du IIssu osseux. V. Masson et fils, Paris, 1867. Rant a R.' The development of the permanent teet !1 in childre n wit h complete cleft lip and palate. Proc Finnish Dent Soc 68, Suppl3, 1972. Ritsilii V ., Alhopuro S., Gy"ing U . and Rintala A . : The use of free periosteum for bone formation in congenita l clefts of t he maxilla. Scand J Plast Reconstr Surg 6: 57, 1972 b. Robbe N.: (Roeselaere, Belgium) Personal communication, 1973. Santo ni-R u giu P. : La ricostruzione dell'arcata alveolare con lembi peri­ ostei nella labiognatopalatoschisi completa. Bollet Soc Med Chir Pisa 34 1, 1966. Santoni-Rugiu P. and Massei A .: La reconstruction de la fissure max­ illaire avec des lambeaux de perioste dans Ie cas de fente labio­ palatine complete. Ann Chir Plast 16: 326, 1971. Santon i-Rug;u P., Salimbenl·Ughi G . and Massei A.: Procedimenti integrativi nella schisi del palato primario. Minerva Chir 27: 953,1972. Sarnat B. G.: Postnatal growth of the upper face: Some experimental considerations. Angle Orthodontist 33: 139, 1963. Sarnat B. G. and Wexler M . R.: Postnatal growth of the nose and face after resection of septal cartilage in the rabbit. Oral Surg, Oral Med, Oral Path 26: 712, 1968. Sarnat B. G.: The face and jaws after surgical experimentation with the septovomeral region in growing and adult rabbits. Acta Oto-Laryng, Suppl 268,1970

77

Schmid E.: Die Annaherung der Kieferstumpfe bei Lippen-Kiefer-Gau­ menspalten ; ihre schadlichen Folgen und Vermeidung. Forts chr Kiefer-Gesichtschir 7: 37 , 1955. Skoog T.: The use of periosteal flaps in the repair of clefts of the p rima ry palate. Cleft Palate J 2: 332 , 1965. Skoog T. : Treatment of Patients with Clefts of Lip, Alveolus and Palate.

Second Hamburg International Symposium , 1964.

Ed. K. Schuchardt, Georg Thieme Verlag, Stuttgart, 1966, p 63.

Skoog T.: The use of periosteum and Surgicel® for bone restorati on in congenital clefts of the maxilla . Scand J Plast Reconstr Surg 7: 113,

1967. Skoog T.: Repair of unilateral cleft lip deformity: maxilla, nose and lip. Scand J Plast Reconstr Surg 3: 109, 1969. Skoog T. : Sk oog's methods of repair of unilateral and bilateral cleft lip. Cleft Lip and Palate, Chapter 19. Ed. W . C. Grabb, S. W. Rosenstein and K. R. Bzoch. Little, Brown and Company, Boston , 1971, p 288 . Skoog T. and Hellquist R.: Restoration of maxillary clefts by delayed periosteoplasty. To be published . Thilander B. and Stenstrom S.: Treatment of primary cleft lip and palate cases in the light of the results of an experimental animal study. European Orthodontic Society. Report of the Forty-Third Con­ gress, July, 1967, p 349. Tortil J. -M.: Interet du lambeau perioste dans la reparation primaire de la breche alveolair~procede de T. Skoog. U:E.R. Sciences Med/~ cales A et B, Universite de Nancy I, 7973.

78

I

Chapter III

Correction of the cleft nose - repositioning the alar cartilage and reconstructing the nasal floo r

General co nsiderations 82 I. Compl ete clefts Operative procedure 83 Preoperative condition Incisions and undermining Dissecting the alar cartilage Repositioning the alar cartilage Reconstructing the nasal floor Result II. Incomplete clefts Operative procedure 90 Preoperative condition Surgi cal technique Result

Comments 92 Healing Results Referen ces 93

80

The Cleft Nose

A technique for correction

General considerations

Nature goes her own way, and all that to us seem s an exception is really according to order Johann Wolfgan g Go eth e (18241

Congenital clefts of th e primary palate are asso ciated w ith a characteristic malfo rm ation of the nose. Whe rea s t he cleft of li p and maxilla is primary in origin , the nasal deformity m ay be regarded as a result of ab normal deve lopmental forc es, g en ­ erated by the discontinuity of the nostril circumference. M edi al­ ly, the alar cartilage is anatomically related to the septum an d shifts moderately with that stru cture. At the ala r base, di sp la ce­ ment of the cartilage is always greatest and correspond s di rect­ ly to the severity of the cleft This is slightly accentuate d by tra ction exerted by the nonunited orbiculari s muscle. In an attempt to explain the genes is of the deformed nostril , Burian (1967) stated that abnor m al con di t ions, present du rin g cartilage formation, influence the eventu a l shape of the alar cartilage; the medial crus shorten s and the late ral part flattens. Tange and Ohmori (1964) have shown, that th e inner and o uter surface of the nose are the same on the cleft as on the no ncleft side, which emphasizes that the necessary compone nts are p re ­ sent but are arranged in a distorted po sit ion. For surgical correction, it is importa nt to realize , that du e to downward and lateral tra ction, the relativ e po sition of th e alar ca rtilage in relation to the upper cartilage has chan ged . Inst ead of normally overlapping each othe r, these st ructures hav e ac­ quired a side-to-side relationship. Fu rthermore, the alar carti­ lage is shifted laterall y with respect t o the upper, mo re fixed, cartilage. These observations indi cate that the basic g u ideline for surgical correction should be to restore the topograp hic anatom y of the nostril by repOSitioning the alar cartilage (Skoog 1969)

82

I. Complete clefts

Operative Procedure

Preoperative condition

f I

1 In this frontal view, the flattened and ob­ liquel y rotated nose is prominently dis­ played . The alar cartilage is pulled out laterall y and droops down across the div ided lip . The asymmetric nos e form s a norma l tip on the noncleh side, but this ef­ fe ct is destroyed by the abnormal anatomy of th e leh side, where the dislocated and straight en ed alar ca rtilage has dev iated from its normal , ove rlapping positi o n on top of th e upper carti lage. Thi s distorted configuration leaves o nl y a d imple to mark the spot where a co ntou red nasal tip should rest .

2 Looking from below, up into the defect, the marked obliquity of the nose and the gross disparity of the nasal apertures are readily apparent. In addition to the S-shaped , flattened aspect of the cleh nostril , the bu ri ed alar base causes the top of the leh nar is to lie on a leve l with the nasal floor of the opposite side . This sa me distorting mechanism reduces th e heig ht of the co lumella on the cleh side by bend­ ing the su ppo rting co lumell ar carti lage into an elo ngated alar ca rtilage . Thi s g ives the nasal rim an abnormally long ap­ pea rance . In addit ion, the tip of the nose angles away from the v iew er in co ntra st to the normal nose w ith its protruding na sa l tip .

83

r

3 With the retractors pulling back on the lip and nose, the cutaneous Iining of the vestibulum is clearly seen to descend all th e way down to the lateral maxillary seg­ ment. Fi xed in thi s position, the alar base becomes everted.

4 This drawing demonstrates the dynam ­ ics of the nasal deformity. The lateral dis­ pla ce ment of the alar base carries the medi ­ al cru s of the ca rtilage with it. Simultaneous­ ly, the lateral forces place the cartilage under torsion about the axis of the alar rim .

84

1

The Cleft Nose

Incisions and undermining

5 After the severe dislocation of the nasal lining has been fully appreciated, the car­ tilaginous border is easily identified at its junction with the lip mucosa , and an incision is made along this line. This horizontal cut then angulates sharply up between the alar and upper cartilages .

6 The intercartilaginous incision is carried up to the nasal septum .

7 Using thin-bladed scissors, the skin is raised over the lateral cartilage. Undermin­ ing continues across the nasal tip to the normal carti lage of the opposite side .

85

Dissecting the alar ca rtilage 8 Beginning at the lateral attachment to the maxilla, the displaced alar cartilage is freed from its estranged position . Outer surface separation is carried out between the skin and cartilage, up to the nasal r o of. The scissors mark the lower extent of the dissection .

9 The alar cartilage is partially freed on the inner aspect as well, for a width of approximately 2 to 4 mm. Care must be ex ercised so as not to perforate this very thin lining. A blunt tipped pair of scissors, kept to the surface of the cartilage, is used for this purpose. There is no danger of penetrating the adherent perichondrium. Exposure is particularly important medially , where the alar cartil age mu st be well mobilized to permit positioning in an over­ lapping fashion on top of the upper cartilage. The lower portion of the cartilage maintain s its integu­ menta l attachments.

10 After mObilization, traction in a postero-Iateral direction , at the upper border of the ala r cartilage, accentuates the malformation.

86

11 Similar ly , without changing the hold of the fo r­ cep s, moving the cartilage in s upero-medial d irection recreates a contoured nasal tip. The medial arch of the cleft nostril is also refashioned by this maneuver, which simultaneou sly reform s the columell a to a nor­ mal height, curv es the nasal rim and raises the alar base .

Repositioning the alar cartilage 12 In o rder to mediall y ad­ va nce the al ar cartilage in ­ to its co rr ect position , on the top of th e upper cartI­ lage, a key stitch is passed th ro ugh t he nasal mucosa and upper ca rtilage and at­ tache d to a dist al alar seg­ m ent. As shown here, this sutu re is pl ace d close to th e septu m , about 4 mm away from the inci sed border.

I.

13 The alar cartilage lining is picked up about 7 mm laterally , and t he two borders are united with a mattress suture ; 4/0 Dexon is used.

14 Marked alar advancement is achieved with thi s key repositioning suture .

15 The alar cartilage now lies in a normal overlap­ ping position on top of the upper cartilage.

16 High up in the recreated dome of the nose, a temporary transfix­ ing suture has been placed thro ugh the con tralateral columel­ la ca rtil age . The interca rtilaginous incisi on has been cl osed without further correction, and the alar base is now ra ised to a normal level.

87

Reconstructing the nasal floor 17 The nasal floo r is not fully reconstructed unti l the lip segments have been incised and prepared for closure . In this case , flaps have been designed as described in the next chapter. In this photograph available lin ing for the lower vestibulum and the major portion of the nasal floor is exposed. The lower corner of this lining is marked by a forceps.

18 The dislocated lining with its attached cartilage is shifted 180' into the floor of the nose, where it is sutured to the muco· periosteal suture lin e, a result of the max­ illary repair desc ribed in the previous chap· ter. This maneuver recreates the vesti· bulum and the alar base sul cus. 19 The alar lining is sut ured into pla ce. Medially, the in cise d septal mu cos a stretches to add ample lin ing for the fl oor. Mobilization of the septal cartilage at the nasal spine aids in closure , In conjuncti on with lip repair, a cutaneous flap , ra'i sed from the upper portion of the lateral lip segment, interdigitates into a triangular opening prepared medially, in the co lumellar base. This further inverts the alar rim, accentuates the sulcus, and narroWS the floor (see Chapter IV, Fig. 30, p . 108).

88

Result

21}-25 Nasal symmetry has been achieved . The flattened alar car­ tilage has been curved to form a contoured nasal tip. The alar rim sweeps gently around to conform to the opposite side, and the sul­ cus at the alar base is naturally shaped without local surgical inter­ ference or the use of any deep sutures. The nasal floor is at correct level. The view from below demonstrates symmetrically equal nostrils. The left alar cartilage has been raised slightly higher than the nor­ mal side to compensate for eventual descent. The columella is straight and of a normal height. Freeing the upper border of the alar cartilage permits advancement of the entire lateral compartment. The shift will naturally be greatest in the dissected upper area, whereas the shorter rim restricts mobil­ ity. This has the desirable effect of reproducing an important fea­ ture of the normal nose, which is particularly apparent in the child , i.e. at the tip of the nose, the dorsal skin stretches over the edge of the cartilage into a horizontal plane, producing a flat triangular surface in front of the nostril. With the combined procedure of maxillary reconstruction by a periosteoplasty, and the described technique for nasal correction, the reconstructed airway reaches the anterior portion of the hard palate. It is of normal width and completely lined.

89

II. Incomplete clefts

O perative procedure

Preoperative condition 26 The nasal deformity associated w ith inco mpl ete cle fts o f th e lip bears a close similarity t o the more distorted an atom y o f com · plete defects . Thou gh the malformation is less severe in th e former instance, all the characteristic stigmata are present: th e al a is still pulled laterally, its base is recessed , the entire nose is o blique ly rotated , and there is a shortening of th e co lumella on the cl eft si de.

27 In view o f the unbroken circu mferen ce o f th e nares, the deform­ ing lateral traction is distributed evenly about the com plete nostril instead of being applied to the lateral segment alone . This broadens the entire columella and shifts the base of the columellar cartilage downwards into th e fl oo r of th e nostril.

90

Surgi cal technique 28-29 Th ',s va ri ant o f th e co m p lete anoma ly requires a mo di ficat ion of the prev iously described procedure. An incision is made laterally in the floor, and the tissues are freed medially to restore the base of the columella . The rest of the repair utilizes essentially the same tech­ niq ues as before, and the alar cartilage is mobilized from an intercartilaginous incision and repositioned.

Result

30 The nasa l floors rest at the sa m e leve l and the appe rtur es are sy m­ metrically equal and separa ted by a straight, normal appearing columella .

,

31 The alar cartilage has been raised to a slightly overcorrected position and the tip is balanced and rounded .

Late results of this procedure are shown in Chapter IV, pp. 777- 720. 91

Comments

Healing

The seemingly intricate pattern of closure utilized in reconstruct­ ing the nasal passage, particularly at the floor of the nose, might be expected to complicate healing or produce harmful scarring. This has not been the case. The flaps are all well vascularized and most of them fall into their natural position without tension. This permits primary healing and complete re­ constitution of the lining prevents scarring from secondary epi­ thel ial izatio n. The intercartilaginous approach is usually as harmless here as in adult rhinoplasty. If the incision has been carried on to the septum, or closure has been inexact laterally, the scar may, however, contract and form a stenosing fold. Since all of the lining within the vestibule has been preserved, correction can easily be accomplished with a Z-plasty. The interdigitating flaps which crisscross the floor of the nose effectively prevent sec­ ondary depression, which may otherwise occur, as conventional sagittal suture lines scar and contract. At the columella and within the entire alar compartment, dis­ section is limited and restricted to well defined anatomical planes. This results in minimal deep scarring, which does not stunt growth, or limit the possibilities for secondary corrections.

Results

The nasal deformity is mainly caused by dislocation and under­ development of the lateral maxillary segment. The permanence of correction, thus greatly depends on simultaneous restoration of the facial skeleton. Though a periosteoplasty builds up sup­ port at the alar base, in complete clefts, the primary maxillary operation is never sufficient to completely raise this corner stone of the nostril to its correct level. In addition, there is often persistent protrusion of the premaxilla. Consequently, some recurrence of the deformity can be expected. Overcorrection, and the use of transfixing sutures, compensate somewhat for this eventual development. Persistent separation of the lip muscles tends to pull the alar base laterally, bringing the entire cartilage with it. Special tech­ niques of primary repair have therefore been developed to re­ store muscle balance in the upper portion of the lip (see Chap­ ter IV). Following this repair, the reunited muscles should pro­ tect the reconstructed nose.

92

The Cleft Nose

The resiliance of the deformed cartilage and its tendency to re­ main in a straightened position is a third factor that may con­ tribute to a recurrence of the malformation. To counteract this obstinacy of the cartilage, in a small series of patients prolonged splinting with corrective acrylic moulds was tried. This cumber­ some treatment was discontinued after it became evident that the effect was minimal. With increased accuracy in diagnosis and following suitable dissection, it is possible in unilateral cleft deformities to fully restore nasal symmetry. The ideal primary result, however, in­ evitably deteriorates to some extent. Minor irregularities can be accepted, as appearance generally improves during the teenage period, when significant facial growth changes take place. Gross, persistent abnormalities should be treated surgically, applying the same principles as used in primary correction. The secondary repair can be carried out at any age; insignificant scarring, an undisturbed alar rim, normal anatomy of the alar base, and the availability of all original tissues permit reopera­ tion under favorable conditions. Additional procedures general­ ly prove more effective than primary treatment, since skeletal incongruence has been reduced and the muscle can be re­ approximated with little tension. Virgin conditions are present in those patients in whom nasal correction has never been attempted, regardless of age. The original deformity has then remained largely unchanged and the described method of surgical treatment can be utilized with only minor modifications.

References

Burian F.: The Plastic Surgery Atlas. Butterworths, London, 1967, vol 2, p 165. Skoog T.: Repair of unilateral cleft lip deformity: maxilla, nose and lip. Scand J Plast Reconstr Surg 3: 109, 1969.

Tange I. and Ohmori S.: Qualitative analysis of the configuration of the unilateral lip. Transact Internal Soc Plast Surg, Third Congress, Washington, 1963. Excerpta Med, Amsterdam, 1964, p 1150. (Read by title, abstract published in Congress papers.) 93

Chapter IV Cleft lip rep air-resto ring the functional anatomy by reconstructing the muscula r fra m ework and pro viding tissue by a d ouble flap design

General considerations 97 Operative procedure 99 Preopera ti ve co ndi t ion Plann ing the m ed ial side in lip repair Di ssecting the med i al si de M axi ll ary reco nstru ction Nasal correcti o n Pl a nning t he la te ral lip seg m ent Di ssect ing th e late ral sid e Mu co us mem b rane closure Reconstru ctin g th e mus cl e laye r Skin closu re Dressing Res ult Late result s 117 Comments 121 References 123

94

The Cleft Lip

A method of repair

in unilateral clefts

General considerations

Deviation from Nature is deviation from happiness.

Samuel Johnson: Rasse/as (7759)

In the cleft lip deformity there is a variable but absolute tissue shortage. To be effective and as anatomical as possible, recon­ struction must therefore preserve and utilize all available tissue.

The muscular deficit is more pronounced than the surface de­ ficiency, and the lack of underlying support is further exag­ gerated by retraction of the nonunited segments. This confused muscular anatomy was illustrated by Sanvenero-Rosselli (1934). Pennisi et al (1969) reviewed the most commonly used methods of lip repair and realized how each technique basically ignored the mal positioned orbicularis oris and failed to restore it to its normal horizontal axis. This is a fundamental err or, for recon­ stitution of the separated orbicularis muscle is a prerequisite to adequately restore the functional and aesthetic framework of the lip. As most methods merely app roximate the muscles at the border of the cleft and do not carry this tissue all the way to the midline, a muscular diastasis is a regular and p ers istent oc­ currence . This is evidenced by a broadening and flatte nin g of the cleft areas , as well as asymmetry of the philtrum and co m­ plete absence of a philtral ridge. The defect is further accentuated by lip movements. In order to restore the normal anatomy and achieve muscle balance it is necessary to unite the divided and retracted orbicularis muscle along the entire height of the lip. The origin and insertion of this circular lip muscle lies in the midportion of the philtrum. Consequently, the disjoined lateral segment must be advanced and sutured to its medial counter­ part at this level.

The method described in this chapter was first reported in 1958. In subsequent years special emphasis has been placed upon complete restoration of the muscular anatomy of the lip. Experi ­ ences with this technique were reported in 1969 (Skoog). Since that time, there has been an increased interest in the abnormal arrangement of the lip muscles. Fara (1971) studied the anoma­ ly in great detail by dissecting twenty-five stillborn children with various types of clefts. From his analysis, he devised a method in which he freed up the muscles at the edge of the piriform aperture bilaterally and restored the muscular sling with an end to end suture. The anatomical observations of Plenk and HoIl­ man (1973) and others may help to further refine operative tech ­ niques . Jackson (1973), aware of the importance of reconstruct­ ing the orbicularis oris muscle, devised an entirely new ty pe of Abbe flap based on this principle . 97

The described procedure also involves shifting tissue from the lateral segment to the medial side. In the upper portion of the lip, a skin flap is utilized to reconstruct the nasal floor . At the free border a full-thickness triangular flap is made to elongate and evert the lip. This idea was introduced by Tennison (1952). Millard (1964) used a small rectangular skin flap to form a white line across the bottom of the lip scar so that the red of the ver­ milion did not blend into the cutaneous scar. His concept is applied here by creating a triangular mini-flap at the vermilion border.

98

1

The Cleft Up

Operative procedure

Preoperative condition

!

1-2 The complete unilateral cleft in this three months old boy reveals all the characteristic features of the lip malformation . The unaffected side is of normal height and configuration with a naturally peaked philtral ridge . In contrast. the opposing philtral border has been pre­ empted by the cleft . The deformity is further exaggerated by retrac­ tion along the cleft edges. This superficial t issue shrinkage is similar to scar contracture following a traumatic or surgically split lip . Me­ dially, the cicatricing force tends to bring the free border of the lip up to the nost ril, obscuring t he definition and ful l ness of the Cupid's bow. Latera ll y, th e scar-l ike process alo ng th e edge has ma rk ed ly sho rt ened the lip.

99

Planning th e m edial side in lip repair

On the medial aspect the aim of recon­ struction is to restore the distorted philtrat lip segment. Us ing the un­ affected side as a model, planning involves: • reposition ing the center portion of the Cupid's bow; simultaneously, • revea ling the existing tissue deficit; and • preparing the medial side for an anatomical repair of the separated tip muscles .

d --~,

/

100

3--4 The philtral ridge on the normal side and the lip midline are identified . The latter is repre sented by a slight indentation at the ver­ milion border and a fine seam in the depth of the philtrum . Both lines are pulled towards the normal side by the uno_nrosed muscle but still serve as con v enient landmarks. The distance between them defines half the width of the central portion of the Cupid ' s bow. The other half can now be determined by measuring out the same distance from the midline along the vermilion border; the end­ point is designed as (a) . A line is drawn from (a) , perpendicular to the lip border, and where it intersects the midline is called point (b). A third reference point (d) is placed at the columellar base, where it joins the cleft, just inside the external naris . A curved line, run­ ning along the muco--cutaneous margin, con­ nects (d) with (a) . Lastly, on the vermilion border at (al, a minute triangle is marked out.

r

Dissecting the medial side

5-6 In these malformati o ns the frenu lu m is usually quite prominent and atta ched close to the free border of the alveo lar process. If leh in its abno rmal position , the persistent frenu lu m acts as a wedge to separate the medial incisors as they erupt. It shou ld be divided up to the level of the bu ccal su lcus . This is carried out before any lip incisions are made, as it will release the medial par t of the lip and giv e a fullnes to the centra l portion.

7 An incision is made along the line a-d, through the full thickness of the lip. The bordering rim of the cleh, where tissues are retracted and of a poorer quality, is dis· carded .

8 Starting in the center at the previously determined point (b), a through and through incision is made along the line a-b. A No . 11 bl ade is used.

101

9 The small vermilion border triangle at (a) is now excised in order to break the sutu re line at this site.

( ~,

10 The marginal tissue, freed by the inci ­ sion, is left attached in the red lip region and used to apply vertical traction to the lip while the repair is carried out. Another clamp has been placed on the cut end of the labial artery.

I I

I I I

I I I

I I

I

11 After these incisions are completed, the lip tissues are fully released and the vertical border retracts and everts. The center of the Cupid's bow falls easily into place in its proper horizontal position, while apart from the triangular fu ll-thickness defect created by incising the free border of the IiI" , the en­ tire lip segment acquires a normal con­ figuration. At (d), an additional incision has been made laterally in the columellar base to provide a recipient site for the nasal floor flap.

102

r

Th e Cleft U p

12-13 Th e thin muscle la ye r of th e medial lip segment is left attached to the ski n, but dis­ sected free from the mucosa and prema xilla along th e enti re ma rgi n of th e ve rtical in cis ion, as far as the middl e of th e philtrum , where th e heavie r orbicu lari s muscle of th e non cleft side in se rts .

103

•

Maxillary reconstruction Maxillary restoration and nasal correction should be completed before planning the repair of the lateral lip segment. Since the technique of periosteoplasty has been previously described in great detail, the brief pre­ sentation here is merely to demonstrate how maxillary reconstruction compliments the lip repair.

14 Medially, a mucoperiosteal flap has been

raised from the premaxilla and turned into the cleft.

15 A substantial mucoperiosteal flap has been advanced from the deep aspect of th e lateral seg­ ment and brought across the defect to meet the medial flap.

.

16 Th e two periosteal membranes are closely

approximated by a double row of sutures. Th ey bridg e the wide maxillary rift comp letely.

,

104 I

The Cleft Lip

17 An incision is made in the buccal sulcus , through mucosa and periosteum, to prepare the anterior lining for the periosteal repair.

18-19 Th e periosteum and cheek tissues are extensively raised, en bloc, and a periostea l flap is dissected off the cheek .

•

20 The flap is now sutu red over the cleft with its inner surface facing the defect.

105

Nasal correction The lip repair is closely integrated with nasal recons truction and it has proved quite effective to coordinate the two efforts. As th is technique has also been previously described, only a capsule view will be presented here. 21 The characteristics of the flared and flattened nostril be­ com e accentuated after peri­ osteop last y.

23 The inner aspect of the nasal floor is formed by repositioning the vestibular lining .

106

22 Repositioning the mobilized alar cartilage normalizes the shape of the nose and raises the alar base.

24 Symmetry ha s been larg ely restored and the alar bases li e level with each other. Thi s rai ses the lateral lip segment upward s and mediall y and thus fa cilitat es planning the final part o f lip r e­ construction.

Planning the lateral lip segment After comp letion of periosteoplasty and the es­ sential part of nasal correction, the design for the lateral segment is outlin ed. The purpose of recon­ struction here is fourfold, • the border is elonga ted to match the height of the other side; simultaneously, • a triangular flap is created to fill the tissue de­ ficit medially; • the edge of the orbicularis muscle is freed from its retracted position in preparation for midline union; and • the skin along the upper portion of the cleft is utilized as a flap to reconstruct the nasal floor,

d

c b

a

d, -

b,

c,

a,

25-26 Point (a , ) is fir st so ught. Thi s is w here th e full b ody o f th e lip m e rg es w ith the mu co us m embran e o f the cleft. It is difficult to use the vermili o n borde r as the so le determinant of thi s poi nt, as there is often an indist in ct and gradua l end to this line rather than a di stinct cut­ off, From point (a,). the flap a ,-b ,-c , is designed to fit the medial defect. Holdi ng the medial lip segment in its normal posi­ tion, the size of an adequate flap can be accurately estimated and the proper design made . The line a runs parallel to the muco-cutaneous junction and is of the same length as a-b, The flap a,-brc , corresponds to the a-b-c defect, with the length and angles being equa l , Adjust­ ment must be made to compensate for some slight unfold ing when the flap is released.

,-b,

This design adapts itself to the individual situation and th e position of the base of the triangular flap will change up to near­ ly 90", depending on the height of the lip . When little lengthening is required, the base li es in a ve rt ical position, but ap­ proa ches a h o ri zo ntal ax i s w h en co n ­ side rabl e e longa ti o n is needed , Th e impo rtance of h av ing the al ar bases aligned at th e proper level is demon­ strat ed by the relative ease in planning further reconstruction of the lateral lip seg m e nt. Idea ll y, point (d,) is placed o n a level w ith point (d). and the distance be­ tween (d,) and its alar base eq ual s th e di stan ce across th e fl oor o f th e unaffected nostril. Thu s, when point (d,) i s brought to (d). a n asa l floor is created with the same dimension s as the normal side. Th e lower down (d ,) is placed , the more the alar base will be raised when the flap is rotated into position , W ith correct planning , crd, equa l s c-d and thus this measurement can serve to check the accuracy of the design. A "m icroflap " i s crea ted at (a ,) to fit into the sma ll triangular defect at point (a),

107

Dissecting the lateral side

27-28 The skin markings are sup erficiall y incis ed with a N o. 15 blade, wh il e a No . 11 blade is used to make a sharp through and through incision along the margins of the triangu la r flap .

29 The mucocutaneous junction in the upper portion of the lip is incised with ou t di scarding any tissue.

108

30 The skin flap designed to reconstruct th e nasa l fl oor i s then undermined in a plane superficial to the underlying muscle.

31 The incisions have opened up the lateral segment, lengtheni ng it the correct amount. A hook passed throug h the nasal floor flap rotates it medially.

32 Further rotation of this flap to the side of the col umellar base just inside the nostril, completes the nasal vestibule, inverts the alar rim , and improves the conto ur of the sulcus at the base of the nostril. The lower triangular, full-thickness lip flap fits ac­ curately into the medial defect.

33 With the upper skin flap held aside, the orbicularis mu scl e is exposed . Its border is freed from the skin for a few mm by sharp dissection and also separated from the mu co us membra ne on its deep aspect. To avoid interfering with cheek musculature, care shou ld be taken not to mobilize the orbicularis beyond the alar base and th us distort muscle function . It should be pointed out that at this stage of repair, the lip muscles have al ready been detached from their ab­ normal insertions along the piriform aperture. This was effected by the periosteoplasty , when the perio­ steum was extensiv ely mobilized away from the lateral maxillary segment.

34 Th e border of the muscle form s a sub­ stantial mass and is held here by two foceps.

109

Mucous membrane clos u re

35 There is a three layer closure. The mucous mem ­ brane, muscle, and skin are all approximated separate­ ly. Starting laterall y, the in cised lip mucosa is sutured back to the alveolus, using 4/0 catg ut on an atraumatic reedle. Careful positioning is important so as not to dislocate the lateral lip segmen t and reproduce asym­ m etry. A key suture brings the flap to the medial seg­ ment at a level corresponding to the new philtral bor­ der . The lateral mucosa is thus advanced acrOss the maxillary cleft, but must not be carried as far as the midline.

Reconstructing the muscle layer 36 In reconstruction , the lateral orbicularis muscle is brought slightly beyond the midline to join its un­ affected counterpart. A 3/0 Dexon stitch , on a circular needle, is passed th rough the upper corner o f the lateral muscle .

110

The Cleft LIp

})'

~L-

37-38 The suture is sec ured media lly at a level just below the na sa l spine .

I

111

39 The initial muscle suture has been tied, effectively restoring the lip. Deviation of the co lum ella is also corrected . In this photograph the muscle union is rein­ forced further down with an additiona l Dexon stitch . A third suture may also be used .

40 The prolabial fl ap, comprised of skin and a thin muscle layer, is sutured on top of the advanced o rb i­ cu laris muscle .

112

41-43 M attress sutures of 3/0 plain catgut are u sed to app roximate the lower segments of the lip . The y can be accurately inserted, since the triangular flap and re cipient defect are prominent landmark s that facilitate suture placement. Deep bites of tissue are taken, through the mucous membrane and muscle . To take tension off the muscle closure , a wide retain­ ing catgut sutu re may be placed intraoral ly, in the up­ per po rtion of t he lip . In the free border of the lip the mucous membrane is closed with 6/ 0 ca tgut sutures .

113

Skin closure 44--45 Since union of the underlying muscle es­ sentia lly bring s th e cleft parts tog eth er, the skin is cl osed under minimal te nsio n ; 6/0 catgut' i s thu s used to accurately adjust the ski n edges . The microflap at the ve rmil ion borde r is too small to su ture but is held in pla ce with one stitch o n each side .

I Ophta lm ic 770 G on m icro-point cutting needle, Eth ico n, In c., Somm ervill e, N.J., U .S.A .

114

46 Behind the retracted nostril, the nasal floor

r

flap fits easily into the base of the columella. Its usefulness can now be fully appreciated .

47 By restoring the underlying muscular frame­ work, the general architecture of the lip has been effectively recreated . The philtrum now lies around a vertical axis and a natural Cupid ' s bow has been formed . In the immediate postoperative photo­ graphs , lip symmetry is slightly marred by the relative protrusion of the underlying premaxilla . 1

Dressing t

48 Surgical tape' is the only dressing used post­ operatively. It can be applied to protect the major portion of the suture line and reduces ten sion dur­ ing healings . The skin sutures are remov ed after four days .

;..

Steri-Slrip® Skin Closures, Minnesota Mining and Manu­ fa cturing Co . (3M). St. Paul, Minnesota, U.S.A.

2

11 5

Result 49-63 Twelve months after surgery scars are hard ly visible. The Cupi d' s bow and the philtrum are clearly defined . The anatom ic rep air o f the orbic ul aris mu scle offers normal mobil ity and help s to cr eate a natu ral appearance . The underlying bony framewor k h as been extensively restored and contributes significantly to th e result of the repair. At the site of the original maxillary d efect a solid base can be felt. The immediate result of nasal reconstructio n remains largely unchanged. The raised alar cart ilage shapes the tip. Laterally, it curves naturally toward s the alar base, which lies at the correct level and is bordered by a distin ct sulcus. Mid line position of the columella aid s in reproducing nostril symmetry .

116

Late Results

The described multifa cette d approach for the primary repa ir of clefts wa s ap­ plied in pati ents sh o wn in Figs. 54-70. Correction w as th us ach ieved by peri­ osteoplasty, reposition ing of the alar cartilage and an anatomic lip reconstru c­ tion. The follow-up p i ctures are chosen to demonstrate certain genera l features of the late results.

54--56 The preoperative photog raph demon­ strates a subtotal cleft of the lip , associated with a complete cleft of the alve o lar process . Reconstruction was carried out at the age of three months.

The result at two year s emphas izes the im­ portance of preserving all av ailable tissue in the initial repair so as to produce a wide , supple lip.

117

57-59 In this boy, born with a co mplete unilatera l cleft, the lip seg­ ments are widel y apa rt. Re storatio n of the orbicularis mu scle prod uces a distinct philtrum in the ce nter of the lip, and the full thickness tria n­ gular flap , transf erred from the lateral segmen t, aids in rep os itioning lip borders as well as in forming a symmet rical Cu pid ' s bow . At four yea rs of age, the alveo lar arch is in perfect al ig n ment and on ex­ posure, th e previous maxillary defect was found to be bridged by new bo ne.

11 8

60-65 Thi s three m on th s old girl presen t ed with a wide comple te cleft and max imu m nasal def o rm ity at th e prima ry recon str ucti on . W hen readmitted fo r pa la te repai r, eighteen m on th s later, bony restoratio n had occu rr ed . M inor seco ndary co rrectio ns of the lip and left n ost ril, acco rdin g to the principl es o f prima ry repair, were added later. The follow-up pi ctu re s show th e r esu lt s at four ye ars of age.

11 9

66-70 This co mplete cleft of the pri ­ mary palate has markedly affected the nose, lip and maxilla . In the primary repair, undertaken at three months of age , maxillary reconstruction was not included , and as a result the bony defect remained essentially unchanged. A periosteopla sty was thus p erformed as a delayed procedure, five year s later. The results at eight years are shown here; the bony defect is now almost nonexistent. Normal upper lip move­ ments are here demonstrated on whistling .

120

Comments

The staggered suture line effectively prevents distorting con­ tracture and secondary lip deformity. In addition, there is little tendency for the transverse scars to widen as the muscular forces pull in the direction of the scar. In time, the scars become relati ve ly inconspicuous. Those bordering the lower triangular flap are, in fa ct, often invisible, and since they are comparative­ ly short, there is no functional impairment. Midline mus cle union, prior to approximating the skin edges, markedly reduces surface tension and limits any tendency for broadening , while the layered closure, without overlapping suture lines, precludes massive scarring through the entire thickness of the lip.

•

Establishing muscle continuity across the midline restores sym­ metry and reproduces the sculptured anatomy of the normal lip with a raised philtrum, a natural central depression, and a peaked, well-defined philtral border . Laterally, the abnormal bulge that hallmarks the retracted orbicularis muscle flattens in­ to the slightly bevelled contour of the normal lip. Following restoration of the musclar framework, there is significant func ­ tional improvement; the cha-nge is most graphic in secondary lip repairs . One such patient reported that his ability to blow a trumpet was markedly improved. He experienced a sense of lip mobility, that he never imagined co uld exist. The lateral full thi ck ness flap effectively elongates the borders of the cleft and supplies bulk to the lower portion of the lip. Its triangular shape helps to evert and protrude the lip . Including the muscle la ye r in this flap has no adverse effects on future function. Most importantly, the design results in a wide and supple upper lip with a distinct Cupid's bow. An essential part of the procedure is the transfer of the nasal floor flap. Though the shaping, positioning and suturing may be regarded as te chn ically difficult, numerous advantages re commend its use: • it furnishes the necessary lining to comp lete reconstruction of the nostril; • the floor of the nose is formed by a transve rse flap, which will not have a tendency to contra ct or become depressed; • tissue is provided to compensate for a defi ciency at the columellar base, thereby increasing the width of this structure and restoring symmetry;

12 1

• rotating the nasal floor flap upwards and shifting it medially contours the ala and a more distinct su lcus is created at the base, without the need of additional dissection or the aid of deep sutures . Breaking the sutu re line at the ve rmili o n border refines the repair. Despite the minute size of the flap , it effectively camou­ flages the scar as it crosse s the mucocutaneous junction. Following surgery the greatest ten sion will be exe rted in the upper portion of the united lip . At this leve l, the resulting pres­ sure effectively repositions the protruding premaxilla. Thi s force reproduces the normal molding action of the lip without result­ ing in tightness of the lower portion that would only distort the growing maxilla . These dynamics are particularly well demon­ strated in bilateral clefts (see Chapter V) .

122

References

Fara M .: The im portance of folding down mu scle stumps in the opera­ tion of unilateral clefts of the lip . Acta Chir Plast 73: 162, 1971 . Jackson I.T. : The im portance of o rbicularis oris in cleft lip repa ir. Abstr ac ts 2nd Internat Cong': Cleft Palate, Copenhagen, August 26--3 1, 1973, P 180. Millard D. R. Jr.: Refinements in rotation-ad va ncem ent cleft lip tech­ nique. Plast Reconstr Surg 33: 26, 1964. Pennisi V . R. and Shadish W . R. : Orbiculari s oris mu scle in the cleft lip repa ir. Cleft Palate J 6. 141 , 1969. Plenk Jr. H. and Hollmann K.: Hi sto logical observations in exc ision s of in co mpl ete cleft lips. Abstracts 2nd Int ern at Congr Cleft Palate, Copen­ hag en, August 26--3 1, 1973, P 179. Sanvenero-Rosselli G.: La divislone congenita dellabbro e del palato. Luigi Pozzi, Roma, 1934. Skoog T.: A design for the repair of unilateral cleft lips. Am J Surg 95: 223, 1958. Skoog T. : Repair of unilateral cleft lip deformity: maxilla , nose and lip . Scand J Plast Reconstr Surg 3: 109, 1969 . Skoog T. : Skoog's methods of repair of unilateral and bilateral cleft lip. Cleft Lip and Pala te, Ed . W. C. Grabb, S. W. Rosenstein and K. R. Bzoch. Little, Brown and Company, Boston , 1971 , p 288. Tennison C. W .: Repair of unilateral cl eft lip by ste ncil method . Plast Reconstr Surg 9: 115, 1952.

123

Chapter V

Repair of bilateral clefts-reconstructing the anatomy in stages

Introduction 127 Surgical correction, general consi derations 128 Maxilla

Nose

Lip

Timing the repair 129 Primary stages of repair 130 Operative procedure Periosteoplasty and alar co rrection Supplementary reconstru ction of the colume lla Lip repair Repair of the second side Secondary lip reconstruction 134 Original deformity Operative procedure

Preoperat ive condition

V to Y plasty

Muscle repair

W ound closure

Result of primary perio st eoplasty

Early result

Late result

Comments 141 Referen ces 142 124

Bilateral Clefts

Methods of reconstruction

Introduction

The entity "cleft lip" describes a spectrum of possible mal­ formations, ranging from the relatively innocuous maxillary depression to the gaping bilateral deformity. The latter is mere­ ly an extended and exaggerated consequence of the same pathophysiologic mechanisms responsible for the more benign lesions. Thus , an understanding of the basic biologic defect which produces all clefts can be used in planning therapy for the many variations of the aberration, including the extreme disfigurement associated with complete bilateral clefts.

1--2 This three month old child demonstrates the classical findings of bilateral cleft lip. The marked protrusion of the prema x illary seg­ ment is most obvious. The deformity is accentuated by retarded de­ velopment of the lateral segments. He ld forward on the elongated vomero-premaxillary stem, the alveolar part of the premaxilla is at­ tached to the nasal septum and is freely movable with these struc­ tu res.

Concentric retraction of the prolabium has occurred . This small "cap " of tissue rests on the elevated and displaced premaxilla. Another conspicious feature of bilateral clefts is the absence of a columella. Even in incomplete deformities this structure is markedly shortened with a distinct tissue deficit. The flared and flattened nostrils on each side of the cleft add to the difficulty in reconstruc­ tion .

•

127

•

Surgical correction, general

considerations

In contrast to the unilateral m alf ormation, there is no no rmal side to use as a model, an d the repair must thus be g u id ed almost exclusively by th e p rinciples mentioned ear lier in t he chapters on unilateral clefts. The recommended techni q ues f or soft tissue repair in the primary management of bil ate ral clefts were first reported in 1965 (Skoog).

Maxilla

Wide dislocation of the maxillary segments is gradually over­ come by the constant guiding pressure of the repaire d lip . T hi s physiologic molding is relatively atraumatic to vomerine an d maxillary growth centers. Staged repairs, closing one cleft at a time, are performed so as to minimize ten sion. A surgi cal set ­ back of the premaxilla should definite ly no t be carried o ut; t he late results are disastrous with marked retardation in m axi ll ary growth and subsequent deformity. Pr eo per ative orthope di c ad ­ justment fails to confront the entire pr ob lem of the protru d ing premaxilla and is less effective, length y an d costl y . O nly wh e n the lateral segments are collapsed is o rtho pedic ex pan si o n car­ ried out priorto surgery. The "floating" premaxilla is a most disabling characteristic of bilateral clefts. With the addition of periosteoplasty on each side, a stabilized and shaped alveolus is fo rm ed.

Nose

As in the unilateral cleft, the principle nasal deformity i s due to lateral pull and displacement at the alar base. In t he b ila teral defect, these unopposed forces spread and flatt en th e nares to such an extent that they totally shift the colu'mell a Into the nostril rim. At the same time, the wide clefts separa te th e car­ tilages so that an unsupported nasal tip results. Bilateral al ar dislocation makes reconstruction particularly difficult, an d m ere medial adjustment of the cartilages is rarely sufficient. Restora­ tion is aided by prolabial flaps, which are used to help elongate the columella. Because of the severity of the nasal deformity, secondary nasal correction almost invariably is required.

lip

As with cleft repairs in general, but particularly true in the bilateral defect, all tissues should be preserved. in this respect, the prolabium is an essential component in restoring normal

128

Bilateral Clefts

width and co ntour to the lip. Even in cases where it may at first seem to be too tiny and too far removed to be of mu ch use in reconstruction, it has been found to be of great value. The prolabium comprises the philtrum and the central portion of the Cupid's bow, and though the tissue is deprived of muscle. the primary repair permits a fuller r econstruction to be carried out later. An important purpose of this closure is to mold the dislocated premaxilla into a normal position . When the final stage is completed, the retracted orbicularis muscle is brought to the midline and the prolabial mu cosa and subcutaneous tissue s are shifted to form the lip tubercle. This restores the muscular framework and general appearance of the lip (Skoog 1973).

Timing the repair Plasti c surgery has four dimensions, the last being time . Recon­ struction thus mu st be carefull y gauged at critical intervals to provide the most physiologic sequence of repair . This principle is particularly valid in bilateral clefts.

•

For purposes of correction, each side can be regarded as a separate defect with the first operation being carried out at about the age of three months. Thi s allows for gradual and less for cefu l molding than would otherwise result from co mplete re­ construction attempted at one time. Barring complications, the other side is repaired three months later. Nasal reco nstruction and maxillary restoration are included in the two primary opera ­ tions. I n asymmetri ca l conditions the most seve rely affe cted side is corrected first. Most bilateral clefts must be secondarily cor rected to recon­ stitute the separated orbicularis muscle. Me chani ca l factors make primary union difficult if not impossible. The secondary operation is performed before the age of five, as soon as the maxillary segments are properly aligned, the tension ha s been reduced and the tissues are pliable. Due to the severity of sec­ ondary deformities, complete restoration is often not possible. Additional corrections may. however, be attempted over the entire growth period and even after full maturity has been rea ched. 129

Primary stages of repair

Operative procedure Periosteoplasty and alar correction 3 The preoperative condition of this patient with bilateral clefts is show, in Figs. 1-2. When this photograph was taken during surgery, periosteoplasty and nasal re co nstru c­ tion had already been co mpleted on the left side, as an initia l step in the repair . The result is an improved nasal contour with elevated alar base and lengthened columella on that side. This elongation remains, however, insufficient.

Supplementa ry reconstruction of the columella

4 In continuing the reconstruction , a triangular flap is designed to further improve the columella, It is comprised of tis sue from the lateral portion of the prolabium . The tip of the flap is placed so that the central portion of the pro­ labium, destined to form the philtrum , will be of normal shape and have a vermilion border wide enough for a Cupid ' s bow, In practice, this means that the medial border of the flap will lie in a vertical position ; laterall y the bor- ' der is placed close to the mucocutaneous j unction ,

130

5 An incision has been made transversely across the base of the columella, where the jun ction between the nose and the lip is indicated by a furrow, and extended along the borders of the flap outlined on the prolabium . The flap is elevated and further mobilized by underm ining the ti ssues proximal to its base on the septum. In this way the tip of the nose is freed , and when brought forward the amount of columellar deficiency is demonstrated.

(

6--7 The prolabial flap is sutured into the columellar defect with 6/0 plain catgut. A marked elongation of the columella on the left side ha s thus been obtained , and there is a good relationship with the raised alar base.

131

•

Lip repair 8 The lip repair is performed as in the unilateral case, see Chapter IV . On the lateral segment, the base of the lower trian ­ gular flap is placed at a right angle to the upper incision line, all three line s are of equal length . Standardized planning facilitates the later repair of the second side. It may also be helpful to tatoo a few symmetrical key points with a fine needle, when the first side is designed.

9-11 It is important at this time to shift the lateral lip segment medially to a higher lev el, so that the alar base is brought for­ ward to rest on the superior aspect of the premaxilla. Pre ssure exerted by the united lip will then effectively mold the protrud­ ing premaxilla into its normal position .

12 This diagram illustrates the functional dynamics of the repaired lip . There is no pressure across the lower portion of the premaxilla and its border is left free.

132

Repair of the second side The second side is treated with a similar procedure and the same standard pattern. This stage is more difficult for several reasons. The cleft has widened; the premaxilla has swung to the opposite side in such a way that its medial edge juts outwards and the prolabial tissues, previously soft and pliable, are now scarred, inelastic, and displaced to the repaired side.

'.

\

13 When the patient is readmitted at the age of six months for reconstruction of the other side, the immediate operative result of the pre v ious repair appears basically unchanged. The scar lines are marked out in blue.

14 Pri or to beginning reconstruction, the operated left maxillary defect is reexposed . As a result of periosteoplasty, bony con ­ tinuity has been achieved across this gap. An additional deposit of bone was needed to com pletely stabilize the segments, and merel y elevating the periosteu m from the new bone was suf ­ ficient to produce the required amount in this particular case, though in less favorable instances subperiosteal implantation of Surgicel is recommended. 15 In this drawing , appositional bone formation to the lateral segment is visualized by comparing with the original , identi ca l defect of th e nonoperated side. The new bone forms a nasal floor at the co rrect level , and the width of the piriform aperture is reduced .

133

Secondary lip reconstruction

Original deformity 16 Thi s asy mmetri c bil ateral c left was r ep aired in the usual fashion . Simu ltane ou sly, perios t eo­ pla sty wa s performed bil aterally.

Operative procedure

Preoperati ve condition 17- 18 At four years of age the patient demon­ strates characteristic residual defects. The lateral lip seg m ents are retracted , separated by the widened prolab iu m and there is marked defi­ cien cy of tissue at the center of th e lip border. The "whi stle deformity" is due not on ly to a defect in mus cle co ntinuity, but also t o displaced prolabia l ti ssues.

) ./

134

V to Y p/asty 19 Additional mu cosa and fullness at the lip border is furni shed by a V to Y plasty. All the soft ti ssue struc­ tures o f th e original prolabium are included in the flap , w hi ch is dissected free down to the mucocuta­ neous junction . The V-flap thus has as its base the mucocutaneous border of the philtrum.

Muscle repair 20 The retra cted muscle borders in the lateral lip ele­ ments are freed from the skin and mu co us mem­ brane. This dissection must be carried past the area scarred by previous surgery . Since muscular adhe­ sions to the maxilla may extend far laterally into the cleft regions, extensive deep dissection is required to permit proper reconstructi on .

•

21--22 The mobilized muscles are united in the midline w ith 4 /0 Dexon s utures. This closure should not exte nd below the up­ per two thirds of the lip . 135

23-24 In the lower portion of the lip the muscles are sutu red to the repositioned subcutaneous tissues of the prolabial flap . If the muscles are united for the full height of the lip, an unnatu ral puckered appear­ an ce will result.

Wound closure 25--26 After muscle approximation it is frequently found that the lip mucosa is still fixed in an abnormal position by scar tis ­ sue over the cleft area . This prevents the complete transfer of the lateral lip ele­ ments to the midline and maintains an asymmetry at the lip border. A supple­ mentary incision in the buccal sulcus, ex­ tending from the midline to the premolar region, gives good exposure during divi­ sion of these fibrous adhesions. The mucosa can then be readjusted and ad­ vanced medially to its normal position, using 4/ 0 catgu ': sutures for closure. Following restoration of the vestibular lin­ ing, the prolabial triangular flap easily ad­ justs itself to its new position . This com­ p let es the V to Y transfer.

136

Result of primary periosteoplasty 27 In con junction with secondary lip reconstructi on, the left maxillary cleft is re-exposed. The periosteum is raised and regenerated bone can be clearl y seen ; it has stabilized the premaxilla completely.

Case report with an early result

28 The bilateral cleft deformity in this

29 Three months later, the previously minute prolabium

girl was treated according to the described procedures. The subtotal cleft on the right was repaired at the age of three mon ths .

is now of normal hei ght and the alar base is at the correct level. An identical c losure was then performed on the op­ posite side.

137

30 By the age of four years, the prolabium has widened beyond normal dimensions due to th e pul­ ling force of the separated muscle. Displacement of the prolabial mucosa ruins the border line of the li p.

31-32 Secondary lip rec onstruction has been per­ formed by restoration of the muscular framework and repositioning of prolabial tissues to the free border As a result, the lip appears normal in its cutaneous portion and a full Cupid's bow has been formed .

Case report with a late result 33 This girl had her first primary cleft re­ pair at the age of three months . She demon­ strates all the stigmata of a complete bilat­ eral cleft.

34 Three months postoperatively the pa­ tient retu rns for repair of the other side. Scarring fr om the original procedure is in­ significant and the premaxilla has swung to­ wards the latera: segment. Lengthening of the columella is obvious, as is the relati ve ly normal position of the alar base. Periosteo­ pia sty had not been devised at this time.

138

•

35 At four yea rs of age the patient was readmitted for delayed periosteoplasty. The premaxilla had considerable mobility and persistent maxillary clefts were present bilaterally. It was possible to line them completely w ith periosteu m, and Sur­ gicel was thus implanted within the created cav­ ities.

The picture demonstrates the relatively normal length and configuration of the columella supplied by the prolabial flaps . The orbicularis mu scle in the lateral segments of the lip remains clearly separated and at the free border of the lip, there is a central thinning . Secondary correction was per ­ formed at age eight, with repair of the separated muscle seg ments and reconstruction at the free border. This was done as described prev iously.

