Congenital Diaphragmatic Hernia (Bochdalek)

Satya Wardhana, Dadik Agus

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The 3 basic types of CDH include the posterolateral Bochdalek hernia (occurring at approximately 6 weeks' gestation), the anterior Morgagni hernia, and the hiatus hernia. The left-sided Bochdalek hernia occurs in approximately 85% of cases. Left-sided hernias allow herniation of both the small and large bowel and intraabdominal solid organs into the thoracic cavity. In right-sided hernias (13% of cases), only the liver and a portion of the large bowel tend to herniate. Bilateral hernias are uncommon and usually fatal.

CDH is characterized by a variable degree of pulmonary hypoplasia associated with a decrease in cross-sectional area of the pulmonary vasculature and dysfunction of the surfactant system. The lungs have a small alveolar capillary membrane for gas exchange, which may be further decreased by surfactant dysfunction. In addition to parenchymal disease, increased muscularization of the intraacinar pulmonary arteries appears to occur. In very severe cases, left ventricular hypoplasia is observed. Pulmonary capillary blood flow is decreased because of the small cross-sectional area of the pulmonary vascular bed, and flow may be further decreased by abnormal pulmonary vasoconstriction.
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Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations

Abstract
Background
This report describes a new technique of sphincter saving anorectoplasty (SSARP) for the repair of anorectal malformations (ARM).
Figure List

