Trapezius sparing minimally aggressive surgical technique for sprengel deformity: A case report

Sprengel deformity is a rare congenital anomaly of the pectoral girdle of unknown incidence. Surgical intervention is indicated in moderate to severe cases having functional and cosmetic impairment. Various surgical corrective procedures have evolved over the past decades, however the extensive magnitude of some of the surgical techniques have sometimes resulted in an unwarranted worse outcome due to associated complications like brachial plexus palsy, scapular winging, sternoclavicular joint prominence, improper scar healing and keloid formation which restrict such procedures to experienced hands at few centres. We report a case of Cavendish grade 3 Sprengel deformity in a five-year-old boy managed with a minimally aggressive modified technique of preserving the trapezius and restricting the surgery to excision of omovertebral bar and supraspinatous part of scapula by a transverse incision overlying the spine of scapula. In Sprengel deformity, the trapezius attached to the elevated scapula is underdeveloped and the technique of retraction instead of detachment of this muscle during surgery, can prevent scar adhesions and improve wound healing. In our patient, satisfactory cosmetic correction and good functional shoulder movements were achieved with minimal intervention.     

Sprengel deformity: pathogenesis and management

Sprengel deformity (ie, congenital elevation of the scapula) is a rare clinical entity. However, it is the most common congenital anomaly of the shoulder. Sprengel deformity is caused by abnormal descent of the scapula during embryonic development. Sprengel deformity is associated with cosmetic deformity and decreased shoulder function. Diagnostic confusion with limited scoliosis can be dangerous to the patient because it may delay proper treatment of other abnormalities that may be present with even mild cases. Sprengel deformity is commonly linked to a variety of conditions, including Klippel-Feil syndrome, scoliosis, and rib anomalies. Nonsurgical management can be considered for mild cases. Surgical management is typically warranted for more severe cases, with the goal of improving cosmesis and function. Surgical techniques are centered on resection of the protruding portion of the scapula and inferior translation of the scapula. Recent long-term studies indicate that patients treated surgically maintain improved shoulder function and appearance.     

Body Image Dissatisfaction in Male Cosmetic Surgery Patients

This study was the first empirical investigation of body image dissatisfaction in male cosmetic surgery patients. Thirty men completed two body image measures prior to their initial consultation. Results were compared to the norms for each of the measures and with a sample of 30 women seeking similar cosmetic procedures. Results indicated that patients did not demonstrate greater dissatisfaction with their overall appearance than men in a normative sample. However, when asked about the bodily feature they were considering for surgery, they reported significantly greater levels of dissatisfaction than the normative sample. As compared to male patients, female patients reported a greater investment in their physical appearance. Implications of these findings are discussed with respect to the nature of body image dissatisfaction and the relevance of body image in the psychology of male plastic surgery patients.     

Operative treatment of severe forms of congenital elevation of the scapula in children

The article presents results of operative treatment of 36 children with severe forms of congenital high scapula. An original and used by us method of operative treatment of children with a severe form of Sprengel deformity is described. Distinctive features of the method are: mobilization of the suprascapular vascular-nervous bundle, correction of scapula deformities followed by a recovery of congruency of the sliding surfaces of the scapula and chest, physiological fixation of the scapula in the new place, separating off the paravertebral muscles and their sewing on to the medial edge of the scapula that allows a recovery of the function of lost trapezoid and rhomboid muscles and in some cases a shortening osteotomy of the clavicle is performed preventing the descending of the scapula. An analysis of the external view of the shoulder made after the operation has shown that the result was good in 57.5% of children, satisfactory in 42.5%. The functional indices characterizing the increased amplitude of movements in the shoulder joint were good in 47.5%, and satisfactory in 52.5%. The cosmetic and functional results of the treatment allow the developed technique to be recommended for treatment of severe forms of the Sprengel disease in children.     

Evolution from Endoscopic to Miniinvasive Facelift: A Logical Progression?

Endoscopy has revolutionized the field of aesthetic surgery, permitting the advent of cosmetic surgery via minimal incisions. The procedures are modifications of subperiosteal lifting techniques which grew out of craniofacial surgery. Nonetheless, the cumbersome instrumentation and changes in operator technique have led to the development of a subperiosteal facelift through minimal incisions without the aid of endoscopy. This miniinvasive approach has yielded equivalent results to our endoscopic rhytidectomies in appropriate patients, with reduced morbidity, edema, and operating time. Further, it permits the avoidance of preauricular scars in the majority (84%) of patients; 63 cases are presented, with a follow-up of up to 4 years.     