36-37 In conjunction with secondary lip reco n­ struction, both maxillary clefts were reexamined. New bone was found to have been deposited bilat­ erally, fully restoring the anatomy. X- rays revealed tooth buds within the newly formed bone.

139

-

)

38-42 The result at age ten, when the patient returned for routine follow -up. Dental occlusion is good and maxillary development has been normal. This girl is musically talented and ca n play the flute .

140

•

Comments

The primary lip repair might be simplified to reduce visible scar­ ring by freshening the edges and making a straight line closure, often termed "lip adhesion". Lip elongation would then be in­ cluded in a secondary stage. On the other hand, the method presented here provides more physiologic molding. There are, however, some technical difficulties because of the minute flaps and the relatively great tension encountered in closing the sec­ ond side .

Lip

Bringing the muscle layer of lateral lip segments to the midline marks a major advancement in the treatment of bilateral cleft. It restores function, improves the general sculptural appearance of the lip, narrows the widened prolabial tissues and changes the prolabium into a philtrum-like structure . It also eliminates tension on the scar lines, which thereby become less visible. In the upper portion of the I ip, it may be difficult to completely advance the separated muscle to the midline through an intra­ oral approach, and external exposure is thus required. For this purpose, an incision is made in the scars at the base of the columella and extended a few mm downwards in the lip scar. The muscles of the lateral lip segments should then be well mobilized, so that they can be easily sutured to the nasal spine and united in the midline. This maneuver, performed bilaterally, contours the upper portion of the philtrum . Reconstruction of the lip tubercle also requires extensive dis­ section to allow complete repositioning of prolabial tissues, which should be freed down to a thin base at the vermilion border.

Nose

•

Lip correction reduces the width of the broadened nose by shifting the alar bases medially. Repeated advancement of the alar cartilages to improve cO'ntour at the tip of the nose may also be performed at this stage. The length and shape of the columella is directly related to the dimensions of the cleft. Be­ ing totally absent in complete clefts , prolabial flaps are useful in reconstruction and apparently do not deprive the prolabium of any essential tissue . 141

Maxilla

Much is gained by reconstructing the cleft maxilla. The primary goal is to establish a normal anatomical framework, thus stabi­ lizing the maxillary segments and thereby restoring function; simultaneously a foundation for the concomitant soft tissue repair is created . The problem of the disjointed maxilla is par­ ticularly acute in bilateral clefts, where the floating premaxillary segment requires definitive treatment to counteract gross func­ tional impairment. Restoration of the alveolar arch in these cases will generally require repeated periosteoplasties, and only when both sides have been treated can complete stabilization of the premaxilla be expected.

Orthodontics

From an orthodontic viewpoint, maxillary reconstruction re­ duces the tendency for collapse of the alveolar arch, though jaw orthopedic treatment will probably still be required . When nor­ mal configuration of the dental arch is attained, the properly aligned jaws can be placed in precise occlusion. Another ad­ vantage of bone regeneration is that teeth are then able to migrate into the cleft area, thus further aiding dental rehabilita­ tion.

References

Skoog T.: The management of the bilateral cleft of the primary palate (lip and alveolus). Part I. General considerations and soft tissue repair.

Plast Reconstr Surg 35: 34, 1965.

Skoog T.: The management of the bilateral cleft of the primary palate

(lip and alveolus). Part II. Bone grafting. Plast Reconstr Surg 35: 140,

1965.

Skoog T.: Skoog's methods of repair of unilateral and bilateral cleft

lip. Cleft Lip and Palate, Ed . W. C. Grabb, S. W. Rosenstein and

K. R. Bzoch. Little, Brown and Company, Boston, 1971, p 299. Skoog T.: Early management of bilateral cleft lip and palate. Read at the 2nd Internat Congress on Cleft Palate, Copenhagen, Denmark,

August 28, 1973.

142

l- _ _

,

Chapter VI

Repair of lateral facial clefts anatomy

reconstructing the muscular

Introduction 746 Operative Iprocedure 748 Preoperative markings Dissection of the muscle layers Repair of the muscles Skin closure Result Comments 754 References 754

Title page: The drawing illu strates a slight right­

sided transverse facial cleft and th e associated wide disruption of oral and bu ccal mu sc ulature.

144

Lateral Clefts

./

Method of repair

Introduction

The lateral fa cial cleft (macrostomia) results from a defective union between the developing mandibular and maxillary pro­ cesses. The lesion invades the complete depth of the cheek and separates the upper and lower lips as it pierces the corner of the mouth. The anatomy of the disjoined lips is otherwise un­ disturbed. The incidence of this conge nital malformation is rare, as atypical clefts represent only 1.5 per cent of all cleft lip and palate deformities. Corrective procedures in the past, fell far short of an ideal restoration and as described, were all similar to tarsorraphy . In the technique recommended by Barsky et al. 1964, the lateral limits of the cleft were determined and skin and mucosa l fla p s utilized in reconstructing a new commissure, whereas the de ­ ficient muscle layer was totally neglected . W ang and Macom ber (1964) recognized the specific mu scular action of this region and united the orbicularis oris m uscle to ade q uately rec onstruct th is defe ct. The present operation is base d on this prin ci p le of repa ir ing the underlying m uscu lar f ramework, incl ud ing the cleft bu ccal muscle, as w ell as clo sing the superficia l cleft.

.

,

146

I

Lateral Clefts

I

t

I

,

1-2 Ev en a minimal lateral facial cleh is associated with a gap in the sup ­ porting musculature. The sling effect th a t these muscles offer to the corner of the mouth is absent, and cau ses the affected side to droop . The deformity becomes more obvious w hen t he mouth is opened, and the separated muscles contract indep endently. This patient has an obvious right-sided cleh, which partially obscures a smaller defect on the leh side. The presence of preauricular tags is characteri stic of congenital mal­ formations involving the first and second branch ia l arches. Accord ing to Grabb (1965), a distinctiv e tag located Ju st anterior to the jun ction of the tragus and antitragus, is almost al ways associated wi th m acro­ stom ia.

147

Operative procedure

Preoperative markings 3-4 The lateral extension of the normal red lip can bee seen on the upper and lower sides of the cleft due to the color contrast be­ tween the mucosa of the lip and the cleft. This difference is ac­ centuated by the presence of a mass of o rbi cularis oris muscle on the lip side, caused by a retracti on of the muscle . The transi­ ti onal zone is u sually found more medially than anticipated. The false co mmissure is marked at the mucocutaneous junction . It curves to the inside of both the uppe r and lower lips and an­ gulat es across the free borders o f the lips, along the ma rgins of normal lip tissue . On the upper lip, thi s line of incision is ex­ tended a few mm into the vermilion border.

5 Even the moderate external deformity of this case inv olve d com plete discontinuity of the or­ biculari s muscle, and a wedged separation with­ in the buccal muscle layer extending into the cheek .

148

Lateral Clefts

t

­ Dissection of the muscle layers

\

6 At the true lip margi n, the dis­ section reveals a retra cted mass of orbicularis o ri s muscle, which ca n be ex posed after extracting it from the surrounding tissue .

8 Th e dissection o f th e m u scle layer lining the cle ft, is con­ t inue d alo ng the upper and lower borders.

I

7 An incisio n alo ng the muco­ cutan eous border o f the cleft ex p oses the ti ssu e defect. Lateral to the cleft, the muscle layer is ret ra cted and incom­ plet ely separated . Subcuta­ neou s di ssectio n is therefore required to en sure that the buccina to r is fully freed and ca n be reco nstituted.

149

Repair of the muscles

9--11 When the dissection is completed, the true magni­ tude of the defect is seen . The margins of the bor­ dering musc les are distinctl y displayed and a sub­ stantial depth of ti ssue is found between the sub­ cutaneous layer and the ora l mucosa . Simp le ap­ proximation of th ese displaced structures will re­ store the norma l anatomical integrity. The closure is p erformed in two layers. It begi n s in the bottom of the cleft, where the muscles and mucosa are brought together in one layer with a rOw of inter­ rupt ed 4/0 catgut ma tt ress sutures, tied on the oral side.

150

I

12-14 The freed ends of the orbicularis form a discrete bulge. This muscle is repaired as a separate entity with a few bu ried 4/0 Dexon sutu res, thereby re­ storing the sling effect to the corner of the mouth .

.'

·t

151

15 The buccin ator repair is supplemented with a few

5/0 catgut sutures on its external surface. A fter the m uscles have been approximated, the th ick subcuta ­ neous fat laye r fits into accura te apPosition atop the muscles. A few fine catgut sutures may be needed in this la ye r to obliterate any dead space and improve the contour.

Skin closure 16--18 As in ot her congenital c left deformities, there is never an excess of tissue. Thi s principle applies to the skin as well, and only minimal tri mming along the borders of the original cleft is required before suturing . The suture line at the angle of the mouth should then be broken to counteract the stra igh t line effect. The superficia l incision at the v ermilion border of the upper lip was used for that purpose. Skin edges can be approximated without tension, using 5/0 non-absorbable material on atrau matic needle.

152

Result 19-20 Two months after surgery, symmetry of the mouth and cheeks is clearly seen. 21 After one yea r, there is a complete re sto ra­ tion of fun ction .

153

Comments

Macrostomia should be recognized as a malformati on in vo lvi ng several tissue layers. The external defect is always combined with a more extensive separation of the deep tissues of meso­ dermal origin, i.e . the oral and buccal musculature. In this respect, lateral facial c lefts show great similarity to congenital cleft lip deformities. Any procedure that is confined to surface anatomy only hides the deep division with a thin tissue cover­ ing. An effective repair requires full exposure of the disturbed anatomy in order that the deficit can be bridged with a solid matri x of muscle. Reconstruction of a commissure then does not present a great problem. The results of this procedure have been gratifying in terms of both function and ap pearance .

References

Barsky A. J., Kahn S. and Simon B. E.: Principles and Practice of Plastic Surgery. Second Ed. , McGraw-Hili Book Comp, New York, 1964, p 419. Grabb W. C. : The first and second branchial arch syndrome. Plast

Reconstr Surg 36: 485, 1965. Wang M. K. H. and Macomber W. B.: Median clefts of the lips; lateral and oblique clefts of the fa ce. Reconstructive Plastic Surgery. Ed. J . M. Converse, W. B. Saunders, Philadelphia, 1964, vol III, p 1533. 154

Chapter VII

The significance of the periosteum in regenerating resected portions of the maxilla; the effects of early bone grafting on facial development; the tissue response to subperiosteal Surgicel ® implantation, and; the results of removing the periosteum fro m membranous bones. Studies in growing rabbits and guinea-pigs

Introduction 158 Osteogenic potential of maxillary periosteum

Cleft anatomy and periosteal activity

Periosteal repair versus bon e grafting- a d ifference in

the qual ity of bone

Environment and periosteal bon e regeneration

Surgi cel @and bone formation

Th e effects of periosteal res ection

Conclusions 172 References 173

156

Regeneration of Facial Periosteum and Bone

Experimental research

Introduction

At its inception, an air of mysticism surrounded the use of periosteal membranes to form new bone. The scientific basis for this procedure was unclear and the technique of "bone­ less" bone grafting provoked a series of stimulating questions. • Does normal maxillary periosteum possess an osteogenic cap acity, which coul d account for the dramati c results obtained through periosteoplasty?

I

• In the original proposal of this procedure it was postulated , that the periosteal lining bordering the ma x illary cleft was cap­ able of forming new bone. If this, in fa ct, was the case, why then, within the congenital defect, did the unmanipulated perio­ steum remain largely inactive? • Is there a qualitative difference between bone produced from local periosteum and bone resulting from autogenous bone grafts? • Is there an environmental influence on the bone-forming capacity of freed periosteum? • What are the effects of Surgicel ® when placed in a p eriosteal lined cavity? • How does the remova l of perioste um from the outer aspect of facial bones affect their future development?

•

In the relati ve ly uncontrollable clinical setting , with the many factors influencing surgical results , the great number of cases required for a proper assessment, and the long time needed for final evaluation, a true analysis cou ld not be made. These in­ quiries were thus taken to the research laboratory, where ex­ tensive experiments were carried out to probe the problems and to better understand the nature of max illary periosteum . In a series comp rised of more than 300 rabbits, aged 2-3 weeks, Engdahl (1972) performed unilateral maxillary resection which included the premaxillo-maxillary suture (Figs. 1- 3). He varied the position of the periosteal lining and the material used to fill the defect. Bone regeneration and maxillary growth were studied by gross examination and by triple fluoro ch rome latel­ ling .

158

f

, This depicts the standard, right -sided, maxillary resection used in Engdahl's experi ments on 3 weeks old rabbits.

2--J These two craniums, the larger from an adult and the smal ler from a young rabbit at the time of resection, are presented to show the considerable maxi llary growth that occurs in this species .

In another investigation, in more than 100 growing rabbits and guinea-pigs, Hellquist (1972) studied the effect of removing the periosteum from the facial bones. Periosteal r.egeneration was fOllowed by consequetive histologic surveys. The growth of the denuded bone, as well as the development of the entire sku ll , was examined gross ly and by using osteometric and radiographic methods. Some of the results of this informative work will be presented here. By courtesy of Dr. Engdahl and Dr. Hellquist, their original illustration s are used in these summarie s. 159

4 This drawing illustrates the tec hnique of early, subperiosteal ma xillary resec­ tion . The periostea l lin ed cavity has been left to fill spontaneously with blood.

Osteogenic potential of maxillary periosteum

In growing rabbits, subje cted to standardized unilateral maxil­ lary resection, the periosteum proved to be essential for maxil­ lary regeneration. The more periosteum preserved at surgery, the earlier and more complete was the restoration of the normal anatomy. .When the periosteum covering the lateral surface of the maxilla was resected together with its bone, and only the medial wall of mucoperiosteum was left in place, bone formation dimin­ ished. Yel, even a single-layered periosteal membrane was capable of forming new bone across a substantial maxillary defect. When the resection included the periosteum on both the lateral and the medial aspects, there was minimal new bone formation at the borders and the defect persisted throughout the entire growth period. Unilateral maxillary bone resection with its covering periosteal lining did not markedly influence the growth and development of the facial skeleton , despite the inclusion of the premaxillo- _ maxillary suture in the resected segment. When subperiosteal maxillary bone resection was carried out and the resulting , periosteal lined cavity was left to fill sponta­ neously with blood and/or serum, bony reconstruction took place at an extremly rapid rate. Regeneration was visible at the end of the first postoperativ e week , and normal anatomy was largely restored in two to three weeks. In some cases suture-like growth sites were obse'rved within the regenerated bone. The new bone grew in harmony with the facial skeleton and only minimal maxillary deformity consequently developed. (Figs. 5-8)

160

5-6 There is complete regeneration of the right maxillary wall . which has a sl ightl y roughened bony surface. Unimpaired skel etal growth is evidenced by the evenly grounded fa cets of the incisors-this is characteristic of a normal bite.

7 This microphotograph . taken in ultraviolet light. demon strate s the sequentia l regeneration of new bone. The animal was sacrificed 23 days after surgery . Fluoroch rome injections were given 15 (yellow). 18 (red) and 21 days (g reen) postoperatively. The dark zone. separating the fluoroscently active areas. represents suture formation within the newly formed bone. Longitudinal g rowth at this site is evident by the distinctly co lored zones along its posterior bony border.

-

Although the enclosing perio steum does not stain with this tech ­ nique. the section demonstrates that the mass of new bone originates from the periosteum . Along the lower border in this illustration. the most recently formed bone (green ) is found on the surface. adjacent to the black periosteum. whereas the red and yellow stained bone. formed a few days earlier, has a more central locati on. The distinct chronologic labelling indicates growth byapposition. S In this transverse section through a rabbit skull. a standard bone resection had been performed and bone marrow aspirate has been used to fill the periosteal cavity. The animal was sacrificed 15 days after surg ery. The normal anatomy is largel y rest o red and a suture ­ like growth site has formed in the po sterior portion of the regenerat ­ ing maxilla. Labelling was carried out 3 (yellow), 9 (red) and 12 (green) days postoperatively. In this study the rate and quantity of bone formation differed insig­ nificantly from the results obtained when a blood matrix was used.

161

Th is series of experiments shows that the maxillary periosteum possesses an osteogeni c capacity capable of completely regenerating bone. It confirms the conclusion s based on random clinical observations of spontaneous maxillary reforma­ tion and also provides a reasonable explanation for the favor­ able results obtained w hen periosteoplasty wa s performed across a cleft. In animal studies, the thin, transparent mucoperi ost eum on th e medial aspect of the maxilla was found to have a less vigorous osteogenic po tential than the thicker and better-vascularized periosteum covering the outer bone surface. In children, the reverse seems to be true. The mu co periosteum on the deep aspe ct of the lateral maxillary segment forms a substantial tis ­ sue la ye r. When this den se periosteal membrane is freed, it proves to be more acti ve in forming bone than the perioste um raised on the outer aspe ct of the maxilla. Similarly, the thin mucoperiosteum of the premax illa demonstrates little bone forming capacity. 80th results, in animal experiments and clini­ cal observations, indicate a direct relationship between mor­ phologic appearance and osteogenic pote ntial.

Cleft anatomy and periosteal activity

One experiment was designed to study the oste ogenic activity of normal periosteum when placed in an anatomical framework that resem bled a congenital cleft. Following maxillary resection mucoperiosteal flaps were wrapped about the ra w bone sur­ fa ces. Under these conditions the periosteum acted in an identi ­ cal manner t o the periosteal lining of tru e clefts, and no bone developed. (Figs. 9-12.) This experiment supports the initial assumption, that in con­ genital clefts the topographic anatomy of the periosteum alone inhibits bone regeneration . The defect might then be expected to enlarge during growth, but clini cally this does not occur, as there is a gradual compensatory collapse of the maxillary seg­ ments, produced by the tight and scarred tissues of the co n­ comitant lip repair . In the ani ma l experiments , this readjust­ ment was preve nted by a rigid bony frame wo rk, which apart from the' created defect, was intact. Furthermore, the soft tis­ sues we re pliable and under no tension .

162

Regeneration of Perio steum and Bon e

9 Resection performed in such a way that the bony borders could be com­ ple tel y lined with mucoperiosteum. On the lateral aspect, the covering periosteum was removed together with the maxillary bon e; media ll y, the mucoper iost eum was split and two flaps were obtained, which were then sutured over the exposed edges.

1 \

10-11 This is the result of early maxillary resec­ tion, where the periosteal membranes were placed in a position that simu lated a congenita l cleft. In this experimental model , alm ost no bone regeneration took place and the defect widened as the maxilla grew forward. No sig­ nificant snout deviation occurred .

12 In anoth er animal o f this experimental group , labelled 15 (y ellow). 18 (red) and 21 (green) days after surgery, the original defect has widened rather impressively with th e gen ­ eral growth of the maxil la. Th e rounded , inactive edges of the bOMY cavity are well demon ­ strated . Note the thick and tortuous prema x illo­ maxillary bone sutu re on the control side.

163

Thus, the periosteum-bone relationship determines the fate of bone regeneration. The location of the new bone, when formed, will be decided by the position of the periosteal lining. This supports the concept of freeing the periosteum and placing these membranes where bone is needed. The results of the animal experiments are in complete accord with clinical ex­ perience in maxillary clefts.

Periosteal repair versus bone grafting - a difference in the quality of bone

In the 1960's, it became readily apparent that bone grafting cleft deformities in early childhood could impair maxillary growth . This alarming observation led to a critical reassessment of the obtained results and at the First International Cleft Palate Con­ gress in 1968, early advocates of this mode of therapy advised against primary bone grafting. The method is, however, still being used in some centers. The discouraging clinical experience with bone grafting cleft deformities makes it particularly pertinent to establish, whether bone produced by bone grafting is of different nature than that formed from local periosteum and blood. Uniform experimental results of autogenous bone grafts, show the rapid and massive formation of a block of bone . The animals, however, soon de­ veloped pronounced deviation of the snout and severe maloc­ clusion . The explanation for these striking deformities was the limited growth within the grafted segment. The new bone se­ emed to inextricably lock the premaxilla and maxilla together , causing deviation as well as underdevelopment of the growing maxilla (Figs. 13-14.) In bone formed in this manner, un­ resorbed kernals of bone grafts could be recognized in the new­ ly mineralized bone. No distinct suture-like growth centers were observed.

•

164

When prior to bone grafting, the lateral periosteal lining was resected with the bone, rapid resorption of the autogenous bone grafts occurred. New bone formation followed, however, although this process was somewhat retarded. The subsequent new bone was thinner than when the cavity had been lined completely with periosteum.

•

13-14 This is the result of early, subperiosteal maxillary rese ction and bone grahing. The animal was sacrificed at maturity.

There ha s been es sen tiall y no growth w ithin the bone grahed seg­ ment, resulting in di stortion and deviation of the snout to w ards the operated side. Severe inversion of the frontal bite has occurred w ith unopposed growth of the in ciso rs. The developmental arrest of the right side of the maxilla impedes th e maturation of the contralateral side and results in a seve rely deformed and stunted maxilla. For comparison . the normal skull of Fig. 6 on p. 161 is sh own again on the leh. In this animal an identical maxillary resection was made at an early stage; bone regenerati o n fr om the preserved periosteum is com plete and growth unimpaired.

This investigation clearly demonstrates, that with in a stand­ ardized maxillary defe ct, the bone produced by bone grafting behaves quite differently during growth than the bone wh ich regenerates from a perio steal lined cavity that has been filled with b lood These observations may well explain the unfortu­ nate results of primary bone gra fting in infant clefts.

Environment and periosteal bone regeneration

Engdahl also studied the influen ce of bone marrow on new bone formation. Following ma xi llary bone resection , w hen the periosteal lined cavity was filled with autogenous bone marrow aspirate, the results were similar to those obtained from bl ood filling , though bone marrow seemed to act as an additional source for bone formation. By remo ving the lateral periosteal wall together with the bone, it was possible to demonstrate that the osteogenic ca pacity of the periosteum overshadowed that of the bone marrow. Local infe ction in the resection area was found to disturb maxil­ lary growth and cause deviation of the snout. This compli cation occurred in a small number of animals.

165

Surgicel®

and bone formation

The tissue response to subperiosteal Surgicel implantation wa s also studied in young rabbits (Skoog 1967). A su bperi osteal pocket was created over the fronto-nasal bones and loo sely packed with Surgicel soaked in blood. On histologic examina­ tion the tissue rea ction was characterized by massive prolifera­ tion of osteoblasts and fine vessels. The ce llular growth orig ­ inated from both the bone surface and the osteogenic layer of the elevated periosteum. At fourteen days, most of the original fabri c had been absorbed. Thickening and hyperemia of the periosteum was then most pronoun ce d. Bony trabeculae formed at an early stage and later there were signs of bone resorption. (Figs. 15-18.)

The conclusions derived from these experiments were that Sur­ gicel m ay be used safely for subperiosteal implantation. Such a procedure, will result in bone formation within the mass, where the fabric itself will be completely absorbed. When Surgicel was implanted into the periosteal lined cavity used in Engdahl 's experiments, it was found that the forma­ tion of new bone wa s delayed within a standard time . The anatomy was not as well restored as in the prev io us series, where the cavity had been filled with blood alone . These ob­ servations reinforce the opinion that Surgicel itself should not be regarded as having osteogenic qualities, but when used as a scaffold to support a periosteal membrane in a desired position, the incorporated blood clot will effectively permit bone forma­ tion within the mass. Surgicel can thus be utilized for recon­ structive purposes to regulate volume, shape and position of the newly formed bone (Skoog 1969). In Engdahl's experiments, the depth of the resected cavity was only about 2 mm . The fabric thus occupied a comparativ ely large portion of the spa ce, which might explain the quantitative results obtained. In addi­ tion, the tissue response of Surgicel, whi ch in clinical experi­ ence some times seems to be a stimulus to periosteal bone formation , may act adversely in the young rabbit, w here the perio steal membrane is quite delicate and possibly acutely sensitive to the foreign material.

166

•

.­ "'

••

.t

15 In growing rabbits, Surgicel , soaked in blood ,

was loosely packed into a subperiosteal pocket over the fronto-na sal bones.

16 In this section, made 8 days later , a layer of undifferentiated cells (osteoblasts) covers the bony surface and is seen to invade the implant. Fi ve vessels and fibril s have al so formed. 17 After 14 days , there is evidence of cancellous

bone formation , ma inly within th e periphery of the implant. Some clearly defined trabeculae ha ve also formed with a surface layer of os teo­ cyt es .

18 Besides evid ence of new bone formation ,

there are also signs of resorption with multi ­

nuclear o steoclasts present along the ed ge of

the bone.

167

19 Thi s se ction through a rabbi t nasal bone w as mad e 7 da ys after the cover ­ ing periosteum had been completel y removed . A thin la yer of perio steum has started to reform over th e denuded bone . (Hematoxylin and eo sin , x 40 .)

, ...'" ,

20 Eighteen days after resec­ tion marked periosteal regen­ erati o n has occurred . The thick­ ne ss of the new tis sue con­ siderably ex ce ed s that of nor­ mal perio steum . There is a richl y cellular inner layer, which lies immediately above the new ly forming bone . (Hematoxylin and eosin , x 50. )

21 This section of the nonoperated side is

presented fo r comparison .

Th e e f fects of per iosteal resection

Observ ations made on more than 150 patients with m ax il lary clefts, treated b y periosteoplasty, indicate that on the ou t er aspe ct of the lateral ma x illary segment, where the periosteum is rai sed and shifted, complete periosteal regeneration took pla ce without impairing ma x illary growth. In fact, an appo s i­ tional la y er of new bone wa s f o und to form beneath the re­ generated periosteum . In Hellquist' s in v estigation in growing rabbits and guinea -pigs, unilateral periosteal resecti o n was ca rried out on the outer aspe ct offacial bones . The extent of resection varied among four ex perimental g roups, the most extensive excision compri s­ ing an area over the nasal bone, the anteri o r portion of the

168

Regeneration of Periosteum and Bone

frontal bone, the premaxilla and maxilla . Within ten days, a new periosteal layer started to form over the denuded bone surface. The regenerated periosteum soon became hypertrophic, de­ monstrating a considerable increase in thickness, when com­ pared to the control side . This was present both in the inner cambial layer and the outer capsular zone . After six months, there was a regression of this hypertrophied periosteum and a normal thickness eventually returned. (Figs. 19-21 .)

22-23 These transverse sections are of rabbit nasal bones, 29 days after unilat­ eral periosteal resec­ tion. A distinct in­ crease in thickness of the entire nasal bone can be seen on the operated side (upper microphotograph) compared with the control shown below. (Hematoxylin and eo­ sin, x 50. )

Osteocyte necrosis is normally found in growing bone tissue. A slight and temporary increase in the number of necrotic osteo­ cytes was noted in the outer cortex of the denuded bones, but the bone tissue itself never became necrotic. Instead, ten days after periosteal resection, when a regenerated periosteal layer was already present, an appositional layer of cancellous bone started to form subperiosteally. This new bone formation was of considerable magnitude, causing a total increase in thickness of the related bones. The two layers of bone were subsequent­ ly integrated , and after six months an increased bone thickness remained. The fine cancellous structure of the new bone was gradually converted into compact bone, but some communica­ tions to the inner diploe persisted. The increase in bone forma­ tion under the regenerated periosteum i s most likel y related to periosteal hypertrophy and associated hypervascularity. (Figs . 22-23) In rabbits, osteometric and roentgenographic studies showed that removal of the periosteum in growing indivudals had little influence on the growth of the facial skeleton, provided that the resection did not include the surface of the maxillary body. When the periosteum was removed from this area , growth changes took place in several animals, causing vary ing degrees of snout deviation . In contrast to changes observed in rabbits after periosteal maxillary resection, growth disturbances were negligible in guinea-pigs, despite the fact that they had been operated upon in an identical fashion and at the same age. Neither did deviation of the snout nor downward tipping of the nasal bones develop in these animals . (Figs. 24-26. ) These different results may well be explained by differences in the skeletal and va scular anatomy in the two species. In the rabbit, the anatomy of the outer, lateral aspect of the maxilla is cribriform and richly vascularized, with a number of thin-walled vessels passing into and through the perforated bone. In the guinea-pig, the corresponding area is purely cortical with a 169

24--26 These pictures of an adult guinea-pig demon­ strate normal bone growth and cranial development after unilateral periosteal resectio n of the facial bones. Th e sur­ gery was performed when the animal s were six days old . 27 The ext ent of the periosteal resec ti on i s shown in this drawing . It comprises the outer aspect of the nasal bone, the anterior part of the frontal bo ne, the prema xil la and the maxilla. In the guinea-pig the bon y surfaces of all these bones are similar ; smooth and cortical. Th e results were the sa me for the entire ex perimental group, ir re­ spective of the exte nt to which the periosteum had been rem ove d.

28-29 Th e craniu m of this adult rabbit shows no im­ pairment of growth, despite exten sive unilateral remo val of its peri osteum at ten days of age . In several anima ls in the rabbit seri es damage to per­ forating maxillary vessels re sulted in deviation of the snout towards the operated side. However, w hen the periosteu m covering the nasal and frontal bones w as removed with the premax­ illary p eriosteu m , but the vascular plexus of the cribri­ form maxillary body was left undisturbed, growth was never significantly imparied .

170

Regeneration of Periosteum and Bone

bone surface similar to that of the premaxilla and the nasal bone. Since the vascular architecture in the maxillary region of the rabbit varies, it is not possible to state accurately the injury caused by the operation in each animal. The experience in these experiments clearly indicates, however, that in rabbits, inter­ ference with the periosteum of the cribriform portion of the maxillary bone seriously affecs major vessels . This vascular damage is likely to impair the nutrition of the entire maxilla. Variations in the vascular anatomy would influence the degree of surgical trauma to the operated animals , and could thus satisfactorily explain the differences in maxillary growth dis­ turbances observed within the rabbit group. Interestingly enough, the moderately reduced dimensions of the rabbit maxilla were compensated for by an overgrowth of the frontal premaxillary process, despite this process also being deprived of its periosteum. This observation demonstrates that the mere removal of periosteum will not disturb the growth capacity of the underlying bone (Figs. 28-29). Furthermore, in all the rabbit experiments, periosteal resection resulted in an in­ crease in width of the nasal bone. Where the resection was limited to the premaxilla and anterior portion of the nasal bone, new bone was laid down on the adjacent portion of the maxilla, even though this area was not included in the periosteal resec­ tion. These findings coincide with observations of other in­ vestigators that the proliferative response to trauma extends to involve the adjoining and intact periosteum .

,

.

,

171

Conclusions

Morphologically, periosteum and bone are well defined struc­ tures. Histologicall y, the two tissues are less clearly separated as the periosteal layer of osteocytes on the bone surface is completely integrated with the syncytial network of osteocytes within the organized bone. From a biological point of view, the distinction between periosteum and bone is in many respects artificial. Thus, periosteum will regenerate as such, but under ce rtain conditions, it will also la y down new bone. Similarly, bone is capable of forming more bone, which will also develop a covering periosteal layer. Regenerated periosteum and bone can be used independently or together. The periosteum, being the more cellular tissue, can reasonably be expected to be the more active component. The utilization of this tissue in the repair of maxillary clefts is but one application of this fascinat­ ing discovery. The effectiveness of free periosteal grafts ha s been demonstrated by Ritsila, Alhopuro and Rintala (1972). This further expands the wide possibilities and the potential use of the periosteum .

172

References

Engdahl E. : Bone regeneration in maxillary defects. An experimental investigat ion on the significance of the periosteum and various media (blood, Surgicel, bone marrow and bone grafts) on bone formation and maxillary growth. Scand J Plast Reconstr Surg, Suppl 8, 1972. Hellquist R.: Facial skeleton growth after periosteal re section. An osteometric, roentgenographic and histologic study in the rabbit and guinea-pig. Scand J Plast Reconstr Surg, Suppl 10, 1972 . Ritsila V ., Alhopuro S. and Rintala A .: Bone formati o n w ith free periosteum. Scand J Plast Reconstr Surg 6: 51, 1972. Skoog T.: The use of perio steum and Surgicel . for bone restoration in co ngenital clefts of the maxilla . Sca nd J Plast Reconstr Surg 1: 113, 1967.

,

Skoog T .: Repair of unilateral cleft lip deformity: ma x illa , nose and lip. Scand J Plast Reconstr Surg 3 : 109, 1969.

173

C hapter VIII

Cleft palate repair-restoring the muscular anatomy and reconstructing the anterior portion of the soft palate

Introdu ction 176 Principles of repair 178 General surgical considerations 178 Age for repair 179 Anesthesia 179 Operative procedure 180 Preoperative condition Infiltration of the operative site Freeing the palatal mu cope riosteum and mobilizing the soft palate Repair of the soft palate muscle layer Reconstruction of the anterior portion of the soft palate Closure of secondary defects Result Bloodloss and replacement Tympanotomy

Comments on operative procedure 192 Comments on results 196 References 197

Title page: This drawing depicts pal ­ ate anatomy in cleft and normal co n­ ditions. Note the anteriorly displaced muscular attachments on the cleft side. Th is pathologic arrangem ent is largely responsible for disturbing muscle function and shortening the palate. A related feature of this ab­ normality is the absence of the aponeu rotic portion of the soft palate. Re constru ctive efforts should focus on these two aspects of the deformity. This illustration has been adapted from von Luschka' s "Der Schlundkopf des Menschen" (1868).

174

Cleft Palate 1

r--­ \

(

\ j) .....

f

• - ­ Palatme aponeurosis

M .levator veIJ palaltni

. M palatopharyngeus

/ -

M palatogloss us

A te:cJlnique o.f pt'-itnal'-y=¥efll · · fai~=-

.1

Introduction

"Es gibt somit meiner Ansicht nach zwei ver­ shiedene Arlen des Gaumenverschlusses,· di e eine dieM der Sprache und ist vorzugsweise zu Stan de gebracht durch die Thiitigkeit der Gaumenheber und des oberen Schlund­

schnurers . .. " Gustav Passavant (1863) Though Passavant clearly visualized the essential function of the levator and "upper pharyngeal constrictor" in forming speech, it has taken surgery a century to develop techniques which satisfactorily restore this lost mechanism for ve l o­ pharyngeal closure to cleft palate patients.

1 This drawing illustrates the normal functions of the levator palati and the palata-pharyngea l muscles. The blue arrows indicate the direction of their pull. These two muscles are most important in velo­ pharyngeal closure, moving the soft palate upwards and ba ckwards to meet the posterior pharyngeal wall. The broad blue and black arrow represents the vector of the muscular forces. The upper portion of the palata-pharyngeal muscle narrowS the pharyngeal diameter.

In the nineteenth century random methods for closure of palatal clefts coalesced and evolved into the procedure known as von Langenbeck's operation (1861). Through long , lateral incisions, von Langenbeck mobilized the palatal mucoperiosteum, de­ tached the nasal mucosa from the posterior margins of the hard palate, and then sutured together the paired margins of the cleft. With minor modifications, this method is sti ll in use today. The works of Victor Veau, published in "D ivision Palatine" (1931), mark the beginning of a new era in cleft pa late surgery. Based on accurate observations and a brilliant analysis of th e 176

Cleft Palate 1

cleft palate malformation, Veau introduced principles which led to a more anatomic repair. He pointed out the functional im­ portance of the abnormal muscular anatomy in these condi­ tions, and paid particular attention to restoring the muscle layer of the soft palate. By preserving the greater palatine vessels, he also found that he could divide the mucoperiosteal flaps anteriorly, thereby elongating the palate.

,

In 1964, Ruding gave a detailed account of the anatomy and function of palatal muscles, in cleft and normal conditions . He emphasized their abnormal immobile insertions into the rim of the hard palate and recommended that all tensor insertions be severed and that the tensor-levator system be luxated from the hamular grooves. He also described a technique for detaching the musculature anteriorly and constructing a levator palati loop. To ensure optimal function of the naso-pharyngeal sphincter, Braithwaite (1964,1968) suggested extensive mobili­ zation and coaptation of the palatal muscles. To this end the lateral pharyngeal space of Ernst was widely dissected, back to the posterior pharyngeal wall and packed to narrow the sphinc­ ter. The superior constrictor was freed from the pterygoid plate, and the hamulus was broken off, allowing medial displacement of this muscle. Most importantly, the muscular palate was com­ pletely freed from the posterior border of the hard palate before . midline approximation was carried out. The functional results obtained with this procedure proved excellent. Based on an anatomic study and review of the comple x muscular inter­ actions of the normal velum as compared with the cleft soft palate, Kriens (1969) advised detachment of the cleft palate muscles from the mucoperiosteum and palatal bone. However, no separation was made near the nasal layer, as severing the muscular insertion at that point was felt to invite a mucosal slough. Kriens approach was made through von Langenbeck­ Ernst incisions which, undoubtedly, hindered extensive and ac­ curate dissection. In :his technique the muscles were ap­ proximated anteriorly, but the palate was not lengthened.

177

Principles of repair

The principle of freeing the palatal muscles from their abnormal attachment to the bony palate and transferring them as a mov­ able muscular sling to a posterior level marks an important and logical development in cleft palate surgery. In the procedure to be described, the aims of the repair are : 1) to reestablish the normal anatomy of palatal muscles, and 2) to elongate the pal­ ate by reconstructing the anterior portion of the soft palate, the zone of the palatine aponeurosis . In clefts, palatal muscles develop with an attachment to the hard palate instead of a mid line affixation at a posterior level (see front page) . The muscular portion of the palate is thus brought forward , producing the characteristic, abnormally short cleft velum. As a result of this displaced insertion, the function of these muscles is seriously hampered and partly re­ versed. When the anterior portion of the soft pa late is exposed at surgery, it becomes evident that there is a marked deficiency of intervening palatine aponeurosis . In the normal palate , this tissue layer is rather substantial. Reconstruction of the apo­ neurotic section seems to be an appropriate way of lengthening the palate . This procedure also serve s to prevent the severed muscles from reattaching anteriorly, and at the same time it counteracts any tendency towards late contracture with con­ comitant forward displa cement of the soft palate . As the pala­ tine aponeurosis is relativel y fixed , mucoperiosteal flaps are ideally suited for this reconstruction.

General surgical considerations In cleft palate reconstruction, care must be taken not to surgical­ ly induce secondary deformities. At bi rth, in median clefts of the palate, the alveolar arch is essentially normal , whereas com­ plete clefts demonstrate character istic ma xillary malformations which remain basically unchanged throughout life, if not surgi­ cally altered. The severe maxillary defo rmities frequentl y en­ countered in adult cleft palate patients have an essentially dif­ ferent character and are the end products of surgical interfer­ ence with growth centers, mucoperiosteum, and vascular supply. Infection and scar formation are additional contributing factors. Improved surgical techniques and control of infection

178

Cleft Palate 1

have reduced these hazards, but though diminished, they still warrant careful attention. For these reasons , surgery on the oral aspect of the hard palate should be as limited as possible. Mucoperiosteal flaps used for elongation of the velum , for ex­ ample, should be made short. This reasoning can also be ap­ plied to complete clefts, where a co mparatively narrow opening remains within the hard palate after closure of the primary pal­ ate. This defe ct is closed separately in one layer, with a flap raised from the nasal septum. To a varying degree all procedures leave the palatal bone ex­ posed . Under the conditions present in the oral cavity, healing by secondary intention inevitably results in so me damage to the regenerating periosteum , with subsequent impairment of local maxillary growth. Scar contracture further complicates the situation by causing a late " buckling " deformity of the adjacent section of the alveo lar arch. Within the hard palate, remaining raw areas should therefore be reduced to a minimum.

Age of repair Preferably, the cleft palate should be repaired before a set pat­ tern of speech develops. In our series , the operation has been performed at about 18 months of age. Recurrent middle ear in­ fection was the only factor that prompted earlier surgery.

Anesthesia The operation is carried out under general anesthesia . In addi­ tion, the operative field is infiltrated with lidocaine solution (Xyl ocaine®) with epinephrine. The supplementary use of a local anesthetic with a vasoconstrictive agent is a definite ad­ vantage in palate surgery. The subperiosteal injection aids dis­ section , and the infiltration facilitates handling the delicate tis­ sues as well as minimizing oozing. Clinical studies by Dingman et al. (1949). Rintala (1965 ). and others prove that the total blood loss is considerably redu ce d by this measure. During surgery, the local anesthetic also permits a higher level of general an­ esthesia to be maintained. 179

O perative procedure Preoperative condition 2 The Dingman mouth gag is used for exposure. The patient's head is hyper ­ extended and supported by a padded ring, while the fa ce is draped with ad­ hesive plastic sheets.' As is comm o n in Eu rope, I prefer to sit at the head of the table. The operativ e drawings are made from this perspectiv e, but for clarity, ali illustrations are here reproduced in a frontal view. In this 18 months old boy the cleft ex­ tends to the middle of the hard palate. The palate is characteristically shorter than normal and the width of the pharynx is increased. The adenoids are visible be­ tween the two halv es of the div ided pal­ ate. t Sleri . Drape®, 3M Co mpany. St. Paul , M innesota, U .S .A.

((J)

All the drawing s present the operative field in a true perspective instead of closely fo llowing exact dimensi ons and keep ing with fixe d proportions as is com­ monly done. Consequently, the hard pal­ ate occupies a smaller ar ea than it does in actuality. Therefore, though the flaps appear to lie in an anterior position, they are in fact localized posteriorly in the hard pa late.

Infiltration of the operative site 3 The operati ve site is injected with 0.5 per cent Xylocaine® with epinephrine. In the hard palate the needle is kept in con ­ tact with the bone until the surrounding tissues blanch. The soft palate, including the uvula, is infiltrated to obtain an even degree of enlargement. Along the border of the cleft , tissues are distended two to three times normal size. 180

Freeing the palatal mucoperiosteum and mobilizing the soft palate

II

4 In the hard palate, mucoperiosteal flaps are designed to lengthen and re- . construct the anterior portion of the soft palate. They are quite short, since the de­ gree of elongation is not dependant upon the length of the flap , but rather on the change in position of its base. In this method one flap has become stand ­ ardized as a small ro tati on flap , and is here shown on the patient's left side. Its anterior border is curved to meet the re­ quirements, when it is rotated into the soft palate . Medially, this anterior incision starts abo ut 2 mm anterior to the cleft posterior spine. The flap from the op­ posite side is planned to cover the full length of the cleft, when rotated into po­ sition. In practice this means that the an­ terior incision is made just in front of, or at the apex of the cleft. Velar incisions are made with a No . 11 sca lpel blade on the oral aspect at the junction of oral and nasal mu co sa , and carried deep enough to expose the muscles.

•

•

181

1

5 The righ t mucoperiosteal flap is raised, ex posing the periosteal attachments of the muscles at the posterior border of the hard palate. The major p alatine vessels enter th e fl ap laterally.

7 Laterall y, th e mobiliza­ tion of nasa! mucosa is ex­ tend ed by blunt dis secti o n in th e loose connective tis­ sue layer along the medial pterygoid plate, t owa rds the nasop haryn x. Freeing the soft tissue na rrows the nasa l co mp artm ent and re­ leases th e soft pa late. The m edi al and posterior mobil­ ity of the palatal flap is still restricted by the neuro­ vasc ul ar bundle at the pos­ terior palatine foramen .

182

6 At the margin of th e cleft, a dental elevator is inserted under the bony edge of the palatal shelf. Th is fr ees the nasal m ucoperiosteu m. Separation is easi ly ac­ complished by kee ping th e instrument close to th e bone while passing it pos­ teriorly around the posterior nasal spine and proceeding latera lly along the pos­ terior margin of the bone. Th is dissection should wide­ ly mobilize nasal m u co ­ periosteum and allow mid­ lin e closure.

8 Through a lateral incision, the hamular process is ex ­ posed behind the maxillary tubero si ty. The wh ite ten sor tendon is clearly de­ m ons trated as it traverses the process . The hamu lus is commonly fractured , but rarely does th is widely ac­ ce pted maneuv er add sign i­ ficantly to relaxation. Alter­ ing th e fun cti o n of th e t ens o r palati muscle may even disturb th e opening mechanism of the Eusta­ ch ian tu b e. The hamular proce ss was not fra ctured in t his case. After mobilizing the so ft palate by free ing th e lateral lin ing of the nasal co mpartment, there is little need for wide dissec­ tion into the pa rap haryngeal space .

9 An oral mucoperiosteal flap is elevated and held aside by a hook. The nasal mucoperiosteum has also been stripped from the bony palate. The forceps illustrate how medial ad­ vancement stretches the mucoperiosteum and shihs the en­ tire soft palate posteriorly. This is all possible, since the muscl es are readil y detached en bloc with the periosteum . Mobilization of the soft palate is restri cted by the greater palatine artery and nerve which, in clehs, emerge m o re an ­ teriorly than normally. The release of these structures per­ mits backwards displacement of the soft palate. For that purpose the postero-medial wa ll of the palatine canal is re ­ moved. A fine osteotome is pla ced at the bony edge border­ ing the palatine foramen . While the neurovascular bundle is protected by a shielding instrument, a small triangular piece of wall is chi sell ed out. Thi s bony fragment is either re ­ moved or turned back on itself by rotating the osteotome laterally. The le sser palatine nerves, emerging close to the resected segment of bone, should not be injured in this maneuver. These sensory nerves supply the soft palate and the tonsillar region. If the greater palatine vessels are divided at the bony fora­ mina, the utilized mucoperiosteal flaps are unlikely to have their blood supply seri ousl y impaired. These vessels are preserved, howeve r, as merely freeing them affords suf­ ficient mobilization of the soh palate, while still maintaining a relatively fixed base . The sensory innervation of the flaps through the greater palatine nerve is also mainta ined .

183

Repair of the soft palate muscle layer 10 Closure of the nasal lining is completed ba ck to the tip of the uvula, using fine interrupted sutures of 4/0 chromic ca tgut on an atraumatic needle.' The knots are placed on the deep surface to obviate bury­ ing suture material.

The palatal muscles sti ll maintain their anterior at­ tachments to the nasal mucoperiosteum. This mem­ brane has been freed extensively which allows the soft palate to be positioned posteriorly by about five mm .

, Ethicon , Inc., Sommervi lle, N. J., U.S.A.

184

11 The muscles have been sectioned at their peri­ osteal insertions anteriorly and are here being dis­ sected away from their attachments to the nasal mucosa for a distance of at least five mm. Thi s is the most delicate feature of the operation, as the muscle fibers insert directly into the thin mucous mem­ brane and, unlike the oral lining , there is no sub­ mucous layer of fatty or glandular tissue beneath the nasal epithelium to buffer and support the dissection . Adequate mobilization is best achieved by in cisi ng the muscles just above the membrane and ge ntl y teasing them backwards with a sca lpel , No. 15 blade. Suffi­ cient rela xation is thus obtained , which normalizes the position of the palatal muscles and permits them to be swung medially and united at a posterior lev el.

12 Once the fibers are div ided the y contract and form a substantial muscle mass . In this picture, these clear­ ly defined structures are marked by two pairs of for­ ceps.

The excellent vascularity of the exposed nasal mem­ brane is demonstrated .at surgery by the presence of fine vessels and multiple superficial hemorrhages. Unlike the mucoperiosteum within the hard palate, the nasal mucosa of the soft palate will stretch. If additional length is needed, an anterior Z-plasty of the nasal mucoperiosteum, a vomer flap (see Fig. 30), or an inverted flap of oral mucosa may be utilized . These procedures produce a staggered closure of the nasal mucosa and reduce the likelihood of future scar contracture.

,

185

13 Mattress sutures are used to unite the

palatal muscles. Th ey m ust embrac e the full

thickness of the muscle layer, as there is a

tendency for the muscle s to retra ct away

from th e wound edge. Wide "tension"

sutures are not needed .

14-16 Closure of the muscular portion of th e so ft palate h as been com pleted by ap­ p roxi m ating the tissue layer co mpris ed of oral mucosa and muscle. Th ree or fo ur verti­ ca l mattress sutures of 3/0 chromic ca tgut on an atraumatic needle are used. Dexon' may also be in terspersed between the ca t­ gut for prolonged support ; 4 /0 plain or ch romic ca tgut is sufficient f o r suturing th e uvular seg ments.

The anterior portions of the freed palatal muscles are united across th e midline, over­ lapping each other in such a way that they form a muscular sling. Since this is ac­ compli shed und er no t ensio n, a few 5/ 0 pla in catg ut sutures ca n be used. 1

Polyglycoli c acid, Davis

186

+ Geck,

Cya namid In ternationa l.

Cleft Pa late 1

Reconstruction of the anterior portion of the soft palate

17-1 8 The leh mucoperiosteal flap is rotated about 90°. It is designed to recon­ struct the anterior portion of the soft pal­ ate and swings easily into place, without undue folding . Its slightly curved an­ terior border reaches across the midline to join the retracted oral mucosa of the opposite side and provide abundant tis ­ sue, where a shortage usuall y exists. In a standard " push-back" procedure, latera l displacement of the borders of the oral mucosa makes midline closure difficult. With the aid of a rotation flap, oral ap­ proximation is easily accomplished. The right mucoperiosteal flap extends across the midline when its anterior border is rotated and sutured to the op­ posite oral mucosa, along the edge of the cleft.

187

19 The mucoperi osteal flaps are sutured togeth er in the area between the musc ular palate and th e h ard palate . To eliminate dead space, some o f th ese sutu res are anc hored to th e nas al m u cosa. The sutures are placed to th e side of the nasa l c losure, to avoid superimposed suture lines .

20-21 W hen closu re is com pleted, bilatera l gaps persist ant eriorly .

188

+­ I

22--24 Flaps of buccal mucosa are used t o partially cove r these raw surfaces. This promotes more rapid healing and reduces pterygoid and palatal scar formation. Cheek donor sites are closed directly and no packs or dental plates are used. The principle of this procedure was rec omme nded by Blair (1912) for repair of palatal defects.

25 In this repair, the cleft is closed without tension. This provides excellent healing co nditions and ex­ cludes the possibility of fistu lization. The soft palate is markedly elongated and the mass and general elastic­ ity of the muscular portion is equally impress ive. All these factors con tribute to the desired end result, a normal speech mech an ism .

189

Result •

26 Nine months after surgery, this follow­ up examination reveals that the palate is well united and appears to be of normal length .

28 There is insignificant scar formation in the hard palate and no evidence o f co n­ tra cture in the reconstructed anterior por­ tion of the so ft palate. The bu ccal flap has effectively prevented any scar from forming a band behind the maxillary tuberosity. 27 Excellent levator function is demon­ strated in thi s picture. On into nation , the po sterior border of the soft palate arches and narrows in a normal fashion , its wide excursions extend to the posterior pha­ ryngeal wall .

190

The ch ild started to talk soon after surgery. No nasality or other signs of velopharyngeal incompetence are now present.

Cleft Pa late 7

•

Blood loss and repl a cement

Although blood loss is reduced during palatal surg ery by pre­ operative infiltration of vaso-constrictive solutions, blood trans ­ fusions are given routinely. In view of the highly labile vascular response of these infants, and in light of early experiences of postoperative shock, we do not hesitate to give blood at the slightest indication. In addition to full replacement o f o bserved blood loss, these children are often given an additional 50 to 100 ml during surgery, or in the re cove ry period .