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Methods
Twenty six males with high ARM were treated with SSARP. Preoperative localization of the center of the muscle complex is facilitated using real time sonography and computed tomography. A soft guide wire is inserted under image control which serves as the route for final pull through of bowel. The operative technique consists of a subcoccygeal approach to dissect the blind rectal pouch. The separation of the rectum from the fistulous communication followed by pull through of the bowel is performed through the same incision. The skin or the levators in the midline posteriorly are not divided. Postoperative anorectal function as assessed by clinical Wingspread scoring was judged as excellent, good, fair and poor. Older patients were examined for sensations of touch, pain, heat and cold in the circumanal skin and the perineum. Electromyography (EMG) was done to assess preoperative and postoperative integrity of external anal sphincter (EAS).
Results
The patients were separated in 2 groups. The first group, Group I (n = 10), were newborns in whom SSARP was performed as a primary procedure. The second group, Group II (n = 16), were children who underwent an initial colostomy followed by delayed SSARP. There were no operative complications. The follow up ranged from 4 months to 18 months. Group I patients have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination with an average number of bowel movements per day was 3–5. In group II the rate of excellent and good scores was 81% (13/16). All patients have an appropriate size anus and regular bowel actions. There has been no rectal prolapse, or anal stricture. EAS activity and perineal proprioception were preserved postoperatively. Follow up computed tomogram showed central placement the pull through bowel in between the muscle complex.
Conclusion
The technique of SSARP allows safe and anatomical reconstruction in a significant proportion of patients with ARM's without the need to divide the levator plate and muscle complex. It preserves all the components contributing to superior faecal continence, and avoids the potential complications associated with the open posterior sagittal approach.
Background
Posterior sagittal anorectoplasty (PSARP), popularized by de Vries and Peña has become the preferred technique for surgical management of anorectal malformations (ARM) [1]. The PSARP involves incision from coccyx to perineal body, to widely expose the external sphincter, the levators, the rectum, and distal fistula to facilitate surgical repair. Dividing the sphincter posteriorly can affect the pudendal nerve and its terminal branches to the sphincter in these patients, who already may be having widespread lumbar and sacral lesions [2]. Despite excellent exposure of the anatomy and exact placement of the distal rectum within the muscle complex, continence often is less than ideal [3,4]. In an attempt to preserve the neurophysiological function of the sphincter we describe a sphincter saving approach to reconstruct ARM.
Methods
Between March 2005 and May 2007, 26 children have undergone a sphincter saving anorectoplasty (SSARP) for high ARM. This study was conducted in accordance with the principles of the Declaration of Helsinki and 'good clinical practice' guidelines. The protocol was approved by the Ethical Review Board of B.P. Koirala Institute of Health Sciences (Ethical Review Board number: 497/062/063). Prior to the surgery written informed consent was obtained from the parents of children.
Exclusion criteria
Patients with cloacal malformations, rectovesical fistula, rectovestibular fistula and low ARM were excluded from the study. Hospital charts and surgical notes were reviewed and clinical characteristics tabulated.
Preoperative management
A thorough perineal examination, urine analysis and an invertogram was done to distinguish between high and low anorectal defects. An echocardiogram was done to evaluate congenital heart defects.
Invertography
This examination was performed at least 12 – 18 hours after delivery in all newborns, using the method described by Wangensteen and Rice [5]. The lateral radiogram was done in the inverted position, with the radio-opaque marker fixed in the would-be-anus site to measure the distance between the most distal gas collection and skin and the last ossified vertebral bone (Figure 1).
Figure 1. Invertogram showing a high blind pouch in a newborn undergoing primary SSARP. A blind distal pouch within 1 cms from the last vertebral bone can be corrected by this approach.
Preoperative electromyography of external anal sphincter
Patients older than 3 years were subjected to preoperative electromyography (EMG) of the external anal sphincter (EAS). Electrical activity was evaluated by needle electrodes in all the patients. A disposable 37 mm standard concentric needle electrode was inserted into the EAS as described by Podnar et al, to evaluate both the superficial part and deep parts of the muscle [6]. The subcutaneous part of the EAS was evaluated by placing the needle electrode perpendicularly to the anoderm at a depth of a few millimeters at the site of anal dimple.
Preoperative localization of muscle complex
To facilitate accurate central placement of bowel within the muscle complex without having to divide the levators all patients underwent real time sonography of the perineum. The child was placed in a prone position with elevated pelvis and legs and perineal anatomy studied a linear 5 MHz probe (Figure 2). The two ischial tuborosities and the medial borders of muscle complex on either side serve as landmarks to ensure central placement of the cannula (Figure 3). The center of the external sphincter on the anal dimple is marked using a muscle stimulator (Bajpai, [20]). A 16 gauge cannula is advanced through the center of the external sphincter till it lies just below the levators as seen on a transverse real time scan. Once the correct depth of the tip of the cannula is verified, it is advanced in the midline towards the coccyx under the guidance of longitudinal real time scan (Figure 4). The cannula is then brought out just below the last palpable vertebral bone. A soft guide wire is pushed over the cannula and secured. The correct placement of the guide wire is checked on a CT scan (Figure 5) with parameters settings adjusted based on the size of the child and region of interest [7]. The path of the guide wire is then dilated during surgery which serves as a tunnel for pull through bowel.
Figure 2. Preoperative localization of the center of muscle complex. A perineal sonogram showing muscle complex on two sides with variable amount of levator fat.
Figure 3. Sonogram showing important anatomical landmarks which guide accurate central placement of guide wire. Points A and B indicate ischial tuborosities. Dashed curved line indicates the medial borders of the levators on both sides. The star in the center corresponds to the position of the anal dimple.
Figure 4. Sonogram showing guide wire (arrow) in the center of the muscle complex.
Figure 5. A computed tomogram verifying the central placement of the guide wire (arrow).
Augmented-pressure distal cologram