A Pragmatic Way to Treat Abdominal Deformities Based on Skin and Subcutaneous Excess

An objective classification for abdominoplasty based on subcutaneous and skin deformities is described. Type 0 patients are those who present excess fat with very little excess skin or without surplus skin, on which liposuction is indicated. Types I, II, and III are patients that demonstrate various degrees of excess skin and three basic patterns of skin resection are described. Type I patients present mild excess skin with a high umbilicus. Type II patients are those with mild excess skin and a well-positioned umbilicus, as well as patients with moderate excess skin. Type III patients present severely excessive skin. One hundred and eleven patients with abdominal deformity were reviewed and the incidence of each deformity was determined on this population. This study presents a practical classification that permits the plastic surgeon to critically evaluate which is the best option to correct abdominal deformities considering specific skin and subcutaneous deformities.     

Frontal Exostose Resection During an Endoscopic Subperiosteal Lifting: Case Report

Ever slowly, plastic surgery has adopted minimally invasive procedures in order to avoid extensive incisions, large scars, and to obtain better results. Endoscopy was introduced into cosmetic surgery of the face in 1992 and it is getting more and more widespread as are its indications, often replacing open surgical approach. Sometimes, a patient seeking a solution to the stigma attached to the aging face may present other problems that are surgically treatable. The authors describe a case of surgical endoscopic resection of a frontal osteoma during endoscopically assisted brow-lift rhytidoplasty.     

Ten years outcome analysis of corporeal plication for Peyronie’s Disease

Objective To evaluate the long-term results of plication of tunica albuginea in patients with penile curvature secondary to Peyronie’s disease. Patients and methods A total of 78 men with penile curvature secondary to Peyronie’s disease underwent corporeal plication over a 10 year period. To assess the long-term results, a questionnaire-based study was undertaken on 73 of these patients with a time lapse of > 6 months after the operation. The questionnaire focussed on the presence or absence of penile deformity and pain, erectile function and the ability to perform sexual intercourse. Results Follow up ranged from 3 to 109 months with a median of 51 months. The cosmetic result was good or excellent (straight or almost straight penis) in 94% by 6 months. A total of 57 replies to the questionnaire were suitable for analysis. A total of 90% patients had a satisfactory cosmetic result, whereas only 71% reported a satisfactory functional result (straight or almost straight penis on erection with pain free penetration and normal sexual intercourse) in the long-term. In patients with > 3 years follow up, the cosmetic and functional success rates were 83% and 67%, respectively, and for patients with > 5 years follow up the corresponding figures were 82% and 71%, respectively. The main causes of functional failure were pain, erectile dysfunction and persisting deformity. There were no major complications associated with the procedure. Conclusions Corporeal plication is an effective surgical option for the correction of penile deformity in patients with Peyronie’s disease, with good cosmetic results and acceptable functional success rate in the long-term.     

High-Tech Facelift

Recent technological advances in our specialty have made us reappraise the way we approach facial rejuvenation. Some of these technological interfaces have made it possible, in the author's exerpience, to improve results and to tackle difficult aesthetic problems. The purpose of this paper is to report how we combine these technological advances in an effort to improve the aesthetic outcomes. These technological advances are: laser skin resurfacing, endoscopy, newer fat grafting procedures, and new alloplastic materials for bone augmentation. Other technological advances are consultations via the Internet, computer imaging for simulation of possible outcomes, etc. Endoscopy is routinely used in our facial rejuvenative procedures, almost always for the forehead, often for the midface and less often for the neck. Fat grafting procedures using newly adapted concepts are used for the brow, glabella, tear trough deformity, cheeks, lips, chin, nasolabial folds, marionette lines, and other areas of soft tissue depressions apparent before or after the lifting procedures. This has allowed us to restore the tridimensional volume and treat the soft tissue atrophy. Patients with significant skeletal soft tissue disproportion due to aging, loss of dentition, prior trauma or congenital defects may receive one or more of the following implants: glabella, cheek, piriformis, angle of the mandible, mandibular body glove type of implant, prejawl implant, chin overlay or a glove type of implant. Our preference is for a porous polyethylene material because of its tissue ingrowth inductiveness. Individuals who have damaged skin due to solar exposure, aging, smoking, etc., may receive Ultrapulse CO₂ laser resurfacing at the same operative setting (more often) or in a delayed fashion. The Versapulse laser is also needed for the treatment of some skin changes secondary to aging such as telangiectasias (Variable Pulse Green) and brown spots (Q-Switch 532). The high-tech facelift has allowed us to treat the severely damaged skin, fat atrophy, bone atrophy in many patients, at the same time that the lifting procedure is performed. This provides a more comprehensive approach to facial rejuvenation. The combination of different techniques and technologies maximizes the effectiveness and minimizes the potential side effects of each one. Scars in the forehead and scalp are avoided. Incision and fat removal in the lower eyelid are often unnecessary. It provides a more precise vertical lifting with correction of the tear trough deformity and gives a tridimensional restoration of the facial volume. The facial disharmony is treated at every level starting from the facial skeletal support to the most external envelope (skin). Over 200 patients have been treated this way with a minimal rate of complications. The high-tech facial rejuvenation has allowed us to improve the surgical results of our patients compared with previous isolated techniques. The combination of each one of the techniques require a precise understanding of the limits and benefits of each. Case examples of the different combinations will be shown.     