Tympanotomy

Mo st patients with congenital cleft palates suffer fr o m Eusta­ chian tube dysfunction . Markedly vi scous middl e ea r fluid is an almost constant finding in untreated cases . The ENT se rv ice routinely performs tympanotomy and evacu­ ates the secretion within the middle ear cavity in connection with cleft palate surgery . Th is is done in the anesthetized pa­ tient, when the repair of the palate has been com pl eted . In cases with tenacious secretions (glue ear) a teflon drainage tube is inserted through the tympanic membrane and left to drain ex­ ternally for as long as necessary.

191

Comments on operative procedure

Ali methods for cleft palate repair result in an initial elongat io n of the velum. Since most techniques require extensive dissec­ tion and advancement of tissue layers, there is, however, a high risk of eventual scarring and contracture. There is also a marked tendency for the tissues to return to their original position. It has , in fact, been shown by Palmer et al . (1969) in a compara­ tive study, that using a "push -back" procedure may result in a palate , which is shorter than that obtained with a simple closure , without employing spe cial lengthening measures. Today , the major problems in cleft palate surgery are still those of ade­ quately elongating the palate and devising techniques to fore­ stall postoperative shortening. Following the described operation, the soft palate generally ap­ pears to attain a normal length, with its posterior border moved back about fifteen mm. Several factors account for this effect. The preoperative shortness of the soft palate, which is mainly the result of abnormal muscular anatomy, is accentuated by superficial contraction along the cleft margins. This feature , which is also characteristic of the cleft lip deformity, is treated by releasing the tissue layers bordering the cleft. Midline clo­ sure is then sufficient to produce elongation, as the resulting suture line is longer than the longitudinal diameter of the orig­ inal , oval-shaped defect. Since this is a posteri o rly directed lengthening, it involves a backward rotation of the soft palate segments. Wide undermining on the nasal aspect of the hard palate per­ mits medial advancement of the mu coperiosteum and further backward rotation of the velum. When the dissection is ex­ tended laterall y, along the sides of the soft palate, the freeing also results in a backward shift-" push-back"-of the palatal segments. On the oral aspect, any restriction in palatal elongation is elim­ inated by severing the mucoperiosteum over the hard palate and detaching it from the posterior border of the bony plate. Freeing the neurovascular bundle at the posterior palatine fora­ men serves the same purpose . Sectioning the abnormal an­ terior insertions of palatal muscles and dissecting them off the nasal mucosa furthe r releases the soft palate. In addition, in re­ constructing the anterior portion of the soft palate, the oral mucoperiosteal flaps are sutured to the nasal mucosa in such a way, that they tend to push the velum backwards .

192

Preoperative condition

29 This three-month-old child demonstrates a complete unilateral cleft with wide separation of the palatal segments. The primary palate (al­ veolar process and anterior part of the hard pal­ ate) was closed by periosteoplasty in conjunc­ tion with a lip repair as described in Chapter II.

30 Eighteen months later the maxillary segments have spontaneously adjusted themselves, producing a symmetrical alveolar arch. Massive new bone formation was then found within the cleft, effectively pre­ venting maxillary collapse. The originally wide bony defect is reduced to a narrow fissure, and the outer surface of the lateral segment bears a near normal relationship to the premaxilla. The topographic anatomy is accurately depicted in this illustration, based on original photographs and plaster impressions. At this stage, the remaining cleft of the hard palate was repaired with a single layer of mucosa, raised as a septal flap. It was tucked under the margin of the palatal mucoperiosteum on the opposite side, and the exposed raw surface waS left to heal by secondary intention. A small triangular flap of septal mucosa was raised posteriorly to provide extra nasal lining for the soft palate. With th is exception, re­ construction was carried out as previously described, with short muco­ periosteal flaps. Thus, the major portion of the palatal mucoperiosteum remained undisturbed during the entire procedure,

194

Clef t Pal ate 1

Result

•

31-32 After four ye ars, the palate is well healed with insignificant scarring, and an almost normal appearance . The dental arch has a normal configuration and occlusion is good . Minimal c rossbite of the ca nine tooth is mainly due to in co mplete dentition at the cleft, where the lateral incisor is missing .

195

Comments on results

Wound healing has always been uneventful and is complete within eight days, at the time of catgut suture dissolution . As buccal flaps are used for secondary wound cover, the only open surfaces remaining are insignificant and overlie bone. At dis­ charge after one week, the length and mobility of the pa l ate is impressive. In our experience, the functional results of this procedure are superior to those obtained by the Veau-Wardill technique. The effect of reinserting the levator and palate-pharyngeal muscles into the middle third of the soft palate is particularly noticeable by the remarkable degree of palatal elevation possible after surgery . Reestablishing sphincteral mechanism of the palatal muscles also acts to promote closure of the pharyngeal isthmus by constriction.

A late tendency of the soft palate to be carried forward by con ­ tracting scar tissue seems to be moderate. This is partially ex­ plained by the restored function of the palatal muscles, but most likely, the degree of contra cture has been reduced by the limited tissue trauma of the anatomic repair and by reconstruct­ ing the anterior portion of the soft palate with firm tissues that are resistant to shrinkage. The presence of calcifications within these tissues at a later stage has been noted in a few cases and probably originates from transferred palatal periosteum . It is a common experience that an increased incidence of mid­ dle ear infection in children with cleft palates can effectively be reduced by palate repair. This relationship was experimentally demonstrated by Schultz (1964) , who produced clefts of the rab ­ bit palate to study the effect of this defect on the Eustachian tube and middle ear. Seventy-fiv e per cent of the animals dis­ played evidence of chronic otitis media. The factor essentially responsible for these infections seemed to be the loss of palatal muscle function. Kriens (1969) analyzed the paradoxical effect of cleft palate muscles on Eustachian tube function, and pos­ tulated that they would perform their normal action if their at­ tachments to the hard palate had been freed. This assumption is likely to be valid, though not proven by clinical evidence . Our present routine of evacuating middle ear secretions in con­ junction with palate repair has not yet been subjected to a fol ­ low-up study and critical analysis.

196

References

Blair V. P.: Surgery and Diseases of the Mouth and Jaws. C. V. Mosby Comp, St. Louis, 1912, p 192. Braithwaite F.: Cleft Palate Repair. Modern Trends in Plastic Surgery. Butterworths, London, 1964, p 30 . Braithwaite F.: The importance of the levator pa lati muscle in cleft palate closure. Brit J Plast Surg 21: 60, 1968. Dingman R. 0 ., Ricker O. L. and lob V .: Bloo d loss in infant cleft lip and cl eft palate surgery . Plast Reconstr Su rg 4. 333, 1949. Kriens O. B. : An ana tomic al approach to veloplasty. Plas t Reconstr Surg 43: 29 , 1969. v . Langenbeck B. R. C.: Operation der angeborenen totalen Spaltung des harten Gaumens nach einer neuen Methode. Deutsche Klinik 73: 231,1861 . v. Luschka H.: Der Schlundkopf des Menschen. Laupp, Tubingen, 1868. Palmer C. R., Hamlen M ., Ross R. B. and Lindsay W . K. : Cleft pa late repair : Comparison of the result s of two su rgical techniques. Canad J Surg 12: 32, 1969. Passavant G.: Ueber die Verschliessung des Schlundes b eim Sprechen. Frankfurt, 1863. Qu oted : Arch path Anat Physio l, klin Med 46: 1, 1869. Rintala A.: Blood loss in cleft palate surgery. Acta Ch ir Scand 129: 288, 1965. Ruding R.: Cl eft Palate. Anatomic and surg ica l conside rations. Plast Reconstr. Surg 33: 132, 1964. Schultz R. C.: Surg icall y produced cleft palates in rabbits. Plast Re­ constr Surg 33: 120,1964. Veau V .: Divisi on Pa latin e. Masson et Cie Ed ., Paris, 1931.

197

Chapter IX

Correction of velopharyngea/ incomp etence by palato-pharyn goplasty -reconstructing the soft palate, and utilizing pharyngeal flap s to provide additional tissue and to p revent secondary deformity Introduction 200 Indications for palato-pharyngoplasty 201 Palatopharyngeal recon struction ve rsus prosthetic devices 202 Pre- and postoperative evaluation 202 Speech Velopharyngeal function Pathology Surgical considerations 204 General considerations The palate The pharyngeal flap Anesthesia O peratiVe procedure 207 The pharyngeal flaps The palato-pharyngoplasty Result Postoperative therapy 212 Results 212

Title page: In this patient, born with a complete unilateral cleft lip and pal­ ate, repair at childhood resulted in velopharyngeal incompetence; the con tra cted soft palate was about five mm short of reaching the post­ erior pharyngeal wall as demon­ strated by cineradiographic examina­ tion, Definitive corrective surgery was performed at age nine, according to the method described in this chapter. The pictures illu strating the operative procedure were actually taken at surgery of this patient.

Anatomy Speech Hearing and nasal function Conclusions 215

Repair of large palatal defects Subtotal reconstruction of the soft palate 217 Reconstruction within th e hard palate 219 References 221

198

Roentgenograms, one year following palato-pharyngoplasty, show the soft palate at rest (A) and elevated on in­ tonation (8). A superiorly based pharyngeal flap is utilized and its base, behind the soft palate, has re­ mained unchanged. Th e position of th e palate is maintained without sig­ nificantly restricting mobility. The raised velum makes broad , high co n­ tact with the posterior pharyngeal wall in a normal fashion and speech is without impairment.

Cleft Palate 2

A

~_ _

~--

Pharyngeal flap

Sofl palale

~-- UvlJla

B

•

Techniques for secondary re p a ir and subtotal reconstructi o n

Introduction

Ismail is something of a conundrum in this seml' barbaric world, ... a most intelligent young man, in manners extremely courteous, and by nature generous and kindly. This de­ scription hardly squares w ith his behaviour on the campaign, when he conducted h im­ self more like Genghls Khan than a civilized human being . .. his cleft palate, his high, rapid, almost unintelligible voice, may have been disadvantages that he tried to overcome by an outward show of grandeur.

Alan Moo rehead: The Blue Nile (1962)

In 1865, Passavant described a method of correcting palato­ pharyngeal incompetence resulting from an ineffective repair of a cleft palate. He incised transversely through the full thick­ ness of the soft palate, turned the separated posterior portion of the palate back on itself so that its upper surface faced down­ wards and the raw wound surface backwards. This wound edge was then sutured to the posterior pharyngeal wall, where a cor­ responding square of mucous membrane had been excised. The palatal defect resulting from the original incision was left to close spontaneously. Schoenborn (1876, 1886) considered Passavant' s technique dif­ ficult and on the advice of Trendelenburg, he introduced a modified procedure-the pharyngeal flap operation . This opera­ tion has been used intermittently since that time, but not until recent years has it gained widespread recognition as a valuable aid in improving the speech of patients with palatopharyngeal insufficiency. In his first publication, Shoenborn described a flap which was based inferiorly and mobilized from the naso­ pharynx. Insertion of the flap into the unrepaired soft palate cleft was combined with a von Langenbeck palate closure. In a later publication he advocated the use of a flap with a superior base and popularized a two-stage procedure . Rosenthal (1924) reintroduced Schoenborn's first method. Numerous papers have since been published on the use of these procedures, both in primary and secondary repairs (Padgett 1936, Conway 1951, Dunn 1951 , Moran 1951, Burian 1954, 1963, Skoog 1954, 1965, Sanvenero-Rosselli 1955, Petit et al. 1956, Stark and DeHaan 1960, Honig 1963, and others). Owsley et al. (1966) and Orti­ cochea (1968) have reported excellent results with using mod­ ified procedures in pharyngeal flap surgery. Since 1951, more than 200 palato-pharyngoplasties have been

performed at the Plastic Surgery Department in Uppsala . An

improved quality of speech was sought in a variety of velo­

pharyngeal deficiencies. Different techniques were employed

and several surgeons performed the operations.

200

Indications for palato-pharyngoplasty

Although the primary goal in the corrective surgery of velo­ pharyngeal incompetence should be the restoration of palatal anatomy, in most patients there are also definite indications for a simultaneous pharyngeal flap transfer . This additional proce­ dure further improves results and in spme cases it is the sole determinant of a successful operation. Based on the experience gained from our large series of patients, in reconstructing the speech apparatus with the aid of a pharyngeal flap, the follow­ ing indications have been adopted.

•

(1) Unrepaired clefts of the palate in patients older than

five years.

In our series of previously unoperated adults, closure of the pal­ ate alone always resulted in velopharyngeal incompetence, de­ spite having adequately positioned the palate at the time of sur­ gery. This occurred because the soft palate had to traverse too great a distance to reach the posterior pharyngeal wall. It has therefore become our routine in these cases to combine palate closure with pharyngoplasty, rather than to attach a pharyngeal flap at a later stage. (2) Submucous clefts of the palate. Indications for operation given under (1) also apply to sut­ mucous clefts which have been neglected for more than five years. (3) Incompetent palatopharyngeal function despite previous cleft palate surgery. This group presents a great many anatomical and functional variations, ranging from muscular, well-united but short palates, to scarred, atrophic palates with little mobility and a varying deg ree of tissue deficiency. (4) Tissue defects requiring reconstruction. The procedure described on p. 218 illustrates the principle of utilizing large pharyngeal and buccal flaps to repair an extensive soft palate defect. (5) Velopharyngeal incompetence due to paresis. In patients suffering from neurological disturbances affecting the velopharyngeal muscles, this operation has proven to be of great value. Marked functional improvement is obtained with a flap supported velum. It enhances the effectiveness of the weakened muscles, e.g . less power will be needed to elevate a soft palate that has been attached at a higher level. In this group, there is obviously no need for surgical elongation of the palate. 201

I

j

Palatopharyngeal reconstruction versus prosthetic devices At present, the merits of using a pharyngeal flap as opposed to a prosthesis provide little controversy. There is basic agreement with Boyle's statement in 1957 that, "if acceptable speech ap­ paratus can be provided by some form of surgery, including the posterior pharyngeal flap, it should by all means be preferred , and the prosthesis reserved for cases where surgery cannot succeed" . In this Department, it has always been possible t o offer surgery to patients with defective speech as an alternative to a pros­ thesis, the patient's general health not withstanding . In patients seeking relief from the in convenience of wearing an obturator, it is my experience that following adequate reconstruction of the palate combined with a pharyngeal flap transfer, speech results are comparable or superior to those obtained with mechanical aids.

Pre- and postoperative evaluation The degree of velopharyngeal incompetence is evaluated by an assessment of speech, ve lopharyngeal closure and palato­ pharyngeal anatomy. For this judgement the close cooperation of the entire Cleft Palate Team is required .

Speech

202

A variety of diagnosti c techniques provide essential information to aid the speech pathologist in making the final diagnosis. Nasality, resulting from nasal emission of air during pronouncia­ tion of consonants, can be measured by special equipment and is of particular interest in the preoperative evaluation of these cases. Test sentences are recorded preoperatively as a base­ line from which to measure speech improvement.

Cleft Pala te 2

Velopharyng eal fu nction

Cineradiography is of great value in obtaining an accurate pre­ operative diagnosis. This technique was introduced in 1955 (Skoog and Nylen) and further studied and developed at this Department by Bjork (1961) and Nylen (1961). With minor spee ch faults , cineradiographic te chnique permits differentia­ tion between those patients, who are lacking the anatomi cal requirements for normal speech and would benefit from a pharyngoplasty, and those who could be expected to retrain a dysfun ctioning velopharyngeal mechanism by means of speech therapy. Following a pharyngeal flap operation , speech depends on the abnormal anatomy of the velopharyngeal region. Movements of the pharyngeal flap itself and other re­ lated speech structures become even more diffi cult to assess, though they may be demonstrated in various speech articulatory positions by cineradiography . In a number of our patients, cineradiography and sound spectro­ graphy were synchronized for a detailed speech analysis (Nylen 1961) . This technique offered valuable information on "cleft pal­ ate speech" in general, but was not found to be a great diag­ nosti c aid in treating particular individuals.

Pathology

Intraoral examination is essential to confirm the diagnosis of velopharyngeal incompetence. The anatomy should correlate reasonably well recorded function. For the surgeon, the identifi­ cation and lo calization of scar tissue and fistulas , the verifica­ tion of palatal tissue deficiency, the appearance of adenoids, the evaluation of the configuration of the nasopharynx, and ob­ servations of palate at rest and during phonation will influence his choice of method and decide his overall management of the problem . The information obtained by visual inspection is also valuable in predicting the probable result of palato-pharyngo­ plasty. The preoperative anatomy has a decisive influence on the final outcome.

203

Surgical considerations

Late stage repair of cleft palates and secondary correction of palatal insufficiency and defects have three main objectives: • The soft palate must be reconstructed and placed posteriorly to restore muscle function and to give sufficient palatal length . • A pharyngeal flap is utilized to maintain this position. • The transferred flap should also furnish additional palatal tissue when needed. Though a pharyngeal flap alone will usually improve the quality of speech, to achieve the best possible result, effective recon­ struction relies primarily on the restoration of the normal pal­ atal anatomy.

General considerations

As adult pharyngoplasty is a major procedure, elective opera­ tions on the palate should only be performed on patients in good general health. Surgical interference with scarred tissues in secondary cleft deformities causes considerable bleeding. Re­ placement of blood interoperatively must therefore be con­ sidered in planning surgery. In addition, localized inflammatory reaction due to the continued use of intraoral appliances should be allowed to subside, by eliminating irritating devices for a few days prior to surgery.

The palate

Unrepaired cleft palates, requiring the combined procedure of a palato-pharyngoplasty, are treated according to the principles of primary repair advocated in the previous chapter. In sub­ mu cou s clefts, the deficient tissue in the midline should be ex­ cised to expose the muscular layer on both sides. Short mu co ­ periosteal flaps are raised from the hard palate as in complete clefts to allow the soft palate to be freed and positioned poste­ riorly. The same principles of treatment also apply to cases where pre­ vious surgery has resulted in velopharyngeal incompetence. These patients most commonly present with a well-united soft palate which, due to scar formation and contracture, is found to be inadequate, both in length and mobility . For exposure, the soft palate is split in the midline, and short mucoperiosteal flaps are raised from the hard palate. The soft palate is disengaged

204

Cleft Palate 2

from its dislocated position by sharp dissection at the posterior borders of the hard palate. This can usually be done without sectioning the nasal lining. Lateral mobilization is carried out subperiosteally along the pterygoid plate. The dissection of scar tissue is mandatory for the restoration of palatal movements. Therefore, all abnormal attachments must be divided and the dissection should be carried close to the nasal lining for length sufficient to allow the muscular portion of the palate to be positioned at a posterior level. In most instances it becomes evident that a sufficient amount of palatal tissue is available, though this might not have been appreciated preoperatively. The presence of scar tissue does not permit a clear identifica­ tion of distinct tissue layers, thus an anatomic repair as in primary operations is not possible . Instead, the palatal seg­ ments must be handled "en bloc", which to some extent facili­ tates closure. A gain in palate length on the oral aspect is ob­ tained by suturing the mucoperiosteal flaps in a rotated posi­ tion.

•

When scarred tissues heal, the tendency for contracture to re­ develop is obviously great. The attachment of a properly de­ signed pharyngeal flap will hold the palate in position during healing and th roughout the critical postoperative period. It will also counteract the tendency towards contracture in minor raw surfaces left on the nasal aspect of the reconstructed palate ; major defects are covered by the flap. At a later stage when tis­ sues have softened, the surrounding tissues should have be­ come sufficiently slack to permit mobility, particularly allowing elevation of the soft palate . In cases with a true deficiency of tissue, the surgical release of whatever remains of a functioning palate is particularly im­ portant. The addition of a pharyngeal flap will mainly provide mechanical closure of the velopharynx.

The pharyngeal flap

In the most common procedures the pharyngeal flap is based inferiorly. In many cases, however, the presence of an excessive amount of adenoid tissue in the nasopharynx makes it an un­ suitable donor site for a flap. In other cases, a larger flap is needed than can readily be obtained. It is then always possible to elevate a superiorly based pharyngeal flap of sufficient length and width to meet any demands. In recent years, I have

205

used this flap almost exclusively, partly because the operation is performed w ith increasing frequency in young patients with nasopha ryngeal adenoids, but mainly be cause the results using a modified technique have been most gratifying.

1 At age nineteen, this pa­ tient underwent palato­ pharyngoplasty fo r velo­ pharyngeal incompeten ce. A superiorly based flap was employed in the pro­ cedure. This pictu re demonstrates an unfortunate late com­ plication of this tech­ nique, w hen performed in the usual fashion: a thick scar band ha s formed at the base of the flap and co ntinued down the mid­ line of the donor site, pul­ ling the entire palate downwa rds and back­ wards, seriously restrict­

The raw area left at the base of the pharyngeal flap will sca r and eventually co ntract, causing late displacement of the flap . In the inferiorly based flap this scarr ing tends to move the pal­ ate upward s and backwards, which may aid the action of the palate in speech. When contra cture develops below a superiorly based pharyngeal flap, a thick band may form which displaces the soft palate downwards and backwards, restricting its move­ ments (Fig. 1). Such late displacement with impaired fun ctio n occurred in al­ most ten per ce nt of our early series. In several cas es sub­ sequent surgery had to be performed. The scar tissue was then excised and the base of the flap shifted upwards. Closure of the wound was obtained by advancing mucous membrane flaps from the sides . To avoid this co mplication of a superiorly based pha ry ngeal flap, an operative procedure was designed in which two supplementary flaps are used to create a lining across the posterior pharyngeal wall , beneath the base of the pharyngeal flap proper (Skoog 1965). The procedure, as presently e m­ ployed , will be described in this chapter .

ing its move ments.

Pharyngoplasties whi ch do not involve the transfer of a phar­ yngeal flap have rarely proved to be worth-while and will not be discussed here .

Anesthesia

The operation is performed under general endotracheal anes­ thesia . Lidocaine (Xylocaine®l, 0.5 per ce nt, with epinephrine , is inje cted into the areas to be incised in the palate and pharyn x. This reduces bleeding co nsiderably and facilitates the surgical procedure .

20 6

Operative procedu re

2 This nine year old boy was born with a unilateral, complete cleft. The lip deformity was corrected at the age of 3 months; the palate was repaired 15 months later, using a Veau-Wardill procedure. As a result of a midline contracture that developed post­ operatively, the soft palate shortened, causing velophary ngeal in competen ce. It was then de cided to reposition the palate and transfer a pharyngeal flap. The patient is under endotracheal anes­ thesia . Exposure by a Dingman mouth gag demonstrates the velum to be abnormally short, though well united .

The pharyngeal flaps 3 The soft palate has been split to expose the pharynx. The cut surlaces are scarred and thin. They measure only about 1 em in length. The scar formation and anterior dislocation of the soft palate ex plains re­ stricted levator function. The presence of adenoids in the epi­ pharynx makes this area unsuitable as a donor site for a pharyngeal flap. It must be raised farther down on the pharyngeal wall , and be superiorly based. This maneuvre is perlormed prior to mobilizing the soft palate so as not to obscure the phar yngeal field with blood from above.

207

4 The flap to be transferred is planned and lifted from the posterior pharyngeal wall, with its base at th e level of the Eustachian cushions. It includes almost the entire width of the posterior wall. Separation is carried out in a plane Over­ lying the prevertebral fascia. Adjacent and parallel to this centra l flap , two similar but smaller flaps are raised , one on each side, their bases being just below the Eustachian orifices and extending downwards onto the lateral phar­ yngeal walls. These flaps are approximately 1 cm in width and 2 cm in length.

5 The two lateral flaps are rotated m ed ially and sutured to each other and to the preve rtebral fascia to form a bridge of mucous membrane, just bel ow the base of the trans­ ferred central flap. One of the two lateral flaps may also be used for lining the base of the central flap, while the other one is placed aCross the posterior pharyngeal wall; 3/ 0 chromic catgut on an atraumatic needle is u sed for suturing . No attempt is made to close the donor areas for the phar­ yngea l flaps .

208

Th e palato-pharyngoplasty 6 Before the central pharyngeal fla p i s transfer red, the soft palate must be completely freed ante ri orly and pu sh ed back into a normal position. In previously operated palates, this necessitates radical dissection through scar tissue along the posterior border of the hard palate. On the nasal as pect, the lining is mobilized from the palatal shelves and late r ally, as described in the primary repair of the cleft palate. In attaching the pharyngea l flap to the nasal aspect of the soft palate it is not necessary, or useful, to create a reci pi en t surface fo r the flap by raising the mucous m emb ra n e at that site. In secondary repairs of the palate, the tissues are gen­ erall y scarred and tightl y bound. Thus, in dividing the soft palate in the midline and freeing it, consider ab le retraction will occur. Under this condition the pharyng eal na p ha s worked well by providing additional tissue, pa rt ic ularly nasal lining . The flap generally falls within th e posterior two thirds of the soft palate. It can be sutured in place without t en s ion and under good exposure. A few mattress sutures and simple adjustment sutures of 4/0 chromic catgut are used in this closure. Posteri o rl y, the nasal lining of the soft palate is used to cover the remaining raw su rface at the base of the phar­ y ngeal flap. Small muco us m embrane flaps are raised and reflected for this purpose, as shown here . If the soft palate itself is sutured to the base of the phary ngeal flap ov er­ corre ction may occur, resulting in restricted mobility and partial obstruction of the air passage.

7 In secondary repairs, the mucoperiosteal flaps, raised from the hard palate bilaterally, are designed short. After the soft palate has been fully released from its scarred at­ tachments and positioned posteriorly, these flaps will shift and rotate medially. They thereby provide an oral lining to elongate the palate, which is so essential to restore function . The anteri or borders of the mucoperiosteal flaps may be united in the midline with little tension. Approximation is accomplished by mattress sutures as described for the primary cleft palate repair, using 3/ 0 chr omic catgut and Dex on . Over the area of the pha ryngeal flap , the needle is passed superfi cially through its mu scular lay er to prevent dead space.

209

Eusta ch ian orifrces

"\ 8 This drawing is oriented so that the viewer is effectively seated in the epipharynx looking downwards. He thus has a backside, lateral view of the pharyngoplasty. The uvula is not used for lining , but sutured independently in front of the pharyngoplasty. A small section on the under­ surface of the central pharyngeal flap may be left without a mucosal covering ; this free portion of the flap will tube itself during the healing process.

9 Palate closure is completed without ten­ sion . The elongation is considerable, meas­ uring more than 1 cm . In this case the raw surfaces over the hard palate were left to heal by secondary intention.

,,'

10 In this picture two instruments raise the posterior border of the palate to expose the lateral pharyngeal flaps , which have been placed across the posterior pharyngeal wall . Following the operation healing was un­ eventful and the patient was discharged from the hospital after 7 days.

210

Cleft Palate 2

Result Pictures taken three months after surgery

" The soft palate is in a relaxed position . Its posterior border remains attached to the pharyngeal wall at the original level where it was fixed surgically. The lateral phar­ yngeal flaps have effectively prevented any postoperative downward dislocation.

•

12 The mobility of the soft palate is shown on intonation; the function of the levator muscles is excellent. In elevating the post­ erior border of the soft palate, the phar­ yngeal flaps on the posterior pharyngeal wall become partly visible. Th ere is no scar­ band formation across or below these flaps. The large raw surface, left inferiorly on th e posterior pharyngeal wall, is comp letely reepithelialized with a slightly paler su rface th an the no rma l mucous membrane of the flaps. Characteristically there is no reducti on in the dimensions of the phar ynx, as at this si te, co ntracture will not OCCur in a tra ns­ verse direction. Speech is now considered to be normal. On the title page of th is chapter, the results of palato-pharyngoplasty is demonstrated in roe ntgenogram s of this patient.

211

Postoperative therapy

Intensive speech therapy is started two months after surgery and continued until maximum improvement is achieved. The patients have then been admitted to a convalescent home for cleft lip and palate patients , where they are trained according to a system recently reported by Lindholm (1971) One basic principle has been to treat the patients individually for periods usually ranging from two to four weeks, and repeat this treat­ ment when indicated. Mothers are often asked to stay with their children and to attend some of the lessons. This permits treat­ ment to continue at home. In many respects the facilities of­ fered at this institute have proved invaluable in the rehabilita ­ tion of cleft palate patients. Following operation, patients are examined regularly at the Cleft Palate Clinic. An y remaining speech impairment caused by other anatomic defects is treated surgically, whenever possible. Thus, in many patients collapse of the maxilla has been cor­ rected by dental orthopaedi c expansion; palatal fistulas have been closed; scar-bands and adhesions in the premaxillary region have been released to allow free movements of the up­ per lip ; and tightness of the lip has been corrected by an Est­ lander-Abbe flap. In cases showing irregularities and defects of the dental arch , extensiv e orthodontic and prosthodontic treat­ ment has been carried out.

Results

The early results were published in 1965 (Skoog). In separate articles, Aschan (1965) reported on hearing and nasal function in more detail, and Lindholm (1971) made a phoniatric evalua­ tion of various speech qualities . The observ ations made in these initial follow-up studies have since been confirmed in a considerabl y larger group of patients .

212

•

Cleft Pala te 2

Anatomy

The technique described for utilizing a superiorly based phar­ yngeal flap has been successfully employed in more than 80 patients, mostly adults. Healing was in all cases uneventful. The base of the pharyngeal flap, which was attached to the soft pal­ ate, remained at a high level, without a scar-band developing below the flap . Though no downward retraction of the palate occurred, a decreased ability to lift the soft palate was a com­ mon finding. This seemed to result from its being bound post­ eriorly to the pharyngeal flap. Although some restriction of movement was present, the patients were all able to actively raise their palates . In a few instances the levator action was forceful enough to move the astricted portion of the pharyngeal wall along with the soft palate. This was demonstrated in cine­ fluorographic films. When the soft palate was elevated , the two lateral pharyngeal flaps shifted into the upper portion of the posterior pharyngeal wall, became visible. Their reddish color differed distinctly from the whitish, scarred epithelium below. Though these flaps car­ ried a muscular layer, they never demonstrated contractility or a tendency for ridge formation; they had flattened and become distended from the pull of the adjacent scar surface. There is, however, a possibility for a functional sphincter mechanism to be generated at the base of these flaps . This has not ye; been in­ vestigated . Surprisingly enough, healing of the large wound surfaces on the posterior and lateral pharyngeal walls by secondary inten­ tion, never resulted in scar contracture or obvious narrowing of the pharyngeal space. Epithelialization added a smooth surface. The postoperative topographic anatomy of the velopharyngeal region was dissimilar in almost all cases, and movements char­ acteristic of normal velopharyngeal function were rarely pre­ sent. This was in part due to the original condition , but was also influenced by surgical treatment. Motion of the lateral pharyngeal walls appeared quite powerful in many cases, par­ ticularly when other parts of the velopharyngeal system were less mobile. In some instances the posterior faucial pillars moved medially like curtains, contributing to velopharyngeal closure. Other abnormal movements were often present.

•

Speech

Locution was best following operation at an early age. Patients treated before they were ten years old , all attained normal or 213

almost normal speech; of those with refractive impediments, 90 per cent were operated upon past the age of twenty. Im­ provement was however, generally marked even in these cases , including eleven patients over fifty, the oldest being 68 years old. Only one per cent of the patients considered their speech not to be improved by the palato-pharyngoplasty. When comparisons were made between movements of artic­ ulatory structures and audibility, no uniform relationships could be demonstrated. This reflects the complex nature of phonetics and manifests a need for further study of compensatory mech­ anisms in abnormal velopharyngeal function . In 20 patients, treated according to the described procedure, the anatomical requirements for surgical correction were particular­ ly favorable . The patients were mentally alert, had good hear­ ing, and could be operated upon at an early age , ranging f rom 6 to 11 years . This group included three children with sub­ mucous clefts of the palate. In the other patients the soft palate had undergone considerable retraction following primary re­ pair, but after scar excision and separation from the hard palate, tissues were found to be adequate to form a substantial soft palate. Prior to surgery all these patients demonstrated marked velopharyngeal incompetence, resistant to speech therapy. Postoperatively, this treatment was successfully con­ tinued for residual difficulties in articulation. Speech , as judged by specialists at least one year postoperatively , was graded as normal in seventeen cases, 85 per cent, and greatly improved in the remaining three patients.

Hearing and Nasal Function

214

In the postoperative oto-rhinological examination hearing was much better than could be ex pected from the aural pathology. Palato-pharyngoplasty emended hearing. An objective rhino­ metric examination, combined with the rhinoscopic findings, demonstrated that both hearing and nasal function are essential factors for articulation . Intelligibility was found to be most de­ pendant on nasal function . It is of great interest, that the width of the nasal airways influenced the size and shape of the aper­ tures on each side of the pharyngeal flap. In asymmetrical con­ ditions, the opening was larger behind the wider nasal passage. This provides a functional explanation for the asymmetry of the velopharyngeal region, which in some cases gave the false im­ pression of an incompletely disrupted palato-pharyngoplasty .

Cleft Palace 2

Criticism of the pharyngeal flap operation for not being a phys ­ iologic procedure may be justified in cases of overcorrection , where the soft palate has been broadly and tightlY attached to the posterior pharyngeal wall, occluding the pharyngeal space to such an extent that nasal breathing is impaired. Speech then has the characteristic closed nasality, and patients have dif­ ficulty in freeing the nasopharynx of mucus.

Conclusions

The predetermining influence of the preoperative condition on the final result makes a meaningful evaluation of this recon­ structive procedure particularly difficult. Yet, in spite of this limi­ tation, some general conclusions can be drawn. • The pharyngeal flap operation has proved to be a most va luable supplementary procedure in late primary repairs of cleft palates and in most secondary corrections of velop har­ yngeal incompeten ce. Following adequate palate repair com­ bined with a pharyngeal flap transfer, postsurgical speech is comparable or superior to mechanically aided articulation . • Normal , or near normal speech may be obtained by a phar­ yngeal flap operation, only when good muscular fun ctio n of the soft palate is present. A suffi cient amount of tissue must also be available to make repositioning effective. The pharyngeal flap will then maintain this new position and compensate for any minor incompetence in velopharyngeal closure. The flap should be made loose enough to allow the soft palate, on elevation, to co ntact the posterior pharyngeal wall. In the superiorly ba sed flap, late displacement by scar formation can be prevented by special surgical techniques. As long as the base of the pharyn­ geal flap does not restrict motion of the soft palate to any sig­ nificant deg ree, there is no difference in basing the flap superi­ orly or inferiorly. There are, however, technical indications and contraindications for the use of each type of flap. • In the superiorly based pharyngeal flap , the technique de­ scribed for creating a mucous membrane bridge across the posterior pharyngeal wall has proved to be effective in prevent­

21 5

ing late scar formation and conco mitant d istortion of the palate. The functional results following this procedure have been most g ratifyi ng. • In cases in which there is poor muscular fun ctio n or a sub ­ stantial deficiency of tissue, a pharyngeal flap will not fu lly sub­ stitute for soft palate tissue. Even in these cas es, howeve r, it can be used to re constru ct a palatal membrane w h ich w il l re­ duce the nasal escape of air, thereby ameliorating a most un­ desirable facet of cleft palate speech. With such an immobile palate, however, certain qualities in sound formation , cha r­ acteristic of normal speech , can not be reproduced. • Speech results will be better if pharyngopl asty is performed early, preferably before the age of ten. The assumption that an early pharyngeal flap operation might later prove inadequate, in the face of pharyngeal enlargement, h as not been substan­ tiated by our series. • Intensive speech therapy is needed to help patients acquire control of their new speech mechanisms and to eliminate secondary speech deficiencies. The apparent variation in the pattern of movements following velopharyngoplasty can be at­ tributed to a difference in the postoperative anatomy an d th e functional capacity of various articulatory structures. Speech therapy, and other facets of treatment, work by reinforced feed­ back. Cinestetic, auditive and visual feed-back links are built up, that may not have existed before . • The abnormal anatomy resulting from pharyngeal flap sur­ gery will have no adverse effects on middle ear fun ction. On the contrary, our observations indicate that an existing hearing loss may be improved by this procedure . • The patient demand for this type of treatment will not diminish significantly with increasing age. Patients over fifty are as anxious as younger people to undergo surgery, even if they have worn a well-functioning obturator and their speech, though nasal, has been quite acceptable. The magnitude of the operation at their age, and the inconvenience of a lengthy post­ operative treatment does not deter them, as these individuals desperately wish to be relieved of their disability. Sometimes they request an operation so as to appear normal to their grand-children , which vividly demonstrates the deep seated psyc hological consequences of a congenital defect. 216

•

Repair of large palatal defects The vast majority of cleft palate patients needing additional re­ constructive procedures present little or no tissue deficit. Cor­ rection according to the described principles of palato-phar­ yngoplasty are then adequate to provide a well functioning speech mechanism. Patients, who have suffered a definite tis­ sue loss of the velum or hard palate as a consequence of the original or subsequent surgery, will also benefit from similar procedures, though speech may not always be completely nor­ mal. Repair of even extensive palatal defects can be accom­ plished through the use of available buccal and pharyngeal lin­ ing and thus does not require extraoral tissues, as evidenced by the following case reports.

Subtotal reconstruction of the soft palate A method for reconstruction of the soft palate, utilizing buccal and pharyngeal flaps, was developed in a patient, in whom the major portion of the soft palate was absent (Skoog 1965).

Preoperative condition 13 This thirty-five year old

patient had suffered a sub­ total loss of the soft palate in conjunction with prima ry re­ pair of a cleft, at the age of three. His speech was poor, despite the use of an ob­ turator. A small remnant of soft palate tissue is seen at the right. 217

Reconstruction

,', ), J' )

/1. !,

~ /

-'<

14 The posterior border of the remaining pal­ ate was incised and a pharyngeal flap, based superiorly, was raised and sutured to the nasal side of the palatal wound edge. The flap, com­ posed of mucous membrane and a thin muscle layer, measured about 5 cm in length It was large enough to fill , without tension , the en­ tire palatopharyngeal opening behind the hard palate.

To cover the pharyngeal flap on its oral sur­ face, a flap of bu cca l mu cosa, based laterally on the hard palate , was planned .

'1'..

1'­

15 The buccal flap was rai sed and rotated medially , In this way a soft palate of normal

size was reconstructed from two flaps, while the base of the pharyngeal flap was left ex­ posed. The margins of the defect, left from the buccal flap, were closed by direct suture. Healing took place uneventfully and the pa­ tient was discharged from the hospital after ten days. During the next eight months considerable shrinkage of the base of the pharyngeal flap took place, resulting in a fairl y wide opening on the right side of the flap , Marked open nasality persisted , though speech was im­ proved when compared to presurgical record­ ings . A supplementary pharyngoplasty was then performed , utilizing two pharyngeal flaps from the nasopharynx, both based inferiorly. One flap was raised from the posterior phar­ yngeal wall and attached to the reconstructed palate, the other was shifted from the lateral wall and used for lining . Healing was without complications.

218

Result

16-17 One year after the second operation, the buccal flap covering most of the reconstructed soft palate is marked by its clear red co lour. The palate ha s a broad attachment to the posterior pharyngeal wall, and the two apertures leading to the nasophary nx are small. Clinical and cineradio­ graphic examination show insignificant mobility of the palate and excessive tongue movements. The transfer of the buccal flap ha s not caus ed any constricting band to develop at the donor site. Since surgery, treatment has been compl e ted with a dental bridge.

Following both operations, the patient has had intensive speech therapy, and at the time follow­ up records were comp leted his speec h was as­ sessed as good. With the method described for reconstru ction of the soft palate, it seems quite fea sib le to utilize two buccal flaps when needed.

Reconstruction within the hard palate

Large defects of the hard palate, resulting from unsuccessful cleft palate surgery, are generally bordered by densely scarred and poorly vascularized tissues, which ma ke them unsuitable for use in repair. An attempt to raise mucoperiosteal flaps for conventional closure in two layers will often re su lt in additional tissue loss and enlargement of the defect. A buccal flap, as was suggested by Padgett (1936), may then be used as a substitute for the defi cie nt tissues. Fistulas, localized at the anterior portion of the palate and with­ in the alveolar pro cess, though generally not large, are most effectively treated by a flap of lip mucosa as an oral lining . The pedicle is conveniently placed in the alveolar cleft. 219

Preoperative condition

18 In this 45 year old cleft pa late patient the defect within the hard palate had existed since his prima ry operation in chi ldhood. Neigh­ bouring tissues were scarred and totally inadequate for closure of the defect by local flaps. They could. however. be mobi lized to line the nasal aspect. A buccal flap was then raised from the right cheek and trans ferred to cover the ora l side . The flap measured about 4 cm in length and was based posteriorly, so that the pedicle could be pas­ sed behind the molars .

When the patient was readmitted after two years, the pedicle had tubed itself and, though it was caus ing no inconvenience, it was sec­ tioned and returned. At that time the healed part of the flap de­ monstrated an excess, both of submucous tissue and lining. After trimming , the mucous membrane could be used to c lose a persiste nt margina l fistula.

Result 19 The final appearan ce of the buccal flap is far superior to that of a transplanted ski n tube pedicle.

220

References

Aschan G.: Hearing and nasal function correlated to postoperative speech in cleft palate patients with velopharyngoplasty. Acta Oto­ Laryng 61.371 , 1966. Bjork L.: Velopharyngeal function in connected speech . Acta Radiol, Suppl 202, 1961. Boyle H, H.: Design for Major Cleft Palate. Staples Press Ltd, London, 1957. Burian F.: Chirurgie rozStepO rtu a patra. Statni Zdravotnicke Nakla­ datelstvi, Praha, 1954. Burian F.: Chirurgie der Lippen- und Gaumenspalten. VEB Verlag Volk­ und Gesundheit, Berlin, 1963 . Conway H.: Combined use of the push-back and pharyngeal flap pro­ cedures in the management of complicated cases of cleft palate. Plast Reconstr Surg 7: 214,1951 . Dunn F. S.: Observations on the pharyngeal flap operation for the im­ provement of speech in cleft palate patients. Plast Reconstr Surg 7: 530, 1951. Honig C. A. : Over Pharyngoplas tiek Academisch Proefs chrift . Bosch, Utrecht, 1963. Lindholm H.: Phoniatric speech evaluation after velopharyngoplasty. Scand J Plast Reconstr Surg 5: 47, 1971. Moran R. E.: Pharyngeal flap operation as speech aid. Plast Reco nstr Surg 7: 202 , 1951. Nylen B. 0.: Cleft Palate and Speech . Acta Radial, Suppl 203, 1961 . Orticochea M .: Construction of a dynamic muscle sphincter in cleft palates. Plast Reconstr Surg 41 : 323,1968. Owsley J. a., Lawson L I., Miller E. R., Harvold E. P., Chierici G. and Blackfield H. M .: Speech results from the high attached phar­ y ngeal flap operation. Cleft Palate J 7: 306,1970. Padgett E. C. : The repair of cleft palates primarily unsuccessfully operated upon. Surg Gynec Obst 63: 483, 1936. PassavantG.: Ueber die Beseitung der naselnden Sprache bei ange­ borenen Spalt en des harten und weichen Gaumens (Gaumensegel­ Schlundnaht und Rucklagerung des Gaumensegels). Arch klin Chir 6: 333, 1865.

221

Petit P.• Mme Borel-Maissony and Psaume J.: A propos des insuf­ fisan ces velaires et leur traitment par pharyngoplastie. Ann Chir Plast

I: 257.1956. Rosenthal W.: Zu r Frage der Gau menplastik. Zbl Chir 51 : 1621 . 1924. Sanvenero-Rosselli G. L.: Verschluss von Gaumenspalten unter Ver­ wendung von Phary nxlappen. Fortschr Kiefer- und Gesichtschir I : 65.

1955. Schoenborn: Ueber eine neue Methode der Staphylorrhaphie. Arch klin Chir 20: 527. 1876. Schoenborn: Vorstellung eines Falles von Staphyloplastik . Verh Deuts ch Ges Chir 15: 57.1886 . Skoog T. : Sekundara gomplastiker. Nord Med 52: 1351.1954. Skoog T. and Nylen B. 0.: Abntgenkinematografisk analys av gom­ plastiker. Nord Med 54: 1367.1955. Skoog T.: The pharyngeal flap operation in cleh palate . Brit J Plast Surg 18: 265. 1965. Skoog T.: The pharyngeal flap operation for cleh palate patients. J Amer Med Wom Ass 21 : 1022. 1966. Skoog T.: Treatment of Patients with Clefts of Lip. Alveolus and Pa l­ ate. Ed. K. Schuchardt. Georg Thieme Verlag . Stuttgart. 1966. pp 188.

204. Stark R. B. and DeHaan C. R.: The addition of a pharyngeal flap to . primary palatoplasty. Plast Recon str Surg 26: 378. 1960.

222

Section II

Chapter X

Reduction rhinoplasty-preserving the nasal dorsum Introduction 226 Operative procedure 227 Estim ation of reduction

Anesthesia

Reduction of the nasal tip

Und erm ining the dorsal skin

Reduction of t he hump

Narrowing the nasal pyramid

Trimming and shortening the cart ilagin o us septum

Shaping the resected hump

Replacement of the hump as a graft

Closure of the wounds

Dressing with tape

Splinting with plaster

Postop erative care

Result

Further examples

Comments 247 Use of the nasal dorsum as a composite graft Nasal tip reduction Late results References 249

224

The Large Nose

------"<-.---­ .

~\

-

-

Nasal bone

- - Septal cartilage

..---,..-. . - --

Lateral cartilage

~ '--T-!\-- Alar

car(ila ge

~- Colurne,IIar

A method of correction

cartilage

Introduction

Le nez de Cieopatre, s 'il eul ell! plus court, louie la face de la lerre Burall change. Blaise Pascal: Pensees (7669)

Since Joseph (1931) introduced hi s method of reduction rhino­ plasty, discarding the prominent nasal dorsum has been a uni­ versally accepted principle. With this technique the uniquely sculptured contour of the normal dorsum is lost and reshaping becomes arduous and fraught with difficulty . All too often, the operative result is marred by the sharp projecting edges of the fractured nasal bones and the denuded septum, and if in­ advertently an asymmetric or excessiv e red ucti on is p erformed , further surgery is frequently required to rectify the fault. Post­ operatively, broadening and lowering of th e bony py r am id is another v exing problem that plague s commonly used pro ce­ dures. As Sheen (1973) points out, when a h ig h , n arrowed nasa l bridge is not maintained, a relaxation of the eyelids occurs. This alters the appearance of the oculo-orbita l r eg io n and effects general facial characteristics as well. This un wa nted result is a direct consequence of failing to provide a nasal roof to brace the repositioned nasal bones. Furthermore , removal of the nasal dorsum may also interfere with the function of the ex ­ ternal nose, causing vasomotor disturbances and neuralgic pain, which are aggravated by exposure to cold (Cottle 1954). To reduce the hazards inherent in present approaches and to effect a more refined esthetic appearance, a method of reduc­ tion rhinoplasty has been designed which maintains nasal inte­ grity . After total removal of the offending hump, the nasal dor­ sum , trimmed to the desired size and shape, is replaced as a free graft. This method was first reported in 1966 (Skoog) and has been used routinely over the past ten years.

226

1

Operative procedure I

--­

Estimation of reduction 1-2 The patient is positioned supine on the operating table with the head raised slig htly. Self-adhering plastic sheets' and towels are used to drape the prepared operative field . The vestibule of the nose is swabbed with antiseptic so lu ­ tion and the nostril hairs are cut. The lower half of the forehead and the entire fa ce are left ex­ posed to permit proper assess­ ment of facial proportions. The reduction can then be adjusted accordingly to fit the fa ce. The dorsal osteotomy line and the limi ts of alar ca rtilage resection are shown.

1 Th is operation was performed on live televi ­ sio n before the Seventh Annual Symposium on Cos metic Surgery at Cedar s of Lebanon ~ospilal . M iam i, Florida . February 10th, 197 3.

: Steri-OrapeC!>, surgical drapes, Mi nnesota Mining and Manufacturing Comp., St. Paul. Minn .,

U.S.A.

227

Anesthesia

3 Starting at the tip of the nose, the operative field is anes­ thetised with approx imately 8 ml of 1 percent Xylocaine ® (lidocaine) containing epine­ phrine 1: 100000. Infiltration is continued subcutaneously along the dorsum to the glabella and over the sides of the nasal pyram id.

5 Through a separate puncture site the needle is inserted into the region of the alar base, and this area is completely anes­ thetized down to the nasal floor and piriform aperture. From this point the injection is extended along the line of the planned lateral osteotomy, up to the level of the medial canthus.

228

4 The membranous septu m, in­ cluding the columellar base and anterior nasal spine, are simi·

larlyanesthetized.

6 Both sides of the nose are stuffed with conon batten soaked in 10 per cent cocaine and an equal amount of 0.1 per cent epinephrine. The packing is left in p lace for ten minutes. The posterior nasopharynx is then loosely packed with gauze to absorb blood and prevent it from dripping down the back of' the throat during operation.

Reduction o f

the nasal tip 7 The alar carti lage is exposed through a rim incision placed 1 or 2 mm above th e inferior bor­ der of the cartilage. Through this incision , the nasal mucosa is dis­ sected off the carti lage over an area correspo nding to the boundaries of the estimated re section.

8 The resection begins by in­ cising the alar carti lage about 2 mm above it s low er border.

9 The ca rtil age is sepa rated from its cutaneou s attachments with a pair of Stille' s blunt-tipped , thin-bladed scissors.

10 The alar cartilage is sectioned medially, and is delivered from the incision to be resected lateral­ ly .

229

Undermining the dorsal skin 11 An intercarti laginous

incision is made be­ tween the lateral and alar cartilages and ex­ tended onto the septal mucosa, curving down­ wards between the colu mella and the in­ ferior m argin of the septa l cartilage . It is im­ portant that no part of thi s incision joins the original rim incision in order to avoid creating a flap o f nasa l lining which may result in problems of reposition­ ing and blood supply.

12 A pair of blunt ­ tipped scissors is in­ trodu ced th rough the incision and the skin is dissected free fr om the dorsum of the nose above the periosteum. The undermining is ca r­ ried as far proximally as necessary and may ex­ tend into the glabellar regi o n.

230

Reduction of the hump 13 The nasal sk in is elevated w ith an Aufricht retractor to expose the lateral ca r­ tilages . A pair of straight-b laded iris sci s­ sors is introduced , and each of the lateral ca rtilages is divided in turn at the previous­ ly determined level of resection , up to th e margin s of the nasal bones .

14 The septal cartilage is then sectioned at the same leve l.

15 A spec ial, straight, thin­ blad ed osteotome is used for cUlling through the bon y com­ ponent of th e hump (se e p. 246).

231

16 The osteotome is inserted horizontally into the inci sions made in the carti­ laginous part of the dorsum, and its edge is advanced until it meets the bony por­ tion. While the ope rat or co ntro ls the course of the in­ stru ment. th e as­ si stant uses a hammer to drive the chi sel through the bone to the g label la. Th is completely frees the hump, and it can then be removed with a straight hemostat.

17 If the hump re­ section is co nfined to the area of the bridg e alo ne, the described procedure will be suffi cien t. In most cases, howe ver , the bony resection shou ld be extended into the glabellar region . A specia lly designed curved osteotome is m ost useful fo r this part of the procedure.

•

18 The straight osteotome is remo ved

and the curved one in serted in its pl ace. Thi s is facilitated by ha ving prev iously elevated the handle of th e stra ight in stru ­ ment slightly t o widen the track with o ut causing a fra cture . When the curved osteo­ tome is driven th rough the bone, it creates a smooth glabellar notch.

232

•

The Large Nose

19 The removed section is larg e, and characteristi­ cally widest at the junction of the bony and ca rtilagi­ nous elements .