Cosmesis and body image after laparoscopic-assisted and open ileocolic resection for Crohn's disease

Background: The objectives of this study were to evaluate body image, cosmetic results, and quality of life in patients with Crohn's disease of the terminal ileum who had either laparoscopic-assisted or open ileocolic resection, and to determine how patients experienced the pre- and postoperative periods after both procedures. Methods: Thirty-four patients participated: 11 patients after open resection (OR), 11 patients after laparoscopic-assisted resection (LR), and 12 patients without resection (WR). Retrospectively, the patients filled out several questionnaires pertaining to body image, hospital experiences, and quality of life. One-way analysis of variance, Student's t-tests, and Pearson's correlation were used for statistical analysis. Results: The cosmetic score was significantly higher in the LR than in the OR group (p < 0.01). Body image correlated strongly with cosmesis and with quality of life. The hospital experiences of the laparoscopic and open groups were similar. Conclusions: Laparoscopic surgery was associated with better cosmesis than open surgery. Patients do not experience laparoscopic surgery any differently from open surgery. Received: 29 September 1997/Accepted: 21 January 1998     

Tuberous Breast: A Surgical Challenge

Since the presentation of the tuberous breast deformity by Rees and Aston in 1976, many surgical procedures have been developed, but the correction of such a deformity still remains a surgical challenge. The authors report the last cases treated in the Department of Plastic and Reconstructive Surgery of S?o Jo?o Hospital-Porto and discuss about the ideal procedure which should be used according to the type of deformity. They emphasize the periareolar approach and the good results obtained by the Liacyr Ribeiro technique.     

Umbrella graft of columella tip: 20 years' experience

We present our experience with nasal grafts over 20 years. The nose, located centrally, always plays a key role in facial aesthetics. Public recognition of this makes rhinoplasty the most popular operation. From the traditional aesthetic point of view, propogated by the media, the nose must be narrow and straight and have correct nasolabial and forehead angles. It is the desire of every surgeon to obtain permanent and satisfactory cosmetic results. However, it is not always possible to obtain good cosmetic appearance using conventional methods when the nose is small or large, when the columella is short, or when the skin is thick. Mostly, nasal tip projection cannot be achieved. In the present article, we report our experiences in primary asthetic rhinoplasty using cartilaginous grafts obtained from septum, costa, and ear as umbrella grafts of columella type.     

Reconstruction of Saddle Nose Deformities Using Porous Polyethylene Implant

Various materials have been employed for nasal contour restoration. We used porous polyethylene implants in reconstruction of saddle nose deformity in 36 cases. Only one complication occurred in the 8–18 months follow-up period. No implant was removed. Both cosmetic and functional results were accepted as pleasing by the patients.     

Surgical Treatment of Rhinophyma: A Comparison of Techniques

Rhinophyma is a rare disease that primarily affects Caucasian men in the fifth to seventh decades of life, characterized by a progressive thickening of nasal skin, which produces a disfiguring soft-tissue hypertrophy of the nose. Severe cosmetic deformity and impairment of breathing may coexist, making the surgical treatment necessary. The authors are conscious that in literature there is not agreement about the ideal treatment of rhinophyma, nevertheless they wish to give their contribution according to their experience with different treatment modalities such as the scalpel, the electrocautery, the dermabrader, and the carbon dioxide laser. The authors believe the scalpel, in association with bipolar electrocautery and local infiltration of dilute epinephrine to reduce bleeding, is the safest means to preserve the underlying sebaceous gland fundi and permit a spontaneous re-epithelialization scarring-free.     

Chest Wall Implants: Their Use for Pectus Excavatum,Pectoralis Muscle Tears,Poland's Syndrome,and Muscular Insufficiency

Solid customized and prefabricated silicone implants have been used by the author for 15 years in a wide range of chest wall deformities. Chest wall implants are often used in males seeking to augment a muscularly deficient or underdeveloped chest; however, their greatest use has come in a variety of deformities both congenital and acquired, such as pectus excavatum, Poland's Syndrome, and pectoralis muscle tears. The implants can be either customized using a moulage technique or are prefabricated, manufactured implants which can be modified on the operating table to repair the contour deformity. The immediate postoperative problem of seroma and subcutaneous implant ``show' has been minimized by careful planning, gentle technique, deep insertion, improved patient positioning on the operating room table, and the use of oral anti-inflammatory medications. The long-term results of these implants seem very satisfactory. The patients are usualy physically active, and the implants show no long-term sequelae such as seroma, infection, displacement, or rupture.     