20 The excised hump is wrapped in saline-soaked gauze and preserved for later trimming and re­ placement as a graft .

•

21 Hump resecti on has been comp leted with a minimum of tissue under­ mining.

22 The striking width of the re sultin g de­ fect in the bridge are a is now evident, and the lateral wall s of the nasal pyramid must be moved medially to narrow the open dorsum.

233

I

Na rrowing the nasal pyramid

23 A special , narrow, thin-blade osteotome is used for the lateral osteotomy.

24 A stab wound is made in the lateral part of the floor of the nose, over the margin of the piriform aperture. The osteotome is introduced through this incision with the guarding knob under the skin. No undermining is done prior to this osteotomy.

25 It is important to co nfine the sectioning of the lateral nasal wall to its base. The instrument should therefore be kept flush with the maxilla, not allowing the edge to run up into the lateral wall of the nose itself. The osteotome is advanced with gentle taps of the hammer for about two thirds of the distan ce to the medial canthus. At this point, there is a sudden drop in resistance and the osteotome takes a slight medial roll. Thi s marks the development of a greenstick frac­ ture, occurring obliquely across the upper portion of the nasal bone. Hinged at the fracture site, a few more taps of the hammer will shift the nasal wall medial­ ly. The wall is now in the desired position and there is no requirement for in- or out-fracturing as in other rhinoplasty operations. When the nasal pyramid has been narrowed in this fashion, the walls remain fixed in their new position . The fracture line fall s well away from the lacrimal system .

234

Trimming and shortening the cartilaginous septum 26 The cartilaginous septum usually requires further trimming to plane it to the level of the bony res ection . This may also be true for the lateral cartilages. Slight over-correcti o n at both sites is desirable to prevent bulbing above the nasal tip . Sparing the mucous mem­ brane, fine adjustment is made with straight scissors.

,

27 Shortening and /o r tilting the nose is often a part of the procedure. This is accomplished by excising an appropriate amount of septal car­ tilage from its inferior border. In order to preserve some excess lin­ ing, the mucous membrane covering this section is separated from the cartilage prior to removing the cartilagino us segment. When it has been necessary to shorten the septal cartilage consider­ ably, the lateral walls of the nose mu st be shortened as well. This is done by resecting the lower borders of the lateral cartilages including their covering mucous membrane.

235

Shaping the resected hump

28 All of the attached mu cosa is stripped off th e underside of the hump. This exposes the bone and cartilage of the nasal vaults on !!ach side of the septum.

29 The lateral walls of the specimen are trimmed using a straight rongeur for the bone and scissors for the cartilage .

30 The septa l section of the hump acts as a strut f or the nasa l roof and ma intains the angulat ion of the hu mp. Removal of this com ponent invariab ly all ows the graft to straighten out.

236

The Large Nose

31 After trimming, the dorsal surface is generally perfectly straight. Should some bony prominence remain, this is rongeured down to the level of the car ­ tilage.

32 The width of the bony segment is maintained. The cartilaginous portion is narrowed considerably by removing the major part of the lateral cartilages, leav­ ing the central section intact. The perios­ teum and perichondrium are not dis­ turbed.

237

Replacement of the hump as a graft

33 The graft has been shortened and trimmed and now confo rms to the pre· pared base.

t

I

34 When the skin of the dorsum is elevated, the osteocartilaginous graft ca n be accurately positioned under direct v ision.

35 The graft readily fits into place and is in broad conta ct w ith the margins of resection, particularly in the bony area where it is firmly supported by the septum and the nasal bones. The nasal profile is normal and flows naturally into the glabellar notch.

238

36 On ly minor adj ustments are necessary to align th e edges of the graft with th e margins of the lateral walls. In spite of the nar­ rowed nasal pyramid, the normal width of the dor­ sum has been maintained and its bevelled contou r is natu rally rounded.

37 In th e majority of cases the graft w ill remai n firm ly in place w ithout fixa ti o n . If it displays any tendency towards mobility, a 4/0 catgut sutu re may be used to fix the tip of the graft to the septu m. Should the hump be inadvertently fractu red du ri ng removal or shap ing , it can be held together with a periosteal catgut suture prior t o re in­ se rti o n.

I

• 38 At the completion of the proced ure , stru ctural anatomy is re sto red. The round ed contou r of th e grafted dorsum contrasts marked ly w ith the sharp edges o f bone and car­ tilage fo ll ow ing the u sua l meth o d s of redu cti o n rhino­ plasty .

•

239

Closure of the wounds

39 No wound surfaces are left exposed . The alar rim incision is accurately

closed with a few inter­ rupted 4/ 0 catgut sutures .

40 The anterior portion of the intercartilagi­ nous incision and its columellar extension

are closed in a simi lar manner by merely approximating the mucosal edges. Laterally, this incision will adjust itself spontaneously, and is left open for drainage .

Dressing with tape 41 Strips of microporous tape' are applied over the dorsum of the nose, gently com­ pressing the skin over the graft and there­ by prev enti ng the accumulation of fluid . I

Steri -Strip@ sk.i n closures . 3 M Comp ., 51. Paul , Minn. ,

U.S.A.

240

42 The tape is also important t o mold the nose, particularly in the supratip area where compression is necessary and difficult to obtain by any othe r form of splinting .

Splinting with plaster

43 As it is easily molded to fit accurately , plaster of Paris is the preferred materia l for sp linting. Two layers of 10 cm wid e plaste r bandag e are cu t int0 a " T" -shape, with the ba se of th e T being broad enough to cover th e entire nos e.

44 T he p laster is m ol d ed t o fit th e nose. It is rein ­ forced over the glabella and a sma ll sling of pla ster is added just below the ti p to p rev ent spread ing . The sp lin t is held in p lace wi th a strip of microporous tape p lace d across the forehead . A str ip o f elasti c t ape, anc hored to each cheek, prevents th e nose from being dislodged. Th e pos terior nasopha ryngeal pa cks a re remo ve d and the nose is not packed postoperative ly .

Postoperative care Almost all patien ts are treated on an out-pa tient basis. Pain and discomfort are moderate and can be readily con trolled with oral analg esics. Post­ operative oozing is minimal and s ubsides in one or two days. There may be some accumula tion of dried bloo d w ithin the nostrils, wh ich the pa­ tients are instruc te d to re move gently, thereby ensuring a patent airway and greatly enhancing comfort. ProphYlactic antibiotics are no t used. The original plaster dressing is removed after one week. At th is time alm os t all swelling has abated and a new well-molded plas ter splin t is applied and le ft in place for another week or ten days to afford added support to the healing gra ft. When the nostrils are cleaned, any remaining ca tgut sutu res are re m oved with th e crust. 241

Result 45-50 Five months postoperatively, the nasal configuratio n has been markedly altered from the preop erative appearance. In profile, the nose is shorter and the naso -Iabial angle has been improved. The bridge is straight and the glabellar notch significantly deepened. A frontal view highlights the narrowed nasal pyramid. The bulbous tip has also been reduced proportionally, and the nostrils are rou nded and symmetrical. In semi-profile the overall reduction is apparent, as is the un­ di sturbed rounded co ntour of the dorsum.

242

---

--~-"-----'-------------------

Further examples

I

,

t 51-54 This result illustrates the wide range of possibilities for shaping and reducing the nose. Utilizing the dorsal hump as a free graft, the surgeo n has greater flexibility in determining the shape , size, and contour of the new nose . The gently rounded dors um appears natural , and the nasa l prominence, so evident in the preoperative photographs, has now been co rrected .

•

243

-..

55-58 Similar techniques can be applied in les s ex­ tensive ci rcum stances. Thi s patient request ed correc­ ti o n of her humped profile w ith lowering of the bridge and mo re definition given to the nasal tip . The proce­ dure involved ra dical removal of the dorsal frame­ work, includi ng the glabellar notCh, narr owi ng of the bo ny pyramid and replacement of th e trimmed speci­ men as a composite graft. Only minor adju stment s w ere made to th e tip an d alar ca rtilag es . The end re sult is a n atural cO ntoured dorsum w ith an even su rfa ce.

244

•

59--00 In this patient a rhinoplasty was performed in an identical fashion to the preceding case. How­ ever, resection and trimming of the hump was slight­ ly altered to produce a straight profile.

245

-

59-60 In this patient a rhinoplasty was performed in an identical fashion to the preceding case. How­ ever, resection and trimming of the hump was slight­ ly altered to produce a straight profile.

245

61 Thin -b lad ed nasal osteo tom es designed for the de­ scribed pro cedure are manufa ctured by AB Stille -Werner, Stockholm , Sweden .

The handle offe rs the operator a firm grip , while the flat­ tened head aids in judging the position of the instrument during th e osteotomy. The double -guarded instru ments are used f o r the hump resect ion, the curved one for the glabell ar region, and the single-guarded chisel is employed for the latera l osteotom y. The numbers indicate th e width of the edge in mm. The illustr ated sizes are the most co m­ monly u sed , although other widths are avai lable.

246

Comments

Use of the nasal dorsum as a composite graft

After removal and recontouring, the nasal dorsum is replaced as a free graft. This represents a new principle in reduction rhinoplasty. Impaired healing and infection might be expected to occur, as the procedure in vo lves the introduction of a com­ posite graft of bone and carti lage to a bed that communicates with the nasal cavity. These complications, however, do not arise. After hump redu ction, narrowing the nasal pyramid ef­ fectively makes the graft bed a closed space. The mucous mem­ brane that line s the lateral wa ll s comes in contact with the septal membrane throughout the length of the dorsum , thereby sea ling off the nasal cavity from the graft . Thus , in over one hundred and fifty operations of this kind , there ha s been no evidence of either infection or delayed healing. During the same period, a number of iliac bone grafts were used to correct post­ traumatic deformities of the nose. Some of these implants be­ came infected and the grafts were l ost , despite being inserted into a bed which did not communicate with the na sa l passages. Regrafting the hump therefore appears to be a safer procedure.

There are a number of very obvious advantages of thi s tech ­ nique :

•

The composite graft consists of original tis sues from the area.

• It can be shaped to render a natural dorsal co ntour, with a rounded and fairly broad bony section accentuated at the osteo­ chondral junction, and with the cartilaginous portion tapering to­ wards the tip. •

The straight graft provides continuity to the entire profile.

• Despite the fact that the dorsal support extends from the glabella to the tip of the nose, flexibi lity is still maintained, as below the bony pyramid the graft is composed of cartilage. • When the graft is replaced after proper trimming, it will mask irregularities and asymmetry. • It rests li ke a roof over the lateral walls and eventually unites with them to form a so lid bond, which prevents spread ing of the nasal pyramid.

247

• The lack of significant complications associated with graft­ ing, and • the superior esthetic results merit its use as a standard pro­ cedure. In this technique, hump resection involves removal of a large intact segment of dorsum. This can only be performed properly with thin-bladed osteotomes such as those demonstrated . The thicker-bladed instruments, commonly used in rhinoplasty, are likely to fracture either the hump or the lateral walls. A proper execution of the lateral osteotomy is essential to nar­ row the base adequately and to provide a stable foundation for the graft. This technique also requires a thin-bladed osteotome and is effected without undermining . On the dorsum , under­ mining is limited to a relatively small area . The possibility of hematoma formation and postoperative swelling are thereby greatly reduced.

Nasal tip reduction

In describing this method of reduction rhinoplasty, the tech­ niques of hump removal and adjustment of the nasal pyramid have been highlighted. Though other facets of the operation have not received as much emphasis, recontouring the tip of the nose or altering the size and shape of the nostrils are ob ­ viously integral components of the operation . The nasal tip reduction is performed at the beginning of the procedure when the nose is firmly positioned and there is little troublesome bleeding. The resection is usually fairly radical, but a rim of alar cartilage is always retained to maintain a natural contour and avoid the creation of an amorphous tip without cartilaginous definition. The remaining arch of cartilage also prevents alar collapse and anterior angulation of the nostril. The final shaping of the tip is delayed until the hump has been removed and the dorsal graft is positioned . Then, if the tip is still considered too prominent, this can be corrected by alar base resection and/or by reducing the height of the columella.

Late results

248

The long-term results of this procedure have been gratifying. Union of the graft has occurred in all cases. There is some degree of resorption of the bony portion , but this has not been to such a degree as to seriously affect the result. Since the car­

The Large Nose

ti lag e reta i ns its orig ina I size and sh a pe, this part of th e graft may appear slightly prominent in cases in whi ch bone resorp­ tion has been most marked. To avo id this unwanted possibility, it is wise to slightly ove rcorrect when trimming the dorsal part of the septal ca r1 ilage. Th is will also prevent any minor skin redundancy in the supratip area from disturbing the fi nal resu lt. The amount of mucosa removed corresponds t o the degree of nasal reduction. All wounds are closed accurately, which results in early hea lin g and insigni fi cant scar formation . Late co ntra c­ tion with subsequent distor1ion has not been obse rved . Th is also app li es to the rim inci sion, which has never been a source of postoperative inconvenience.

References

Cottle M . H.: Nasa l roof repair and hump removal. Arch Otolaryng 60 .' 408, 1954. Joseph J .: Nasenpiastik und sonstige Gesichtsplastik. Kabitzsch , Leipzig, 1931 , p 88. Sheen J .: Secondary rhinop lasty. Presented at the Seventh Annual Symposium on Cosmetic Surgery. Miami, Flo rida, February 10th, 1973. (Not pub li shed .) Skoog T.: A method of hump reduction in rhinopla sty. Arch Otolaryng 83: 283, 1966.

249

Chapter XI

I. Correction of protruding ears by conchal resection Introduction 253 Anesthesia 254 Operative procedure 255 Preparing and draping Plannin'g and resection An esthesia Conchal resection Closure of the wound Dressing Result

Comments 262

II. Reconstructing the anthelix by perich on drioplasty Introduction 264 Operative procedure 265 Preoperative condition Preparing the perichondrial flaps Reconstructing the anthelix Wound closure Immediate result After four weeks After supplementary conchal resection Perichondrial cartilage regenerati on Final result

Variations in operative technique 272 Comments 276

III. Perichondrial otoplasty in an irregular deformity of the ear Preoperative condition 277 Operative procedure 277 Incisions Unfolding the cartila ge Perichondrioplasty, utilizing flaps and a free graft Skin closure by a flap transfer Immediate result Final result

References 283

Title page : Accen tu ated by his closely cropped hair thi s bust of Augustus Caesar ex hib its a pair of clearly pro­ truding ears This familial trait can be seen in statues of many of the Roman Emperors. Courtesy of Direzione Generale dei Monumenti Musei e Gallerie Pon tifi­ cie, Citta del Vati cano.

250

I

Chapter XI

I. Correction of protruding ears by conchal resection Introduction 2 53 Anesthesia 254 Operative procedure 255 Preparing and draping Plannin·g and resection Anesthesi a Con chal resection Closure of the wound Dressing Result Comments 2 62

II. Reconstructing the anthelix by perichondrioplasty Introduction 2 64 Operative procedure 265 Preoperative condition Pr ep aring the perichondrial flap s Reconstructing the antheli x Wound clos ure Immediate result After fo ur weeks Aft er su pple mentary con chal res ect i on Perichondrial ca rtilage regeneration Fi n al result Variations in operative technique 2 72 Comments 2 76

III. Perichondrial otoplasty in an irregular deformity of the ear Preoperative condition 277 Operative procedure 2 77 In cisions Un folding t h e cartilage Pe richondriop lasty , utilizing f la p s and a fr ee graft Skin clo sure by a flap t ran sfer Immed iate result Fin al resul t References 283

250

Title page: Accen tu at ed by his closely cropped ha ir th is bust of Aug ustus Caesa r exhi bits a pair of clea rl y pro­ tru ding ea rs. Th is fami lia l trai t ca n be seen in statues of many of the Roman Em perors. Courtesy of Direzione Ge nerale dei Monum enti Mu sei e Ga ll eri e Pontifi ­

cie, Citt!! del Vati ca no.

Helix -_~

~--1-----';----Crus posterior of anthelix

\-- --'-- -

Tnangu lar fo ssa

--,=~---'-"----- Crus anterior 01 anthelIx

AnthelIx

-_~

- - ----,r7'- - - - Co ncha 01 auricle 0-;-­

. . .-

Tragus

- -- - Anlllragus

--

252

1 In this moderately protruding ear the greenshaded area defines the position of the aural cartilage. The anthelix is less devel o ped than nor­ mally.

I. Correction ofprotruding ears by conchal resection

Introduction

•

The ba sic anatomical defe ct of protruding ears is a localized abnormality of the aural cartilage . Its dorsal folding i s incom­ plete at the lateral border of the co ncha , and this congenital deformity presents as underdev elopment or absence of the antheli x. With this principle at last realized, attempts at correc­ tion became more purposeful, and a number of new tech­ niques were introduced to r econ struct the anthelix (Lu ckett 1910, McEvitt 1974, Cloutier 1961 , Sten st rom 1963, Baruch 1970, Muhlbauer 1972, and others). Significant improvement in the general configuration of the ear can now be made. Approximately seventy -fi v e per ce nt of cases of protruding ears require reconstruction of the anthelix. In the remaining twenty­ five per ce nt, with only limited protrusion , a fairly well develop ed anthelix is present, and the m ost striking feature of the mal ­ formation is an oversized concha. With th is type of disfigure­ ment, it is more advantageous to redu ce the concha than to re shape the anthelix. An elliptical co nchal resection has thus been devised and has, in these selected ca ses , produced most sati sfa ctory resu Its (Skoog 1958). Th is te ch n iq ue u til izes th e ex ­ cept ionally ri ch vasc ular suppl y of the ear which time and again, both in the literature and in personal exp erien ce, ha s enabled the la cerated ear t o survi ve, even on the narrowe st pedicle,

253

Anesthesia

With few exceptions, local anesthesia is used in corrective sur­ gery for protruding ears. Most of bur patients are treated when they are about five years old. At this age, children can gen­ erally be persuaded to submit to the temporary discomfort of the injections, when assured that the entire procedure will then be completely painless . Confidence is gained when they ex­ perience immediate anesthesia, and this encourages good pa­ tient cooperation. Lidocaine (Xylocaine®) has marked sedative effects and occasionally the young patients may fall asleep dur­ ing the operation. When the anesthetic subsides, analgesics are usually required.

254

Operative procedure

Preparing and draping

2 The patient is placed in a supine position, with the head raised slightly, and the face , neck and ears are prepared with antiseptic solutions. No hair is removed, as it is retracted away from the surgical area with tape. Both ears are then draped with an aperture adhesive sheet.' This effectively partitions off the operative field, yet, it permits the surgeon to keep under constant sur­ veillance the relationship of the ear to surrounding structures . The drape remains secure and does not dislodge during the procedure.

Planning the resection

3 This ear is moderately protruding due to an enlarged concha, while a distinct anthelix is present. An estimate of the exce ss co ncha is made, and an ellipse is marked out for resection. Its greatest width , usually about five mm, is generally opposite the tragus. The excision is planned for the deepest and most posterior part of the conchal cavity, as indicated. Superiorly it follows a curve under the anterior crus of the anthelix, while inferiorly, it angulates behind the antitragus. The four sinuous lines of the diagram represent the convolutions of the ear surface . If the lines of resection are placed correctly, when the edges are reappro x i­ mated they will fit snuggly together.

1 Steri-Drape'3l , Small aperture drape 16"x 16 ". 3M Comp., St. Paul , Minn., U .S .A.

255

I

Anesthesia

4 Approximately 5 cc of 1.0 per cent Xy locaine ® (lidocaine) with epine­ phrine are injected subcutaneously into the previous ly designed ellipse. The cartilage is then pierced by the needle and a sim ilar amount of an esthetic is deposited in the posterior subcutaneous layer. A circular periauricular nerve block will also produce satisfactory an esthesi a. Adjacent to the auditory canal , the se nsory nerve supply of the co ncha is to a varying extent derived from the auricular branch of the vagus. Separate su bcutaneous infiltration of this area with 1 to 2 cc anesthetic so luti on is therefore required. With this technique the injection of about 10 cc, 0.5 per cent Xylocaine ® with epinephrine, will o rdinarily be sufficient.

...

~-

Concha! resection 5 Starting at the medial margin of the marked area, a through­ and-thro ugh incision is made with a No . 11 blade .

6 The knife passes perpendic­ ular through the back o f the ear as it foll ows the outline along the anterior surface .

256

j

7 An elliptical segment, comprised of the full thick­ ness of the ear, is excised. The skin, now has a tend­ ency to retract away from the cut edges, revealing the protruding carti lage. This protuberance is most evident on the medial side, where some trimming may be required . 8 The edges of the wound can now be readily ap­ proximated . Resistance may still be encountered at either the upper or lower poles . This is overcome by breaking the spring of the cartilage 'with a subcutan­ eous incision at the end of the ellipse.

9 A slight discrepancy may exist between the two sides of the ellipse, which can be corrected by remov­ ing one or two small wedges of cartilage from the lateral edge.

257

11 Suturing the cut car1ilage edges to­ gether, as shown in this drawing, folds the ear backwards and ac­ centuates the anterior anthelical crus.

Nonabsorbable suture material (4/0 Supramid,' white) is used. 10 The elliptical excision corrects the height of the concha, but may not rectify a prominence of the upper pole. This protrusion is due essentially to an insufficient folding of the anterior crus of the anthelix and can be simply cor­ rected by excising a small wedge of car1ilage from this area.

I

Societe Steril Catgut (SSe) , Neuhausen am Rhelnfall , SW itzerland.

258

,.

I

Closure of the wound 12 Wound closure begins in the middle of the ear with a double vertical mattress suture of 4/0 plain catg ut.

1

,

1

13 The suture is tied on the posterior surface. Four

such sutures are usually required .

•

(

14 The skin edges come together easi ly as the suture line falls behind the ant helix .

I

15 This drawing diagrammatically depicts the vertical mattress suture used in closure . All layers are closely approximated.

259

16 On the anterio r surface, a few 6/0 catgut skin sutures supplement the closu re. Posterio rly, a few additional sutures of 4/0 catgut are used to ensure adequate hemostases.

17 At the end of the procedure the r elatio nship of the ear to the head is normal. The reduction in con­ chal depth has tucked the ear backwards, allowing the original anthelical fold to lie in a normal plane.

Dress ing Th is type of operation does not invo lve recon­ touring the cartilage, a procedure which requires splinting during healing to prevent recurrence of the deformity. Therefore, a simple protective dressing is all that is needed and it is left in place for ten days . At that time the catgut sutures can be washed away with the crust. This suture material leaves no undue markings and is of ob­ vious advantage in pediatric practice.

260

Result

18-19 These preoperativ e pictures rev eal ob v ious protrusion of the ear. This effect is generated by an enlarged concha, while the anthelical fold is reason­ ably well dev eloped .

20-21 Six months after correction the patient demon­ strates a normally appearing ear, and the position has remained unchanged since the last sutures were placed, see Fig. 17. The wounds are well healed and the conchal scars are virtually invisible . They are partially hidden behind the anthelix and antitragus.

261

Comments

The conchal resection does not impair blood supply to the ex­ ternal ear, either at the time of, or subsequent to surgery . Heal­ ing has always been by primary intention and is complete in about one week. The resulting scars show no tendency to de­ teriorate, which is particularly important in the visible anterior portion. This excellent appearance probably reflects the ten­ sion-less skin closure . The cartilage has also been approx­ imated without tension , thus permitting the ear to remain in its new position. No serious complication has occurred in a series of 150 cases , and there has been no loss of sensation along the helical border. This type of resection preserves the original curve of the ant­ helix and simply readjusts this important structure to a normal position . In closure , the resected margins are aligned edge to edge and thus heal without forming a step or other irregular­ ity. Although the width of the resected ellipse is at most only about five mm, it radically improves the appearance of the ear. The effect is ensured by careful selection of the site of resec­ tion . The procedure not only lowers the concha but also per­ mits the ear lateral to the excision, to rotate into a plane closer to the head . Ear protrusion may, in some cases, be limited to specific areas due to localized enlargement of the concha . In these instances, the site and size of the resection are adjusted accordingly. In conclusion, this method should be employed only in cases with an acceptable anthelical fold , and where the major part of the deformity is due to an excessively large concha . Then the aesthetic results should be excellent.

262

II. Reconstructing the anthelix by perichondrioplasty

r

Introduction

•

Approximately seventy-five percent of patients with protruding ears require anthelical reconstruction. The smooth , rounded curve of the naturally shaped anthelix is, however, difficult to duplicate. Surgical attempts to reconstruct the anthelix usually violate the natural framework, replacing this peaceful arrange ­ ment with sharp edges ; and then the cartilage , which is re­ silient to molding and intractable to shaping , tries to regain its original position. Sutures often produce ex cessive folding and a pinched look, or they flatten part of the ear and cup the remain­ ing portion, resulting in an " hour glass deformity". The delicate balance between concav ities and con v exities is thus destroyed. A new method of corre ction ha s therefore been dev ised, which reshapes the antheli x but does not result in a conspicuous, un­ natural contour. The underlying principle for this procedure is to use the mobilized peri chondrium to generate cartilage, thereby maintaining the folded ear in the desired position . The clinical work is an application of ex perimental studies on aural perichondrium by Skoog , Ohlsen and Sohn , reported in depth in Chapter XII.

•

I

264

Operative pro cedure l

Preoperative condition 22-23 This protruding ear, in an eight year old boy, demonstrates the characteristic absence of a distinct anthelix . The flattened appearance reflects the in­ completely folded crus posterior.

24 Lightly pressing on the outer margin giv es the ant­ helix a more pronounced , softly-curved contour and puts the upper portion of the ear in a natural relation­ ship with the side of the head. This effect is reproduced when a perichondrioplasty is pertormed.

25 The patient is seen here on the operating table, draped and prepared for surgery. Periaural infiltration with 0.5 per cent Xylocaine® (lidocaineL con t aining epineph rine, is usually em­ p loyed, but in this instance special indications dic­ tated the use of general anesthesia,

I ThiS technique was first rep o rted at th e Fourth Biennial Meet ing of the lord Skoog Society in Valencia, Sp ain , May, 1973.

265

Preparing the perichondrial flaps

26 The posterior surface of the aural cartilage , corresponding to the anthelix, has been exposed .

27 The distinct groove of the crus anterior is easily identified and an incision is being made along this furrow, through the perichondri um .

28 The perichondrium is ele­ vated off the cartilage laterally, as far as the region of the posterior crus.

266

29 A similar dissection is ca rried out m edially, ove r the co ncha .

30 This maneuver is fa cilitated by the use of sma ll , sharp-edged elevators, whi ch strip o ff the ad­ here nt perichondrium . A knife may also be used , but it is then difficult to avoid damaging the cartilage. No cartilage should be left on the raised perichondrium; neither shou ld any peri­ chondrium remain in place, still adherent to the aural cartilage.

Reconstructing the anthelix •

31-33 In reconstructio n. the mobilized per ichondrial flap s are used for recontouring the ear cartilage, and the sutures are adjusted to give the desired fold to the anthelix. Two nonabsorbable (S upra mid) sutures sec urely an chor the perichondrium in position . The fibrou s nature of human perichondrium permits thi s method of reco nstruc­ tion.

267

34 A tightl y sea led sub peric hond rial pocket has been produ ced by using a supplementary, co ntinuous 5/0 Dexon suture along th e borders of the peri­ chondrial flaps. Bl ood drawn fro m the patient is being added to this created cav ity to act as a medium for ca rtilage growth .

Wound closure

35 The wound edges are accurately approximated with a running mattress suture of 4/0 plain catgut. Thi s suture effectively stops oozing from the edges and will have dissolved, when the patient returns for his first d ressing in ten days. No permanent marks are left by this suture material.

Immediate result

36-37 The upper portion of the ear ha s been com ­ pletely repositioned and normal anthelical crura have been formed. The immediate operative result em pha­ sizes the relatively large concha that remains to be corrected. In this case a secondary procedure was per­ formed, as shown on the next page, though total re­ constr uction can be made in one stage. A light, well-fitted co mpress ive dressing is used to protect the ear postoperative ly.

268

After four weeks 38--39 Four weeks postoperatively, the configuration of the ear is essentially un changed . This demonstrates the stability of perichondrial reconstruction, since in this case the molding force on the cartilage apparently had to be considerable. As a secondary procedure , a conchal resect ion was now performed. An elliptical, full thi ckness ear section was excised in the depth of the conc ha , co rrespond­ ing to the greatest conchal width. The technique for this procedure was described earlier in this chapter.

After supplementary conchal resection

40--41 The immediate results show the limits of the

resection. The ear has now attained a completely nor­ mal shape.

269

Perichondrial cartilage regeneration

42 In conjunction with the second stage of the procedu re, the perichondrioplasty was un­ covered. A thin, transverse section of the gen­ erated cartilag e has here been removed for histological examination . A black Supra mid sutu re, that had been left in place in the peri ­ c hondrium, can be seen at the upper resection border. 43 The shape and thickne ss of the newly formed cartilage can be better assessed in this drawing.

44 The newly formed cartilage, shown in the upper two thirds of this microphotog raph, differs from the normal ear cartilage at the bottom of the picture in that it possesses less regular stru ctures and an increased cellularity .

I

.. 270

45 Th e outer area of the new ca rtilage is shown in this picture. The richly ce llular zone at the sur­ face indicates that re generation o ri ginates from the perichondrium . (Hematoxy lin-eosin , x50.)

Final result 46-48 The results, six months after surgery, show the ear remaining in its immediate post­ surg ical shape and position.

•

271

Variations in operative technique

Case 1. Preoperative condition 49-50 In this five yea r old boy, the complete anthelix is poorly de­ veloped and is in fact effectively absent along the entire rim. As a result, the ear stands out at right angles to the head . In the upper portion of the ear, reconstruction was carried out with the use of perichondrioplasty along the po ste ri o r surface, as de ­ scribed in the previous case. In the mid-portion of th e ear, the en­ larged concha was reduced subcutaneously by removing an elliptical segment of cartilage.

I Result 51-52 The shape and relative position of the ear is corrected . The rounded , normal con figurat ion of the anthelical fold has been recap­ tured , branching out superiorly into the thin shelf of th e crus anterior, and gradually disappearing into the soft curve of the crus posterior. A slight thickening of the ca rtilage could be palpated at the site of the perich ondrioplasty. During follow-up over 6 months, no changes oc­ curred .

272

Protruding Ears

The above patients, used for demonstrating the surgical proce­ dures in perichondrioplasty, have both presented marked en­ largement of the aural concha, which required excision. Since perichondrioplasty is a technique that offers great possibilities for remolding the ear cartilage, it is a matter of personal pre­ feren ce in any particular case, as to what extent this method should be combined with a conchal reduction. The following example demonstrates correction of prominent ears by peri­ chondrioplastyalone.

Case 2. Preoperative condition

53-54 This fi ve yea r old boy presented with markedly protruding ears. The auricle lacks a natural contour and , in particular, the anthelical fold appears flatt ened .

273

Preoperative markings

55 Exerting gentle pressure on the rim reshapes the ear and forms a normal anthelix. The re­ Quired degree of fold ing is indi­ cated by the area ou tlined in blue, with the solid central line highlighting the created ridge. A perichondrioplasty WilS per­ f o rmed, which co rrected the ear according to the dotted pattern.

274

..

56 To secure orientiltion for the perichondrial dissection, the an­ terior markings are trilnsferred to the posterior surface in the fo l­ low ing mil nner. A fine need le is used t o pierce the ear. When the point shows through the skin, the tip is sta ined with methylene blue and the needle is then with­ drawn . Thi s leaves a blue imprint on the posterior surface of the cartilage in the desired spot.

Immediate result 57- 58 Reconstructing the anthelix has given shape to the ear as well as restoring the normal relationship of the ear to the side of the head . In a f rontal view the helical rim is seen to over­ ride the less prominent anthelix in a norma l fashion . Compa r e Figs. 53-54.

Final result

59--61 Th ree months after surgery, the immediate operative re­ sult has remained unchanged. T he anthelical ridge sweeps naturally into the graded prominence of the curved posterior crus and the fold of crus anterior. The se structures shape and define the triang ular fossa.

275

Comments

If free spanning sutures or nonspecific connective tissues are used to fold the cartilage back on itself, they will eventually be­ come lax and the ear will return to its original position . In ele­ vating the perichondrium, and suturing the layers together in a pocket above the old cartilage, new cartilage soon forms within the cavity . This reinforces the suture line and the cartilage sur­ faces become adherent to each other in a sculptured and per­ manent relationship . The cartilaginous proliferation is limited by the perichondrial membrane and new cartilage fills the roofed connection much as clay is deposited in a mold, up to the top and no more. The procedure uses a posterior approach, which leaves an inconspicuous scar and the newly formed tis­ sue is recognized on palpation as only a slight thickening of the ear cartilage. To achieve a pleasing result, the position of the ears must be symmetrically corrected and the harmonious balance between the curved and flattened areas restored. With a perichondrio­ plasty the cartilage is gently folded , not cut or crinkled Though experience undoubtedly is necessary to decide exactly what is needed in each particular case, using the perichondrioplasty technique facilitates anthelical reconstruction and provides an effective method of molding the ear into a natural shape. The regenerative potential of perichondrium is probably most pronounced in the growing individual. The tissue reaction in­ duced by perichondrioplasty is, however, repairative and should thus be present even in older patients . This view has been confirmed by the successful results obtained with adults and has also been demonstrated in animal experiments.

I 276

III. Perichondrial otoplasty in an irregular

deformity of the ear

Preop erative condition 62--03 Thi s striking ear deformi ty arises fro m an ab­ normal transverse foldin g o f th e ca rtila ge, ext ending from the anterior crus of the an theli x through the heli­ cal rim . The top part of the ear h as thus become bent and pointed . The drawing depicts ca rtil age config ura­ tion in a poster ior view. The patien t is a fi ve y ear old girl ; her left ear is normal and no simil ar malfo rma­ tion is known within the family.

Conventional otopl asty techniques fail to o ffer a sa tis­ factory operation f o r correcting this abno nmal ity. As a method for repair, it was decided to unfold the car­ tilage and to restore the norma l anatomy of the car­ tilage by a perichondrioplasty .

Operative procedure

Incisions 64 On the posterior surface , the skin has confor med to the reduced ear dim ensions. An in cision is made opposite the abnormal transv erse fold and ca rri ed into and along the postauricular groove. The skin was then undermined in the upper portion of the ear as far as the level of a normal anthelica l ridge .

277

Unfolding the cartilage

I

I

65 On exposure, the deformed cartilage was found to be fixed in an abnormal posi­ tion by a thin layer of scar-like tissue ex­ tending the length of the fold. These fibrous adhesions were cut and radically removed by sharp dissection , ca re being taken not to damage the adjacent cartilage. A fine double-edged dissector (Yasargil), used in microsurgery, proved to be an ideal in­ strument.

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lage unfolded and the ear regained its normal size. It then became apparent that the flattened cartilage surface lacked a normal sculptured appearance, in particular, an antheli cal ridge was ab­ sent. For recon stru cting this ridge, an incision through the perichondrium is planned (blue) to meet the normal ant­ helix, present in the lower portion of the ear. In the area of dissection the perichon ­ drium has been stripped off the carti­ lage .

I 278

Perichondrioplasty, utilizing flaps and a free graft

67-68 Two perichondrial flaps have been raised , care being taken to ensure that no perichondrial tissue is left on the cartilage . The flaps have a firm fibrous nature , which limits the deg ree of retraction.

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------_/

69 The perichondrial flaps are easily ad­ justed to curve the underlying cartilage into a normal appearing anthelical ridge. A few non-absorbable (Supramid) sutures and 5/0 Dexon hav e been used.

The scissors ly ing under the united flaps demonstrates the comparatively small re ­ construction that could be accomplished by available perichondrium.

279

70 At this stage, the mi d -portion of the ear lacked stability in the area where th e peri­ chondrium had been removed. To bolster the repair it was decided to cover th e peri ­ chondrial defect w ith a free graft, taken from the back of the au ral concha. The perichondrial graft has been dissected free and is now being removed.

''\, \

71 The free graft is held just above the denuded donor site, spread out between a forceps and hemostats. The re is lillie ap­ parent difference betwe en its oute r and in ­ ner surfaces. Yet, it i s i m po rta n t that the orientation be maintai ned with the cartiiag i · nous side facing downward s. This inne r sur­ face only possesses a co v ering cell layer capable of generating cartilage_

72 The graft has been secured over the defect with 5/0 Dexon sutures. This com­ pletes the perichondrioplasty.

280

?C: \

•

Immediate result

77-78 The normal size and shape of the ear is restored. The heli­ cal rim presents an even conto ur and the antheli ca l c rura have reappeared . Only a minor irregularity still indicates the original fold at the posterior border of the anthelix. For additional support during the healing period , a roll of vas e­ line gauze is fitted over this area and held in place with two cat­ gut sutures . In addition, a simple protective bandage was worn for ten days, at which time the catgut sutures had dissolved and healing was complete .

Final result 79-80 The immediate operative result has remained unchanged over a th ree months follow-up period . The reconstructed por­ tion of the anthelix curves naturally between the reformed scapha and triangular fossa. Subcutaneous scarring is in­ significant but a slight, even thickening of the cartilage can be palpated along the entire perichondrioplasty and it completely stabilizes the ear. The postauricular skin flap has pro v ided ade­ quate coverage for the posterior surface.

282

l

•

References

Baruch J. : Correctio n des o reilies d ecoliees par striation anterieure de l'anthelix . Ann chirp last 75: 159, 1970. Cloutier M . l.: Correcti on of outstanding ears. Plast Reconstr Surg 28: 412, 1961. Luckett W . H.: A new operation for prominent ea rs based on the anatomy of the deformity. Surg Gynec Obsl 70: 635,1910. McEvitt W . G. : The problem of the protruding ear. Plasl Reconslr Surg2: 481,19 47. Muhlbauer W . D.: Eine ein f ache und physiologische Methode der Kor­ rektur abstehender Ohren. Chirurgica p laslica 7: 126,1972. Skoog T.: Sy n punkte r pa den operativa behandlingen av utstaende bron . Reported to the Scandinavian Association of Plastic Surgeons, 7th Congress, Sept 5, 1958. (Not pub li shed.) Skoog T., Ohlsen L. and Sohn S. A. : Perichondrial potential for car­ tilaginous regeneration. Scand J Plasl Reconslr Surg 6: 123, 1972. Skoog T .: En ny operati onsmetod fbr utstaende bron . Read at the an­ nual meeting of the Swedish Surgical Society, November 29, 1973. Stenstrom S .: A " natural" technique for correction of congenitally prominent ears. Plasl Reconslr Surg 32: 509, 1963.

283

Chapter XII

Perichondria l potential for generating cartilage Experiments in rabbits

Introducti on 287

I. Regeneration of ear ca rtilage 288

Experiment 1

Experiment 2

Experiment 3

Experim ent 4

II . Growth of cartilage from free perichondrial grafts 293

Experime nt 5

Experi ment 6

III. Pathogenesis of cauliflower ear 295

Expe rim ent 7

Conclusions 296

References 298

I

Title page: In an experim ent designed to elu cidate th e pathogenesis of cau li ­ flower ear, a hematoma was created between perichondrium and carti lage in a rabbit's ear. Aft er four weeks, new cartilage has formed extensively within the collection of b lo od . The raised perichondrium is retracted and correspondingly the o ri ginal ea r car­ tilage bu lges over the mass. (Toluidine b lue, x 50 .1

284

Cartilage Regeneration

Ear cartilage

Regenerated cartilage

Experimental research

Peflchondflum

Introduction

Numerous experiments have been devised to mold diced auto­ logous costal cartilage into a useable structure, as a surgically shaped cartilage would be an invaluable clinical adjunct in re­ constructing the human ear, either following injury, or in con­ genital deformities (Peer 1955, Kruger 1964, and others). How­ ever, the earl y inve stigations yielded no or insignificant new car­ tilage (Walia et al. 1962, Peer et al. 1966). These researchers failed to generate growing cartilage because they did not re ­ cognize the vast potential of the seemingly unimportant peri­ chondrium and thus ignored it completely in their respe ctive ex­ periments.

I

Our attention was turned to the perichondrium after studying the following phenomena. The cauliflower ear, the common dis­ figurement that besets wrestlers, develops from the trauma of bumping and twisting the ear . In the acute stage there appears to be hemorrhage beneath the perichondrium, which lifts it up off the underlying cartilage . New cartilage is formed in this blood-filled space, and repeated trauma perpetuates this process and adds still more cartilage. As cartilage itself is known to have little innate regenerative acti v ity, the source of this cartilaginous proliferation is probably the perichondrium. The situation is thus analogous to that seen in the periosteum-bone relation­ ship described in Chapters II and VII . Initiated by the above observations of periosteal bone formation and the postulated pathogenesis of new cartilage development in cauliflower ears, a series of experiments was conducted to investigate the chondrogenic potential of the perichondrium. These inv esti.gations were carried out in 2- 3-month-old rabbits (Skoog, Ohlsen and Sohn).

287

I. Regeneration of ear cartilage

Exp eriment 1

A. In the rabbit ear, the peri chondrium is grossly unremarkable and there is little to di sting uish it from ordinary co nne ctive ti s­ sue. In a pilot study (Skoog et al. 1972), thi s thin, nondescript t issu e layer was carefully dissecte d off the cartilage and rai sed as a flap. A 10 x15 mm oval shaped defect in the underlying car­ tilag e w as created , and the perichondrium covering the poste ri or surfa ce of the cartilage w as removed w ith the specimen . The perichondrial flap was then repositioned ove r the gap in the cartilage to re-establi sh perichondrial con tinuity. The other ear served as a co ntrol and there the rese ction of cartilage in cluded the coveri ng peri cho ndrium on both sides .

Results

No growth of ca rtilage was found in the co ntrol group, and after fo ur weeks a distinct breach remained between the cut edges (Fig . 1) . In the rabbits that were left f or a long er per io d of o b­ se rvation , some fi bro us scarring did occur. Thi s cicatri cin g pro­ cess de creased t he size of the defect and somewhat deform ed th e ear. In marked contrast , the defe cts that had been brid ge d w ith a perichondrial flap showed the d evelopm ent of new cartila ge (Figs. 2 and 4). The degree of response varied, but there wa s a con sistent formati o n of new cartilage in all cases w here a peri­ chondrial flap had been left to bridge the defect. The dev elop­ ment was more pronoun ced at four week s than earlier, but even in the le ss advanced cas es new ca rtilage formation was clearl y evident.

1 This ph otom icrogra ph demonstrates the per­ sistent gap in rabbit ear cartilage four weeks after surgical rem oval of a full thickness section of ca r­ tiJage and cove ring peri­ chondrium . (Hematoxy lin and eosin, x25.)

288

Cartilage Regeneration

2 In this specimen , where a br idge of peri ch o n­ drium was placed across a created defect in the cartilage, new, lighter staining cartilage has formed between the cut ends two weeks after surgery . The thi ckened appearance of the original perichondrium , as well as the regen ­ erated perichondrium covering the upper car ­ tilage surface can be seen . (Hematoxylin and eosin, x 45.)

.,.c.,-_ Ear cartilage ~---j""''''':;i--

Regenerate d carltlage

-• •

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• 3 The high powered view of the normal cartilage (upper half), with its mature cells, can be com­ pared with the young cartilage derived from the peri chondrium . The matrix of the new cartilage has formed up to the cut edge of the original cartilage and appears firmly adherent to its sur­ face. (Hematoxylin and eosin, x 17 5.)

I ~

4 This mi crophotograph from the center of the new cartilage shows it at an immature stage . There are several examples of active mitosis and the cells have become surrounded by the car­ tilage matrix . The regenerated perichondrium is seen at the top . (Hematoxylin and eosin, x 175.)

289

8. The defect in the first experiment was relatively small and thus , in a succeeding stud y the size of the removed segment of cartilage was enlarged. Another difference in experimental con­ ditions was that in one group of this second series a blood clot was placed in the created defect before repositioning the peri ­ chondrial flap . In the remaining rabbits no blood was added before replacing the flap .

Results

No appreciable difference was found between this experiment and the earlier work , where short perichondrial flaps had been utilized to generate cartilage . The response was directly related to the duration of the experiment. In the cases where the peri­ chondrial flap was pos itioned on a bed of clotted blood new cartilage completely filled the defect. In the remaining cases , the formation of new cartilage was more sparse. In contrast to the malformed control ear, the " flap " ear developed much more normall y . These studies clearly demonstrate the chondrogenic potential of the aural perichondrium, though it might be argued that regeneration took place from the cut edges and that the peri­ chondrium merely acted as a scaffold to guide the development of cartilage from both sides of the gap . To refute this possibility a second study was designed.

Experiment 2

A. A perichondrial pocket was constructed by removing a sec­ tion of cartilage while still leav ing the anterior perichondrium in­ tact. The cut cartilage edges were then brought together and sutured shut. This puckered the perichondrium into a bulb­ shaped recess, which had no continuity with any raw cartilage surface. 8. In another experimental model a " reversed " perichondrial pocket was created in the following way. The cut edges of the ovalshaped defect were approximated after hav ing folded the previously freed and reconstituted perichondriu m between the cut edges of cartilage . Suturing the elliptical defect shut, bunched the posterior skin about the folded perichondrium . The " activ e" surface of this perichondrium was thus facing outwards and the cut cartilage edges were completely sealed with a con­

290

•

Cartilage Regeneration

tinuous perichondrial layer bulging out under the skin. In one group of rabbits blood was placed subcutaneously, between the skin layer and the perichondrial flap, while in another group this was not done.

Results

A. When the perichondrium was simply raised and brought to­ gether along the bases , new cartilage developed inside the pocket, the mass being clearly defined by the enclosing mem­ brane.

B. In the cases where the perichondrial pocket had been turned inside out, to form a pocket, an irregular clump of new cartilage had grown between the raised perichondrium and the covering skin. No cartilage developed inside the pocket, which became completely obliterated . Thus , the generation of cartilage does originate from the deep, dissected surface of the perichondrial membrane only; though there is little to distinguish one side from the other, both grossly and microscopically. In the group, where a blood clot had been placed between the perichondrium and the skin, a subjective increase in cartilage was seen. In several cases the sutures used to close the car­ tilaginous defect had ruptured due to a heavy growth of new cartilage . This new cartilage was found to arise between the car­ tilage edges and the perichondrial flap .

Experiment 3

In view of the forementioned technical difficulties of keeping the cartilage edges sealed, the experiment failed to unequivocal­ ly pinpoint the growth of cartilage to the perichondrial flap and to exclude the possibility of the cartilage edges participating in the chond rogenesis . A way to isolate the development of new cartilage was to raise a perichondrial flap and set it down across a 1 cm diameter teflon ring. This completely separated a portion of the peri­ chondrium from the cartilage. In this "perichondrium through a hoop" experiment new cartilage developed in the middle of the ring. There appeared to be some mechanical limitations, caused by elevating the flap too far off the vascular surface, but though there was some decrease in the rate of growth, new cartilage did develop . 291

In a group of rabbits, where a blood clot had been used to fill the ring, the effect of hematoma as a matrix for perichondrial cartilage growth was strikingly evident. This experiment confirmed that the perichondrium was indeed the source of this new growth, not the cut ends of the remain­ ing cartilage.

Experiment 4

With the virility of perichondrium becoming established, the chemistry of the tissue was further investigated (Wasteson et al. 1974). In the rabbit ear, a control defect and the standard car­ tilage resection leaving the perichondrium to bridge the gap on one side , were consecutively made. At weekly intervals, for six weeks,5 mm punched speci mens were taken from the control area, the flap, and the untouched cartilage and tested on its ability to incorporate " SO •. The results showed that the uptake was approximately the same for both normal cartilage and the tissue which was derived from the perichondrial flap. Both tis­ sues contained papain resistant material which was precipi­ table by CPC (cetylpyridinium chloride) , demonstrating the presence of polysaccharides. The macromolecular characteristics were also identical when tested by gel chromatography . Control areas, where cartilage and covering perichondrium were com­ pletely removed did not take up any radiosulphate. Thus, biopsies taken from regenerated cartilage showed that the newly formed tissue synthesizes a substance which with regard to its chemistry and macromolecular composition seems to be identical with chondroitin sulphate.

292

II. Growth of cartilage from free perichondrial grafts Having established the chondrogenic potential of the peri­ chondrium of the preceeding experiments , it was then necessary to further elucidate the involved mechanisms and to better de­ fine the limitations and possibilities of utilizing this tissue for reconstructive purposes.

Experiment 5

The first study programmed along these lines was an outgrowth of utilizing the long perichondrial flap. In the previous work the raised flaps were based on rather precarious and tenuously suf­ ficient pedicles. This indicated that free grafts might thrive equally as well. A study was thus devised to further test the perichondrium by removing it from its original blood supply and transferring it as a free graft (Sohn et al. 1974). The trachea was chosen at the recipient site for the graft, because tracheal reconstruction has been a vexing clinical problem and many dif­ ferent material sources have been tried to rebuild stenotic and gaping defects. As cartilage is the normal supporting matrix of that structure , it would be an obvious advantage to be able to position perichondrium over a defect and obtain new cartilage. A two-thirds resection of two cartilaginous rings was carried out in two different areas, separated by three to six tracheal rings. Care was taken to preserve, intact, the mucous membrane lin­ ing of the trachea. If a puncture was inadvertantly made, the site was closed and a new area was chosen. A coating of blood was allowed to collect and partially fill the defect. After taking the perichondrial graft from the ear in the usual manner, it was immediately transferred and secured to the more superior defect. The second gap was left undisturbed, to serve as a control.

Results

Two to ten weeks after surgery, the results conclusively showed that new cartilage had developed where the grafts had been positioned. In contrast, in the control areas there was no growth of cartilage, where the defect was occupied by non-specific granulation tissue. The developing segments were irregular, and more cellular than the neighboring tracheal cartilage (Fig. 5). When compared to the normal hyaline cartilage of the trachea the new cartilage cells had less developed lacunae and were not as compartmen­ talized as the mature, original chondrocytes. As with the spec i­

293

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mens obtained in earlier experiments using perichondrial flaps of the ear, the cartilage that was generated across the trachea did not possess dark elastic fibrils, though a lighter elastoid pattern could be discerned. This suggested that the regenerated cartilage more closely resembled its aural precursor.

l

The new cartilage was found to be completely enclosed in peri­

chondrium. The exterior part. representing the original peri­ chondrium, was definitely thicker than the original perichondrium , whereas the newly formed perichondrium covering the remain ­ der of the growing cartilage was of a normal, thin appearance.

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The tracheal lumens were of normal caliber throughout and there was no evidence of any collapse or significant narrowing that might have compromised respiration. During the course of the experiment the tracheal size increased considerably. Despite this marked change no stricture occurred , which may indi cate that the new cartilage grew commensurately with the rest of the rabbit.

Experiment 6

294

The possibility of using free perichondrial grafts in other parts of the body were also studied (Ohlsen et al 1974). Molds of mesh wire were then utilized as a scaffol d on which the peri­ chondrium was draped. The rolled wire surfaces with the at­ tached perichondrium, sometimes with active surface facing in­ wards sometimes with the order reversed, were then placed in various parts of the rabbit body. These mesh molds were placed in the omentum , the li ve r, and the neck area. Cartilage was generated from them in all instances, though not in large amounts .

III. Pathogenesis of cauliflower ear

A review of the literature fails to give a clear account of the mechanism of the cauliflower ear Kelleher et al. (1967) felt that the traumatic event that caused the ear deformity was the shearing of a thin layer of cartilage along with the perichondrium and the subseq uent development of a serous collection be­ tween this very thin layer of cartilage and the remaining surface . Microscopic studies were used to corroborate their hypothesis. The specimens were taken from clinical cases examined a few days after the initiating traumatic event. This delay is the im­ portant factor in evaluating the study. In the light of our previous research it seems more likely that the perichondrium alone had been sheared away with the anterior skin surface, and in the time interval between the insult and the analysis, new cartilage cells had begun to proliferate. Thus, when examined under the microscope some three days later, it appeared that a layer of ca rtilage had been stripped away with the perichondrium, while actually this was an actively proliferating layer arising from the perichondrium itself. That the cartilage was sheared away is un­ likely because of mechani cal limitations and secondly because it would mean that the new cartilage must develop from the old layer of cartilage which has previously been shown to be a very slow if nonexistent precursor of new ca rtilage. Converse (1964) localized the patholog y to the anterior ear surfa ce because the skin here is firmly adherent to the perichondrium and co n­ sequently, when trauma occurred the perichondrium was rip­ ped away from the cartilage by this shearing force. In his opinion, the new tissue that developed was not new ca rtilage , but merely nonspecific granulation tissue.

Experiment 7

Appreciating that there was an incomplete understanding of the pathogenesis of cau liflower ears an experimental study was designed to demonstrate the pathophysiology of this deform ­ ity (Ohlsen, Skoog and Sohn 1974) . In one ear, a co llection of blood was placed under the raised peri cho ndrium which was then sutured back in place and the skin closed . In the other ear, an equal amount of blood was deposited between the intact perichondrium and the skin .

Results

In the first study, new cartilage developed under the perichon­ drium, but in the ear in which the blood was left above the sur­ fa ce of the cartilage covered by the perichondrium complete resorption of the clo t occurred (Figs. 6-7). The cauliflower ear was thus shown to be mushrooming ca rtilage, arising from a

295

i

6 This section of a rabbit ear was made 4 days aher an experimentally created hematoma in the subcutaneous tissue layer. The collection of blood is seen adjacent to the undisturbed peri­ chondrium. (Hematoxylin and eosin , x45.)

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7 After 14 days, the subcutaneous hematoma is largely absorbed without causing any rea ction in the underlying perichondriu m and cartilage. There is still a slight thickening of the ear ; in another week the anatomy was fully restored . (Hematoxylin and eosin , x15.)

..

layer of raised perichondrium which was further stimulated by a sero-sanguinous medium. The subperichondrial hematoma was extensively invaded by chondroblasts within two weeks, and over a period of four weeks the new tissue gradually changed into more mature cartilage (Figs. 8-11) . It was a consistant finding that the separated perichondrium retracted to form a flat surface, which caused the original cartilage to raise and buckle over the hematoma. Similarly to what is observed in human pathology. Based on this instructive series of experiments successful methods for treating cauliflower ears have been developed .

•

Conclusions

This series of experiments have demonstrated the perichon­ drium to be an active, adaptable and malleable tissue which has promising possibilities in reconstructive surgery. Clinically , the work has so far led to the technique of perichondrial oto­ plasty for correction of protruding ears, as described in Chapter XI. This potent tissue may prove to be a valuable asset in sol v ­ ing structural enigmas in the ear and in other parts of the body.

296

•

Two weeks

8-9 Two weeks prior to collecting this specimen, a subperichondrial hematoma w as placed on the front of a young rabbit 's ear . There has been a massive migra­ ti on of cells into this medium. Cha racteristically, the covering ear cartilage is rai sed and thinned , whereas the bordering, straightened perichondrium has thickened . The higher-power view of the newly developed t issue indicates the impending formation of ca rtilage in the aggregation of mesen chyme-like ce lls . (Hematoxy lin and eosin , x 15 and x 40.j

Four weeks

10- 11 At 4 weeks, the tissue developing with in a subperichondrial hematoma presents the characteri stics of young cartilage. Along the border of the original cart il age, residuals of the imp lanted h em atoma are still present, now trans­ formed into islands of vascularized, non­ specific connective ti ssue.

At greater magnifi ca ti on the newly formed tissue revea ls marked histo logi c changes in two weeks. The cells have proliferated and become rounded , a car­ tilage matrix has form ed separating the cells from each other demonstrating the fibrillar structure o f ear cartilage. (Hematoxylin and eosin , x 40 and x 130.)

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References

Converse J. M.: Acquired deformities of the auricle. Reconstructive Plastic Surgery. Ed. J. M . Converse, Saunders, Philadelphia , 1964, vol III , P 1107. Kelleher J . C., Sullivan J . G., Baibak G. J. and Dean R. K .: The wrestler's ear. Plast Reconstr Surg 40: 540,1967. Kruger E.: Die Knorpeltransplantation. Carl Hanser Verlag , M unchen, 1964. Ohlsen l. and Sohn S. A.: The chondrogenic potential of free peri­ chondrial grafts. Experiments in rabbits. (To be published in 1974.) Ohlsen l., Skoog T . and Sohn S. A. : The pathogenesis of cauliflower ear. Experiments in rabbits. (To be published in 1974.) Peer l.: Transplantation of Tissues II. Williams & Wilkins Comp, Baltimore, 1955. Peer l. , Walia I. and Bernhard W.: Further studies on the growth of rabbit ear carti lag e grafts. Brit J Plast Surg 79: 105, 1966. Skoog T., Ohlsen l. and Sohn S. A.: Perichondrial potential for car­ tilaginous regeneration . Scand J Plast Reconstr Surg 6: 123, 1972. Skoog T., Ohlsen l. and Sohn S. A.: The chondrogenic potential of the perichondrium. (To be published in 1974.) Sohn S. A. and Ohlsen L.: Growth of cartilage from a free peri­ chondrial graft placed across a defect in a rabbit's trachea. Plast Reconstr Surg 53 : 55, 1974. Walia I., Peer L. A., Bernhard W. G. and Gordon H. W .: Does growtn occur in young rabbit ear cartilage grafts transplanted in young rab­ bits 7 Plast Reconstr Surg 29: 259, 1962. Wasteson, A., Ohlsen L. and Sohn S. A .: Biosynthesis of chondroitin sulphate from perichondrial flaps. (To be published in 1974.)

•

298 •

Chapter XIII

Face-lift operation -

advancing the skin, subcutaneous tissues,

the buccal fascia and cutaneous muscles in a two-layer shift Introduction 302 General considerations 305 Su rgical procedure

Anatomy

Anesthesia

Operative procedure 308 Supplem enta ry intravenous anesthesia

Nerve block

Incisions

Dissection of the temporal and lateral cheek areas

Advancement of the superficial fascia over the buccinator area

Dissection of the postauricular area and neck

Advancem ent of th e platysma

Adjustment of the orbicularis oculi

Advancement of the superficial fascia of the cheek

Advancement and excision of redundant skin

Dressings

Result

Comments 324 Bleeding

Nerve lesions

Postoperative care

Healing

Advantages of a two-layer shift 326

Forehead wrinkles References 330

300

The Aging Face

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A method of correction

•

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Introduction

Self-love, my liege, is not so vile a sin As self-neglecting William Shake speare : Henry V (1598)

The Quixotic wanderings of Ponce de Leon epitomize man's endless quest for youth. With magical incantations , secret potions, and a vast array of ineffective devices, men have vainly sought to halt the relentless windmills of time. Nowhere is the harsh reality of aging more expressive than in the weathered and wrinkled face. Crossed with the tireless passage of deepening creases, the drooping folds and lax, overhanging skin pouch into sagging bags and unsightly jowels. The ev en contour of the youthful chin disappears, and the smooth tex­ tured surface turns to pleated parchment. Through each passing year, the furrowed profile remains unaided by a myriad of misleading panaceas. Only in plastic surgery is there a pragmatic alternative to the frustrating inevitability of aging. The face-lift operation has recently gained wide-spread accept­ ance by the lay popUlation and the medical profession at large. As in other aspe cts of plastic surgery, there has been a con­ tinuing search to improve techniques and achieve better and more lasting results , but surgical methods have remained basi­ cally unchanged and fairly routine. All the operations com­ monly employed share two principal features : (1) in under­ mining, the dissection is carried out almost exclusively within the subcutaneous tissue layer, close to the dermis, and always external to the superficial fascia and the platysma; and (2) in closure, tension is placed mainly on the skin (Hollander 1957, Gonzalez-Ulloa 1962, Pickrell 1967, Spira et al. 1967, Conley 1968, and others).

This fails to consider an important relationship in the aging face, for as Conley cogently recognizes, "The absorptive and atrophic changes in the skin are three dimensional; with relaxation of these soft contractile elements and their supportive structures. These deeper anatomic struc­ tures are in reality the foundation and architecture of the integu­ ment, and by deterioration in their position would automatically be reflected in facial form and expression. "

Yet, in spite of these studied remarks, in Conley's approach, as in the majority of methods, nothing is done to readjust or re­ position the deeper structures . Recently (1972) Pennisi and Capozzi recommended that the layer of fat, that lies beneath the skin flap, be separately suspended, but again this was done without undermining or other surgical interference. For a simi­ 302

The Aging Face

lar purpose, Aufricht (1960) plicated the subcutaneous tissues. The fascia and the facial mus culature, however, have thus far been essentially abandoned. In the face , as in the rest of the body, the skin and the sub­ cutaneous fat are intimately related to each other and form a compound morphological entity, enclosed by the superficial fas cia. An analysis of the mechanics of aging makes it apparent that the two interconnected layers will shih together and are equally responsible for the sagging fa ce, while the displaced cutaneous muscles, the platysma and the orbicularis oculi , produ ce wrinkling and folding . When these basic anatomical changes are ignored and the surgical correction concerns itself with the skin alone, the result is compromised . To remedy this fundamental error, a technique has been devel­ oped which is in part founded on a new set of principles. In addition to tightening and excising superfluous skin, the sub­ cutaneous fat layer with its fascia, as well as the cutaneous muscles of the neck and face, are repositioned (Skoog 1969, 1972, 1973).

303

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304

General considerations

Surgical procedure

The bi-pronged hallmark of this operation is: (1) the mobiliza­ tion of skin and subcutaneous tissues at a level deep to the subcutaneous fascia of the cheek and to the platysma , and (2) a readjustment of redundant skin by a two-layer shift. advancing the cutaneous and fascial-muscle layers separately. This tech­ nique is based on certain distinguishing features of facial anat ­ omy.

Anatomy

On its external aspect, the platysma is intimately associated with the skin and subcutaneous tissue of the entire anterior neck . The under surface of the muscle, however, is not fixed to the deeper structures , and a potential space is present between the smooth fascia of the platysma and the external cervical fascia. This anatomical configuration allows the superficial layers to glide with the platysma over the deeper, fixed struc­ tures. Thus, the platysma provides a corner-stone for rearrang­ ing superficial neck tissues. Traction on the muscle redistributes the cutaneous .Iayers in a smooth, even plane. The span of the platysma varies with individuals, but generally a comparable advancement procedure can be performed in the mandibular area . In the face, the fascial architecture is another reference point for reconstruction. In the temporal , preauricular and particular­ ly in the parotid area, the facial , or deep, fascia is distinctly defined, covering major nerves and vessels which pass closely underneath. In these areas the superficial, or subcutaneous , fascia is fixed to the dense, deep fascia by fibrous adhesions. At the anterior border of the masseter muscle this close ana­ tomical relationship ceases. Anteriorly. over the expansile buc­ cinator. an areolar space exists just beneath the subcutaneous fascia, extending as far as the nasolabial fold. In dissection, when this cleavage plane is entered, the covering skin and the subcutaneous fat with its smooth fascial lining are easily raised en bloc. superficial to the fatty ball of Bichat, the suctorial pad. This lobulated mass of fat varies in size but is a constant finding , even in the thin and elderly . It covers the parotid duct and the facial nerves and vessels on the external surface of the buc­ cinator. As a result of this arrangement of the fascial framework , redundant skin and subcutaneous fat in the buccal area droops and bulges at the nasolabial fold, and conversely, lateral ad­

305

vancement of the superficial fascia (buccal fasci a) within this area effectivel y takes up any slack at the angle of the mouth and softens the pronounced nasolabial fold . To eliminate troublesome wrinkles situated at the late ra l canthus of the eye, the orbicularis oculi muscle may also be separately rearranged .

Anesthesia

Local anesthesia with a vasoconstrictive agent is preferred in all cases. There is a significant reduction in bleeding when compared to conditions under general anesthesia , even when supplemented by local infiltration. Fu rthe rmore , local anes ­ thesia eliminates the need for endotrache al equipment . T his facilitates draping and positioning the pa tie nt, while simulta­ neously reducing the possibility of operative field contamina ­ tion. The many hazard s associated with intubation are also avoided , and the recovery phase is quicker and easier. Adequate analgesia for this large operati v e field often requires the administration of an amount of anesthetic that approaches the maximum permissable dosage . Systemic reactions, m ani ­ fested by a rise in blood pressure and pul se are common. These side effects, in part caused by the va soconstrictor ag ent, can be reduced by employing regional block anesthesia w hich anesthetizes the area innervated by the infraorbital and man­ dibular nerves as well as the superficial cervical plexus . The immediate tract to be incised is infiltrated locally. This tech ­ nique has reduced the required anesthetic by about half; 1 per cent lidocaine (Xyl o caine ®) with epinephrine is used for the nerve block, and 0.5 per cent lidocaine with epinephrine for local infiltration along the lines of incision. Operative analgesia is established in five minutes and has a duration of three hours . In the block procedures, care must be taken to position the needle accuratel y . As the patient is asleep during the injection and paresthesiae cannot be confirmed, the surgeon must be completely familiar with the technique. Regional block anesthesia is superior to local infiltration as it does not obscure the anatomy with massive amounts of fluid . The lift can be more effecti vely and accurately executed when skin and subcutaneous tissues are undistorted. Furthermore, any change in facial nerve function can be detected during the operation, and pain and swelling are less in the post-operative period.

306

•

The Aging Face

1

The patient is placed under intravenous general anesthesia while the block is performed to obviate the pain associated with repeated injections, and thus limit the psychomotor re­ sponse. Thiopental (Pentothal @) is preferred as it induces a short light sleep, and will often keep the patient sedated for a considerable part of the operation. Should there be discomfort during certain operative manipulations, the block may be tem­ porarily augmented by additional administration of Pentothal or any other desired anesthetic. When analgesia is inadequate, one should not hesitate to repeat the block . No complications have occurred with this biphasic technique, which has been used for many ye ars.' It has proved most satisfactory for pa­ tient and surgeon alike. It does require restriction of oral intake for at least six hours prior to surgery. If the entire procedure is expected to last for more than three hours, the operation is completed on one side before the other side is anesthetized. Again, the regional block is repeated under intravenous anesthesia. Even with nerve block anesthesia blood loss is insignificant. This surprising finding is basically a result of using an ana­ tomic plane of dissection, but in a large measure the physical and mental relaxation afforded by systemic sedation contribute to this diminished blood loss. In an analogous setting Webster (1972), Dingman (1972), and others co nfirmed this observation. They reported minimal bleeding when local anesthesia was supplemented by a combination of sedatives and tranquilizers.

I The technique has been developed in cooperation with Dr . S6ren Englesson, Associate Professo r, Department o f Anesthes ia, University Ho sp ilal , Uppsala , Sweden.

307

Operative procedure

2 In this procedure, the subcutaneous fascia within the buccinator area and the platys ma are identified at their lateral borders . These struc­ tures are freed on their deep surfaces and ad­ vanced in a postero-superior direction . The or­ bicularis o cu li may also be exposed and re­ arranged in the lateral canthal region. The limited area of sharp undermining is in­ dicated in yellow-green , while with in the blue space, mobilization can be accomplished by blunt dissection.

Supplementary general anesthesia

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3 The patient is placed in the recumbent posi­ tion on the operating table. The face is prepared for surgery and draped with self-adhering trans­ parent plasti c sheets 1 Under intravenous gen­ eral anesthesia , a regional nerv e block is ad ­ ministered . The surgical assistant must be pre­ pared to prop up the lower jaw if any sign of obstruction develops. An intravenou s ca nnula is maintained through­ out the operati ve procedure so that if needed, additional anesthesia or se dation may be given. The patient is carefully observed during surgery by monitoring pulse , blood pressure and heart fun cti o n by ECG when indi cated .

•

308

Nerve block

•

4 Infraorbita l nerve block. The infraorbital fora­ men is located just below the infraorbital margin and about two cm from the lateral surface of the nose . Approximately 2 ml of 1 per cent Xylocaine® (lidocaine) with epinephrine is in­ jected around the nerve as it leaves the foramen .

5 Mandibular nerve block. In this technique an external route is recommended (Moore 1967). The puncture site lies just below the zygomatic arch, ove rlying the middle of the mandibular notch. At this point, approximatel y 1.5 cm in front of the tragus of the ear, a 5 cm 22 gauge needle is in serted at an angle perpendicular to the skin. At a depth of about 4 cm, the needle pOint usually meets the lateral pterygoid plate. The mandibular nerve is found just posterior to this bone. The needle tip is theref ore redirected posteriorly until it no longer co ntacts bone. In this area about 4 ml of 1 per cent Xyloca ine" with epinephrine is injected, but before infiltrat­ ing it is important to aspirate for blood so as not to inad vertantly give an intravascular bolus of anesthetic.

309

6 Superficial cervical plexus block. The superficial branches of the cervical plexus emerge behind the middle of the sternocleidomastoid muscle, along its posterio r margin. This area is similarly injected subcutaneously and subfascially with approximately 4 ml of 1 per cent Xylocaine® solution with epin ephrine, using a 22 -gauge needle. In addition to the nerve blocks, the area to be incised is infiltrated to ensure hemostasis. Approximately 10 ml of 0.5 per cent Xylocaine'" with epinephrine is injected bilat­ era lly. 7 The areas of skin anesthesia produced by nerve b locks correspond to the regions supplied by the infraorbital nerve, the mandibular nerve and the superficial cervical plexus.

310

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Infraorbital nerve

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Mandibular nerve

Cervical plexus

Incisions

8 The incision begins superiorly, appro ximately 2 cm within the frontoparietal area of the scalp, and angulates in an inferolateral dire ction to the preauri cu lar area. Inf erior ly it courses around the lobule of the ear and follow s the postauricular f old to the level of th e tragus whe re it angles posteroinferiorly, just w ith in the hairline, for a distance of about 4 cm. Initially, to hide the scar line, the preauricular incision was curved into the auditory canal. This , however, often even­ tually distorted the tragus w hich wa s far more object ion­ able than the in consp icuou s scar now obta ined . It also ob­ scured the delicate stru ctures of the tragus under the thicker skin advanced from the cheek. Some patients may object to a postauricula r scar pla ced beside the hairline . To av oid thi s the posterior in cisio n can be moved into the scalp region as was once suggested by M cindoe . As a result the hairline will be raised in this area . In men the temporal incision is usuall y made in front of the hairline . In time, it becomes possible to estimate the extent of tem­ pora l skin reduction . Starting 1 to 1.5 cm behind the tem­ poral hairline, the hair is cut close to the sca lp to coincide with the area to be rese cted . Th ere is no need fo r further hair removal, as the stra nds can easily be retra cted away from the operative field with ad hesive drapes .

311

Dissection of the temporal and lateral cheek areas

9 Dissection is begun in the frontoparietal area, in the loose areolar plane, superficial to the temporalis fascia and the temporal vessels . In developing this part of the flap, blunt dissection can be used anteri ­ orly to avoid damage to the frontal branches of the facial nerve. The degree of temporal undermining required for raising the eyebrow and for correcting the lateral canthal region depends on subcutaneous tissue mobility and is estimated prior to surgery .

10 Cheek undermining is begun with the scalpel and completed with a pair of scissors. Block anesthesia facilitates the dissection between the thin fascial under­ covering of the subcutaneous tissue layer and the deep fascia of the face , which is left undisturbed over the wound surface . A vascular network behind each fascial sheet is easily visible.

11 Comparatively few vessels pass between these two systems and any vascular communication can be separated and controlled without difficulty . The forceps point to a pair of connecting vessels. Char­ acteristically in this area an artery and vein run close together; when cut, both ends must be secured.

312

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Over the parotid fascia the subcutaneous tissue ad­ hesions are firmer and in the zygomatic area there are also rather tight attachments to the underlying bone.

A dvancement of the superficial fascia over the buccinator area

12 At the I~vel of the anterior border of the masseter muscle the anatomical plane of dissection changes abruptly. In front of this line, the tissue layers can be easily separated by cautiously spreading the scissors. In this manner, the instrument can be advanced to the nasolabial fold without effort. In the roof of this space, the clearly defined superficial fascia (b uccal fascia) bordering the subcutaneous fat layer, displays a char­ acteristically smooth surface. On the floor of the cavity, the buccal fat pad of Bichat protrudes, and is here shown between the scissor blades . Depending on the size of this well-defined mass of fat, the parotid duct, branches of the fifth and seventh cranial nerves and a few vessels may be visible. Exposure is readily completed without injuring the se vital structures, which are all transversely arranged. Frequently an intersecting vessel guards the entrance to this space and must be divided and ligated. (See Fig 1, P 304.)

13 The scissors have been introduced into the bucca l space and advanced by blunt dissection as far as the nasolabial fold. Here they meet resistance, as in front of this line the skin is firmly adherent to underlying muscle.

313

14-15 At this stage, shifting the subcuta­ neous fascia in the buc­ cinator area can be de­ monstrated. In the photo­ graph the lateral edge of the fascia is grasped with two pairs of forceps. The drawing shows the re­ lation of the fascia to overlying redundant sub­ cutaneous tissue and the masseter muscle. No traction has yet been applied .

-Buccal fas cIa Fat pad of aichat

M. Buccinator ..:j;-!-- - M

Masseter

16-17 Gently pulling the superficia l fascia backwards markedly redistributes the overly­ ing tissues and is partic­ ularly useful in correc ting the sagging cheek and the depressed nasolabial fold. An excess of skin and fat at the angle of the mouth can now be effectively eliminated . The extent of advance­ ment is usually about two cm . Overcorrection is possible .

The advanced fascia is fixed to the masseteric fascia by 3/0 Supramid' and 3/0 Dexon' sutu res. I

314

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Dissection of the postauri cular area and neck 18 In the postauricular area the superficial fascia is

rarely well-defined . It can be identified, however, when the skin is raised by sharp dissection, close to the mastoid fascia. Care is exercised to prevent damage to the sensory nerves that course im­ mediately beneath this fascia. The vascular plexus of the flap is also protected as shown here by staying in the correct plane of dissection .

19 Cervical skin dissection stops at the upper an­ terior margin of the sterno cleidomasto id muscle , where it is crossed by the platysma . At this level , the lateral edge of the platysma is identified and freed , starting at least 1 cm inferior to the mandible and con tinuing for approximately 3 cm. Here this dissection is performed just in front of the greater auri cu lar nerve.

20 In front of the sternocleidomastoid muscle, the dissection moves anteriorly for a few cm on the underside of the platysma , in co ntrast to the usual outer surface approach . On the inner aspect of the platysma the undermining is facilitated by using the anatomical cleavage plane, which lends itself to blunt dissection. The mandibular branch of the facial nerve is protected by proceeding bluntly and staying below the level of the mandible. The edge of the platysma is elevated , demonstrating the natural space deep to it. The tip of the scissors lies between the external jugular vein and the greater auricular nerve .

21 After sufficient mobilization , traction at the edge

pulls the entire platysma in a posterosuperior direc­ tion , producing a remarkable effect on redundant neck tissues. No further undermining is necessary to improve midline contour.

315

Advancement of the platysma

22-23 The edge of the platysma with its accompanying fascia is sutured to the mastoid fascia, level with and posterior to the ear lobe . The platysma should now be stretched tightly . The interconnecting ar­ rangements of the subcutaneous and cuta­ neous layers evenly dist ri bute this tension to the midline, thus permitting realignment of the integument of the entire neck. Over­ correction is possible and may temporarily produce an unpleasant feeling of tig htn ess over the larynx. The edge of the platysma is gene rall y advanced 2 to 3 em. N on­ abso rbable sutures are used for fi xat ion, ca re being taken not to include the sensory nerves in the sutures. For this reason, the needle should pass vertically through the mastoid fascia.

24 After suturing of the platysma, there is little area in the postauricular region left exposed . The anterior border of this small defect now als o represe nts the extent of effective subcutaneous undermining . This significant advancement has been made without applying direct traction to th e skin itself.

316

•

25-26 In some individuals , a similar procedure can be car­ ried out at the inferior aspect of the cheek . Here, the range of the platysma varies and, when present, the muscle often does not hav e a clearly defined deep fascial surface. A more entailed dissection is thus required at the border. Traction on the facial platysma is less dramatic than in the neck, but it will effect a marked improvement in the man­ dibular contour. As is demonstrated in the second suture, the tissues can generally be advanced by approximately 2 cm. When the muscle is thin or absent the superficial fascia is included in the sutures. In all subcutaneous closure, 3/0 Dexon is used .

Adjustment of the orbicularis oculi 27 The lateral border of the orbicularis oculi is ex­

posed and held by for­ ceps. To smooth overlying skin and prevent excessive

wrinkling at the lateral canthus, the mus cle may be splayed out and sutured in this spread position. The or­ bicularis oculi may even be split laterally and the cut ends separated , without dis­ turbing eyelid fun ction. If correction of the eyelids is deemed necessary, this can be executed as a sep­ arate maneu ver, either at the beginning of the face­ lift operation or at a later stage. In conjunction with blepharoplasty, crawsfoot wrinkles may also be eliminated by local resection of the orbicularis muscle .

317

Advancement of the superficial fascia of the cheek 28 In the cheek area the full thickness of the flap is shifted in a posterosuperior direction and stabilized with a few interrupted Dexon sutures, placed between the subcutaneous fascia and the facial fascia covering the deep wound surface . Dead-space is thereby obliterated and tension on the preauricular suture line is also reduced by these support­ ing sutures . The effect of this fascial shift depends on the mobility between the skin and the re­ lated subcutaneous fascia. In most patients, the fibrous connecting bands are sufficient­ ly loose so that tightening the fascia does not restrict skin advancement. When the skin is lined with a heavy and distended adipose layer, tension applied to its fascia may not be fully transferred to the super­ ficial layers. Relaxing incisions through the fascia into the subcutaneous tissue will allow for an evenly extended shift across the entire face. Similarly, fibrous septa between the skin and its deeper layers may prevent the skin from being completely stretched. These connections should be identified and severed at this stage.

318

29 The major skin redundancy has been eliminated by merely shifting the deep tissue la yers . Tension has thus far only been applied to the platysma and the fasciae ; the skin and the subcutaneous fat have been almost fully advan ced w ithout interfering with the vascular supp ly to the flaps.

31 9

,.

Advancement an d excision of redun dant skin 30 The ski n i s now advanced to th e desi red tautness , and the overlapping ed ge is in cised at th ree se lected points, up to the excisional margin. A key tension su ture i s secured at each of these points . The first and m ost im portant stit ch is placed above the ear, at the anterior crus of the helix. T he second is positioned higher up in the temporal ·regi o n , and the third point is si tuated p os teriorly, at the peak of the postauricular incision. Thi s last suture is dem o n strat ed in a sub­ sequ ent photograph . Betwee n these sutures the un­ necessary skin is excised in a line para ll el with the adjacent skin edge. In the temporal area , excess scalp is removed in such a way that suturing the anterior, h air-bearing tem­ p o ral flap redi stributes the ten sion between the key sutures. In th is area 3 / 0 catgut ' is used . Thi s sub stance will produce no more scarring than nonabsorbable material , and it has the added advantage of disso lv­ ing in about o ne wee k.

I

Elhi con, In c., Sommervi lle. N .J., U.S.A

320

In tighten ing the skin, and drawing it upwards and backwards, a pu cke ring wil l generally become evident at the t op of the incision . Thi s triangular r ed undancy is transve rsely exci sed .

31 In correcting the neck area , t he skin is dra w n in the direction of the postauricula r f old . In this p arti c­ ular case, the flap e:
32 The superfluous skin in the pre- and p ostauricular area is excised so that the skin edges can be ap­ proximated without tension. This reduces scar forma­ tion in the most visible area of the meloplasty. Sec­ ondary distortion of the tragus or the ear lobule is also avoided .

33 When the cheek flap is advanced, subcutaneous trimming of the fat layer is often necessary to even out the preauricular suture line. Nonabsorbable ma­ terial (4/0 Supramid) is used in this closure. At the ear lobe accurate edge to edge alignment is essential for primary healing . This is effectively performed with a few well placed mattress sutu res.

321

34 Since the success of this procedure d oes not de­ pend on tight skin closure, there is no need f o r heavy retention sutures. Excision is adju sted acco rding ly. In th e p ostauricu lar fold , 4/0 ca tgut sutures are used, whil e in th e posteri or sutur e lin e 3/0 non abso rba ble material is emp loyed t o preve n t di s rupti o n , w hich migh t otherwise be initiated by head m o vements in th e early postop rali ve pe ri od . N o d ra ins are neces­ sary.

/j

Dressings

35 The sulure lin es are covered wi t h steri le tape' Stri ps of tape are als o app lied on th e che ek and neck, converging towards the crus of the helix t o produce even tra ctio n on the skin, wh ile concomi t antly red uc­ ing suture line tension . The taut tape dress ing , b ei ng inelastic, acts to pre vent fluid accumulation in th e subcutaneous dead space . A light compression dress­ ing is then applied. 36 First dressing change o ccurs five days postopera­ tively . Under the tape, the skin shows no sign of in­ flammation nor is there any redness or swelling along the suture line itself. Where catgut sutures have been used, they will come out w ith removal of the tape. Hair growth is temporarily retarded where the tape has been firmly adherent to the scalp. At this dressing almost all sutures are rem oved , only a few remain in the scalp, in the postauri cular area, and one at the ear lobe. These sutures are remo ved in 3 days.

, Steristrip-Skin-Closures'lil, Min nesota Mining and Ma nufac lur in g Company, St Paul. M innesota, U.S. A.

322

'!

,

,

Result 37--42 These photographs contrast the pre- and post­ operative appearance . The pictures illustrating the operative procedure were taken at the surgery of thi s patient. Upper and lower eyelid blepharoplasties were performed at a later stage.

,

I

323

Commen ts

Bleeding

In the recommended plane of dissection, there are com­ paratively few blood vessels and any bleeding encountered is easily controlled. Where local infiltration has been used, there must be meticulous attention to complete hemostasis. Hemo­ static clamps should be placed accurately and neatly to mini­ mize tissue damage and to prevent injury to adja ce nt nerves. For a similar reason pinpoint ligati o n of blood vessels is pre­ ferred to coagulation. The blood loss will rarely exceed 100 ml for the entire procedure. This remarkably small volume is in part explained by the anesthetic technique. Medially, in the cheek and in the neck where the dissection is ca rried out bluntly, the separation is performed in an almost avascular plane. In these areas, tight tissue la ye r closure may also accou nt for the absence of an y hematoma, either in the cheek or anterior to the sternocleidomastoid muscle. Due to interfe re nce with areolar tissue layers even a very small amount of blood, however, may cause some peripheral discoloration at the nasolabial fold or in the lower part of the neck, appearing a few days after surgery. Should postoperative bleeding occur, the collection of blood will be limited to the temporal and preauri cu lar area or to a triangular section of the postauricular region. Compression is easily applied to these areas by the dressing , and drains have thus been omitted.

Nerve lesions

With described technique dissection is carried out near im­ portant nerves and ve sse ls. The proced ure may thus appear to be fraught with a high incidence of injury to these structures . This has not been the case. In our experience there has been no incident of fa cia l nerve injury. In criti ca l areas mobilization is performed bluntly, close to a clearly defined fascial plane, and underlying nerves and major vessels are easily avoided . As in other techniques, the most difficult dissection is still over the branches of the greater auri cu lar nerve. The mandibular branch of the facial nerve, which runs beneath the platysma, is we ll protected if one observes the forementioned pre ca u­ tions. This is a safe procedure when the surgeon has a good knowledge of the anatomy involved.

324

.

The Aging Face

Postoperative care

Despite the magnitude of this operation it is not very traumatic for the patient, either physically or psychologically. Local complications are rare because of the careful anatomical dis­ section and the blanketting type of closure. The operative site therefore needs no special attention and frequent dressing changes are unnecessary. The anesthetic technique deve loped for this operation permits the use of a sm aller dose of local anesthetic than is generally required for procedures of this kind. This in turn decreases systemic reactions to the drug. The administered intravenous anesthetic is short and given at the beginning of the procedure . Thus , the depressa nt action of the drug has essentially dis­ appeared by the end of the operation. This creates an alert but comfortable patient, who can be discharged im mediatel y after surgery and supervised postoperativel y on an out-patient basis. Postoperative pain is not great when subcutaneous tissues have not been extensivel y infiltrated, and following nerve block an­ esthesia, analgesic requirements are considerably reduced.

Healing

The plane of dissection preserves an excellent blood supply to the undermined skin, while the advancement of deep ti s­ sue layers permits skin closure with only moderate tension in the temporal region, slight tension in the postauricular suture lines, and no tension in the preauricular area. The skin flaps are thus uncompromised and healing never becomes a problem. All sutures can be removed in about a week. In our series, there has been no instance of skin slough , and the complication of hair loss, related to undue tension in closure of the hair-bearing scalp flap, has not occurred.

325

Advantages of a two-layer shift

Skin , subcutaneous tissues, and cutaneous muscles , all con­ tribute to an aged appearance. The radical mobilization of these tissue layers is thus a basic prerequisite for the success of a face-lift operation. Thi s is readil y accomplished by utilizing sub­ fascial planes of di ssection . There are obv ious benefits in using this general operative tech ­ nique and in particular, the two-layer shift provides ce rtain unique advantages: • Sharp dissection is required only within a limited area and can be carried out under direct vis ion , while the major under­ mining is performed bluntl y. • Tight, deep closure minimizes the possibility of hematoma formation . • By restricting the dissectio n to anatomical clea vage planes postoperative swe lling is minimal . •

This atraumatic operative technique mi nimizes sca rring.

• Extensively freeing and shifting the superficial fascia of the face and the platysma in the neck allows advancement of all the sub cutane ous fat and covering skin . • The skin ca n be advanced farther when it is positioned as a second layer. • The procedure is most valuable medially, where correction is greatly needed, but whe re it is usually most difficult to obtain. • Holl ow cheeks fill out and become more natural , when the subcutaneous fat is repositioned. • Since most of the tension is redistributed to the deeper layers, closure does not jeopardize the circul ation to the flaps; heali ng is therefore uneventful. • Minimal suture line tension redu ces the risk of hypertrophy and spreadi ng of the sca rs . • The advan cement produces an even distribution of super­ ficial tissue layers.

326

,

The A ging Face

• Plication of deep tissues is unnecessary and th us cannot m ar the final result with unsightly masses and othe r irregu la rities . • As the platysma a nd the superficial fascia are connected t o the skin alone, and not restricted by deep facial musculature, there is little tendency for these structures to lapse into their preoperative state. • Since the skin itself is not left under undue tension , the im ­ provement in facial appearance is more permanent th an could be expected with conventional techniques. • In the neck, tightening of the platysma is effective in re­ distributing the vertical, submand i bular ("turkey gobbler") folds seen in many patients. However, marke d m uscular bands of the platysma will require additional sm all i ncisions to resect the hypertrophic, contracted segments responsible for these folds. In one of our patients the posterior border of the platysma, in its new dorsal position, folded back on itself in certain head positions. This offending portion of muscle was easily divided through a small transverse incision, thus ameliorating the prob­ lem. This basic face lift is obviously insufficient for those patients with marked submental fat accumulations. Those situations demand supplementary excisions of the overabundant fat through submental incisions placed in a transverse crease underneath the chin. For additional support in closure Adamson et al. (1964) advocated plication of the platysma in the midline. The platysma advancement method has been used over the past eight years with excellent long term results. This experi­ ence has been confirmed by Ellenby, who also reports no com­ plications with this technique. "An Encore. Usually the patient is warned that to keep a good result requires a second operation in 18 months, and then the improvement should be good for 5 years. In illustration, if you pull hard on any elastic element overnight, by morning another inch or two of slack can be easily taken up. The second proce­ dure is merely a preauriCUlar tuck to get that extra inch . .. "

This advice of Gillies is often difficult to follow. The contented patient is usually quite reluctant to undergo additional surgery unless it is absolutely necessary.

327

Forehead Wrinkles

Cuta neous muscles are responsible for several charact eristic features of facial aging. The frontalis muscle produces wrink­ ling of the forehead, which is not remedied by skin excision ; the results of such operations are too transitory to justify their use. The topographic anatomy of the muscle an d its dense, widespread dermal insertions make muscle ti gh tening im­ possible or ineffective. Forehead wrinkles are , however, satis­ factorily eliminated by direct surgery to the responsible muscle, reducing its action by partial excision . The procedure is fairly simple , and natural mobility of the forehead skin is maintai ned by leaving an adequate amount of muscle. There is thus d i · minution, but not loss of expression .

A scalp incision is made parallel with and a few cm inside the frontal hairline. It is carried through the epicranial aponeurosis down to the areolar tissue layer just above the periosteum . With a pair of blunt scissors, undermining is easily accom­ plished in this plane down to the supra-orbital ridges . The fore­ head skin is thereby separated with the attached frontalis muscle. Covered by a thin fascia, the muscle is clearly visible on the deep aspect of the raised forehead flap. Above the orbits it forms a distinct, sizable layer, which thins out as it approach­ es the hairline and separates into mL1scle fiber bundles . The topography of the muscle and good exposure allows subtotal excision to be accurately performed . The dissection is facilitated by local infiltration of 0.5 per cent lidocaine (Xylocaine ®) with epinephrine, bleeding will then be limited to a few vessels which are well secured. Glabellar wrinkles may also be eradi­ cated through this approach, which gives access to the procerus and corrugator muscles as well.

In removing the frontalis muscle, the forehead skin expands and excision is usually necessary. Depending upon the require­ ments of the particular situation , a trapezoidal or bispindle­ shaped segment of skin may be removed. By pulling the skin upwards in wound closure, forehead wrinkles disappear and drooping eyebrows are raised. The effect of this lift is directly related to the extent of undermining and to the position and size of the reduced skin. Wound edges are brought together under some tension. The tightness of the sutured flap and the effectiveness of a light compression bandage placed over the forehead prevent hematoma formation.

328

The Aging Face

After an initial stage of fixa tion and immobility, the forehead skin gradually becomes free from periosteal adhesions and simultaneou sly the remaining muscle fibers are reactivated . This process occurs over a period of several months. The regular face-lift operation reju venates neck, cheeks and or­ bital regions as if a soft hand had wiped off folds, wrinkles, bags and pouches without major change to individual appear­ ance. The eradication of forehead wrinkles, however, results in a more obvious alteration of facial expression, which the patient at first may consider too drastic. Also, the initial immobility of the skin may be an unpleasant sensation . Both of these effects are particularly striking in the immediate postoperative period, and the patient should be well-informed as to the course of events following surgery and the considerable time required for natural skin mobility to return.

329

References

Adamso n J. E., Hort on C. E. and Crawford H. H. : The surgical correc­ tion of the " turkey gobbler deformity" . Plast Reconstr Surg 34: 598, 1964. Aufricht G.: Surgery for excess skin of the face and neck . Transact Internat Soc Plast Surg. Second Congr, E & E Livingstone, Edinburgh, 1960, p. 495. Co nley J .: Face-Lift Operation. Charles C. Thomas, Springfield, 1968. Dingman R.: Severe bleeding during and after face-lifting operations under general anesthesia. Plast Reconstr Surg 50: 608, 1972. Ellenby J. D.: Personal communication. Gillies H. and Millard Jr. R.: The Principles and An of Plastic Surgery, II. Little , Brown and Company, Boston, Toronto, 1957, p 400. Gonzalez-Ulloa M.: Facial wrinkles. Plast Reconstruct Surg 29: 658, 1962. Hollander M. M.: Rhytidectomy: Anatomical, physiological and surgi­ cal considerations. Pla st Reconstruct Surg 20: 218 , 1957 . Moore D. C.: Regiona l Block. Fourth Ed ., Charles C. Thomas, Spring­ field, 1967. Pennisi V. R. and Capozzi A.: The transposition of fat in cervico­ facial rhytidectomy. Plast Reconstr Surg 49: 423, 1972. Pickrell K. L.: Reconstructive plastic surgery of the face. Clinical Symposia (CIBA) 79: 71, 1967. Spira M., Gerow F. J . and Hardy S. B.: Cervicofacial rhytidectomy. Plast Reconstruct Surg 40: 551, 1967. Skoog T.: Useful techniques in face lifting . Read at the meeting of the American Association of Plastic and Reconstructive Surgeons, San Francisco, April, 1969.' Skoog T.: Principiella synpunkter p a tekniken vid face lifting. Pre­ sented at the 25th annual meeting of the Swedish Association for Plastic Surgery, Stockholm, June, 1972. Skoog T.: Rh yt idectomy-a personal expe rience and technique . Pre­ sented and demonstrated on live television at the Seventh Annual Symposium on Cosmetic Surgery at Cedars of Lebanon Hospital , Miami, Florida, February, 1973. Webster G . V. : The ischemic face-lift. (To be published .)

•

I I am indebted to Jay D. Elleoby, M .D., Miami, Flori da, fo r his assistan ce in presenting this paper.

330

Chapter XIV

Reduction mammaplasty ­ transposing the nipple on a cutaneous flap

Introduction 334 Methods of surgical correction 335 Author's methods 336 Developmental and vascu lar co nsiderations Ge neral surgical considerations

I. Transposition of the nipple on a single-based cutaneous flap 341 Preopera tiv e markings 341 Lo cating the new nipple site Planning the resection Design of the nipp le transposition flap Anesthesia and operative position Operative tech nique 347 Pr epa rati on of the n ipple flap Reduction of th e breast Positioning the nipple fl ap Reconstru ctio n of th e breast Wound closu re Dressing Postoperative ca re Result Correct in g th e nipple and areola Commen t s o n resu lts 367 Healing of skin and breast tissue Vascularity of the nipple fl ap Appearance Permanence of results Innervation of the nipple and areola Lactation II. Transposition of the nipple on a double-based cutaneous flap 376 III. Correction without a nipple flap 378 References 379

332

Title page : Venus figu rine, ea. 20.000 B.C. Th e original was uncovered at Willendorf, Austria and is now on ex­ hibit at th e Naturhistorisches Muse­ um, Vienna. The height of th e sculp­ ture is approximately 12 em.

Breast Hypertrophy

A method of reduction.

Introduction

Discomfort and disability due to the pull and bulk of large heavy breasts are the primary indications for surgical interven­ tion. In an effort to improve esthetic results, surgery end eav ors to restore lost grace and symmetry as well as reducing sheer mass and weight. Fixed standards for correction are d ifficult to define in view of the ever changing concept of the id ea l b rea st. From the primitive "Venus figurines" of Paleolithic Cro-Magnon man to the refined beauty of Grecian sculpture, a wide spec­ trum of attitudes is represented . Every epoch and every cul­ ture has established a distinct and d ifferen t prototype of beauty. In parti cular, the female breast has been subject to the mer­ curial whims of society, and shape, size, and general import­ ance have received fluctuating emphasis. The corsetted , up­ lifted, padded bodies of a few short years ago, have now in part been replaced by the bra-less look of today's fashion . Sir Astley Cooper (1840) eloquently commented upon the beauty of the female breast and the functional significance of its shape. "The natural obliquity of the mamilla, or nipple, forwards and outwards, with a slight turn of the mpple upwards, is one of the most beautiful provisions in nature, both for the mother and the child. To the mother, because the child rests upon her arm and lap in the most convenient position for sucking, when the child reposes upon its mother's arm, it has its m outh directly applied to the nipple, which is turned outward to receive it; whilst the lower part of the breast forms a cushion upon which the cheek of the infant tranquilly reposes ". These principles of physiologic anatomy must be carefully con­ sidered before attempting to reconstruct the breast. Adherence to the fu nctional anatomic design will result in a breast which is natural in shape, and in complete harmony with the individual. Even in markedly distorted , hypertrophic conditions basic fea­ tures of the normal anatomic framework remains unchanged and may be utilized to direct glandular reduction.

334

Methods of surgical correction

With res pect to treat ment of the nipple, o perati ons for the cor­ rection of hypertro phi c and pend ulous breasts ca n be divide d into two m ai n categories : th ose in whic h the nippl is trans ­ posed on a vascu lar pedicle , and those in which it is transfe r­ red as a free graft. The latter procedure, in wh ich ni pp le and areola are completel y detached and grafted to a previ ousl y pre­ pared area , has fallen into disrepute from both a fu ncti on al as well as a cos metic standpoint. The only remai ni ng i ndication for usin g t hi s technique is in exce ptional cases of giganto­ mastia. All method s of nipple translocation have o ne co mmon f eatur e. They strive to secure an adequate blood supply to the ni ppl e by utilizing the glandular andlor cutan eo us vasculature . In the majority of proce dures a per i-areo lar incisi o n is made that sacrifi ce s the cutaneous vesse ls. Con seq u en tly the n ip ple and areo la derive their blood suppl y so lel y fro m the b rea st tis­ sue. The glandular rese ction can th en be per formed in sev eral different ways . In some of t hese method s th e proced ure is car­ ried out so that the ni p ple is t ranspo sed o n a gla nd ular pe dicle, either singl y or doubly based. The more widel y emp loy ed tech ­ niques a re listed in Table 1 according to the su rge o ns res pon s­ ible for their introduction . For a complete review, reference is made to Lalardrie and J o uglard (1973)

•

Glandular

Glandula r

vessels

+ cutaneous vessels

Cu taneous vess els

Single pedicle

Bies en berger 1931 Joseph 1931 Banko!! 1959, Penn 1960 Dufourmentel-M ouly 1961 and others

Joseph 1925 Schw artzm ann 1930

Sko og 1963 Lalardrie 1972 Lalardrie ­ Jouglard 1973 Oul ie 1973

Double pedicle

Gillies-M cind oe 1939 Ragnell1946 Maliniac 1948 Pitangui 1962 and others

Strombeck 1960

Skoog 1963

Table 1 The various techn iques for breast reduction are classified with respect to the blood supply of the nipple and whether a single or double based pedicle was used.

335

Schwartzmann (1930) advocated p reserving some of the cut­ aneous vascular communications of the areola in addition to the glandular vessels. To achieve this, he left a bridge of skin at­ tached to the glandular pedicle on which the nipple was tra ns ­ ferred, the epidermis having been carefully removed by sharp dissection . Later Strombeck (1960) applied this technique to a procedure designed with a double pedicle . The logical progres­ sion of this concept was then to sever all glandular connections and to transpose the nipple with its vascular supply limited to cutaneous vessels (Skoog 1963). This was successfully per­ formed using either a single or double based pedicle. Methods of partial amputation of the bre ast or suspension operations, which are performed without n ipple transposition , are not included in these categorie s. Neither have operations confined to skin resections, nor techniques with limite d ap pli ca­ tion been considered.

Author's methods

Developmental and vascular considerations

336

In about eight hundred breasts , the Gillies-Mcindoe technique, the Strombeck operation, and occasional free grafting of the nipple were the procedures initially performed. Disappointing results encountered with these earlier operations led to the de­ velopment of a basically different approach . The new method involves transferring the nipple on a cutaneous pedicle and is founded on principles which take into account the evolution and vascular anatomy of the breast.

1 Reconstruction of the mammary gland in a 38 cm human fetus. After a model by Broman (1927) . From a locali zed thi cke ning of the skin, the plaque of Langer, epi ­ theli al sprouts pen etrate into the subcutaneou s layer, where they will form the milk ducts of the mature gland. The acini develop about the seven th month.

Histogenesis of the breast demonstrates its ectodermal ori g in . Ingro w ing epithelial cords branch in to the subcutaneou s tis­ sues, forming ducts and secretory aci ni of the gland (F ig 1). Concomitantly, la rge arterial branch es are formed whi ch enter the deep aspect of this maturing ma ss of tissue. In planning reconstructive proce dures, surg eo ns have equ 2 led this develop­ mental anatomy with the vascular anatomy. Howe ver , initi ally and thro ughout childhood the ni ppl e and the areola are es­ sentially components of the pectoral skin, a fact which in part determines their vas cular supply throughout life . A clearly defined subcu taneous vascular system , related to the breast. was depicted in the anatomical drawings of Vesali u s, as f ar back as 1568. In 1840, Cooper gave a m os t accurate account of the anatomy of the breast. He emphasized the very vascular nature of the nipple and areola , and described in detail the four principal arteries supplying them . Laterally, the bran ches from the external mammary artery and the long thoracic artery are both derived fr o m the axillary artery . Mediall y , the t wo prinCipal branches originate from the internal mammary artery, penetrat­ ing the c hest wall at different levels.

" The se arteries greatly vary in their course . . . They pass to the basis of the nipple, an d there they have late ral branches of com­ m unica ti on, and from these proceed paralle l arteries, which are continued from the basis to the apex of the nipple, and send vessels to the papillae at the apex; wh ilst others pass backward to the lac tiferous tubes, and entering the centre of the gland, comm unica te with the deeply sea te d arteries which enter at the back of the organ from the intercostals. 337

2 In this illustration, redrawn fr om Cooper's text, the veins returning the blood from the surface of a la ctat­ ing breast are well demonstrated. Both arteries and veins are of large size and somewhat serpentine. The ve ins on the right pass to the internal mammary, and those on the left to the axillary ve in. Axillary tribu ­ taries encircle the nipple and form a net-work with frequent communications on the surface of the breast.

The veins of the nipple origina te in bundles or bushes of capil­ lary veins, from which larger branches aris e that form a network at the roots of the papillae cutis, and then they enter much larger veins, wh ich pass to the b ase o f the nipple. The ve ins beginning thus at the nipple pass into large branches of veins, which enter a venous circle at the areola, and from this circle, veins proceed from the nipple to the axillary and ce­ phalic vein of the arm, also into a vein which pierces the inter­ cos tal muscles between the cartilage of the second and th ir d ribs, and which enters the internal mammary vein, an d one w hich penetrates below the fourth rib the intercostal muscles, to term ina te in the internal mammary in tercostal veins. Other veins are found le ss regular in their course than those which I have described." These observations have, by and large , been confirmed by later in ves tigators. After injection with marking dyes, Mar cu s (1934) dissected vessels entering the gland and was able to demon­ strate their continuity with a superficial anastomosing system of pe r iareolar arteries . The presence of a well-developed superficial vascular system related to the nipple and the areola is clearly demonstrated in the described operative pro ce dure, where subcutaneous vessels by themselves prove sufficient to supply the nipple and areola. 338

1

{

3 In this standing patient the central meridian of the breast is outlined in black . It passes through the nipple and continues on the chest wall.

General surgical cons iderations

4 With the patient lying flat on the operating table, the breast moves laterally and upwards towards the axilla . The central axis of the breast, outlined in red , now lies in a totally different location. Any pattern for reduction designed with the breast in this rotated position would result in a medially displaced nipple.

The female breast is characterized by great mobility . The changeable position of the nipple is influenced by age, race, parity, general stature, and posture. These variables would appear to make uniform formulae difficult to apply to any par­ ticular operation. Furthermore, the normal asymmetry between breasts and the corresponding differences in overlying skin dis ­ tension fu rther limit efforts to standardize methods. For these reasons free-hand estimation was the technique ad v ocated for breast reduction . However, in experience gained from mamma­ plasties performed in this manner, nipple location as well as glandular reduction showed relatively little variation in relation to certain guide lines, and preoperative planning proved un­ expectedlyefficacious.