Evaluation and treatment of adult spinal deformity. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

Spinal deformity is a complex and dynamic process that occurs in both the sagittal and coronal planes of the thoracolumbar spine. Successful treatment is aimed at achieving satisfactory balance in both of these planes. The spinal curvatures in the adult differ greatly from those in adolescents. As a general rule the adult curves tend to be stiffer, whereas adolescent curves are more flexible. In addition to cosmetic concerns, adult patients frequently present with pain and neurological symptoms in contrast to adolescents who usually do not experience this degree of pain or neurological symptoms. The treatment of adult spinal deformity differs substantially from that of adolescent deformity. Surgeries in the former tend to be more complex procedures associated with higher rates of intra- and perioperative complications. The goals of surgery in the adult are to obtain a solid fusion with a balanced spine, to relieve pain, and to prevent further deformity. A secondary goal is to correct the curve, and, in so doing, to improve the cosmetic appearance. In this review the author addresses the basic principles of spinal corrective surgery in the adult and provides insight into the varied treatment options available.     

Psychopathology and Body Image in Cosmetic Surgery Patients

The purpose of this study was to investigate the presence of psychiatric symptoms and evaluate the perceptive, cognitive, and behavioral aspects of body image in cosmetic surgery patients. These parameters of 20 cosmetic patients and of 20 control patients matched for age, gender, education, and marital status who attended the general surgery department for minor surgery were compared in a cross-sectional design. Symptom Check List-90 (SCL-90), Beck Depression Inventory (BDI), and The Multi-Dimensional Body Self Relations Questionnaire were administered to both groups. No significant difference was determined in the rates of psychopathology of the patient and control groups. Scales assessing self-image did not indicate any significant difference between the groups. Four (20%) of the cosmetic patients, however, were diagnosed with body dysmorphic disorder according to DSM-IV. Cosmetic patients were usually defensive towards psychological evaluations. A wide range of diversity was determined in the psychiatric evaluation of the cosmetic patient group. While some patients exhibited healthy psychological traits, some had severe depressive disorder or nearly psychotic somatic preoccupations.     

Cornelia de Lange syndrome: A rare case,presented with unilateral pes equinovarus

Cornelia de Lange syndrome is a genetic disorder with multiple system abnormalities. It is especially characterized by typical facial appearance and hirsutism. Growth and mental retardation, gastrointestinal, cardiovascular, and orthopedic abnormalities are other important features of this syndrome. In this case, we present a rare manifestation of Cornelia de Lange syndrome with a unilateral pes equinovarus deformity without other more specific orthopedic manifestations. Ponseti method's was applied as the initial procedure. Afterwards, complete subtalar release was performed. After four years follow-up, clinical and radiological results were satisfactory. Unilateral pes equinovarus deformity may be a part of this syndrome as well as a sporadic presentation. The discrimination is important for anesthetic procedures and surgical outcomes.     

Tibialis anterior tendon transfer for residual dynamic supination deformity in treated club feet

Twenty-seven previously treated club feet in 25 patients were evaluated retrospectively following tibialis anterior tendon transfer to the dorsum of the foot to correct residual dynamic supination deformity. In 11 feet, the transfer was combined with additional soft tissue and or bony procedures to treat other accompanying deformities. Electrophysiologically demonstrated peroneal weakness causing muscle imbalance contributed to the etiology of this dynamic deformity. At follow-up, none of the patients had dynamic supination deformity during ambulation. All showed active contraction of the transferred tibialis anterior tendon. There was no case of overcorrection. Functional and cosmetic results were assessed by parents and surgeons as being excellent. Tibialis anterior tendon transfer is recommended to correct residual dynamic supination deformity and to restore muscle balance after satisfactory correction of idiopathic club foot contractures.     

Motivation for Rhinoplasty: Changes in 5970 Cases, in Three Groups,1964 to 1997

The motivational factors were divided into three categories: (1) independent decision, (2) observation of previous patients, and (3) external influences. The results of the percentage breakdown of the patients in our present study are compared with previous results are presented in 1983 in this journal. Once again, the independent decision of the patient was the most important factor in deciding to have cosmetic rhinoplasty, followed by their observation of results in other patients. These two factors have been the motivation in approximately 80% of all the patients in all three studies. The age breakdown of cosmetic rhinoplasty patients shows that after the age of 21, as patients get older, a smaller and smaller percentage of patients was motivated for surgery by independent decision alone. These older patients need external influences to motivate them to have surgery. In most cases, the desire for surgery had smoldered in them since adolescence, and they needed an external ``OK' to have it done.