Nipp le location is dependent on two coordinates which are con­ stant for each breast. It lies 1) on the central meridian of the breast, 2) at a level relative to the inframammary fold. The meridian, outlined as the midline of the breast , must be determined in the standing patient, for when supine, th e breast shifts laterally and rotates on the thorax. Measurements for the new nipple site obtained in the upright and recumbent posi­ tions may thus differ considerably in the hypertrophic breast IFigs. 3 and 4) . This also makes fixed skeletal reference points unreliable. 339

In breast hypertrophy the position of the iRframammary fold remains basically unchanged. Its inferior displacement, due to excessive breast weight, is always rectified when the surplus mass is excised. Invariably, in current techniques, the lower border of the resection is placed in the inframammary fold. This fact. however, has not been utilized in fashioning patterns for reduction and reconstruction . In the present plan the new nipple site is located on the midline of the breast at a fixed distance above the level of the inframammary fold. In gross asymmetry, the design for the proposed nipple site must compensate for unequal skin distention, caused by volume differences between breasts. The principle of reduction is mainly that of a wedge excision. In mammary hypertrophy, however, the breast also is enlarged transversely and is usually broadly attached to the pectoralis fascia . This widened base must be reduced in shaping a nor­ mally proportioned breast.

•

340

I. Transposition of the nipple on a single-based cutaneous flap

Preoperative markings

Locating the new nipple site 5 With the patient standing , the surgeon sits in front of the hypertrophied breast, making the appropriate measure­ ments and drawing the patterns with a fiber-tipped marking pencil. Mu ch of this preoperative blueprint will be lost dur­ ing skin preparation, but sufficient markings remain to serve as a guide for a definitive design , diagrammed just prior to beginning the procedure.

341

-

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6 First, the central meridian of the breast is outlined through the nipple.

7 The level of the infra mammary f old is marked on the chest wall as it crosses the cen­ tral meridian of the breast, and is then trans­ ferred to the anterior surface of the breast. When the level of the inframammary fold has been visualized between the breasts, a ruler, placed horizontall y across the chest and breast. at eye level, w ill aid in this marking.

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342

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8 The new nipple site is located on the central meridian of the breast, 4 to 5. 5 cm above the in ­ terse ction of this line with the projected infra ­ mammary fold . At thi s stage it is wise to check the distance from the sternal notch to the future nipple center. It va ries with the weight and build of the patient and with the degree of hypertrophy . Rarely d oes this measurement exceed 23 cm and ver y infrequently will the distance be less than 20 cm . The usual range is between 21 and 22 cm . Reduction and reconstruction will further raise the nipple position 2 to 4 cm . Its distan ce from the sternal notch will then be 19 to 20 cm.

Planning the resection 9 Resection is planned as a wedge with its apex at the new nipple site. From this point two lines . 9 cm long. are drawn at 110 0 angle. One must allow fo r the great difference in vertical versus horizontal skin ten­ sion sometimes present in the ptoti c breast. This dis­ parity is compensated for by evenly distending the skin surface when outlining the wedge to be removed . The breast elements bordering the rese cted segment are used for reconstruction .

10 In developing this de­ sign. a goniometer was used to accu rately determine the angle of the wedge resec­ tion. When the skin is placed under even tension. this angle changes insignificantly with the size and shape of the individual breast. A standard pattern may therefore be used for this purpose. It re­ gularly applies to the skin excision . In essentially ptotic conditions and when there is glandular atro­ phy, the breast tissue reduc­ tion must obviously be ad­ justed accordingly.

343

11 The ends of th e 9 cm li nes are then joined to the medial an d lateral ends of the existing inframam mary fold. The in ­ cisio ns are made along these lines. The terminal part of th e curved medial line joins the infra mammary fold almost horizontally, whereas the lateral line of resection is more ve rtical .

12 An oval, 6 cm horizontally by 4 cm v erticall y, is planned for th e new ni pple site. Again, the ski n is flattened an d eve nly distended when th ese markings are made. In th e ptotic breast, the measure m ents for this oval fenest ra tion are recheck ed w ith the patient lying on th e opera tin g ta b le .

13 At this stage it is helpful to compare nipple position on each side by measur­ ing their respective distances from the sternal notch. When one breast is larger than the other, the skin above the areola is correspondingl y more distended. The new nipple site of the heav ier breast may then fall as mu ch as 1.5 cm below that of the lighter breast . Generally there is a corresponding difference in the inframammary fold levels. Reduc­ tion recreates a symmetrical relation­ ship.

,

Simplified design As a guide to preoperative marking, a simplified techni que can be used. The new mpple site is placed on the meridian line, 20 to 23 cm from the sternal notch. Planning is aided by a triangular device with an apical angle of 110 0 and sides 9 cm in length .

344

14 The planned nipple site is marked on the central meridian of each breast, at a fixed distance, 20 to 23 cm from the sternal notch. The change in nipple position is re­ evaluated while supporting the breast in its new position. At this time the general rela­ tionship of the breast to the torso is also appraised.

15 This device is made according to the measurements given in Fig . 9, and in addi­ tion to the standard patte m f or breast re­ section it includes an outlin e f or the oval area that will accomodate the tran sp o sed areola. The transparent plastic material is relative­ ly rigid an d can be steri lized.

16 The apex of the device is placed at the future nipple location and the design is drawn. The skin must be evenly distended during this outline. It is also important to recheck the measurements with the patient supine, as skin tension will change with position.

Design of the n ip ple transposition flap

17 The single-pedicle nipple flap is based laterally, adjacent to the new areolar site. The width of the base is thus between 6 and 7 cm. The length of the flap varies ac­ cording to the degree of ptosis. It extends about 4.5 cm beyond the center of the nip­ ple to preserve the periareolar venous plexus of Haller. The areolar area is cir­ cular, with a radius of 2.5 cm when the skin is distended. A lateral base of the flap was chosen be­ cause the main venous return from the breast is directed towards the axilla. The circulation of a medially based flap has, however, proved to be quite ade­ quate (Ouli8 1973)

345

Anesthesia and operative position

18 In performing operations of this magnitude. gen­ er al endotracheal anesthesia is preferred and usual­ ly employed. The operating table is flexed with the head of the table elevated about 30 ' . This places the patient in a semi-.sitting po sition. which facilitates the final estimate of the degree of needed resection. as well as aiding in the reconstruction. The patient is then draped and her arms are padded and strap­ ped to her sides. Her shoulders are lev elled. so that the pectoralis major muscle is in a neutral position. This posture should be maintained throughout the operation.

19 The lower extremities are used for monitoring blood pressure. and for intravenous drug and fluid administration . Man y anesthesiologists feel that patients undergoing surgery in a semi-sitting posi­ tion require mechani cally assisted ventilation.

Minor reductions can be carried out satisfactorily under lo cal anesthesia. For this purpose the infra­ mammary fold area is infiltrated with 0.5 per cent Xylocaine ® (lidocaine) with epinephrine and the tis­ sue layer deep to the base of the breast and over­ ly ing the pectoralis fascia is similarly infiltrated . using 0.25 per cent Xylocaine with epinephrine. This provides a nerve block for the entire breast .

346

Operative technique

Preparation of the nipple flap 20 The nipple flap itself may best be planned and outlined when the patient is on the operating table . The new nipple site and the estimated re­ section are also rechecked at this stage .

21 The skin is ma x imall y distended by a tight, en­ circling sling of gauze placed around the base of the breast.

22 Under these conditions, a standard 5 cm diameter medicine glass may be used for outlining the size of the new areola, or this ci r­ cular incision may be made free-hand as shown .

23 Another superficial in­ cision is made along the bor­ ders of the flap, care being taken not to cut th rough the dermal layer at the base of the flap.

347

24-25 Except for the areo ­ lar area, the nipple flap is deepithelialized. This is most easily accomplished by sharp dissection with the encircling sling still in place_ There is a definite plane in which the super­ ficial skiQ layer can be removed w i th ease and with minimal bleeding . This leaves the deep dermal lay er intact and protects the un derlying major vessels, w hich are usually superficial and located close to the dermis .

26-27 Towel clips are placed along the borders to stabilize the flap. Superior and inferior margins are in­ cised through the subcutaneous tissues.

28 Distally the flap is undermined in the subcutane­ ous layer.

348

29 While separating the flap at th e areola, gentle traction is placed on the nipple to ensure the inclusion of some glandular tis sue. Thi s gives the areola ad­ ded thickness and allows the nipple to protrude, when placed in its transposed position.

,

,

,

30-31 After undermining ,

the distal end of the flap is divided.

349

32-33 In a previous publication of thi s method, it was recom­ mended that the entire flap be separated at the subcutaneous level. Though the immediate circulation of this flap always proved to be excellent, it was observed in some cases that the transposition of such a thin flap produced curling and folding, with subsequent venous obstruction . For more stability the lower two -third s of the flap is now made slightly thicker by in­ cluding a layer of g landu lar tissue . This measure may also in crease the arterial bl oo d supply of the flap.

350

Reduction of the breast

34--35 In general the glandular resection can be car­ ried out according to the skin markings. These lines are superficially incised to define clearly the area of resection. The inframammary incision should then be placed about 1 cm above the fold, to compensate for any dislocation that might occur when the lower wound edge retracts.

36-37 In many breasts, there is an inferior displace­ ment of glandular tissue in relation to the skin. It is then necessary to support the gland from below and bring it up into a more normal position while the skin incisions are extended through it. The cor­ rected relationship of the skin and gland is tempo­ rarily secured at the new nipple site by a trans­ cutaneously placed towel clip.

351

--

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II 38-39 While the nipple flap is held aside, the central wedge-shaped section of the breast is incised along its borders. The incision is carried through skin and breast tissue from the planned new nipple si te to the infra mammary fold . The re section moves laterally, with care being taken not to jeopardize the base of the nipple flap .

352

40 In this method, the resection is com­ prised of both skin and breast tissue. The simple design applies to most hypertrophic conditions . It is realized that in cases of atrophy, an extensive glandular resection should not be carried out The precise amount is unpredictable prior to surgery, but the size of the wedge can be deter­ mined fairly easily when the gland is ex­ posed and the new size of the recon­ structed breast is appraised .

41 The entire reduction is now complete and the resected segment has been re­ moved en bloc . The partially amputated breast has lost much of its characteris­ tics; released of excessive pull , the remain­ ing breast tissues attain a higher and more normal position on the chest wa ll. The various components can now be brought together to form a rounded and naturally shaped breast .

353

42 With one temporary suture placed just below the new nipple site and a tow el cl ip fixed subdermally at the corners of the breast segments, the breast componen ts are approximated. Any glandular excess i s now apparent, either from undue tightness in the closure, or by a marked increase in consistency of underlying breast tissues. When present, the latter phenomenon is often localized just above the resected wedge. It is due to folding and compres ­ sion, and is :haracteriscica lly felt as a hard lump. An y excess glandular tissue is ex­ cise d, so th at the entire breast attains uni­ form softness. This surplus tissue can be removed superiorly, or from the medi al or lateral breast segments as they are equa lly well vascularized .

43 In the oval area to which the areola will be transposed, only the skin that re­ mains after the wedge resection should be excised.

354

After vertical closure it may even be con­ sidered that too much glandular tissue has been excised. The excess invariably pre­ sent in the infra mammary region can then be used for substitution, as described un­ der reconstruction.

Positioning the nipple flap

44-45 The great mobility and flexibility of

--:=- ­

the nipple flap allows the areola to be easily shifted into its site. Accurate posi ­ tioning of the flap is important. With the medial and lateral breast elements a­ ligned , the nipple flap is gently draped across the breast up to the new nipple site . Medial and superior " overdrape " of the flap is marked with ink on the underlying skin .

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v 46 The temporary suture is removed to facilitate preparation of a bed for the nip­ ple flap.

47 The area outlined for the flap is under­ mined between the subcutaneous layer and the gland . This is the only undermin­ ing done in this procedure .

355

~ 9 A small tissue wedge is excised at the superior edge of the base of the flap , permitting this por­ tion , when trans­ posed, to fold under the corner without compression .

50--51 The fl ap may be ma intained in its new position by a few fine catgut sutures . If fixation is used, it must be done with care, keeping the flap flat except for the minor fold at the superior part of the base . It must also be placed under normal ten sion so as not to impair circulation. If the areola becomes cyanoti c, when sutured in its new position , the flap should be reexposed and repositioned, so that undesirable kink ­ ing is eliminated. Generally, the problem is a result of excessive rotation , or an ex ceptionally long flap has not been spread far enough medially .

356

I

52-53 After transposing the flap, the areola remains in place naturally. In securing the areola, excess dermis is included on both sides to obtain broad apposition , thereby reducing late scar formation . Since stitc h marks show only on the cutaneous side, it is recommended tha t the sutures there pass only through the subdermal layer ; 4/ 0 catgut on an atraumatic needle is used .

Reconstru ction of the breast 5~55

Th e two segments forming the lower half of the breast should come together with ease , and there should be no need for any sutures to hold the glandular sur­ face s in close alignment or to obliterate any dead space. The wound can thus be closed by simply approximat­ ing ski n edges with an intradermal suture . On the lateral side, it is important to pass the needle accurately with­ in the dermal layer to avoid damage to the subdermal vessels which are at the base of the nipple flap.

357

-'

56 In bringing the breast ele­ ments together, the line of clo­ sure corresponds to the original central meridian of the breast. When this suture line is at­ tached to the lower margin of the incision, a new inframam· mary fold is created above the original one.

/

57 At this stage the central pull on the breast remnants and the tightness of the skin , in and below the new fold , obscure a persistent excess of breast tis­ sue, which is always present in the infra mammary area, medial­ ly as well as latera lly. Its remov­ al is essential for an esthetically pleasing res ult.

358

58--61 Medially, two hooks are placed at the upper margin of the wound and the dissection is carried between the subcutane­ ous fat and underlying gland, up to the new infra mammary fold . The level of dissection is easily identified by the presence of a thin fasci a coverin g the gland . It is important to preserve all subcutaneous fat , thereby equalizing the thickness of lower and upper wound mar­ gins. The glandular resection curves along the line of the new in fra mammary fold and in­ cludes the most media l attach­ ment of the gland up to the pec­ toralis muscle fascia. Thi s re­ leases the tension of recon­ struction , and proportionally narrows the base of the new brea st . If the initial wedge resection has been too radical , the re ­ dundant tissue present below the new infra mammary fold ca n be used to refi ll the recon­ structed breast . The surplus glandular tissue is freed suffici­ ently to allow it to be tran s­ posed underneath the breast segments on a broad base .

359

62 Latera l ly, the g landular excess is similarly mobilized and excised along the infra m ammary fold, thereby expo si ng the la ter al border of th e pectora li s m uscle. Cautious dissection and care­ ful attention to h emostasis must be exerci sed so as not to inte rfere with the blood sup ply to th e nipple fla p. This compl etes the release of the m di al and late ral "tethe r" of th e re constructed breast. and a more conical shape is att ai ned . Wh en t he dead space, left by re moval of excess tissue , is ob literated with b uried sutures, the breast contour is better defined.

63 Wound closure below the new inframammary fold is preferred to the technique of adlusting the suture line into the fold . The infra mammary fold thus assumes a natural configuration , and skin closure can be accomplished with less tension . The suture line is more exposed but in this trans­ v erse position, scarring is less . As the upper por­ tions of the breast are used for re construction , they natu rally assume the normal position of the breast , and no sutures are required for position­ ing or fixing them to the thoraci c wall . The sub­ cutaneous la yers are sutured together to giv e an even contou r to the inframammary area.

360

•

Wound closure 64-65 Usually the transverse wound can be closed w ith only a few minor adjustments. A slight skin excess is often prese nt medially and laterall y along the upper border of the w o und . Th is strip of skin and subcutaneous fat should be excised b efore approx im ating the sk in margins, to avoid an unnecessary superior bulge. In large breasts, a more lo calized skin redundancy m ay app ear on the upper lateral bor­ der. The superfluit y is eliminated by excising a "dog-ear" near t he breast, as shown here, not chasin g it around the thorax, o r over the sternum if a medial redundancy exists . Subcutaneous closure is effected by means of 3/ 0 and 4/ 0 catg ut sutures. Intradermal running sutures are preferred for skin app rox­ imation, using synthetic material , gauge 3/ 0, on an atra u mali c needle. With the described technique, minor areas of undermining in the infra· mammary region are effectively closed by subcutaneous suturing, making drainage unnecessary .

6&-67 The operation is complete on the right side. Altogether 600 g were rese cted from this breast. An identical procedu re is carried out on the left breast.

361

•

/

Dressing

/

68 All wounds are sealed and reinforced with sterile tape.' Their application across the vertical suture line prevents separation of the wound edges and helps to neutralize tension during healing .

69 Micropo rous tape' is also used to support the re­ constructed breast. For further support an elastic bandage may be applied. It must not be placed too tightly, or it will interfere with the circulation to the nipple. The nipple· itself is sensitive to pressure at this stage and is therefore protected with a ring of gauze placed under the bandage.

, Steri-Strip ~ Skin Closures, Minnesota Mining and ManufactUring Co . (3M), St. Paul, Minnesota, U.S.A.

2

362

Micropore Surgical Tape,~ 3M Company .

Postoperative care

70 The first dressing chang e is made eight days following surgery, when the patient normally leaves the hospital. De­ spite the presence of dried blood and serum, the

I

I

microporous tape remains firmly adherent to the skin. There is no skin reaction to the tape or delay in wound healing .

•

71 The catgut sutures at the edge of the areola have been dissolved be­ low the skin , and they are extracted as the tape is removed. 72 Following removal of the catgut, micro­ porous tape is reapplied for continued support, and these strips are left in place for approximately one more week.

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.

73 No other dressing is used and the pa­ tient is now able to wear a brassiere. The intradermal sutures are also left in position for another week.

363

Preoperative condition

74-80 The preoperative condition is com­ pared with the result at 8 weeks. There is a proportionate reducti o n in all breast dimensions . The recont oured base is esthetically rounded as a dire ct co nsequ­ ence of reducing its transver se diameter. This has been accomplished through a major centra l resection with suppleme ntary glandular excisions made medially and laterall y. The normal co nnection s o f th e re­ maining breast tissue to th e pectoralis fasci a have been retained and th e brea st moves naturally w ith chang es in arm positio n . The posture of the pati ent i s also m arked ly improve d . The protruding nippl es lie in a natural and central position, at the top of the breast cone. Sensibility and contracti lity of the right nip­ ple and are ola are not chang ed by the operation . On the left side th ese functions were considerabl y redu ced, but had re­ turned to normal after twel ve mo nths.

364

Result

365

Correcting the nipple and areola

8 1 Massive breast hyper­ trohpy is present in this young woman . The areo la is char­ acteri sti call y distended with a smooth, even surface, fading into the s urrounding skin. The nipple is flat and the bordering tissue is depressed. 82--83 At surgery the nipple was raised on a cutaneous flap in the described manner. Skin tension wa s relea sed and deep tra ction on the nipple was eliminated when the lactifer­ ous ducts were cut. The areola then contra cted and a pro­ tuberant nipple with a normal skin surface was formed. True nipple inversion may also be corrected in this way, but more extensive dissection is then necessary.

366

Comments on results

,

Healing o f skin and breast tissue

In reconstruction , the vascularity is not impaired by any plastic procedure to the gland, as the two cut surfaces are brought to­ gether by simple apposition , without torsion, tension or sutur­ ing. For this reason deep lumps and irregularities are unlikely to form and normal breast consistency, present at the comple­ tion of the operation, remains essentially unchanged. Undue con cern from routine breast examination by other doctors is thereby avoided , except in the subareolar area, where the superficial flap sometimes attains a firm consisten cy .

,

Vascularity of the nippl e fl ap

. r

The described method provides excellent conditions for heal­ ing. The possibility of skin necrosis is eliminated by leaving the skin attached to the underlying glandular tissue . Furthermore , all resections are made from the center of the lower pole of the breast, and consequently the remaining tissue derives ample blood supply from both the medial and lateral mammary ar­ teries, irrespective of the size of glandular resection. The largest reduction in one breast was 2000 g.

From this clini cal material it is evident that the cutaneous bran ches originating from the axillary artery are quite sufficient to ensure nipple survival. When the nipple flap is raised, it in­ variably has a good arterial supply , and the nipple and areola attain a rosy color from trauma to their vascular innervation . In describing the technique of transposing the flap , great em­ phasis was placed upon the importan ce of maintaining good venous return from the flap . If due consideration is given to this techni cal problem , at completion of surgery, the areola will in­ variably demonstrate ex cellent cir culation , as evidenced by good color and rapid capillary refilling . I n some patients, redu ced circu lation to the areola may be ap­ parent within 24 hours after surgery, as ev iden ced by discolora­ tion, edema, and a prolonged capillary refilling time. These changes gradually subside and resolve in two to three weeks . In view of the pathophysiological vas cular rea ctions taking place in a cutaneous pedicle during the early postoperative period (Palmer 1970 and Palmer et al. 1972), the flap and areola must not be exposed to pressure from tight bandaging or an expanding hematoma. Care should be taken t o eva cuate any late hematoma that might develop, to protect the newly established vessels.

367

84-85 Reducti on of the pendulous breasts in th is forty-four ye ar old w o man , required special attention. The inferio r dislocation of the gland , in relation to the skin , was estimated at surgery to be ap ­ prox imately 4 cm. Reduction an d reposi ­ ti oning were carried out acco rd ing ly , as shown in Figs . 33 and 34; 550 an d 67 5 g were rem oved from the ri g ht and left breasts respectively. Initiall y, nippl e sensibility was moderately re duced , but contractility and sensibility had returned to normal by one month.

•

This procedure has been successfull y used in breasts of ali shapes and sizes. The average length of the flap has been about 12 em, with the longest measuring 18 em. In the ver y ptotic breast the long pedicle has been equall y successful, prob­ ably because the gradual distension of skin and subcutaneous tissues has enabled the vessels to elongate in the direction of the flap . In this way circulation has adjusted to its environment , apparently serving as a " delay" of the flap.

j

,I

Since a cutaneous flap is used to transfer the nipple, any cir­ culatory distu r bance affecting its viability will cause only limited tissue loss, leaving the volume and shape of the reconstructed breast undisturbed. In other methods, where the nipple is trans­ ferred on a glandular pedi cle, any areolar loss is only the sur­ fa ce manifestation of deeper tissue necrosis within a broaden­ ing sector of the gland. Separation is then lengthy, agonizing , and often disastrous.

368

I~

Breast Hypertroph y

Appearance

This technique permits the surgeon considerable fle x ibility in shaping the new breast. The reduction may be as extensive as desired without fear of endangering the blood supply to the re­ maining tissue. The prin Ciple of reducing the volume by a wedge resection offers unlimited possibilities for individual variation in reconstruction, ranging from a conical, protruding shape, to a more spherical or flat breast. The size and general type of configuration is thus determined by the surgeon. There are, however, some basic features of the procedure which significantly influence the end result and render the recon­ structed breast natural, in position and appearance: • the nipple is located on the centra l meridian of the breast, which remains unchanged; • the inframammary fold conforms to the original crease at th e level of the midline of the breast; • the base of the breast is proportionally reduced and rounded by resecting attachments to the pectoral fascia medially and laterally; • the shape of the breast is naturally rounded , centered around an axis through the new nipple site, perpendicular to the chest wall; this is a result of the superior portion being essentially undisturbed and the lower half of the new breast being com­ prised of two adjacent, solid components which are joined sym­ metrically in an insignificant shift from their original position ; • the contour is smooth and rounded in all quadrants, as the remaining skin has not been undermined ; • the areolar area protrudes slightly due to the buttressing ef­ fect supplied by additional flap tissues; • the nipple is distinctly shaped and protruding, even if it has

been markedly flat prior to surgery ;

• the reconstructed breast moves naturally with the position

changes of the arm, as the undisturbed suspensory apparatus

attaches the entire gland to the pectoral fascia.

As this method possesses great adaptability, it ca n be used in

all types of hypertrophic and ptotic breasts and may also be

successfully employed in asymmetric conditions. (Figs . 84-97)

369

8 ~9

In this woman, aged twenty-three, hypertrophy was asso ciated with as ymmetrical development in each b reast, particularly on th e right side, where there was marked latera l dislocation of the n ip ple ; 725 g w ere resected from each side. The nipple was raised on the standard cutaneous pedicle. Nipple sensation was consi d ered norm al in six months.

I

• 370

Breast Hypertrophy

In this case of ptosis and marked atrophy in a multipara of fifty, the glandular resection was limited to a narrow wedge. The reduction on the right and left sides were 150 and 125 g, re­ spectively. The skin excision and nipple transfer were carried out according to the standard pat­ tern . After surgery the sensibility of the left nipple was reduced for two months. Both areolae de­ monstrated good contractility.

9~92

Permanence of results

Reduction mammaplasties using glandular pedicles to elevate nipple position and rebuild the breast cone, have a great tend­ ency to deteriorate postoperatively . Invariably, in spite of thoracic wall fixation and skin tailoring to fit the new breast snugly, the glandular mass which has been pushed up to the centre, gradually descends, as its weight and mobility distend the skin below the nipple. In this way the breast becomes dis­ torted . The co nvexity of the upper surface is flattened and the conical shape of the breast is lost. Simultaneously, the areola is displa ced and retracted, and this wandering nipple assumes a bizarre position higher up on the breast. Slings of dermis (Maliniac 1950, Kirsch 1953, and others) or fascia lata (Lewis 1956) have been recommended to counteract separation and slipping of the transposed tissues. However, when Strombeck (1964) applied the dermal loop technique unilaterally, he found no discernable difference in the tendency of breasts to descend. 371

f

Such undesirable late effects have not been seen, and are not t o be expected in cases operated upon according to the technique described in this chapter . With this method, the remaining breast segments are parts of the upper portion of th e breast, held in place by the undisturbed suspensory ligaments. These fibrous connections have a tendency to shorten after glandular reduction, placing the remaining breast at a more normal level. Thus, in reconstruction , suspension of the gland does not depend on sutures or the use of the skin as a brassiere . Further­ more, the 'nipple flap, spread between the infra mammary fold and the areola, and comprising a broad layer of dermal tissue, effectively prevents distention below the nipple. This support also aids in maintaining the conical shape of the breast, with the desired convexity above the nipple. Since the nipple does not change position postoperatively , the permanen ce of results must be appreciated in planning the operation . Unlike many other mammaplasty procedures, no allowan ce is made for a tendency of the nipple to rise . (Figs . 93-97.) As breast tissue , utilized in forming the new breast, is not dis­ sected away from the covering skin, n o late irregularities of breast contour develop, nor is there any danger of scar forma­ tion between the skin and gland. Appearance is equally satisfy­ ing whether the nipple is transposed on a unilaterally or bilat­ erally based pedicle. Enlargement of the mammary gland during pregnancy and its subsequent regression after delivery may have adverse effects on breast shape along with a marked redu ction in breast vol ­ ume. In planning a correction in juvenile breast hypertrophy, this fa ct should be born in mind.

Innervation of the nipple and areola

In 10 patients, consecutively operated upon according to this method, nipple and areola sensibility were un changed in 4 breasts after one week, being de creased, poor, o r absent in 16. At the end of three months these figures were 13 and 7, respe ctively. One year after the pperation further improve­ ment was recorded; all nipples but one were then considered to have normal or near normal sensation. These data are based on subjective assessments of nipple sensibility, which >n essen ce is more valid than o bjective re­ coraings . 'In many cases of gross hypertrophy nipple sensation

372

93 This patient was forty-three yea rs o ld when 1000 g were re­ sected from the right and 800 g from the left breast .

94 This follow-up photograph was taken four months after surgery.

95-97 Four years later the early operative result remains largely un­ changed.

373

had been greatly reduced priorto surgery, possibly on the basis of nerve traction. Some of the patients have reported a post­ operative increase in nipple sensation, and a heightened sexual awareness. Craig and Sykes (1970) reported loss of nipple sensation to be much more common with the described technique than follow­ ing operations, in which the nipple had been left in continuity with the gland. They related these results to the preservation of nerve pathways, which in dissections were demonstrated to pass through the gland into the nipple. Schwartzmann (1930), on the other hand, held the opinion that preserving a cutaneous bridge to the nipple left the nerve supply intact. Observations made in Our series indicate that separation of the nipple and areola from the gland does not necessarily result in sensory denervation; should it occur, the possibilities for reinnervation are as good as with any cutaneous flap. It is of particular in­ terest that breast correction, without the use of a nipple flap, occasionally resu Its in tempora ry complete anesthesia of the nipple and areola. In this technique, described on p . 378, the areola is circumcised and peripheral undermining is limited to the subcutaneous layer, leaving the nipple and areola attached to the gland . Erection of the nipple and contractility of the areola could be de­ monstrated in 16 out of 20, one week following the operation . After three months results in this respect were 18 out of 20. At the one year follow-up there was contractility of all areolae. In the early postoperative period sensibility and areolar con­ tractility were rarely the same on both sides, despite the identi­ cal operation being performed bilaterally. According to Craig and Sykes, erection of the nipple may depend more on the pre­ servation of an intact blood supply than on preservation of the nerve supply, a view that we have confirmed. Nerve function may also suffer temporarily from impaired circulation in the early postoperative period . In some cases this was probably the cause of decreased sensibility.

Lactation

374

In creating the nipple pedicle the lactiferous ducts are severed and after flap transfer the possibility of reestablishing a func­ tioning lactatory system is extremely slight. This does not pose an extreme hardship, as breast hypertrophy alone is often as­ sociated with diminished mammary secretion which will de­

Breast Hyp ertrophy

crease with any type of glandular reduction. In addition, a num­ ber of these women have litte wish to nurse their children Many patients undergoing mammaplasty are post-menopausal, and quite a few have completed their families or do not desire children. In the event of pregnancy, lactation can be effectively suppres­ sed with Stilbesterol without worry of developing cysts or tumor masses (Adams 1957). Needless to say, patients of child­ bearing age should be informed that breast feeding will not be possible following surgery, but invariably, for these women the esthetic considerations far outweigh the importance of future lactation.

,

375

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•

II. Transposition of the nipple on a double-based cutaneous flap

98-99 When the nipple is tran sposed on a bi ­ laterally based cutane ous flap , the design and technique is similar to that for a single-based pedicle .

100 As the flap becomes folded in the transfer, it does not include any glandular element except for a thickness of tissue directly under the areola. When the subcutaneous fa! layer is trim­ med extensively, the deep dermal surface may even be exposed in areas. This results in an ex­ ceed ingly thin but viable flap.

In this modification, the nipple pedicle is based medially as well as laterally. Transposing a bulky flap with this design is cumber­ some. To make nipple transfer less awkward, the entire flap is trimmed to comprise only a thin layer of subcuta neou s tissue, and the wedge-shaped glandular reductions are still performed as described. In some two hundred cases, a comparison study of both tech­ niques revealed little difference in postoperative vascu larity. An apparent gain in total blood volume, derived from two sources, ca n in fact not be demonstrated. This probably refle cts a de­ crease in effective blood supply as a consequen ce of kink ing the flap during transfer, thus negating any advantage obtained by employing a double-based pedicle. In addition, healing , ap­ pearance, and permanence of results are essentially the same for both types of flap s.

376

•

101-102 In this case of breast reduction, transposition of the nipple was performed with a double-based cutaneous flap . The glandular re sectio n was wedge-shaped as in method I, and amounted to 900 g on the right and 850 g on the left side. 103-104 These photo­

•

graphs show the result one yea r after surgery . Two months postop­ eratively the sensibility of both nippl es was co n­ sidered normal.

.0~106 When this patient gave birth t o a child three year s after mammaplasty, Stilbestrol was administered. She experienced no difficu lty with her breasts. Her condition eight years postop­ eratively is shown in the ac­ companying photographs.

377

III. Correction without a nipple flap

There is no need for creation of a flap for raising a nipple less than five cm . 'The new areolar site can be determined as de­ scribed, whereas skin reduction should be individualized. With­ in two cm of the areolar margin, the vascular network is pre­ served and the overlying epithelium is removed, leaving a thin dermal layer for protection. Only limited subcutaneous under­ mining is then required around the new areolar location to raise the breast to its planned position. Any glandular reduction is carried out as a wedge-excision beneath the areola.

107-108 In this nineteen year old girl asymmetry was corrected by reducing the size of the left breast to match that of the right. The wedge-shaped resection was made below the nipple, and no flap was needed. After surgery breast groW1h continued but symmetry was maintained.

378

References

Adams W. M .: Mammaryplasty with free transplantation of the nipples and areolae: A thirteen year follow-up report. Transact Internat Soc Plast Surg, First Congress, 1955. Williams & Wilkins Comp, Baltimore, 1957, p 371. Bankoff G.: A new simplified method of mammaplasty. Calif Med 90: 349,1959. Biesenberger H.: Eine neue Methode der Mammaplastik. Zbl Chir 55: 2382, 1928. Broman I.: Mann iskans utveckling fore fodelsen. C. W . K. Gleerup, Lund , 1927, p355. Cooper A. P. : On the Anatomy of the Breast Longman, Orine , Green, Brown and Longmans, London, 1840. Craig R. D. P. and Sykes P. A.: Nipple sensitivity following reduction mammaplasty . Brit J Plast Surg 23: 165, 1970. Dufourmentel C. and Mouly R.: Plastic mammaire par la methode oblique. Ann Chir Plast 6: 45, 1961 . Gillies H. and Mcindoe A. H.: The technique of mammaplasty in con ­ ditions of hypert rophy of the breast. Surg Gynec Obstet 68: 658 , 1939. Joseph J .: Zur Operation der hypertrophischen Hangebrust. Deutsch Med Wsch r 51 : 1103, 1925. Joseph J.: Nase nplastik und sonstige Gesichtsplastik nebst Mamma­ plastik. Verlag Curt Kabitzsch, Leipzig , 1931 , p 770. Kirsch R.: Verbess erungsvorschlag zur Mammaplastik. Zbl Chir 78: 1826, 1953. Lalardrie J.-P. and Jouglard J .-P.: Plasties mammaires pour hyper­ trophie et ptose. Masson et Cie, Paris, 1973. Lewis G. K.: A method of mastopexy with fascia lata transplants.

J Int Call Surg 26.' 346,1956 Maliniac J . W.: Breast Deformities and their Repair. Grune & Stratton, New York, 1950. Marcus G . H.: Untersuchungen uber die arterielle Blutversorgung der Mamilla . Arch klin Chir 179: 361,1934.

379

a

Ouli,; J.: Utilisation d'un lambeau areolo-mamelonnaire pedicule interne au cours des plasties mammaires de reduction. Presented at the 19th annual meeting of Societe Franqaise de Chirurgie Plastique et Reconstructive, Marseille, Oct 20, 1973. Palmer B.: Sympatheti c de nervation and reinnervation of cutaneous blood vessels following surgery. Scand J Plast Reconstr Surg 4: 93, 1970. Palmer B., Jurell G, and Norberg K.-A.: The blood flow in experi ­ mental skin flaps in rats studied by means of the ...·'Xenon clearance method. Scand J Pl ast Reconstr Surg 6: 6, 1972. Penn J.: Breast reduction II. Transact In tern at Soc Plast Surg, Second Congress, 1959. E & S Livingstone, Ltd, Edinburgh and London , 1960, p 502 . Pitanguv I.: Une nouvelle technique de plastic mammaire. Ann Ch ir Plast 7: 199, 1962. Ragnell A.: Operative correction of hypertrophy and ptosis of the female breast. Acta Chir Scand 1946, suppl. 113. Schwartz mann E.: Die Technik der Mammaplastik . Chirurg 2: 932, 1930. Skoog T.: A technique of breast reduction . Acta Chir Scand 126: 1, 1963. Strombeck J. 0.: Macromastia in women and its surgical treatment. Acta ChirScand 1964, suppl. 341 . Vesalius A.: De humani corporis fabrica. F. F. Senesis & J . Criegher, Venetiis, 1568, p 368.

380

Chapter XV

Reconstructing the nipple with an intact ductal system Introduction 384

Anesthesia 385

Operative procedure 386

Preoperative condition

Design for reconstruction

Dissection

Wound closure

Result

Comments 389

References 390

382

Introduction

Nipple inversion is a commonly encountered breast abnormal­ ity with pronounced hereditary transmission. The condition has been known to occur consecutively through many generations. The generally accepted theory that explains the pathogenesis is based on embryologic studies and was presented by Basch (1893). He considered inversion to result from a developmental arrest and showed that inverted nipples lack muscle fibers , which in the normal breast, arise from the muscular plaque within the areola. Flat and inverted nipples often cause physical and emotional distress. During pregnancy , when the circular areolar muscle thickens and contracts, a stricture forms and the nipple is further restricted from protruding above the surface of the breast. This renders nursing difficult or impossible. Mastitis may also occur, particularly during lactation. In addition to the increased in­ cidence of infection, the psychologic significance of this de­ formity can be of considerable importance. Little surgical interest has been generated by this malformation, and only a few operative methods have been described. Kehrer (1888) recommended wide areolar excision, including the smooth muscle layer, leaving a 2 mm zone adjacent to the base of the nipple. When the peripheral skin margin was sutured, under tension, to the circumcised nipple, the grooved defect turned into a flat nipple. In four cases operated upon in this manner, he reported good function . Having the opinion that the contracted areolar muscle was the essential distorting feature , Basch recommended a double subcutaneous myotomy and postoperative treatment consisting of frequent stretching or suture-fixation; thus applying continuous traction to keep the nipple in an improved position. In Sellheim's operation (1917) the nipple was freed and a number of small triangular skin seg­ ments were excised at the base in order to produce a "collar", mushrooming the nipple and preventing it from slipping back into the breast. The shortened circumference of the new nipple base was then sutured to the outer skin edge, which repre­ sented the original margin of the areola. Unfortunately, with this technique, what was gained in the early part of the opera­ tion was to a great extent dissipated when the wound edges, of markedly disparate lengths, were approximated. After heal­ ing and subsequent scar spreading due to the extensive peri­ pheral pull, the result deteriorated further.

384

}

J

Inverted Nipples

The following procedure was devised to present a permanently everted nipple, which is both functionally and aesthetically ac­ ceptable (Skoog 1952, 1957).

,

I

Anesthesia

Local anesthesia is used and the subcutaneous layer r)f the areola and a narrow periareolar zone are infiltrated with ap­ proximately 8 ml of 1 per cent lidocaine (Xylocaine ®) con tain­ ing epinephrine. The injection also penetrates the depth of the inverted nipple .

385

Operative procedure

Preoperative conditio n 1 In profile, the nipple is recessed and re­ tract ed. The bilateral deformity is permanent and the nipple can never attain a natural protuberance, which is a functional as well as an aesthet ic lim itation.

Design for reconstruction 3 With the skin stretched, a ci rcle of about 3 em in diameter has been draw n around the nipple . Four inner and four outer triangl es, with bases of equal length , are outlined along th e circumference. These areas repre sent the amount of skin to be removed . The pattern has been incised through the subcutane ous l ayer. U sing a traction suture facilitates th e operation .

386

2 The circular areolar muscle forms a walled rim abo ut the grooved nipple .

Dissection 4 The four central triangles hav e been ex­ cised down to the breast tissue, and the pro­ pellerlike flaps are freed extensiv ely in the subdermal layer . While tension is main­ tained on the nipple, the fibrous connections which bind the nipple, can now be released. The dissection is carried between the outer lactiferous ducts, and the retracting ele­ ments are severed until the nipple assumes a more protuberant position . Care sho uld be taken not to injure the ducts. The procedure can be executed with safety, as the deep vascular supply is quite adequate even on a thin nipple base.

I

Wound closure 5 The "p ropeller blades" ha v e been folded to­ gether and sutured with 4/0 Supramid' This forces the reconstructed nipple outwards in 6 The outer triangles are then excised and ap­ a mushroom fashion, while at the same time it becomes isolated in the middle of a proximation of the cut edges reduces the wide wound. exposed area.

7 Mattress sutures are used to place the cir­ cumcised nipple in broad apposition to the peripheral wound edge .

I Synthet4c, nonabsorbable suture material (Societe Sledl Ca tg ut. sse, Neuhausen a m Ah ein fa ll . Switzer­ land).

•

387

8 A Gillies' corner stitch is most useful in securing the various corners. 9 The base of the reconstructed nipple has been sutured to its new bed without ten­ sion and without effecting protn.;sion .

Result 1G-11 The new nipple silhouette protrudes above the surface of the breast. The pos­ sibility of lactation has been maintained, while aesthetic considerations have . at the same time, not been neglected. Nipple sensation was never impaired.

388

Comments

The nipple has a rich blood supply with communicating capil­ lary networks closely interwined with the lactiferous ducts. This provides excellent healing conditions and , despite the extensive dissection with wide undermining of the areola and nipple and the fact that the utilized skin flaps are narrowly based , tissue necrosis is not to be expected and healing is by primary inten­ tion. Most sutures can be removed after eight days, but as the circular incision was closed under some tension, the corner stitches are kept in place for a further week. Following this operation, sensory nerves may reach the nipple from the deep subcutaneous layer, or centrally through the breast tissue. In all patients nipple sensation remained normal. The major indication for surgery is the desire for normal nurs­ ing . In these cases, the operation is usually performed in the third or fourth month of pregnancy . At delivery most patients can then immediately breast feed their children. It is essential, however, that the mother takes an earnest interest in nursing. The seriousness of the patient's motivation should thus be con­ sidered before planning an operation. In subsequent preg­ nancies, the possibility for lactation is as good as previously, or even improved. It has been noted, however, that during preg­ nancy breast enlargement widens the base of the nipple with some secondary flattening . This is most likely to occur when the ducts are very short, and the reconstituted nipple is formed mainly from folded areolar skin. This treatment is now increasingly sought after for psychologic reasons. Recurrent infections, originating from fissures. can also be eliminated by this procedure. In these conditions simple sectioning of the ducts and everting the nipple is an alternative procedu reo The effectiveness of such measures is demonstrated in the previous chapter.

389

References

Basch K.: Beitriige zur Kenntniss des menschlichen M ilc happarats. Arch Gynaek 44: 15, 1893.

Kehrer F. A.: Handbuch der Geburtshijlfe. Ed. P. Muller. , F Enke, Stuttga rt, 1888, vo l 3, p 450. Sellheim H.: Brustwarzenp l astik bei H oh lwa rzen . Zbl. Gyniik 41 : 30 5,

1917 Skoog T.: An op erati on f or inverted nipples. Brit J Plast Surg 5: 65, 1952. Skoog T.: U na operaci 6n para pezones umb il icado s. Ana l Arg entin Med2:3 1, 1957.

390

=

Chapter XVI

Excision of the axillary sweat glands

Introduction 394 General considerations 395 Surgical technique Anesth esia Operative procedure 396 Preparation of the operative field Anesthesia Desig n of ski n flaps Excision of sweat glands Wound closure Dressing technique Result Comments 407 Operative technique

Hea ling

Results

Microscopic findings

References 410

• Title page: Section of axillary skin in a patient with axillary hyperhidrosis, showing the well -defined layer of sweat glands just deep to the dermis_

392

Axillary Hyperhidrosis A method of surgical treatment

Skin

Sweat glands

l l

r

Glandular fascia dissection

Axilla ry

fat

Introduction

Excessive and inappropriate axillary sweating is an acute prob ­ lem troubling many individuals, particularly women. Patients with this complain are emotionally sensitive and perspire pro­ fusely at the slightest stimulus. Their difficulties begin at pu­ berty with the maturation of the apocrine glands. Hyperhidrosis intensifies the stresses of the changing adolescent body and causes the effected individuals to have very unsettled lives. Handicapped by their obvious discomfort and embarrassed by persistent perspiration with stained clothing and an unpleasant odor, they are often barred from many occupations and social activities. Their choice of dress is necessarily limited, and the corrosive action of sweat on fabrics may impose a trying finan­ cial burden , Finally, dermatitis and intertrigo may develop in the chronically damp axilla. Satisfactory therapy for axillary hyperhidrosis has hitherto been relatively unsuccessful. Systemic medication with anti­ cholinergic drugs or sedatives has been tried , but as a rule , such large doses are required that troublesome side effects are likely to occur, Topical antiperspirants, usually containing aluminum salts, may be of value in mild cases, but in marked emotional hyperhidrosis, the copious secretions rapidly wash away the astringent salts, Local radiation therapy may prove effective, but in v iew of the serious complications associated with adequate dosages, its use is obviously contra-indicated. Sympathectomy, employed with limited success in palmar and plantar hyperhidrosis, is not applicable for selective treatment in the axillary region, Axillary sweating occurs in a specific area of skin, clearly demarcated by hair growth, This anatomical pattern allows ef­ fective surgical removal of the sweat-producing tissue, Since 1962, when an operation was first devised to treat hyper­ hidrosis of the axilla (Skoog et al), this teChnique has success­ fully been used in several hundred cases, Subsequently, Hurley and Shelley (1963,1966) presented a method in which they ex­ cised a segment of axillary skin with its attached sweat glands, in an effort to remove the most active mass of glandular tis­ sue, They claimed it was possible to reduce sweating to 20-40 per cent in this way, The nature of the disease is such , how­ ever , that partial removal of the sweat glands is ineffective in all but minimal cases, A total excision of axillary sweat tissue is the treatment of choice and offers the patient the only op­ portunity for complete relief,

394

•

General considerations

Surgical technique

The operation is based on a precise knowledge of the super­ ficial axillary anatomy. The axilla proper is not entered , thus there is no danger to its contents. Following the skin incisions, flaps are elevated in the plane between the investing fascia of the axilla, which covers the axillary fat pad , and the fine fascia underlying the layer of axillary sweat glands. The offending apocrine glands are located on the undersurface of the skin flaps. Surgical resection is performed with great care to avoid cutting into the dermis itself, thereby minimizing damage to the subdermal and dermal vascular networks.

Anesthesia

Local anesthesia, lidocaine (Xylocaine®), is strongly recom­ mended for this procedure. The vasoconstriction obtained by adding epinephrine markedly reduces bleeding and facilitates dissection. Subcutaneous axillary infiltration is only slightly painful, and causes little postoperative discomfort. A lengthy experience with this technique on an out-patient basis has shown no disadvantage or increased complication rate .

•

'.

395

Operative procedure

•

Preparation of the operative field , The axilla is shaved prior to surgery . With the patient in a recumbent position, the surgical area is exposed by a 120 degree abdu ction of the upper arm. The operative field is prepared in the usual manner, and sealed off with adh esive plastic drapes' Owing to profuse sweating, the axilla rapidly becomes co vered with wat ery fluid after cleansing . For pra ctica l pur­ p oses, this may be regarded as steril e sec retion, whi ch w ill cease after injection of local anesthetic.

, Steri-Drape®, surgical drapes , Minnesota M ining an d Manufactu ring Comp,.S t. Paul, M in n., U .S.A.

396

Anesthesia

2 The hair-bearing area of the axilla is anesthetized by sub­ cutaneous infiltration of 10 to 15 ml of 0.5 per cent Xylo­ caine ® with epinephrine . Both axi llae are anesthetized before begin ning surgery, so as to keep the patient relaxed throughout the entire procedure.

Design of skin flaps 3 The operative field lies mainly within the central portion of the axillary fossa, and is well-defined by hair growth. It is oval in shape with its long axis following the dire ction of the arm. For exposure, an incision is outlined transver sely across this area and placed in one of the skin creases. In ad­ dition , two longitudinal incisions are planned , which inter­ sect this line so that all hair-bearing skin is divided into four flaps . One incision is made perpendicular to the transverse inciSion, in the depth of the axillary fossa, while the ot her begins about one cm away . Each of the crossing lines is ex ­ tended just beyond the transverse incisi on. T hese marks will serve as guides for the accurate flap rea lignmen t at the time of closure.

397

4 The incisions are carried through the skin and the sub­ cutaneous layer, which is formed almost entirely by sweat glands. A cleavage plane on the axillary fascia facilitates the elevation of the skin flaps, which are raised with their sub­ cutaneous layer attached. A thin fascial membrane is ex­ posed on their under surface, through which bulges the lobulated , redishbrown tissue of the sweat glands. The glan­ dular layer presents a typical picture in color and structure, and is easily distinguished from surrounding fat and con­ nective tissue. In most cases of hyperhidrosis, the sweat glands represent a SUbstantial tissue layer, several milli­ metres thick and firmly anached to the dermis by glandular ducts .

398

Axillary Hyperhidrosis

1

t

'. - - - -- - - - - -- - - - -- - - ­

Excision of sweat glands 5-8 The glandular layer is gently dissected off the deep der­ mal surface with curved thin-bladed scissors _Careful pre­ servation of the subdermal vascular network is essential to maintain skin viability_ Holding the flap with hooks and tightly st retching it over the surgeon's finger during dissec­ tion, aids significantly in keeping the vasculature intact . In this way the fine subdermal vessels encountered in the plane of dissection are flattened and pressed into the dermis. The glandular tissue is thus easily removed while the assistant's forceps gently lifts the tissue, thereby stretching the glan­ dular ducts. The ducts are sectioned, ca re being taken not to injure the dermis. If the sweat glands are elevated by heavy traction, they will ca rry the vessels with them, and the

399

dissection may even enter the dermal layer. During the procedure some veins become exposed, while the arteries are generally not visible, due to spasm. The veins appear to drain towards the periphery of the glandular area, i.e. towards the bases of the flaps. A network of finer ves­ sels becomes visible on the dermal surface when the glan­ dular tissue ha s been removed and tension on the flaps is released . Toward the margins of the hair-bearing area, the glandular layer becomes thinner and ends in small isolated lobules, w ith ill-defined limit s. It is important to make the excision radi ca l , and to extend well out into the periphery to ensure complete glandular excision. With the aid of magnifying glasses ( x 2.5) it is possible to remove almost all lobules. On the average, about fifteen g of glandular tissue can be excised from each axilla. A great many hair follicles protrude from the deep surface of the dermis . As they are short, resiliant, and difficult to fixate, only a few are cut off with scissors when the sweat glands are removed. Excising them all would be a tedious and painstaking task, which might unnecessarily jeo­ pardize the blood supply to the flaps. It is as convenient to begin excising the glandular layer from the base of the flap as from its tip.

400

401

Wound closure

r

r 9 After careful hemostasis, the skin inci­ sions are clo sed with interrupted sutures of 4-0 plain catgut. Some nonabsorbable material is also used in each sutu re line . In closing the s urgi ca l wound , the apices of the flaps are first approximated at the trans­ verse incision line. The small nicks made at the time of the original incisions allow ac­ cu rate repositioning . A three-point subder­ mal stitch is used at both of these sites.

402

10 Some of the sutures used for juxtapos­ ing the skin edges also fix them to the axil­ lary fascia covering the deep surface of th e wound . The skin flaps are thu s immobilized during healing. Should postoperative hem orr hage occur, it is likel y to be con­ tained in the area of one flap as each flap acts as a separate co mpartment to limit the spread of the hematoma. Vertical mattress sutures were originally used in closure, but simple interrupted sutures passed through the skin near wound edge, are less traumati c and eq uall y effective.

Dressing technique 11 The suture lines are covered with mic rop oro us tape.' The tape is placed across th e entire under­ surface of the arm to compress the undermined area. In the axillary fossa, the tape covers the suture line on ly, so the und ermi ned skin will not tent up. No drainage is need ed . Sler i·Strip C9 skin closu res. 3M Comp., St. Pau l M inn., U .S.A.

The outer dressing has been modified since this operation was first reported. A much lighter dressing is now employed , which allows pressure to be effectively applied to the wound, while at the same time permitting maximum mobility for the patient . The operative field is treated as if there were two separate wounds-one on the upper arm, distal to the transverse in­ eison, and th e other within the axillary fos sa. As the arms move, these two parts will move in relation to each other . To prevent shearing, which inevitably occurs with a single dressing, it is necessary to dress the two wounds separately.

403

12-14 A roll of non-absorbent synthetic wool ITacryl), wrap­ ped in gauze and less than half a clenched first in size, is placed in the axilla and fixed to the chest wall by an elastic adhesive. This material retains its resiliency even in the face of oozing. As the chest wall slopes medially, adduction of the shoulder pushes the dressing into the axilla rather than downwards.

404

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15-16 The distal wound is covered simply with a light pad taped to the upper arm . To avoid a collection of blood and serum be­ neath the flaps, the patient is instructed to compress the wound by firmly pressing his arm to his side a few times every hour post­ operatively during the day of surgery. All dressings are removed aher one week . The majority of the catgut sutures will come out on the microporous tape, as it comes free from the skin. A light gauze pad is then ap­ plied and held in place with adhesive tape . Five days later, healing is usually complete and the nonabsorbable sutures are removed. No further dressing is then required.

405

Result 17 Six months postoperatively. Healing has been uneventful and even the very tips of the flaps have survived . The scars are red­ dened , but otherwise their quality and ap­ pearance are excellent. Hair growth has been considerably reduced. The axillary skin is soft and pliable, and a full range of shoulder movements is possible. Sweating was completely absent for about three months and then returned at an ac­ ceptable level. There was a simultaneous return of sensation .

406

•

Comments

Operative technique

The recommended pattern of in cisions offers excellent ex­ posure, while maintaining an adequate blood supply to the skin flaps , It also prevents late scar contracture, Other incisions have been tried with less success, One continuous longitudinal incision is not advisable, as proper exposure is difficult and the possibility of contracture in a straight scar, along the entire ax ­ illa, is considerable , An S-shaped incision with rounded flaps is also unsuitable, because of the danger of scar contracture and subsequent bunching of tissue, A Z-incision, using two large flaps, increases the risk of hematoma formation, as deep skin suture fixation cannot be used to full advantage , The larger flaps are also more sensitive to pressure, Taipale (1972) com­ pared these different incisions and confirmed that the recom­ mended approach gave superior results, Despite extensive thinning of the axillary skin close to the der­ mis, the flaps show good circulation at the end of the opera ­ tion, The subdermal vascular network, being exceptionally rich in this area be cause of its branches to the sweat glands and hair follicles, is adequate to supply these thin flaps, The hinged, two-part dressing has proved to be far superior to the bulky pressure dressing used originally, It allows the patient to be treated on an o ut-patient basis , This new type of dres­ sing probably is in part responsible for the very low incidence of postoperative hematoma, If this complication should occur, there will be an increase in pain and discomfort, These signs allow quick recognition of the problem, and the hematoma should be evacuated as its continued presence jeopardizes the survival of the skin flaps,

Healing

Provided the dissection is performed with. a strictly atraumatic technique, healing occurs by primary intention in ten to twelve days, The incidence of skin necrosis has been insignificant in our series, and when it did occur, was confined to the very tip of a flap, This tissue loss has never been of consequence, and the patients were not greatly incapacitated during the period of healing, which was prolonged by about two weeks, With scar development, the undermined area becomes in­ durated after a few weeks, This manifestation of the normal healing process subsides as it passes through the stages of

407

maturation common to all scar tissue. The transverse cutaneous scar lies in a natural skin crease and gradually becomes almost in v isible. The two longitudinal scars may spread slightly, but do not hypertro phy or lead to c ontracture.

Results

The functi ona l results of this operation can now be evaluated on the basis of ten years experience. In the immediate postoperative period , there is anhidrosis of the operated area as well as marked diminution of sensation. No untoward lo ca l symptoms are experienced during this period . On the contrary, many patients express great sati sfac­ tion with the result. As the skin flap s becom e reinnervated, in about three months, there is som e retu rn of swea ting , to what may be considered to be a normal or less than normal amount. Sensibility w ill then also have fully returned. Th e effect of rein­ nervation is succinctly elucidated in Ponten's (1960) ba sic re sea rch . In investigati ons w ith grafted sk in, he demonstrated a regu lar and fairl y co mpl ete return of glandular function as a direct result of the reconstituted nerve supply. In about 90 per cent of th e pati ents, the final results have been excellen t. In exc eptionall y stressful situations , some patients may still expe rience considerable sweating , as even small remna nts of glandular tissue may be sufficient to produce a larg e vo lume of sweat. Thus, it is difficult to und ersta nd, how less radical procedures can serve as adequate treatment for this condition . In the rem aining 10 per ce nt of our patients, there has been a Significant reduction in sweating, though not considered suf­ ficient to bring about complete reli ef. Re-examinat ion, including a starch-iodine test, in some of these cases revea led localiz ed areas of profuse sweating , generally at the periphery of the op erati ve fi eld, indi cating in co mplete excision rather than sweat gland regeneration. Re-operation di sclosed glandular tissue in th ese areas , and exce llent results followed excision. Com­ pensatory hyp erhidrosis of other area s has not followed this procedure . In patients with exce ssiv e sweating w ho present with a com­ paratively thin layer of sweat gland tissue, it is parti cularl y im­

408

•

Axillary Hyperhidrosis

portant to carry out a complete excision. This group is com ­ prised predominantly of highly nervo us individuals. A few had been emotionally disturbed to such an extent, that psychiatric treatment was ne ce ssary. The psychological effe ct of discomfort. anxi ety and stress, as­ sociated with this disorder, may not be fully appreciated until the patient is cured. It is difficult to find a more grateful group of patients. This has led to the in creasing popularity of surgical treatment in axillary hyperhid rosi s, as both the medical profes­ sion and the public have become aware of the po ss ibility of a cure .

Microscopic findings

The excised tissue has been exa mined microscopically in a great many cases, with similar findings in all instances. There was an abundance of sweat glands, predominantly of the apo­ crine type, with wide lumina and signs of hyperactivity. Eccrine glands were only infrequently found . This consistent observa­ tion seems to contradict the view held by Rothman 1954, Mon­ tagna 1962, and others, that the eccrine glands are mainly responsible for excessive axillary sweating , while the apocrine glands are of less significance .

•

409

References

Hurley H. J. and Shelley W. B.: A simple su rgi cal approach to the management of ax illary hyperhidrosis. JAMA: 186: 109,1963. Hurley H. J. and Shelley W . B.: Axillary hyperhidrosis. Clinical features and local surgical management. Brit J Derm 78: 127, 1966. Kuno Y.: Human Perspiration. Thomas, Springfield , 1956. Montagna W.: The Structure and Function of Skin. Acad Press, New York,1962. Ponten B.: Grafted skin. Observations on innervation and other quali­ ties. Acta Chir Scand, Suppl 257 , 1960. Rothman S.: Ph ysiology and Biochemistry of the Skin. University of Chicago Press, Chicago, 1954. Skoog T. and Thyresson N.: Hyperhydrosis of the axillae . A method of surgical treatment. Acta Chir Scand 124: 531 , 1962. Skoog T. and Thyresson N.: The su rgical treatment of axillary hyper­ hidrosis. Brit J Derm 78: 551, 1966. Taipale S.: Hyperhidrosis axillae--Erfarenheter av olika operations­ metoder. Reported to the Scandinavian Association of Plastic Sur­ geons, 14th Congress, June 14, 1972. (Not publ is hed .)

410

Chapter XVII

Repair of syndactyly - reconstructing a normal commissure and providing adequate skin coverage Introduction 414 General considerations 415 The interdigital commissure Skin coverage Age at operation

Anesthesia

Operative procedure 417. Design for reconstructing the commissure Pattern s for finger separation Separating the fingers Reconstructing the commissu re Skin coverage Result Comments 424 References 427

Title page: Syndactyly, is used sym­ bolically in the Buddha of the Yakushi ­ ji Temple at Nara, Japan. In this mag­ nificent seven teenth century bronze statue, all the fingers are webbed for half th eir length to prevent faithful subjects from slipping through the protective hands of their benevolent Buddha . Photo by Mr. Ogawa, Nara; courtesy of Seiichi Ohmori, M.D., Tokyo .

412

Syndactyly

A method of correction

Introduction

The shell must break before the b ird can fly

Alfred, Lord Tennyson : Th e Ancient Sage (1885)

Syndactyly is one of the most common congenital malforma­ tions. Occurring about once in every two thous and births, most frequently in males, it has a predilection for involvement of the ring and middle fingers. There is often a family history of a sim­ ilar disorder. The degree of deformity ranges from complete fu sion of all fingers , to minimal involvement, with only a sma ll persistent web present between two digits . Often the abnormality occurs in combination with other malformations of the hand . Poland 's syndrome, ipsilate ra l absence of the sternal head of the pec­ toralis major and syndactyly; and Apert' s syndrome , acroce­ phalosyndactyly, are examples of associated defects. The purpose of this chapter is not to review sy ndactyly per se but rather , the presentation will be confined to its proper sur­ gical treatment, based on an operative procedure first reported in 1965 (Skoog).

414

General considerations

The nature of the disease has intrigued the surgeon and invited easy solutions. The most obvious possibility, of simply splitting the union between the fingers, has had disastrous consequences. Effective correction of syndactyly must be based on certain fundamental principles : (1) A normal commissure should be created to restore proper function and appearance. (2) Skin deficiency should be fully replaced to avoid tight skin closure. (3) Scars should be positioned so as not to initiate secondary deformity. Underdevelopment of the fingers, marked distortion, flexion deformities and recurrent webbing , all arise as a consequence of failing to observe these basi c tenets of repair.

The interdigital commissure

In the nineteenth century, Zeller (1810) and FE!iizet (1892) re com­ mended the use of local flaps to line the commissure. Many modifications of this principle have since been developed. Ket­ telkamp and Flatt (1961) reviewed the most commonly used techniques. In our experience, a normal commissural configuration is best obtained by using two flaps. When properly designed , they will permit normal function of the separated fingers and eliminate hazardous tra'1sverse scars, which may contract and reproduce webbing.

Skin coverage

In syndactyly, there is always a deficiency of skin . Any attempt at repair must appreciate this consistent finding and provide complete skin coverage for the separated fingers. A procedure which merely shifts and repositions skin without compensating for the tissue deficit, is destined to fail, despite the apparent in­ genuity of the recommended designs. Didot, in 1849, presented such a pattern. Though brilliantly conceived, the theoretical concept was a serious clinical error.

415

/

Provided a fr ee skin gra ft is used for replacement, one o r two fl a ps from o ne finger may be used to cove r it s neighbor. This principle of robb ing Peter to pay Paul is most advantageously used in selectively providing high quality sk in to sen siti ve and important areas . The co ntact surfaces that oppose the thumb and raw bony surfaces are in particular need of skin flaps. The flaps are constructed in suc h a way as to pr oper ly p ositio n scar lines. As scars fail to keep pa ce with normal ski n growth, stag­ gering th e suture line perm its unhindered development. Break­ ing the line of closure at points of highest stress will also counte ra ct any tendency to develop restri cting contrac tu res. As the normal fin ger is tape red fro m its base to its tip , the shape of the covering skin must co nform to these dim ensions. If the skin flaps or grafts fail to co rrespond to finger proport io ns, then a constriction will develop, usually at the base , hampe ring further growth and fun ction.

Age at operation

Anesthesia

416

Surgi ca l correction is preferably undertaken at four years of age . At this stage of development, anatomically favorab le con­ ditions exist. Th e hand has lost some of its infantile, fa tty char­ acter and has ass umed a more mat ure appea rance . The dang er of di sturbing future growth is also reduced, as is the tende ncy for hypertrophic sca r formation. A del ay beyo nd thi s time may retard the learni ng process and might have cripplin g psycho­ logical effects on the child who . at school , is parti cul arl y vulner­ able to the criti cis m and ridi cule of his peer s. Earlier operation can prove desirable in ex ce ptional instan ces, especially where the webbing is co nsidered t o markedl y effect finger growth, i.e. where o ne finger is permanently fle x ed when fused to its sho rter neighbor. In this case, surgery can be performed as early as one yea r of age.

When the procedure is perfo rmed on children , general anes­ the sia is empl oyed . In adult syndactyly, an axillary nerve block ca n be su itabl y used.

•

Operative proc edu re - Design for reconstructin g the co m m issure

1 Thi s child was b o rn w ith three fin ger s o n his left hand jo in ed and co mpl etely web­ bed to each o th er f or th eir entire leng th . Being bound to th e s ho rt er littl e fi nger, th e oth er fin ger s are fi xe d in a semifl exed positi o n. S in ce thi s might hav e impaired ear ly d evelo pment, th e ring and little fin ­ gers were sepa rated at o ne y ear o f ag e. The su b seq uen t pictur es are of th e op era ­ ti ve procedure fo r co rrec ting th e rem ain · ing def o rmity . Thi s was p erform ed o n e yea r aft er th e initi al surgery . Th e sa m e t ec hniqu es were empl oyed on both occa­ sio ns.

/ 2 The new inte rdigi t al co mm issu re is de­ signed on the palmar an d dors al aspects of the hand . The flap is based, on the volar surface , where the broken lines represent the level of the normal w eb creases . The width of this flap corres pon d s to the breadt h of a normal co mm is sure, which m ay be estima t ed fr om the adja ce nt web spaces.

3 On t he d o rsal aspect, the width of the f la p is defin ed by the dist ance between the metacar pal heads. In the juvenile han d, these points are dem arcated by dimpling of the skin . T his fla p aris es more proximal ­ ly than the corres po ndi ng volar flap . T he level of t h e p lan ned pa lma r web dete r­ m ines t h e len gth of th e flap , as ad d it io na l length is unn ecessary . In pra ct ice, the top o f thi s flap lies midway on th e pro x imal ph alanx .

4 17

Patterns for finger separation

4 Covering for the ring finger is planned from available skin at the expense of the adjacent long finger . The radial sur­ face of the ring finger is an important contact area for the thumb and thus rece ives prefe rential treatment The amount of ti ssue bo rrowed fr o m the neig hbo rin g fin ger is determined by the length o f skin necessa ry to fold about the ring finger and join a similarl y co nstru cted flap from the d orsal aspect. The flap is fir st designed o n the v olar surface, w here triangular proj ecti o ns mark the lev el o f the interphalangeal jo ints. Th ese triangl es mu st be large en o ugh to prev ent contra cture. W hen a free g raft sub ­ sequentl y is used to cover th e denuded fin ger, the scars w ill thus be broke n at c ru cial points. A similar effect wi ll be o btained w ith the flap clos ure. The skin pallor reflects the use of a bloodless field tech­ nique.

5 A pin, placed perpendicularly through the web at the level of the projections, coordinates the markings on both surfaces. The outlined flaps fit together in a jigsaw puzzle arrangement, as skin from the dorsal aspect of the long finger is inserted to completely cover the rin g finger. A generous allowance of tissue must be provided to fully wrap the ring finger with skin. Minimal tension, present at the time of surgery, will eventually enclose the finger in a tight, restricti v e glove that limits blood flow and may result in impaired growth and development.

418

Separating the fingers

6 In raising the v olar flap, a clea v age plane beneath the sub­ cutaneous tissue protects the digital nerves and arteries. Enclosed in a fascial casing , the neurov ascular bundle is clearly seen on the ulnar aspect of the long finger and is faintly visible through the overl y ing fat of the ring finger. In this instance, the deep anatomy was left undisturbed ilnd merely required separation into soft tissue compart­ ments. When the arterial bifurcation arises high up on the fin­ gers, one branch must be sacrificed. However, the fused nerves can easily be spread apart by incising their com­ mon epineurial sheath and apportioning the separated seg­ ments respectively, one to each finger .

7 On the dorsal aspect, some subcutaneous tissue is left on the donor finger to prov ide a suitable base for an onlay, full thickness skin graft. Careful dissection protects the vascular plexus, as evidenced by the prominent v eins at the base of the fingers. Here, the tips of the fingers are so firmly adherent to each other, that sharp dissection is needed to divide them.

•

419

Reconstructing the commissure

8 The dissection is completed, permitting sepa ration of the fingers. The den uded sur­ face displays the normal anatomy of the web space, partly cove red by the transverse interdigital ligament.

9 The positioned triangular flap s give ade­ quate coverage to the depth of the commis­ sure. When united, the result is a normal appearing and functioni ng inte rd igital fold . The ba se of th e vola r flap furnishes the full w idth of the commissural border, and the dorsal flap produces a natura lly sloped sur­ fa ce.

Skin co verage

10-11 The unprotected contact surface of the ring finger is seen as the flaps are retracted. The extent of the s ignificant tissue deficit is clearly demonstrated.

An accurate, but untensed approximation of these irregula rly' shaped flaps is per­ formed, us ing 5/0 non-absorbable sutu res . Regardless of the degree of synda cty ly or the reconstructive design employed, an open area is always present at the base of the finger. Thi s s ite will be covered with a full thi ck ness ski n graft.

420

12-13 As the long finger has been used to supply skin for the ring f inger, a large de­ nuded area remains to be resurfaced . Si nce m ost of the subcutaneo us tissue wa s re­ moved when the flaps were take n , t h e finger has been partially bared down to the d igital fascia, and the periosteum has been left ex­ posed over the di sta l phalan x. In leaf-shaped ski n graft is taken from the hairle ss inguinal area . Th e pattern accurate ­ ly fills the defect of the long finger and also supplies tissue for the bare area at the base of the ring finger. The donor site is closed primarily.

14 The sp read fingers reveal how extens ive an area needs to be covered with skin to ad equately repair syndactyly. The grah is su­ tured edge t o edge w ith 5/0 plain catgut A n atraumatic technique mu st be u sed if rapid healing and good result s are to be ob­ tained.

15 The long and ring fingers sha re a com­ mon skin border and consequently the lo ng finger is slightly flexed, whe n bound to its sho rte r partner. In sepa rating th e fingers, a noticable skin tightness became evident on the vo lar surface. A relaxing in cisi on has bee n made at the proximal pha lanx, and the resulting ra w su rface covered with a skin graft to remove undue tens ion and permit full ex tension of the finger.

42 1

Result

16-20 In these postoperative photographs, taken three months after surgery, the separated fin­ gers are of normal shape and have been co mpletely covered, with ­ out skin tension . The interdigital fold is at the correct leve l and the commissure has a norma! configuration.

T

422

Syndactyly

21 This picture demonstrates the full thickness skin graft used to cover the long finger. Its original shape has been maintained. No con­ tractures have developed along its borders, which indicates that there has been no ten­ sion during healing. There is little to dis­ tingui sh the graft from the surrounding skin. It is pliable, can glide over the surface of the underl y ing structures, and can be expected to grow commensurately with the general de ­ velopment of the child .

22 On the ring finger, where the flaps have been sutured together, the broken scar line has ef­ fectively prevented any cont ractu re from de­ ve loping . The importan ce of the st riated graft is obvious; it has permitted tension-less heal ­ ing and kept the ba se of the finger from being encircled by a constricting ring of skin.

•

423

23 In this ca se of minima l webb ing be­ tween the middle and ring fi nge r, thare appears to be amp le skin for rec onstru c­ tion , At oper ati on, ski n w as tak n from the dorsal and vo lar asp ects to adequa te · Iy cover the commissure. Ra w areas were

then left on both sides and resurfaced with full thickness grafts.

24 Suture lines and grafted areas are out­ lined in this postoperative photog rap h. Nine years after surgery, a normal web space is seen to lead down a gentle incline to the palmar levet.

Comments

In the method of reconstructing the commissure, the natural landmarks facilitate flap design. Based proximally with a rich blood supply, the flaps are un co mpromised an d rem a in via b le even t o their tips. Transference and alignme nt is easily accom­ plished , and the sutures can be accurately placed without ten­ sion. Healing is thus never a problem. Scarring is insignifican t and the configuration of the flaps is such, that the pull of any scar that might devel o p does not lead to a distorting contra c­ ture , as is the case in many procedures. where transversely aligned flaps reproduce a web defect. Similarl y objectio n ab le. vertical scars in the depth of the commissure develop an u n ­ naturally deepening furro w. while free grafts present the likeli­ hood of generalized contracture. The described te chnique pro­ v ides a normal appearing commissure. sloping n atu rally to the vo lar surface. and the resulting broa d interdigit al fo ld is com­ prised of repositioned palmar skin. There is no limitatio n of m o­ tion , and neither is there recurrent webbing or secondary de ­ formity . Ev en in minimal syndactyly , w here there appears to be re ­ dundant skin. extra cover is still required (Fig s. 23-24) . If suf­ fici ent tissue is g rafted to compensate for the deficit, and care is exercised in positioning the scar lines. most instances of syndactyly can be adequately treated . Difficult circumstances in­ variabl y demand improvisations. Caution is advised in dealing w ith multiply involved digits. It is safer to operate on o nly o ne side of the finger at one time . An 424

~-- . -----

,

•

Late results

25 Marked bi lateral syndacty ly is clearly visible in the chubby hands of this one year old boy. Four years later, the features of the hand be­ came more distinct and surgery was then performed. Several full thickness skin grafts were needed to cover the large skin defi cits over the contact surfaces of the fingers.

26-27 Three years post­ operatively. Finger de­ velopment has been nOr­ mal and function is un­ impaired . The borders of the refurbished areas are outlined.

28 In contrast to the result achieved i n the child shown above, the un­ fortunate sequelae of improper treatment is depicted in this photo­ graph of the boy' s father. He and three of his sons had multiple fin­ ger syndacty ly. Surgery in ch ildhood, had left his hand crippled and deformed. Treated without skin replacement, the little finger had to be amputated and the remaining, distorted digits rest almost func­ tionless in a brace of contracting scar tiss ue .

•

425

,

exception is made when the fingers are so tightly fused to­ gether, that full extension can be obtained only after separating both sides. In firmly connected fingers , complicated by syno­ stosis, the exposed bone will accept a skin graft but, as pre­ viously mentioned , this circumstance is an ideal setting for using a local skin flap. With few exceptions, the results of this procedure have been most satisfactory. There has been no incidence of flap necrosis, neither has significant scar formation developed. In most cases, re-examined five to seven years postoperatively, the grafted skin has permitted normal finger development and the border­ ing scars are soft and linear, without evidence of contracture (Figs. 25-27). In some cases there was, however, some volar skin shortening, which was demonstrated on hyperextension , but this caused little or no functional impairment. The common experience of skin grafts becoming roughened and greyish­ brown, on the volar surface of the hand , was confirmed in our patients . Secondary skin contractures reinforce the concept that all cases of syndactyly need ample skin replacement. Should disabling scars occur, they are easily corrected by breaking the scar line and grafting additional skin. Fingers that are hampered and harnessed by a tightening jacket of skin, should be transversely incised. This relaxing incision will leave a wide gap of tissue , which can then be covered by a full thickness skin graft. To reiterate, in order to obtain satisfactory results in the treat­ ment of syndactyly one should approach the problem with the understanding that: •

additional skin is needed;

• skin flaps should be carefully designed to cover, but not restrict the developing fingers; • the size and shape of grafted skin should be accurately esti­ mated; , • the scars should be staggered for elongation, and broken so as to avoid a longitudinal direction at the flexion creases; and • surgical execution should be meticulous and as far as pos­ sible atraumatic.

426

--

,

References

Apert E.: De I'acrocephalosy ndactylie. Bull Soc Med Hop, Pa ris

23: 1310,1906 Blackfield H. M. and Hause D. P.: Syndactylism. Plast Reconstr Surg

76: 37,1955. Davis J. 5.: Plastic Surgery. H. Kimpton , London, 1919, p 243. DidotA.: A Notesur la separation des doigt s palmes, et sur un noveau procede anaplastique destine prevenir la reproducti on de la difformite. Bull Acad Roy Med Belgique 9. 35 1,1849.

a

FelizetG.: Operation de la syndacty lie co ngenitale . Rev d 'Orthop 3:

49,1892. Kettelkamp D. B. and Flatt A. E.: An evaluation of syndactylia repa ir. Surg Gynec Obstet 772: 471 , 1961 . Poland A. : Deficiency of the pectoral muscles. Guy's Hosp Rep 6: 191,

1841. SkoogT.: Syndactyly. Acta ChirScand 730: 537, 1965. Zeller 5 .: Abhandlung uber die ersten Erscheinungen venerischer Lokalkran kenh eits· Formen und deren B ehandlung, samt einer kurzen A nzeige zweier neuer Operation·Methoden, namlich: dieangeborenen verwachsenen Finger und die Kastrazion. J . G. Binz, Wien, 1810, p 107.

I

427

Chapter XVIII

The pathogenetic cycle in Dupuytren's contracture is discussed with respect to microscopic and clinical observations, as well as the possible role of predisposing factors

-

Introduction 430 Contracture of the palmar aponeurosis 432 Funct ional anatomy Embryology Pathology and pathogenesis The aponeurotic nodu le

The aponeurotic cord

The transverse bands

Finger cont racture

The sub cutaneous tissue

Contracture developing in scar tissue 444 Iatrogen ic contracture Knuckle-pads 445 Plantar manifestations 447 Peyronie's disease 448 Hereditary predisposition 448 Acqu ired pred isp osition 449 Ti ssue trauma and immobil iza ti on Spec ific age nts Comments 451 Li abi lity f o r co mpensati o n References

428

453

Dupuytren's

Contracture 1

Pathology, pathogenesis and predisposition

.

COlltraElio digitorumfilliflr.e manus, i,11'olam iI/ius. /

artifex lapicida quidam,faxUln immen­ rumvolucDs, adeo tendines in finifi:rz manu, IvolaNGgnis ad digitol.annularem minimum definen. &

te,. ei attraCl:i fun t , vt 1m avinculis quib.retinetur

• I.xati. oleuatique, du.schordas rub cute teof.sin altum referrent. contrac1:ique duo hi digiti & at· trotH,pollea remper manferint.

Digiti

1 Felicis Pia teri Obserua­ tianum, in hominis . Basileee, MDCXIIII.

Plater's patient was a famous sculptor who developed a contracture of the left ring and little fingers. The artist dated his troubles to mov· ing a large piece of stone. Although Plater accurately described the clinical manifestations of the disease as two raised cords, tightened and permanently contracted under the skin, he incorrectly assumed that these bands were displaced tendons, torn loose from their deep palmar attachments.

Introduction

The world literature on Dupuytren's contracture contains an abundance of detailed, but often contradictory publications. In 1832, Baron Dupuytren himsel(stressed how incoherent and misleading concepts of the disease had led to haphazard treat­ ment and general bewilderment. "If we consider the multitude of reasons assigned as a cause of this disease, the quantity of remedies proposed for its cure, and the various hypotheses put forth on its origin, it is not surpris­ ing that many surgeons should have regarded it as incurable ... It has at different times been attributed to a rheumatismal affection, to gout, some external violence, a fracture, or the metastasis of some morbid cause . .. "

Unfortunately, an aura of confusion still prevails, and even re­ cent articles perpetuate these old misconceptions. Undoubtedly, in many instances there is a predisposition to acquiring the disease, often of a hereditary nature. A number of factors may then precipitate its development, and rigid adherence to a single school of thought, for instance strictly trauma or solely hereditary causes, is untenable.

430

Dupuytren 's Contracture 1

Regardless of the exact etiology or etiologies involved, the at­ tainment of a fuller understanding of the pathogenesis is the logical way to evaluate the various clinical features and develop a rational method of surgical management. Dupuytren implicated the palmar aponeurosis as the site of the pathologic process. "The dissection was continued by exposing the palmar fascia, and I was astonished to perceive that this fascia was tense, retracted, and shortened From its lower portion were given off kinds of chords . . . I cut through the prolongations extending from the fasc ia to the fingers; the state of contraction imme­ diately ceased . .. incontrovertibly . . . retraction of the fingers, depends, in these cases, on a retraction of palmar fascia .. These observations are the crux of the issue. The primary pathology is confined to the palmar aponeurosis .

I

In 1948, I completed a study of Dupuytren ' s contracture with particular emphasis on the clinical symptoms and pathologic anatomy. The correlation of these findings led to the hypothesis that microrupture of collagenous tissue was the initiating event in the cycle of pathogenesis . This theory provides a fairly com­ plete model, which accomodates the known features of the dis­ ease. With passing years, additional observations have added support to the original argument. In 1959, the transverse palmar band of the aponeurosis, a relatively inactive component, was found never to be involved in the pathologic process. This sub­ stantiated the role of trauma. The clinical application of this discovery has been instrumental in the development of the new surgical approach of selective aponeurectomy.

431

Contracture of the palmar

aponeurosIs Fu nctio nal ana t o m y

The complicated anatomy of the palmar aponeurosi s m erely reflects the different functions of this fibrous framew ork . The longitudinal fasciculi, which branch out to the fingers , protect the deep structures from everyday trauma (Fig. 2). To accomp­ lish this, the aponeurosis must be firmly anchored to the pa'i m with its interdigitating components working as a unit. The superficial attachments, which extensively cover the volar sur­ face, keep the ove rlying skin securely moored to the aponeuro­ sis. They tighten to prev ent shifting of the skin when t he hand grasps an object. T he deep attachments are more localized, forming septal bands at strategic points. They integrate in an ingenious fibrous tunnel system, which creates protected path­ ways f o r nerves and vessels.

'.

2 This illustration depicts the normal anatomy of the palmar aponeurosis . The transverse palmar band is ba rely visib le between the pretendinous fascicu li. Distal ly the regular open­ ings in the aponeurosis, corresponding to ·the inter­ spacing palmar monticuli, are seen.

432

Dupuytren '5 Contracture 7

The ulnar side of the hand bears the brunt of heavy work, and consequently the aponeurosis is more developed there . These thicker, stronger structures are graphically demonstrated in a hand that engages in strenuous physical activity. The structural variation between the radial and ulnar aspects accounts for the different degrees of pathologic involvement. The transverse fibers of the aponeurosis are separated into two distinct groups, the transverse palmar band and the interdigital ligaments of the web spaces. The transverse palmar fibers de­ serve special attention, since this continuous band is never the site of Dupuytren's contracture. As with other parts of the aponeurosis, the density varies from a well-defined structure, about one cm wide, to a few strands of fibrous tissue . The liga­ ment is limited to the midpalmar region, and the flexor tendons of the index and little fingers define its borders. The fiber bund ­ les combine with the deep paratendinous septa to form a group of fibrous tunnels that traverse the palm (Fig . 3) . This entity may be considered a separate anatomical structure. It aids in stabiliz­ ing the transverse palmar arch, maintains flexor tendon posi ­ tion , and shelters the underlying nerves and vessels.

Embryology

The morphogenesis of the palmar aponeurosis indicates that the individual structures develop from different primordia. In the embryo the transverse bands originate independently and approximate with the longitudinal structures at a later stage of development. Separate, transversely-arranged clusters of mesenchymal tissue can be visualized in cross sections of 1.9 cm embryos. This early differentiation proceeds rapidly, and by 16 cm the midpalmar compartments of the fetus schematically represent the connective tissue framework of the adult (Skoog 1948).

433

•

3 In the midportion of the palm , the longitudinal elements of the palmar aponeurosis hav e been resected ; distally, the se ctioned pre ­ tendinous bands are found to hav e deep attachments, whi ch bran ch to ea ch side of the flexor tendons. The interdigital ligament, i.e. the superficial transv erse band that crosses the distal portion of the palm, is not depicted in thi s drawing . The fibrous framework formed by the transvers e palmar ligament and anchoring septa is demonstrated. This fascicular system divides the palm into protective tunnels, four for the flexor tendons, alternat­ ing with three compartments for the nerves, arteries and lumbrical muscles.

434

Pathology and pathogenesis

The aponeurotic nodule

The first clinical sign of Dupuytren's contracture is a nodular thickening of the palm. These nodules generally develop within the pretendinous bands of the palmar aponeurosis, and are mainly confined to regions, where the presence of deep attach­ ments indicates special functional demands on the aponeurosis (Fig. 4). The nodules are composed of nonspecific connective tissue and, depending on the stage of evolution, they vary from an ill-defined, richly cellular cluster of fibroblasts to poorly-dif­ ferentiated scar tissue (Figs. 5-7).

4 This hand displays an early stage of Dupuytren's con­ tracture. A characteristic nodule has formed within the fifth pretendinous band, over the metacarpal head. There is slight contracture of the involved aponeurotic sec­ tion, which tends to flex the little finger. The nodule first appeared about two weeks after a localized crush injury and slowly enlarged. Tightness of the related pre­ tendinous band then progressively developed during the ensuing seven months of observation.

5 This photomicrograph of a fresh aponeu rotic le­ sion shows hemorrhage and nonspecific granula­ tion tissue. An increased

vascularity is part of the reparative process. (x370)

6 This pictu re demon­ strates a nodule at a later stage of development. It is composed of an ir­ regular aggregation of un­ differentiated fibroblasts. (x500)

7 Gradually the aponeu­ rotic nodule mature into a dense, scar-like tissue.

(x500)

435

Severa l fa cto rs indi ca te that the nodule is but a manifestation of healing in response to localized injury. In the transitional zone between normal aponeurotic tissue and hyperceliular areas , it is possible to demonstrate br eaks in the collagen fiber bundles, particularly in areas where the proces s appears to be of relative­ ly recent onset (F ig . 8). The consistent finding of hemosiderin in the center of fresh nodules further indicates that there has been hem orrhage associated with the lesions in the aponeur­ osis. In n o dules which have developed into larger, growing cel­ lular masses, multiple hemorrhages are f o und in various stages of reabsorpti o n . This finding is probably a reflection of con­ tinued trauma to the protruding , fairly-well vas cu larized nodular mass (Fig . 9).

8 This longitudinal sec­ tion is taken th rough a palmar aponeurosis that is involved with Dupuy­ tren's contracture . Col­ lag en fiber bundles (a) are stained black with Heiden­ hain' s iron hematoxylin. Composed of richly cel­ lular ti ssue, the grey area s (b) corres pond to aponeu­ roti c nodule s. I n serial sec­ tion s some bundles pass into the nodu les, others end at the nodule bor­ de rs. ( x l00)

b

1

9 This section from the aponeuroti c nodule shown in Fi g. 4, dem onstrates a fairl y fres h hemorrhage in the cellular tiss ue. The presence of iron pigment is demonstrated by Berlin blue staining . (x 500) About ten days prior to removing this specimen , the pati ent's little finger was forcefully hyper­ extended and a sharp bu rning pa in was ex­ perienced in the nodule.

436

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Dupuytren 's Contracture 7

The actual development of aponeurotic nodules has been ob­ served following open wounds of the palm with laceration of the aponeurosis. This sequence of events may also occur in closed lesions following excessive strain, i.e. accidental hyper­ extension of fingers or hard manual exercise in untrained hands. Following this trauma, the nodules have appeared several weeks later with the main symptom being some slight initial tenderness. In the succeeding months the nodules have either regressed or developed into a true Dupuytren' s con­ tracture. The long interval between trauma and clinical symp­ toms explains why a causal relationship is often overlooked. The incident may not be remembered years later, when the pa­ tient first presents for medical treatment.

In an effort to ascertain whether indirect trauma could account for the microruptures of the aponeurosis, immediately before surgery, in a few cases of Dupuytren 's contracture, the longi­ tudinal fasciculi were overstretched by hyperextending the fingers. Microscopic examination of the specimens confirmed the assumption that within the distal portion of the palm , recent partial ruptures of various sizes had occurred (Figs. 10-12). Microruptures usually originate at the fixed points where the longitudinal fasciculi are attached by fibrous bands to the bony structures. Here, where the stress and strain is the greatest, are the common sites of pal mar nodule formation. In 1960, Larsen, Takagishi, and Posch reported on an investiga ­ tion of Dupuytren's contracture in which special care was taken in the orientation and sectioning of the specimens. They con­ firmed the presence of hemosiderin in the nodules and demon­ strated disrupted fibers abruptly terminating at the nodules. Larsen and his associates were also able to reproduce the dis­ ease in monkeys, were through exposure and traction they produced fiber ruptures of the palmar and plantar aponeuroses. Nodules visible to the naked eye were found exclusively at the sites of rupture. In the first two or three months they were soft and reddish-grey, but later as their vascularity decreased, they became firmer and yellowish in color. Their microscopic ap­ pearance was virtually indistinguishable from that of the char­ acteristic Dupuytren nodules, and hemosiderin was readily . found in the first few months. These findings strongly support the contention that microrupture within the aponeurosis is an essential factor in the pathogeneSis.

437

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10 After induction of anesthesia, but prior to begin ning surgery for Dupuytren ' s contracture, the patient's fingers were forcefully hyper­ exte nded . 11 - 12 In longitudinal

sections of the resected aponeu rosis, multiple fresh fascia l ruptures are demonstrated (al. T he split fiber bundles appear wavy and frayed (bl . Some fibers pass undistu rbed through the main sites of rupture . (Heidenhain's hematoxylin. x 40 and x 4501

a

a

There is a marked similar­ ity, with respect to the a r­ rangement of collagen fiber bundles, between these created ruptures and the pathologic lesions seen in Fig . 8.

438

b

Dupuytren '5 Contracture 1

Further credence is lent to this argument by the clinical ob­ servation that maturing granulation tissue, developing in re­ sponse to aponeurotic injury, resembles foci of Dupuytren's contracture.

The aponeurotic cord

The second characteristic of the disease develops at a later stage, when the longitudinal fasciculi, related to the nodules, change into tendon-like cords. This leads to permanent flexion of the corresponding fingers (Fig. 13). The mechanism is in­ itiated by scar contracture at the site of the healing lesion. The tensed, shortened band is subjected to greater strain than other parts of the aponeurosis and, as a result, it becomes hypertrophic. The increase in collagen fibers, visible as thicken­ ing of the band, corresponds directly to the use of the hand (Fig. 14). Accordingly, in persons who do heavy manual labor and in those, who try to counteract contracture with energetic stretching, thick cords develop. Conversely, thickened bands will atrophy once tension is eliminated by simple division, if the ends are not allowed to reunite. As a therapeutic measure, cord sectioning is therefore effective in marked flexion contrac­ ture, where a large gap results from extending the released

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13 This hand is involved with classic Dupuy­ tren's contracture. There has been nodular formation at the base of the ring finger and proximal to this, the pretendinous band has transformed into a taut cord, which keeps the finger in permanent flexion. The creased skin is wrapped about this thickened fibrous band, and puckering is most marked directly over the nodular mass.

14 This longitudinal section displays the compact

collagen fiber bundles of the aponeurotic cord. (x500)

439

a 15 The drawing schematically illustrates the typical pathologic in­

volvement of Dupuytren's contracture. The nodular masses are char­

acteristically localized to the meta carpophalangeal region . The cor­

responding pretendinous band has developed into a thickened and

contracted cord , which keeps the finger in forced fle x ion. When ex­

posed to similar mechanical processes the deep aponeurotic atta ch­

ment s also become hypertrophic . These fibers attach to the joint

cap sule s and the deep fibrous framework of the hand ; they also in­

sert directly onto bone. When contracted , cutaneou s extensions of the

aponeurosis produce pits and furrows , this most often occurs in the

distal palm .

The transv erse palmar band (a) and its deep conne ctions are nev er

pathologically affected .

finger . In a minimal contracture, a simple incision might have

the unwanted effect of inducing rapid healing between the

severed ends . Thick scars may thus develop, which only further

the progression of the disease. Similarly, wide resection of the

cord at its proximal and distal ends will allow the intervening

portion to disintegrate, provided it is not left under tension or

does not acquire new attachments.

To offset the bow-string effect on the shortening pretendinous

bands, thickening occurs at their deep attachments, with an in­

crease in collagen deposits . This happens particularly in the distal portion of the palm, where the pull on the deep connec­

tions of the aponeurosis is most intense (Fig . 15) . The sub­

stantial bands which may form at this site also degenerate,

once tension is released by removing the overlying longitudinal

cord. Occasionally the deep bifurcating atta chments of the pre­

tendinous bands adhere laterally to the capsule of a meta­

carpophalangeal joint in such a way that to release flexion

contra cture of that joint, they must be completely removed. The

anatomy of these aponeurotic connections was comprehensive­

ly studied by Karfik (1949) and further elucidated by Gosset

(1966) and Stack (1973) .

440

,

Dupuytren '5 Contracture 1

The longitudinal fasciculi of the aponeurosis are also attached to the skin by short bands, which pass through the subcutane­ ous fat layer. When this fibrous system is extensively involved, the overlying skin puckers and becomes firmly fixed to the aponeuro~is. When there is isolated involvement of cutaneous adhesions, their retraction will cause the pathognomonic pitting of the ski n.

If there is considerable contraction following healing of a rup­ ture or, if the involved aponeurotic bands are inelastic, more ruptures are likely to occur, since further strain is placed on the shortened parts. A vicious cycle develops. Attempts at exten ­ sion aggravate the situation and increase finger flexion. In addi­ tion, when contraction arises in one fascicular system, the de­ licate balance between adjacent fibrous systems is upset, and tension is placed on bundles not directly involved. Once started, therefore, the process may spread over the entire hand . Vari­ ations from this rather uniform pattern of disease may arise in anomalous aponeurotic bands, most commonly related to the thumb.

The transverse bands

The transverse palmar band of the aponeurosis is never in­ volved in the pathologic process at any stage of Dupuytren's contracture (Skoog 1967). This significant observation supports the view that strain on the fibrous elements of the aponeurosis is an essential factor in the pathogenesis of the disease, since in any normal hand function the transverse palmar fibers are never subject to stress sufficient to rupture them. Furthermore , no tension is applied to them when adjacent parts of the apo­ neurosis contract. In marked contrast, the transverse fibers of the interdigital bands are frequently the site of contracture . Unlike the palmar fibers the interdigital bands are tensed in separating the fingers and also tighten to limit flexion of a finger, when the other fingers are extended. The respective involvement and non-involvement of the two systems of transverse aponeurotic fibers clearly demonstrate the inseparable relationship of trauma , tension, and possible overexertion to pathology. These simple observations antiquate most hypotheses put forth as to the origin of Dupuytren's con­ tracture.

441

Finger contracture

In the fingers, as in the palm, the disease is primarily related to the fascial elements, which only in part represent a distal continuation of the palmar aponeurosis. The two systems merge at the base of the fingers, forming a complex fascicular structure necessa ry to meet special functional demands at th at si te. In the vast majority of cases the pathology is chara cte ristically confined to the ulnar portion of the hand and in particular, there is a predilection of the ring finger to be involved by co ntracture. Bruner (1970) m ade an elegant anal ys is of the specific dynamic forces at work in the selection of the affected digit. He con ­ cluded, that the preference of Dupuytren 's contracture for the ring finger must be on an anatomical, mechanical and func­ tional basis. Deeper structures ma y also be involved independent of the palmar aponeurosis. These fibrous bands and sheets originate at the metacarpophalangeal level. The band which extends from the ulnar aspect of the fifth metacarpal head is most con­ sistently subject to pathology. When contracted, it flexes the proximal interphalangeal joint and occasionally causes ulnar deviation of the little finger . It is often overlooked in surgery, obs cured by superficially located and more contracted cords . In younger persons this band may be the lone focus of contrac­ ture, sometimes following an injury, but often with no apparent preceding trauma . In the fingers, the intricate fascial anatomy makes the course of the disease most unpredictable, and the pathologi c anatomy shows wide variations. Depending on the fibrous stru cture in­ volv ed, particularly in the metacarpophalangeal region, the nerves and arteries may be found deep, superficial, or even penetrating the newly formed tissues. In planning surgery it is important to note the extent of pathologi c involvement. Gen­ erally, the volar skin is extensively affected , and on the deep aspect the bands which attach to the sides of the tendon sheaths and the phalanges become contracted.

The subcutaneous tissue

442

A continuing argument has existed , stemming from the diver­ gent views of Dupuytren and his contemporary Goyrand, as to the true site of pathology in Dupuytren 's contracture. Whereas

Dupuytren's Contracture 1

Dupuytren felt that the disease mainly invested itself in the palmar aponeurosis, Goyrand (1833) offered the conflicting hypothesis, that the pathologic process was restricted to the subcutaneous tissue. These apparently irreconcilable view­ points have persisted to the present time, and MacCallum and Hueston (1962) have maintained, that the "subdermal fibrofatty tissue" is the seat of pathology. Dabrowski (1967) concurred with their opinion and considered the etiology to be neurologic and based on a lesion of Th 1. The consensus of opinion, however, is that Dupuytren's original statements are indeed correct and that the focus of pathology resides in the palmar aponeurosis . Unquestionabl y, some nod ­ ules do arise in the subcutaneous tissue layer, but their develop­ ment is related to the fibrous bands connecting the aponeurosis to the skin. They result from the direct trauma of gripping and carrying objects. It is this essentially chushing and shearing ac­ tion, which produces the micro ruptures. Any superficial dimpl­ ing of the skin can easily be released by freeing these constrict­ ing bands from the aponeurosis and thus eliminating the pulling mechanism, which perpetuates contracture. When the anchor­ ing bands are disconnected from t heir aponeurotic moorings, they loose their tightness and atrophy . The skin regains its nor­ mal quality and resumes its original appearance. Since skin manifestations are always secondary , skin need never be ex­ cised . In the interspacing monticuli, which lie immediately prox­ imal to the finger webs, aponeurotic fibers are absent. Con­ sequ ently, contractu re and subsequent skin involvement can ­ not occu r.

J I

The subcutaneous manifestations are, however, generally peri­ pheral offshoots of the main fo cus of the disease, and any ap­ parent absence or deficiency of fatty tissue is most often merely a mechanical readjustment, secondary to the displacing process of fibrous proliferation. Hueston attempts to support his conjec­ ture, that the pathologic process resides mainl y in the sub­ cutaneous laye r, by arguing that recurrence is a natural con­ sequence of incomplete excision of subcutaneous tissue . This suggestion is untenable in light of the effective and permanent results of selective aponeure ctomy. In this procedure all sub­ cutaneous tissue is left intact, and in over one thousand cases there has not been a palmar recurrence of the disease. Re­ currence has, however, occurred in the fingers, and the partic­ ular mechanism behind this development will be discussed later. 443

Contracture developing in scar tissue

The cicatricing process following surgery ortrauma to the hand may be part of the Dupuytren's spectrum. Post-operative con­ traction has often been misconstrued as a recurrence of the disease, when in fact surgical scarring has been the nidus around which contracture develops de novo. This undesirable process is met repeatedly in the fingers. It can be effectively eliminated by removing the offending tissue and replacing it with a free skin graft, th us barring excessive scar formation .

Iatrogenic contracture

A vivid demonstration of the inadvert en t development of scar­ ring and subsequent co ntra ctu re was observed in the 1950' s. During that period total aponeurectomy was performed , and a pressure d res sing was consequent ly app lie d to stabilize the widely unde rmined palm and prevent hematoma from forming. The tight bandage sometimes caused pressure sores to arise in both the thumb web space and on the ulnar aspect of the hand. Later, subcutaneous contracting bands formed in these areas, displaying a characteristic deformity (Fig. 16) . These cords were unrelated to the aponeurosis and lack ed the deeper attach­ ments of the normal fasciculi. Although aberration s from the normal fascial configuration might possibly explain this de­ velopment, it is probable that the tight dressing was responsi­ ble. The fact that this peculiar condition was seen only in pre­ viously operated hands lends further support to the opinion, that it does indeed represent a con tra ctu re of iatrogenic etiol­ ogy (Skoog 1973).

16 A graphic example of iatrogenic contracture is demonstrated by this patient with an abduction and fl exion deformity of his little finger. A distinct cord has also formed within the thumb web. He had previous surgery to his palm and little finger and then his hand was bandaged with a tight dressing postoperatively. Fourtee n years later he presented with these abnormal cont ra ctu re s, caused by sub­ cutaneous, scar-like bands, which developed where pressure had been excessive. Despite severe distortion on extension, flexion is un­ disturbed. Surgical correction was easi ly performed (see p. 4821.

444

Knuckle-pads

In 1893 Garrod described subcutaneous nodules situated on the dorsal aspect of the proximal interphalangeal joints, and coined the term knuckle-pads (Figs. 17-18). These nodules are ir­ regularly shaped and fairly firm. On cursory examination they may appear to be bony projections, but are in fact soft ti ssue masses confined to the subcutaneous tis su e la yer, and integral­ ly connected to the extensor tendon mechanism. Though knuckle-pads are tender when they first arise, they usually be­ come painless except for an increased sensitivity to cold Or trauma .

17-18 This hand demonstrates typical knuckle-pads. The process is

most prominent over the proximal interphalangeal joint of the ring finger. The involved joint functions easil y, but flexion of the distal interphalangeal joint is restrained , when the finger is in the shown position. In fl ex ion, the extensor tendons normally co ntribute passive­ ly to distal joint function by slackening . When a knuckle-pad is present it restri cts thi s movement.

I

J

----.._/ 445

Knuckle-pads are frequently found to be associated with Dupy­ tren's contracture, and the co-existence of both processes sug­ gests a common etiology. The microscopic picture confirms this assumption. Specific fibers, running obliquely from the palmar aponeurosis to the dorsum of the fingers, bear a close relation­ ship to the extensor tendons (Fig. 19). The extensive range of movements at the proximal interphalangeal joints is likely to contribute to the development of fibril ruptures over these areas, and to produce mechanical irritation during healing. This plays a significant role in the formation of excessive scar tissue, and may explain why knuckle-pads occur in individuals with a certain predisposition . Apropos are the number of cases in which knuckle-pads spontaneously regress following excision of the palmar aponeurosis and subsequent release of tension within the aponeurotic extensions to the dorsal aspects of the fingers. The incidence of knuckle-pads is far from rare, but they are often ignored as they infrequentl y impair finger function. Sur­ gery is generally carried out for cosmetic reasons , or to resolve the problem of the patient being unable to wear a ring . In either case, the offending knuckle-pad is shaved away until the pro­ truding surface has been planed even with the tendon.

19 The drawing illustrates fibrous extensions from the palmar aponeurosis to the dorsum of the finger. These fibers reinforce the digital fascia and form a distin ct band whi ch inserts at the meta­ carpophalangeal region, in close proximity to developing knu ckle ­ pads (Skoog 1948)

446

/ 20-21 These photographs show the plantar manifestations of

Dupuytren's disease. The nodular thickening is characteristically found at the medial border of the plantar aponeurosis. This 51 year old man also had severe Dupuytren's contracture of both hands.

Plantar manifestations Careful examination will reveal that almost 20 per cent of pa­ tients with Dupuytren's contracture of the hands have less de­ veloped, but identical tissue changes in the feet. These are typically located at the medial border of the plantar aponeu­ rosis, in the hollow of the foot (Figs. 20-21) Due to the anatomy of the plantar aponeurosis, the process does not lead to flexion contracture of the toes, and most patients are not aware of these pedal lesions until large nodules have formed and begin to cause discomfort on walking. The appearance of the disease in the foot would therefore be of little clinical significance, if not for the all too frequent and catastrophic misdiagnosis of this condition as a fibrosarcoma. In numerous cases, this had led to unnecessary lower leg amputations.

..

The tragic sequence of events begins with the patient complain­ ing of tenderness in the sole of the foot. He then consults his physician, who finds a plantar lesion and biopsies the nodule, The pathologist perceives the swirling proliferation of fibro­ blasts in the microscopic specimen and incorrectly classifies this as a fibrosarcoma. By the time the clinician has received the pathology report and the patient has been recalled, the mass, aggravated by the trauma of surgery, has markedly en­ larged, The surgeon misinterprets this rapid growth as a ma­ lignancy, and armed with the pathologist's diagnosis and his own clinical impression, he proceeds with the unfortunate and totally needless operation,

447

The consistent appearance of nodules at the site where the functional demands are greatest, and the formation of a scar­ like mass within the homogenous structures of the aponeurosis, suggest a traumatic origin. The recurrence of a still larger nodule following partial removal, as in the above example, and the fact, that a cure is obtained only after performing a resec­ tion adequate enough to prevent a similar pattern of healing, also implicates trauma as a causative agent (see p. 495).

Peyronie's disease (induratio penis plastica) An association of Peyronie's disease with Dupuytren's contrac­ ture was first reported by Kirby (1849). He related their oc­ curence to a generalized gouty diathesis. Since then numerous reports on the coincidence of the two diseases have been pub­ lished. A common etiology has been suggested because of a similar age of onset, the localization of pathology to connective tissue and the rather obscure origin of each disorder. Though, it is interesting to speculate about this possibility, there is, how­ ever, no concrete evidence to warrant such a conclusion.

Hereditary predisposition There is conclusive evidence that individual predisposition plays a role in the etiology of Dupuytren's contracture. This in­ creased susceptibility probably reflects a general biologic de­ fect, which helps to explain the association of a number of maladies with Dupuytren's contracture. In recent years, Dupuy­ tren's contracture has been considered to be but one facet of a generalized collagen disease. 448

Dupuytren's Contracture 1

In the majority of cases an inherited factor is involved . This is vividly demonstrated in cases where the disease can be traced back through five generations. In my series, the family history was positive in about 44 per cent. apparently due to inheritance of a Mendelian dominant characteristic with low penetrability. The fact that nine out of ten cases of Dupuytren's contracture occur in men, implies a sex-linked relationship. The increase in incidence of Dupuytren's contracture with in­ creasing age is probably related to generalized tissue changes. This complex phenomenon is dependent upon a broad array of known factors. A number of presently unknown causes are probably also involved . The individual pattern of tissue ageing may reflect. what we refer to as the hereditary predisposition for the disease.

Acquired predisposition Tissue trauma and immobilization

Following a fracture, a widespread infection, or any severe in­ jury of an upper extremity, nodular infiltration often develops within the palmar aponeurosis. After lengthy immobilization the process begins when the patients first start to use their hands, or when forced exercises are introduced to restore mobility and full extension of the fingers . When swelling and stiffness disappear and the soft tissue regains its normal quality, the ch anges in the aponeurosis regress and then usually remain unchanged, even after several years of observation. Rarely will this process initiate the development of progressive Dupuy­ tren's co ntracture. Surgical intervention is contraindicated in the acute stage, and a continued conservative attitude is ad­ visable. This temporary form of the co ndition may also occur in races not normally affected by Dupuytren 's contracture. The same series of events may take place in the lower ex­ tremity, after trauma or following long periods of immobiliza­ tion . Symptoms first appear when the patient again begins to support himself on the foot. With few exceptions the pathologi­ cal changes are typically confined to the medial border of the plantar aponeurosis. These localized nodules are generally 449

overlooked because of the concomitant swelling of the foot, and they usually regress in the course of months or years. Once this transient condition was labelled as rasciitis plantaris (Franke 1895). The tissue reactions induced by severe trauma are of a complex nature. It is hardly possible to suggest any specifi c factor to explain the associated temporary predisposition to Dupuy­ tren's disease. Clinical observations of this type make it ap­ parent, however, that immobilization and vasomotor disturb­ ances change the qualities of the aponeurotic tissue, thereby ex­ posing collagen fiber bundles to microruptures .

Specific agents

The very high incidence of Dupuytren's contracture in epilepti cs may well be caused by prolonged administration of barbiturates (Skoog 1948). Similarly, patients sometimes develop progres­ sive contractu res at an exceptionally early age, following con­ tinued use of sedatives containing barbituric acid . The pathol­ ogic process has been halted when medication was withheld. Schauman (1944) reported on the association of Dupuytren's contraC1ure with chronic hepatitis and polyarthritis in patients with systemic lupus erythematosus. MacCallum and Hueston (1960) observed an unusually large number of cases of Dupuy­ tren's contracture in chronic invalids and alcoholi cs . The postulated relationship of an increased incidence of Dupuytren's contracture in epileptics treated with anticon­ vulsants, and a similarly high incidence of the disease in chronic alcoholics stimulated Pojer et a/. (1972) to investigate, whether a liver function disturbance might not be the common cause. They found abnormalities in the serum-levels of " he ­ patic excretory enzymes" in both groups, though evidence of hepatic cellular dysfunction was not established among epilept­ ics. To what degree abnormal liver function influences the nor­ mal metabolism of collagen is unknown . The possibility that peripheral enzyme systems themselves may be disturbed has yet to be investigated.

450

".

Comments

The numerous observations reported here on the symptomat­ ology and pathology of Dupuytren's contracture strongly in­ dicate that trauma is a causative factor. This concept of the pathogenesis explains why the ulnar part of the aponeurosis is most frequently involved: it is the area where the greatest strain occurs, in grasping and in passive support. Whether or not one accepts that acute, indirect trauma or occupational strain in­ duces the development of Dupuytren's contracture, the in­ disputable relationship of contracture to an open aponeurotic lesion is self-evident. The comparatively small influence of manual work on the in­ cidence of the disease, and the fact that it rarely follows ac­ cidental lesions of the aponeurosis demonstrate, however, that individual predisposition is the most important consideration. Most probably, generalized changes in the biomechanical qualities of the connective tissue may arise from various con­ ditions. The increase in incidence of Dupuytren's contracture with advancing age reflects a generalized fragility of ageing tis­ sue, which looses its elasticity and tensile strength. The numerous fractures that afflict older individuals testify to this point. The aged hip snaps under pressure insufficient to even bruise younger, more resilient bone.

•

In summary, Dupuytren's contracture appears to be the end re­ sult of connective tissue changes fol/owing ruptures of the aponeurotic fiber bundles. It develops i n persons with a con­ nective tissue predisposition to the disease. Trauma is the ca­ talyst and the essential fault lies with the connective tissue it­ self The characteristic manifestations of the disease in the hand are a consequence of the complex anatomy of the palmar apo­ neurosis and the pathologic picture is fundamentally one of scar formation and contracture.

Liability for compensation

Although there is a definite relationship between trauma and pathology, the major importance of predisposing factors make it impossible to justify workman' s compensation in most cases of Dupuytren's contracture. The only instance, where reparation is unquestionably justified, is where contracture develops at the site of a previously open wound.

451

r Other forms of certain trauma, including crush injuries and for ceful hyperextension of the digits, may be equally re­ sponsible for localized lesions of the aponeurosis, which could initiate the development of contracture . A definite causal re­ lationship is, however, generally difficult to prove. Another group of patients, which might be considered for com­ pensation, includes those with neuro -vascular disturbances fol­ lowing more generalized tissue trauma, such as fractures , severe local infections and other disorde rs causing prolonged immobilization. In all of these conditions each case must be evaluated on the basis of its own merits and tempered by the uncertainty of individual predisposition.

•

452

References

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1970. D~browski T.: Microscopic lesions in Dupuytren's disease. Acta Med Polana 8: 477,1967.

Dupuytren G.: Permanent retraction of the fingers, produced by an affectio n of the pal ma r aponeu rosis. eli n ical Lectu res on Su rgery. Lancet 2: 222, 1834. Transl. from Ler;ons Orales de Clinique Chirurgi­ cale, 1833. Published periodically by G. Bailliere, Paris. Franke F.: Ueber die Erkranku ng der Knochen, G elenke un d Ba nder bei der Influenza.Arch klin Chir49: 487, 1895. Garrod A. E.: On an unusual form of nodu Ie upon th e joints of the fingers. 5t Barth Hosp Rep 29: 157, 1893. GossetJ.: Maladie de Dupuytren et anatomie des aponeu roses palmo­ d igita les. Maladie de Dupuytren. L'Expansion Sci entifique Franca ise, Paris, 1966, p 15. Goyrand G.: Nouvelles recherches sur la ,,"traction permanente des doigts. Mem acad roy med 3: 489, 1833. Hueston J. T.: The incidence of Dupuytren's contracture. Med J. Austr

2: 299,1960. Hueston J. T.: Dupuytren's Contracture. E. & S. Livingstone Ltd, Edinburgh & London, 1963. Karlik V.: Dupuytrenova kontraktura. Nakladem Spolku l:eskych Lekaru, Prague, 1949. Kirby: On an unusual affection of the penis. Dublin Med Press 22: 210,

1849. Larsen R. D., Takagishi N. and Posch J. L.: The pathogenesis of Du­ puytren's contractu reo J Bone Jt 5urg 42 A: 993, 1960. MacCallum P. and HuestonJ. T.: The pathologyof Dupuytren's con­ tractu reo Austr New ZealJ 5urg 37: 241, 1962. Plater F.: Obseruationum, in hominis affectibus plerisque, corpori & animo, functionum laesione, dolore, allave molestia & vitia incom­ modantibus. C. Waldkirch, Basileae, 1614, p 140. Pojer J., Radivojevic M. and Williams T. F.: Dupuytren's disease. Its association with abnormal Iiver fu nction in alcoholi sm and epi I epsy. Arch Intern Med 729: 561,1972.

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,

S chaumann J .: On Dupuytren ' s contraction, hepat it is ch ronica (cir­ rhosis hepatis) and pol y arthritis as equivalents of lupus erythematosus . Acta Derm- Vener 27: 1, 1944 . Skoo g T.: Du puytren's contraction. With special reference t o aetio logy and improved su rgical treatment. Its occu rrence in epileptics. Note on knu ckle-pads. Acta Ch ir Scand 96, 1948, Supp l 139. Skoog T .: Dupuytren 'scontracture . Postgrad Med 21 : 91, 1957. Skoog T.: The pathogenesis and etiolog y of Dupuytren 's contractu re, Plast Reconstr Surg 31: 258, 1963_ Skoog T .: Pathogenie et traitment chirurgicale de la maladie de Dupuytren .Maladie de Dupuytren. L'Expansion Scientifique Franca ise, Paris, 1966, .p 82 . Skoog T. : Du puytren's contractu re: pathogenesis and su rgical treat ­ ment. Surg Clin N Amer47: 433,1967.

Skoog T.: Transverse elements of the palmar aponeurosis in Dupuy ­ tren ' s contracture .Scand J Plast Reconstr Surg 1: 51, 1967. Skoog T. : New concepts of Dupuytren'sdisease. Read at The 27th Annual Meeting of the Canadi an Society ofPlastic Surgeons, London , Ontario, June 6, 1973 .

Sta ck H. G .: The Palmar Fascia. Churchill Livingstone, Edinburgh and London 1973.

.­

454

Chapter XIX

Selective aponeurectomy (fasciectomy) -

preserving the

transverse palmar band and subcutaneous fat tissues, while not interfering with superficial and deep lymphatics of the hand Indications for surgical treatment 458

General considerations 459

Anesthesia 460

Nerve block at the wrist Selective aponeurectomy 462

Skin incisions

Superficial palmar lymph atics

Subcutaneo us undermining

Raising the palmar flaps

Exposing the cord

Resecting the cord

Clearing the palm

Closing the wound

Dressing

Result

Deep con trac ting bands 477

Adduction contractu re 478

Thumb in vo lveme nt 480

Iatr ogenic contracture 482

Multiple Z-plasties 484

Postoperative care 486

Comments (incisio ns, dissection,

skin cover and wound closure, resu lts ) 488

Recurrent contractu res 491

Plantar lesions Operative procedure 495

Result

References 497

456

..

DupuytrenIS

Contracture 2

~

-=

-­ -=--

Surgical Treatment

Indications for surgical treatment

The degree of personal inconvenience and disability is the ma­ jor criterion in determining the need for surgical treatment in Dupuytren's contracture . This is tempered by the individual's occupation and activity. A musician will naturally be hampered by the disease at an earlier stage than a comparably afflicted office worker. Flexion contracture of up to thirty degrees can be readily re­ leased with prompt restoration of function postoperatively. Beyond this degree of deformity, surgery becomes more dif­ ficult and results less predictable. If finger contracture exceeds sixty degrees, the patient should be informed that secondary changes can adversely affect the full return of function and that lengthy physical therapy may be required. When the proximal interphalangeal joint becomes flexed over ninety degrees, there is permanent derangement of the extensor apparatus, capsular shrinkage and, in long-standing cases , joint surfaces have changed their configuration and become asynchronous. Amputation or arthrodesis must then be considered, since cap­ sulotomy or arthroplasty usually will not restore function . Again, personal factors such as the patient's occupation , avail­ able time, and his ability to bear the discomfort of post­ operative exercises are determinants in the choice of surgical management. As the pain associated with Dupuytren ' s contracture is classi­ cally mild, localized and transitory, it should not influence the decision to operate. If severe or persistent, this symptom must be recognized as being related to coexistent disorder and treated accordingly. The initial sign of a developing nodule is best left untreated, as it may regress spontaneously.

458

General considerations , Surgical treatment has ranged from simple aponeurotomy (fasciotomy) to total excision of the palmar aponeurosis, includ­ ing the transverse palmar ligament and paratendinous septa . Sectioning a contracted band alone may be adequate, when skilfully performed and supplemented by prolonged splinting (Tubiana and Thomine 1966). Until a few years ago, however, radical aponeurectomy (fasciectomy) was the preferred treat­ ment. The subcutaneous and subaponeurotic fatty tissue, in­ cluding the fat pads of the metacarpophalangeal region, were also removed. Consequently much of the deep structures were left denuded of their protective covering. These dissections in­ terfered markedly with the palmar lymphatics, there was con­ siderable postoperative swelling , and the operated hand was immobilized for a protracted length of time . Shaw and Barclay (1957) stated in their forthright appraisal of results, that healing within one month after radical surgery was considered satis­ factory, and that three months had usually passed before their patients returned to work. In our early series, patients who underwent radical procedures complained postoperatively of paresthesia, difficulty in grip­ ping, a feeling that the palm was "unprotected", or that they had lost strength. On examination , the normal skin creases were less distinct, and much of the palmar definition had dis­ appeared giving the hand an unnaturally flat, simian ap­ pearance. Research on the pathogenesis of Dupuytren's contracture and clinical experience gained from over one thousand operations have led to the development of the procedure of selective aponeurectomy (Skoog 1967). It has been used successfully for the past twelve years. This approach preserves the transverse palmar ligaments as well as the underlying paratendinous septa. These structures are preserved to safeguard the delicate anatomy of the deep palmar space and protect the fine archi ­ tecture from continued trauma. As excellent exposure is im­ perative, an accompanying new pattern of incisions has also been introduced, and a special effort has been made not to in­ terfere with the superficial and deep lymphatics.

•

r

459

Anesthesia

Local anesthesia is preferred to general anesthesia as it is sim­ pler, less hazardous, and permits out-patient surgery. A block of the median and ulnar nerves at the wrist is the most efficien t method. It ca n easi ly be administered by the attending surgeon just before beginning the operation . Rarely , a suppl emen tary block of the dorsal bran ch of the radial nerve ma y be required . Th e dissection itself is the only part of the operation requiring a bloodless field. After this stage is completed the tourniquet is released, hemostasis secured, and the sk i n closed. A tourni­ quet around the upper arm is well tolerated for up to thirty minutes. When the initial part of the procedu re is expected to exceed this time, an axillary block is used .

/

460

I

/

Nerve block at the wrist 1-2 These drawings demonstrate nerve block anes­ thesia of the hand. The median and ulnar nerves are lo ca ted deep to the palmaris longu s and the flexor carpi ulnaris tendons, respectively. Being m o re super­ ficial , the median nerve lies just beneath the ante­ brachial fascia . A fine needle is in serted at the level of the pro x imal wrist crease, ju st radial to these tendons, and approximately 4 ml of 1 per cent Xy lo­ caine ® (lidocaine) with epinephrine, is injected around each nerve. Should paresthesia be elicited on intro­ duction of the needle, it must be withdrawn sufficient­ ly to avoid intraneural injection . An intravascular in­ fusion of anesthetic can be prevented by aspiration prior to infiltration .

•

3 When needed, the superficial branches of the radial nerve can be blocked by subcutaneous infiltration at the radial border of the wrist. Approximately 4 ml of 1 per cent Xylocaine® with epinephrine is used, care being taken not to injure the subcutaneous veins.

461

Selective aponeurectomy'

Skin incisions 4 The main focus of co ntra cture lies over the base of the ring finger where a large post-traumatic lump has formed. This holds the proximal interphalangeal joint in forced flexion at 30 ', while the palmar cord further limits finger motion. The dimpled skin has drawn the proximal skin crease towards the palm and, though not visible in this illustration, there is also a palpable band to the third finger . The pallor of the hand, in this and subsequent photographs, reflects the blood­ less field technique used during surgery. With the tourniqu et adjusted, a transverse line is marked in the distal palmar crease. The length of this incision is directly proportional to the section of aponeurosis to be excised . In this case, despite ap­ parent involvement limited to the third and fourth longitudinal bands, an extended aponeurectomy is planned to remove developing bands to the other two digits as well. 5 To permit proper exposure, a proximal perpendi­ cular line is marked out midway along the transverse incision. Extensions are made distally over the cords and continued on the involved fingers. The distal incision is not planned for the middle finger, as the pathologic process lies only in the palm in this ray. In an effected finger , a Z-plasty is almost in­ variably required. One limb of the Z-plasty is plan­ ned at this stage. It can be placed on the ulnar or radial side, but is best situated in the most severe­ ly in volve d area. The base is located proximally or distally, depending on which site offers the best blood supply to the flap . The two stage Z-plasty is used to allow for accurate adjustment at a later stage. Not until all the inv olved skin is under­ mined and full y extricated w ill the true size and shape of the first flap be apparent. On extension of the finger , this flap will also shift in an unforsee­ able manner. Raising only the one flap at the outset thus permits greater flexibility at the end of the operation , when the position and configuration of the second flap are easily determined. Distal to the flexion crease, the incision angulates to the ulnar side of the middle phalanx where the in­ volvement is most severe. I This technique was demon strated on liv e television before the

Fifth Congress of the Int ernational Confederation for Plastic and

Recons tructive Surge ry , Melbourne, February 24, 1971.

462

Dupu vtren's Contracture 2

Superficial palmar lymphatics 6 The drainage of the superfi cia l pal­ mar lymphati cs is practically un­ distu rbed by these incisions, which conform with the "watershed" of the pa lm . Distal to the transverse palmar crease, and just proxima l to the inter­ digital fo lds, the lymphatics drain into the spaces between the pretendinous ba nds. These areas are not disturbed. Proximal to the transve r se crease, drainage is di r ected towards the bor­ de rs of t he aponeuroses . The lymph flow from skin and subcutaneous ti s­ sues i s thus not significantly impaired by raisi n g the designed flaps .

j

463

Subcutaneous undermining 7 Extent of subcutaneous undermining required in this parti cu lar case is indicated in this illustration . Characteri sticall y, the dissection is very limited . In the palm , it never proceeds beyo nd the borders of the aponeurosis and on the fingers, exposure is directly over the pathologic process .

464

Raising the palmar flaps 8 The proximal palmar dis section is limited to two triangular flaps , raised in a plane that ret ains all the fibro -fatt y tiss ue attached to the covering skin , ir­ respective of whether it is pathologically invo lve d. As the co rd is often fixe d to the dermis with little interpo sing tissue , it may be nece ssa ry to d evelop a flap which is relatively thin in these areas, and which might seem to be precarious and sus ceptab le to tip necrosis. This flap , however, is perfectly v iable be­ ca u se of the development of dermal collaterals. The fourth lon gitudinal fas cicul u s has tr ansformed into a well-defined cord , which passes above the un­ derl ying transverse band .

9 The scalpel blade marks the radial edge o f th e aponeurosis. The di ssection should not proceed be­ yond thi s line, as immediately adjacent to this bor­ der, perforating vessels sweep around the apo­ neurosis to supp ly the palmar skin . The venous and lymphatic dra inage fr om the proximal portion o f the palm is also via thi s route . A similar te chni qu e has been used on the ulnar side . This photograph depi cts the limited extent of the wedge-shaped aponeurosis and demonstrates that there is no requirement for a more extensive procedure.

465

Exposing the cord

I

10 Distally, undermining is limited to the narrow area surrounding the cord. The firm­ ly adherent skin must be freed from it by sharp dissection. The unfolded skin is larger in area than could be estimated by viewing it in its previously puckered position and in a primary operation, it is invariably found to be sufficient for adequate coverage. Lat­ erally, the subcutaneous tissue can be peeled away from the distinct cord . At th e distal end of the cord the bulging lump is uncovered .

466

, 1 Broad cutaneous extensions are present at the base of the finger.

Dupuytren 's Contracture 2

12 The scissors' blades lift up suc h a ba nd to the radial side of the ring finger . When isolated, it can readily be divided at its skin attachment.

•

13 The cord and nodular masses have been exposed along their entire length . The white structures are in marked relief to the sur­ rounding fatty tissue . Although there ap­ pears to have been major undermining , the dissection ha s not st ra yed fr om the cord surfa ce. A limited approach is im portant at this level, so as not to cause unnecessary tissue trauma or interferenc e with the lymphatic drainage from the distal portion of the palm . Nerves, arteries and other normal structures are also protected in this way .

467

•

•

Resecting the cord 14 The co rd is sectioned at the level of th e tran sve rse palmar ligament. In div iding it, th e tran sverse fiber bund les are not always v isible, as th ey are sometimes adherent to the undersurfa ce of the cord . W hen the cut ends are separat ed, the transverse fibers are simil arl y sp read apart, but aher the cord ha s been carefull y dissected away the ligament resum es its origi­ nal position .

15 The partially released cord is still he ld by persistent deep attachments, which inhibit full extension of the finger. Th ese stru ctures have a regular position; familiarity with their anatomy greatly fa ci litate s the dissection (se e Fi g. 15, p. 440). Usually involvement of fou r sets of band s ca n be dis­ tingui s hed, the septal attachments proximal to the transve rse palmar band are the least affected. Immediately distal to th e tran sverse palmar ligament, two well-defined deep bands originate, as demonstrated in this photo­ gra ph . Their size corresponds directly to th e degree o f contract ure. Exci- I sion close to the cord causes the remainin g se gments to retra ct. They will then gradually atrophy.

468

16 The cord is now free from the surround in g tissues up to the leve l of the metacarpophalangeal joint, where another pair of restri cting bands is always present. The scalpel is in cisi ng the ulnar branch.

..

17-18 The band running deep to the radial side of the metacarpophalang ea l joint is severed in a similar manner.

1 469

19 Over the prox imal phalanx, the nodular mass is

easil y separated from the deep tissues as no distinct attachments exist at this plane.

20 Distal to the nodular mass, additional attachments characteristically branch t o each side of the middle phalanx and the interphalangeal joint . On the rad ial aspect, the pseudotendinous band passes beneath the neurovascular bundle and is here sectioned at its at­ ta chment to the side of the tendon sheath.

21 In approaching the ulnar branch at this level , the dissection is carried across the v olar aspect of the finger . Care should then be taken to avoid entering the tendon sheath.

22 On the ulnar side, the dissection is ex tended down to the bone, as incomplete ex cision may permit a loose end to reattach itself and thus initiate a recur­ rence . In long-standing cases of Dupuytren's contrac­ tu re, an exostosis may develop at the site of the bony atta chment. If it is large , it sh o uld be remo v ed.

470

I 23 In the distal portion of the palm, the cord is sit­ uated superficia lly and thus the dissecti o n has caused little subcutaneous tissue disturbance. This accounts for the normal postoperative size and configurati on of the fat pads. On the finger, a more extensive pro ­ cedure ha s partial ly exposed the deep structures, bu t the normal tissue layers remain intact. Nerve s and vessels are undisturbed, enclosed in their thin con­ nective tissue sheets. Th e instrument indicates the radial neurovascular bund le. The mOre limited dis sec­ tion on the ulnar aspect has left the con tralateral neu rovascu lar structu res hidden in a fatty covering. Thi s careful dissection safeguards the lymphatic drainage from the fin ger.

24 The splayed section exposes the compact tendon­ like cord. The brown spots, always within the nodular mass, are hemosiderin deposits from old hemor­ rhage s. The complete removal of the cord, which in actua lity is a relatively sma ll amount of pathologic tis sue, enables the finger to be fully extended.

471

•

Clearing the palm

25 The pro xima l portion of the cord has been freed from the transverse band and the deep septal attach­ m ents are exposed, div ided at a superficial level and left in pla ce . The y ca n do no harm , since they cannot reattach to any fun ctional structure . The other longi­ tudinal fa sciculi have also been removed .

26 After resection of the pretendinous bands, an operative field is left in wh ich the nerves, vessels and lubr ical mu scles are veil ed by a sheet of fine con­ nective tissue, which is shown tented up by a pair of forceps. As this sheet represents the deep limits of the dissection, the deep lymphatic drainage remai ns unimpeded. 27 The characteristically uninvolved transve rse pa lm ar band is slung protecti vely aCroSS the deeper, un­ affected structu res (compare Fig . 3, page 434) . This band is not removed as it is never the site of patho­ logy.

This picture differs markedly from the detailed ana­ tomic specimen produced in what is ca ll ed radical aponeurectomy with nerves, arteries and muscles be ­ ing extensively exposed . The damage to lymphatic circu lation from this technique is easil y ove rl ooked .

/ 472

•

Closing the wound

28 After completing the dissection, the tourniquet is re leased . The hyperemic re ­ sponse is immediate in the fingers, but somewhat delayed over the mid-portion of the pal m. The hand is clenched about a wadded sponge and firm pressure is applied for five minutes . Oozing will cease at this time, leaving only the major vessels to be ligated. As the technique is essentially a­ traumatic and the aponeurosis is relativel y avascular, troublesome bleeding is not en­ countered. Occasionally no vascular ligation is necessary. Skin edge bleeding is con­ trolled by approximating the cut surfaces. Nonabsorbable suture material,' 610 or 510, is used to close the wound . A Gillies intra­ dermal co rner stitch unites the vario us cor­ ners . A few mattress sutu res a re used to fix the skin borders to the transverse band , thereby helping to obliterate the palmar wound pocket.

'.

29 Encircling mattress sutures completely close the cavity left by remov ing the cord distally in the palm.

30 In this case the finger incisions could be closed directly under moderate tension. This would be a serious error, howeve r, because a tight, longitudinal scar in this location is likely to contract and reproduce the flexion deformity. As most cases involve a skin shortage longitudinally, the Z-plasty offers an ideal way of lengthening this axis.

I Supramid. black. Soci ete Steril Catgut (SSe) , Neu ­ hausen am Rh einfall, Switzerland .

473

31 The second stage of the Z-plasty is now planned . The size and location of the new limb is estimated by swinging the pre v ious­ ly developed flap into position.

32 The second flap is raised on the op posite side to interdigitate with the other limb of the Z-plast y and accurately conform to the ski n defect.

. 1­ .......

J

•

33 Good blood supply is evident through­ out the closed wound, even at the several corners of the flaps.

474

Dupuytren 's Contracture 2

Dressing

34 The suture line is sealed with mi cropore surgical tape .' It may appear fut il e to apply the tape to a wet, oozing suriace, but after a secure dressing is placed about the hand, the tape will adhere, supporting and pro­ tecting the wo und .

35 A light compression dressi ng is applied with a piece of gauze and a bolus of non­ absorbent syntheti c materia l (Tacr yl) placed in the center of the palm to exert pressure 'where it is needed most. The operated fingers are splinted in extension , while th e unaffected fingers remain free. The patient may leave th e h ospita l im­ mediately after surgery , and is instructed to flex his fingers every hour as much as the bandage permits. A sling is necessary for the first twenty-four hours only.

J

Steri-Strip~

Skin Closures. Minn eso ta Mining &

Manufac tu ring Co . (3M Company), $ 1. Pa ul, Minn . U .S.A .

475

Result

36 The patient re turn s for the fir st dres­ si ng change after o ne week . He has experienced little discomfort and there has been no apparent swelling of the hand . The tape is firm ly adherent to the skin .

37 Despite the bulky bandage and the fingers having been splinted for one week, he is able to flex his fingers quite easily.

38 Tape removal reveals no tissue rea cti o n and heal­ ing is co mplete. Most of the sutures ca n now be re­ moved , and the few remaining ones are left for another five days. This patient returned to manual work three weeks after surgery.

476

Dupu ytren 's Contracture 2

[

Deep contracting bands

39 Although the pretendinous bands are the dominant feature of Dupuytren 's con­ tractu re, deep co ntract ing bands are often equally re sponsib le for the deform ity. As demons trated in this photograph, they are particu larly prone to develop in the little finger , o ri ginating on the ulnar side o f the fifth metacarpal head . They often displace the neuro vascular bundle , which ride s a­ cross and someti mes spirals ab out thi s lateral band . The intimate relationship o f th e band to the overlying digital nerve il­ lustrates the need for cautious exp lo ra­ tion. Th e search for a deep band is an inte­ gral part of th e procedure, as an unresolved contracture, f ollowing removal of the main offending cord. may be the result of failure to do so.

A similar ana tomic configurat ion may be

present in the distal po rtion of the palm . When deep attaching bands are the pre­ dominant pathologic force , they will con ­ tract and displace the neurovascular bundles above them. These structures then assume a preca riously super fi cial position under th e ski n. It is important to recognize them at thi s abnormal site to avoid un­ nece ssa ry injury.

477

Adduction contracture 40 This sixty-nine year old carpenter developed progres­ sive contracture of his ring and little fingers over a four­ teen year period. There was extensive palmar involvement, but the severe adduction contracture between the two fingers was his most bothersome problem.

41 After clearing the palm, an offending band which restricts adduction is seen . This fibrosed interdigital band binds the two fingers together.

42 After removing the contracted interdigital ligament a bifurcating extension of the fifth pretendinous band is seen to continue down the ulnar side of the ring finger, partly visible in the previous photograph. This is the major cause of adduction.

478

Result

-

43-45 One year after surgery the finge rs are straight and the palm has regained a normal configu ration . There is a full range of motion. Th e previ ously bound fingers move inde pendentl y of each other. The scar lines are hardly visible. Healing was complete after twelve days and the pa­ tient returned t o work four weeks after surgery.

479

/ Thumb involvement 4&--47 The palmar aponeurosis rarel y ex ­ t end s t o the thumb. In this hand a con­ tract ed cord is present w hich crosses th e th enar eminence and draws the thumb t o­ wards the palm , reducing the effective n ess of the grip. A lo ngitudinal incision is made directly over the co rd , and a Z-plasty is designed at thi s stage t o give adequate exposure and compensate fo r sk in retraction. Th e glossy ski n surface is due to a pro­ tective co ating o f plastic, sprayed on prior to surge ry .

48 The fibr o us cord is visualized in its en­ tir e length .

\ 480

49 When the co rd is sectioned, the thumb is fully extended and a one cm long gap is produced.

50 Dissection is readily accom­ plished, as there is no extensive network of intercommunicating bands binding the cord to the deeper structures. Care should be exercised to avoid inju ry to the digital nerves, which lie in close proximity to the operative field. One of these sizable nerves is ex­ posed at the base of the upper distal flap.

51 The Z-plasty lengthens the incision and staggers that scar line ; wound edges are approximated with 5/0 Supramid sutures.

Result

52 Five months postoperatively. The scars are almost indistinguishable from the sur­ rounding tissue, and the patient is complete­ ly relieved of his disability. For thumb web contracture a similar ap­ proach , utilizing a large Z-plasty, is recom­ mended.

481

Iatrogenic contracture The origin and characteristics of this type of con­ tracture are described on p. 444.

53 This patient underwent radical aponeurectomy for Dupuytren 's co ntracture, affecting the palm and fifth finger. The hand was tightl y bandaged to prevent hematoma. As a resu l t, an ulnar subcutaneous scar de­ veloped, w hi ch graduall y progressed to this charac­ teristic co ntracture of the small finger, six y ears after the original surgery.

54 The exposed cord is confined to the subcutaneous tissue and exte nds from the fa scia of the hy pothenar eminence to the middle phalanx .

482

55 After resection the finger can be fully extended.

Z-plasties , with thickly-designed flaps, have been used to supply adequate skin coverage, and thus permit full ex­ tension of the finger. The transve rse palmar suture line has been placed in the skin crease.

Result

J

r

(

I 5&--57 One year postope ratively th ere is no sign o f recurrence.

483

Multiple Z-plasties 58 In this unusual manifestati on of Dupuyt ren ' s contrac­ ture, the pretendinous band to th e middle finger i s con­ tracted and an extension of the path ologic process ha s in ­ volved the fibrous system on the ulnar aspect of the finger, reaching beyond the distal interphalangeal joint. The basic incision is made immediat ely ove r the cord, and supple­ mentary incisions are planned, utilizing three Z-plasties.

•

•

484

•

59 This pattern of incisions permits wide exposure of the entire pathologic process.

Result

J

60-61 Two years postoperatively there is a full range of motion. The broken scarline effectively prevents secondary deformity from late scar contracture.

485

Postoperative care

In the vast majority of cases , rehabilitation is possible without the aid of a trained physiotherapist. but this requires the sur­ geon to supervise and encourage his patient to actively use his hand. Fingers not operated upon, are left unbandaged and kept mo­ bile . Regular activity effectively prevents postoperative swelling and flexion exercises are thus started the day following surgery. In cases operated upon for light or moderate contracture , the treated fingers may also be allowed some mobility when the bulky dressing and splints are removed after one week. Full range exercises are begun as soon as healing is complete, gen­ erally after two weeks. Extension and flexion exercises in warm water for twenty minutes, twice daily, is recommended. At this early stage, when swelling and stiffness are minimal, rehabilita­ tion is generally comfortable and rapid. Meticulous care in skin closure acco unts for complete primary healing within two weeks. Disunion , even within minor areas, particularly when occurring in flexion creases, prolongs the period of immobilization and causes an unfortunate delay in in­ stituting a rehabilitation program. When started in the third postoperative week or later, the transition to full activity is more difficult and the return to normal function is consequently hampered. Though surgical trauma is minimal in selective aponeurectomy, after three to four weeks the operated area thickens with edema and fibrosis. This is the critical period. The tissue reaction usual­ ly resolves spontaneousl y, but the patient' s activ e u se of his hand and daily exercises will further the regression of edema and hasten scar resolution. Mobility is mandatory for those pa­ tients who have an intense reaction to surgery. Failure to reach a full range of motion at this stage may lead to permanent in­ capacity. The problem is never severe in the palm or meta ­ carpophalangeal region. The reaction is most pronounced over the fingers, where the dissection has been most extensive. In long-standing contracture, there is a great tendency for the finger to return into. its preoperative position , because the joint capsule and tendons have adjusted themselves to this ab­ normal posture. Progressively longer periods of splinted exten­ sion should then be accompanied with a co mmensurate amount of time spent in flex ion exercises. One navigates the difficult strait of Scylla and Charybdis in maneuvering the finger into full extension without compromising function. If conces­

486

I

Dupuytren's Contracture 2

I

sions are to be made, it is better to have good flexion with slightly impaired extension, than to have a stiff, straight finger, In these difficult situations the assistance of an experienced physiotherapist is needed, Forceful extension during surgery, in order to completely over­ come severe fle x ion contracture is not recommended , as this ma y result in capsular rupture and eventually lead to further sca r formation , Gradual , systematic extension in the earl y post­ operative period will usuall y give superior result s, even though some final flex ion deformity may remain, Skin replacement is infrequent in the recommended te chniques and is only applied to minor defects, The co rre ct care of the grafted areas should be explained to the patient; protection may be needed for workers engaged in certain activities, until there is some return of sensation,

487

Comments

Incisions

The skin incisions used in this procedure provide excellent ex­ posure and make safe dissection possible. Although they may appear to compromise skin survival and lead to necrosis, this has not occurred. Despite the several incisions, the skin re­ mains extensively attached to the underlying structures, as little undermining is done. In contrast to other procedures, a rich blood supply is thus maintained and the main pathways for the palmar lymphatics are respected.

Dissection

The dissection is relatively limited, and confined exclusively to the diseased tissue; some of it does not even require excision . As the fibrous bands within the subcutaneous-tissue can no longer connect with the excised longitudinal fasciculi, they are left to atrophy. The branching septal bands may also remain attached deeply, once they have been sectioned at the cord.

"

•

The transverse palmar band constitutes the deep limits of the dissection. With this technique the risk of injury to the under­ lying nerves and vessels is reduced, and the various anatomic compartments of the palm, each with its fascial covering, are not entered. The deep lymphatics are thereby protected and general trauma to the hand is minimized. Also with the fingers, deep lymphatic pathways are as far as possible left undis­ turbed; the neurovascular bundles are not exposed , ex cept where the close relationship of the nerves and arteries to the contracted bands makes exposure necessary for their protec ­ tion. Though the finger survives equally well on a single digital artery, cold climate definitely has adverse effects on fingers supplied by one major vessel. Prophylactic removal of pretendinous bands is a matter of sur­ gical preference, influenced by the patient's age and predisposi­ tion for the disease. There is little difference from a functional point of view, whether the longitudinal bands of the apo­ neurosis are partially or completely removed.

Skin cover and wound closure

488

Although it is often stated that skin grafts should be used to replace the markedly dimpled and adherent skin of Dupuytren ' s contracture, this is not the case. Skin involvement is merely a

•

62 Thi s picture demonstrates widespread skin involveme nt in

Dupuytren's contracture; the pro­ cess developed over a twelve year period. After surgery at an early stage, there was a re­ curren ce and severe flexjon de­

formity developed in the little finger . At a secondary operation all pathologic tissue was radically removed. This permitted com­ plete unfolding of the puckerS'd skin. Despite some extensive thinning of palmar and digital ski n, healing was complete in

63 This photog raph , taken one year later, shows how the skin has re­ gained its original qualities. The normal appearing palm results from leaving the uninvolved sub­ cu taneous fat tissue undisturbed. The outlined scars demonstrate the standard incisions and the multiple Z-plasties required over the fingers. Function and strength of the hand is fully re­ stored.

two weeks.

secondary change, and totally re ve rsible . Following dissection along the deep dermal surface, the palmar skin will unfold and soon regain its normal resilience . This original tissue is superior to any sk in graft. (Figs. 62-63) The re is no need to replace the indented skin of the finger either. Available skin ca n be skilfully shifted with the Z-plasty technique suggested by Mcindoe (1946). When required , mUltip.le Z-plasties are preferable to the larger, more restricting flaps ad­ vocated by Iselin (1955). The properly planned Z-plasty is safe and the flaps will survive even when they are thinned to dermal thickness. In primary operations, it ordinarily provides adequate exposure and ample skin for closure. In marked contracture there may be co nsiderable shrinkage of skin, and if the finger were to be fully extended there would be a tissue deficit. which would require a skin graft. As extension is limited in these cases by the diseased joints, the available skin is always adeq uate to cover the defect.

489

In closing th e palmar wou nds, dead space is effectively ob­ literated by suturing . Postoperative hematom a w ill thus rarel y develop and fluid will not co lle ct. A firm pressure dressing is not required. Using a comfor1able bandage assures the best possible blood supply during healing. This usually allows sutures to be removed in 10 to 12 days.

Results

The impOr1ance of maintaining the integrity of both the super­ ficial and deep lymphatics is evident in the postoperative period Edema is negligible, and in many instances all of the swelling has subsided when, after one week, the patient returns for his first dressing change . Early healing permits rapid rehabilitation and patients can ohen resume heavy manual work within four weeks aher surgery. Reco ~Jery follow ing this procedure is thus quicker and much more uneventful than after the more extensive operations previously used. The normal configuration o f the palm is unchanged, with the distinct transverse palmar crease, the metacarpophalangeal fat pads, and the palmar arch well preserved. This allows the hand to mold properly about the surface of an object, permitting an effective grip. Although the subcutaneous tissue is left inta ct. recurrences do not occ ur at this site, as there is no distinct apo­ neurotic mooring to which t he remaining fibrous septa may anchor themselves and thus renew contraction. Nor has any recurrent contracture been found to originate in the remaining transverse bands or the deep attachments or the palmar apo­ neu rosis. The co nserva tive technique of selective aponeurectomy has permitted surgery in cases where a more radical procedu re could not be safely performed. Advanced age is no longer a contra-indi catio n to surgical co rre ct ion, as confirmed by Bruner (1967) a nd others. The procedure of selective aponeurectomy combines simplicity w ith thoroughness and offers the ideal result with the least sur­ gical trauma . The stated principles of pathogenesis serve as a frame wo rk on which this operation is based, and the results support these basic tenets.

490

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Recurrent contractures

A true recurrence must be differentiated from pathology pro­ gressing to a new area. Only when disease appears in an old operative site, can the term recurrence accurately be used. It rarely o cc urs in the pall"(l following a complete removal of the longitudinal elements of the aponeurosis. This necessarily care­ ful, but complete dissection is easily performed with sele ctive aponeurectomy. The finger presents a different situation. At surgery, a com­ paratively large area is expos ed. The more extensive dissection often requires the exposure of tendon sheaths, and may bare the dermal undersurface, lea v ing this denuded area to undergo vigorous scarring. The cumulativ e effects of scar formation and constant irritation due to finger motion produce a re curren ce. In some cases, the operative treatment of a recurrent contrac­ ture may appear to be an easy task , but it is usually fraught with numerous difficulties. Psimary and secondary pro cedures are completely dissimilar. In the latter case, there are no clear anatomical planes and the all-pervading scar tissue is closely adherent to the translocated nerves and arteries. Even moderate contracture is u sually associated with severe joint and tendon sheath involv ement, and complete restoration of function is often diffi cult to obtain Postoperative therapy is painful and lengthy, and there is a marked tendency for repeated recur­ rences. The limitations and the obstacles that are ever present, when one deals with recurrent Dupuytren's contracture, mu st be em phasized . Hueston 's (1963) opinion that skin grafts can be used effective ­ ly to treat recurrences has been supported by my personal ex ­ perien ce . The skin cove ring the re current contracture is usually shrunken and inelastic due to wide-spread scarring. Following finger extension, this local skin is inadequate for complete cov­ erage. A graft furnishes needed skin and , when placed broadly across the finger, forms a bar of relatively avascular tissue, which will prevent excessive scar formation and inhibit future contracture. A technique for surgi cal corre ction , w hich can be applied in the majority of recurrent finger contractu res, is illu ­ strated in Figs. 64-69 .

491

'

Recurrent contracture

___- --.J e

64 Seventeen years prior to admission , this 63 year old man was operated upon for Dupuy­ tren's contracture of his left little finger . At the time of the photog raph, the disease had ex­ tended to the palm, involving the bands to the thisd and fourth fingers, and recurrence had developed in the little finger. An atypical, probably iatrogenic, cord was found on the ulnar side of the hand, abducting and rotating the fin g er.

65 At the time of surgery the palmar contracture was treated in the usual manner. Th e patho­ logy of the recurrence in the little finger differed from the characteristic presentation in the primary disease. There was no distinct cord , but rather a diffuse scarring of the subcuta­ neous tissue, involving both the tendon sheath and the surrounding skin. Z-shaped incisions were used for exposure.

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\~ 66 After clearing away the diseased tissue, con­

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siderable extension was regained , but the in­ elastic tendon sheath ruptured, exposing the flexor tendons. Two additional incisions (blue) were then designed for further mobilizati o n of the Z-plasty flaps, so they could be shifted to cover the denuded tendons.

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-

67 The supplementary incisions also released severe scar contracture of the skin, and full finger exten si on was thus made possible.

68 When the flaps are s utured over the bare ten­ dons , the true skin deficit is apparent. The re ­ maining raw surfaces, one proxima l to the finger base and the other distal to the flaps , present tissues suitable for skin grafting, i.e. the fatt'ii' subcutan eo us layer, the tendon sheath and the neurova scular bundles . These w o unds were accurately covered with two full thi ckness skin grafts taken from the w rist. 69 When skin replacement is necessary, a full thi ckness g raft from the v olar aspect of the wrist is the preferred source for many reasons . It provides a better match than using tissue from more distant donor sites, the area is al­ ready anesthetized by the wrist b lock, and ad­ ditional drap ing and preparation are not re ­ quired. The quantity of skin is usuall y suf­ ficient, and closure is easily accompli shed w ithout th e development of significant scar­ ring .

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493

Result

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\

\ 70-71 One year later there is no evidence of re­ currence, The thin scar lines are outlined in the photograph. Grafted skin has main­ tained its original dimensions and has an excellent appearance. A full range of motion has been obtained. The scar at the donor site is characteriotically linear. Z-plasty was utilized at the ul nar border of the palm .

In the case described, Z-plasty was adapted to meet the need for flap cover­ age in certa in areas of the finger. More commonly, when the finger is extended, • the two triangular flaps of the Z-plasty become separated, leaving an oval­ shaped, transversely placed defect be­ tween them. Only one graft will then be required. In both instances, skin tension should be completely released when the • finger is fully extended, before grafting. For this reason supplementary relaxing incisions are needed and these will usually extend to the media-lateral axis on each side of the finger.

494 I

Plantar Lesions

The clinical features and patholog y of plantar man ifesta tions in Dupuytren's disease ar e described on page 448.

Operative procedure 72 This nodu lar thickening ha s developed in th e ho llow of the f oot of a 45 yea r o ld man . Re section is planned to allev iate di scom­ fort. A broad-based flap is outlined to pro­ v ide w ide exposure.

7 3 In di ssection, the nodule is fou n d to bul ge fo rwa rd from the medial edge 01 the plantar aponeuros is, th e w hite bord er co ntra st ing w ith the mass. At this site, w h ere deep fibro'i:i s bands anchor the aponeurosis to the bony skeleton, the maximum force on t h e apon eurotic arch in body support occurs. The constant stress and strain make this area susceptibl e to Dupuytren's disease .

74 Resection is ca rried out throug h a WIde w indow, cut parallel to the longitudi n al fascicul i. Th e borders must be straight and clean, and the distance between incisions wide eno ugh to prevent any scar tissue from bridging the gap. The pathologi c pro­ cess is confined to the aponeurosis and does not penet rate beneath this structure .

75 The nodu le ha s been longitudinally sec­ tion ed. White bands of normal apo neurotic tissue streak the tan-colored mass. 495

Result 7&--77 Healing has been uneventful w i th an even

scar. Six months after surgery the patient is asymptomatic. The profile shows th e normal foot contour. There is no sign of re curren ce, and there has been no arch disturbance despite the aponeurotic resection.

496

•

References

Bruner J . M.: Recent advances in the treatment of Dupuyt ren 's disease. Symposium on Surgery of the Hand , Vienna, 19 67 . Hueston J . T : Dupuytren's Contracture. E. & S. Livingstone Ltd , Edinburgh & London, 1963. Iselin M.: Chirurgie de la Main. Masson Edit, Paris, 1955. Mcindoe A.: Personal co mmunicati on, 1946. Shaw M . H. and Barclay T L.: Dupuytren's contracture. The results of radical fasciectomy . Tran sactlntern at Soc Plast Surg, First Congr, 1955. Williams & Wilkins Co, Baltimore, 1957, p 428. Skoog T.: Dupuytren's contra ction . With special reference to aetiology and improved surgical treatment. Its occurrence in epileptics. Note on knuckle-pad s. Acta Chir Scand 96, 1948, Suppl 139. Skoog T: Pathogenie et traitm en t chirurgicale de la maladie de Du­ puytren . Ma ladie de Dupuytren. L ' E ~pansi o n Scientifique Francaise, Paris, 1966, p 82. Skoog T : Dupuytren 's contracture: pathogenesis and surgical treat­ ment. Surg Clin N Amer 47: 433, 1967. Skoog T: The tran sverse elements of the palmar aponeurosis in Dupuytren 's co ntractu re. Scand J Plast Reconstr Surg 1: 51,1967. Skoog T .: Management o f Dupuytren 's contracture.-A rational ap­ proac h based on its path ogen esi s. For telev ision dem o nstrati on . Transa ct Fifth Intern at Congr Plast Recon str Surg, 1971. Butterworths. Australia, 1971, P 606 . Tubiana R. and Thomine J.-M .: Les complications des aponevrec­ tomies. Ma ladie de Dupuytren. L'Expansio n Scientifique Francai se, Paris, 196 6, p 91.

497

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Biographical data

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Tord Skoog was born in Sweden on December 11 , 1915. He attended the medical faculty of the University of Uppsala and graduated in 1942 . He remained in U ppsala for postgraduate training in general surgery under professors Gunnar Nystrom and Olle Hulten . both of whom had a particu l ar interest in re­ constructive surgery. In 1945. Dr Skoog went to Finland to study the plastic surgical treatment of war casua lties under the direc­ tion of professors Richard Fa ltin and Atso Soivio . The following year he was awarded a British Council Scholarship for plastic surgery with Sir Haro ld Gillies and Sir A rchibald Mcindoe . Afte r this f ell owship he returned to Sweden and wrote hi s th es is on Dupuytren 's co ntra cture. In 1949. the A merican Association of Plastic Surgeons invited him to discuss hi s do ctoratewo rk . They 499

1

also extended an invitation for him to visit leading specialists of p lastic surgery and hand surgery in the United States. During the Korean war , he had an opportunity to be a United Nations Forces observer and to report on the treatment of burns incur­ red during this conflict . In 1948, Dr. Skoog was entrusted with organizing a Department for Plastic Surgery and Burn Injuries at the University Hospital in Uppsala and in 1960, he w as appointed Professor of Plastic Surgery at the University of Uppsala, the first such chair to be established in Scandinavia. In 1955, Dr. Skoog coordinated the First International Congress of Plastic Surgery, held in Stockholm and Uppsala, and acted as General Secretary for the meeting. He proposed the Statutes for the present International Confederation for Plastic and Recon­ structi ve Surgery and served in the position of General Secretary from 1955 to 1959. During this formative period many national societies for plastic surgery w ere instituted as a result of his efforts. He remained on the Exe cuti " e Committee from 1959 to 1967. Since 1965 he has been a member of the Executive Com­ mittee of the International Society for Burn Injuries. His honors include numerous v isiting professorships and he was awarded membership in the following societies:

Honorary member : American College of Surgeons,' American Burn Associationi Asociaci6n Espanola de Cirugia Plastica Re­ paradorai Asociacion Medica Argentina,' Canadian Society of Plastic Surgeonsi CeskoslovenSka Lekafska Spolecnost,' Sociedad Chilena de Cirugia P/ijstica y Reparadora i Chirurgi Plastici Fenniae; Finnish Surgical Society,' Japan Society of Plastic and Reconstructive SurgerYi Societe Franr;a ise de Chi­ rurgie Plastique et Reconstructivei Societa Italiana di Chirurgia Plastica Riconstruttiva,' Turk Plastik Cerrahi Cemiyeti. Corresponding member: American Society of Plastic and Re­ constructive Surgery,' American Soci ety for Aesthetic Plastic SurgerYi British Association of Plastic Surgeons,' Oansk Selskab for Plastik- og Rekonstruktionskirurgi,' Verein igung der Oeut­ schen Plastischen Chirurgen. Member : International Surgical GrouPi Academia Regia Sci­ entiarum Upsaliensis. 500