This examination was done on children with previously constructed colostomy. A lateral radiogram of the pelvis was made after injecting the contrast medium via a Foley catheter into the distal bowel with sealing of the distal
Primary or staged SSARP
The decision to perform a primary SSARP was determined by the neonate's general condition, and the presence of the air column within the rectum blind pouch within 1 cms of the last ossified vertebral bone (Figure 1). If the baby was unwell with features of sepsis or a very high pouch a high sigmoid colostomy was made and SSARP performed at a later date.
Surgical technique
After the bladder is catheterized, the patient is placed in prone jackknife position (Figure 6). A transverse incision is made just above the coccyx (Figure 7). In patients with sacral agenesis the incision is made over the last palpable spine. The incision is deepened in its subcutaneous plane to expose the coccyx. The periosteum over the coccyx is removed and coccygectomy performed (Figure 8). No dissection is done in the midline. The rectal blind pouch is mobilized within Waldeyer's fascia. The rectal pouch is detached from the anterior area of the sacrum by using a finger. Laterally the rectal pouch is attached to the pelvis by a thick ligament with the middle haemorrhoidal artery. Resection of this ligament is necessary for detaching the rectal pouch. The blind rectal pouch is opened longitudinally (Figure 9). Separation of the rectal pouch from the urethra or the vagina is performed by combined sharp and blunt dissection. The separation of the rectum and the urethra is started by creating a plane of dissection in the common wall of the fistula (Figure 10). Once a plane is found, the separation of the rectum from the fistula continues until the fistula is completely free (Figure 11). The fistula is closed in two layers. Rectum is mobilized upwards by clearing the perirectal adhesions so that adequate length is available for pull through without anastomotic tension (Figure 12). The external sphincter is once again defined with electrostimulation. The path of guide wire which was placed preoperatively is serially dilated until it accommodates Hegar dilators of sizes 6 – 12 (Figure 13). The rectum is then pulled down through the tunnel and fixed to the proximal edge of levator plate by several sutures (Figure 14). Finally a standard anorectoplasty performed (Figure 15). The transverse incision is closed in layers.
Figure 6. A transverse incision is made over the last palpable vertebra.
Figure 7. Dissection is deepened to expose the coccyx. The periosteum over the coccyx is removed and coccygectomy performed (arrow).
Figure 8. The blind rectal pouch is isolated (arrow).
Figure 9. The rectal pouch is opened longitudinally (arrow).
Figure 10. The separation of the rectum (black small arrow) and the urethra is started by creating a plane of dissection in the common wall of the fistula (white arrow).
Figure 11. Complete separation of the rectum (black arrow) from the fistula (white arrow) continues until the fistula is completely free.
Figure 12. Rectum (arrow) is mobilized upwards by clearing the perirectal adhesions so that adequate length is available for pull through without anastomotic tension.
Figure 13. The path of guide wire is dilated serially till it accommodates a appropriate sizes Hegar Dilator.
Figure 14. Rectal pouch is fixed to the proximal edge of levator plate by several non absorbable sutures (small arrows).
Figure 15. At completion of SSARP. Note the complete sparing of the posterior midline skin and excellent cosmetic appearance.
Postoperative management
Two weeks after the repair, the patient was started on a protocol of anal dilatations. If a colostomy was constructed it was closed after the neoanus accepted the desired size of dilator.
Assessment of continence
At the follow-up visit, modified Wingspread Scoring [9] was adopted to investigate the fecal condition in children older than 3 years. The operative outcome was designated as "excellent," "good," "fair," and "poor." Continence was defined as the ability to stay clean without staining or soiling both day and night without pads or diapers. Soiling was defined as an inadvertent loss of small amounts of feces staining the underwear. Incontinence was defined as regular loss of solid feces. Constipation was defined as less than 3 spontaneous bowel movement per week, rectal impaction, or abdominal fecalomas.
Post operative electromyography of external sphincter
Post operative EMG was performed 3 weeks after anorectoplasty. Any sphincter abnormality was assessed by investigating the location, integrity and activity of EAS. Activity at rest and under voluntary contraction were analyzed and compared to their preoperative values.
Results
Ages, sexes, as well as other main features of the patients who underwent surgery with this technique are summarized in Table 1. In 10 newborns, SSARP was performed as a primary procedure without prior colostomy. Sixteen children were treated with initial colostomy in the newborn period followed by delayed SSARP. There was no operative mortality. There was no difficulty in gaining enough length for pull-through, regardless of whether the patients had undergone prior colostomy. No conversion to traditional PSARP approach was necessary. The mean operating time was 72 minutes ± 13.2. The follow-up ranged from 4 months to 22 months. No patients have shown ischemia or stricture of the anorectal anastomosis. We obtained excellent results with regards to short hospital stay, functional bowel movements and attractive cosmetic results.
Bowel function in neonates (Group I)
The 10 neonates and infants, who are yet too young to be evaluated for continence, have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination. The average number of bowel movements per day was 3–5, without the need for any laxative or enema.
Bowel function in older children (Group II)
The functional outcome was assessed in 16 of our patients who are now older than 3 years of age. Fecal continence was excellent and good in 13 (81%) and fair and poor in 3 (19%) of the patients, Table 2. The average number of bowel movements was 2–5 per day.
Table 2. Results according to Clinical, Radiological and Electromyography assessment
Perineal sensations
Preoperative perception of heat cold and painful stimuli was present in all 16 children. These children continued to appreciate the sensations with the same magnitude in the postoperative period.
Follow up Computed Tomography
Follow up CT scans revealed rectum placed in the center of the muscle complex in all patients (Figure 16).
Figure 16. Follow up CT scan showing rectum (straight arrow) placed in midline to the muscle complex (block arrows).
Electromyographic studies of EAS
Preoperative electrical activity of the EAS was seen in 13 patients, which was preserved after SSARP (Figure 17). Three patients with absent EAS activity had sacral agenesis.
Figure 17. Postoperative EMG of EAS during rest and voluntary contraction showing preservation of integrity and function of EAS showing polyphasic motor unit potentials (scale).
Discussion
Despite large research and improved understanding of embryology and pathophysiology of ARM, the problem of obtaining better functional results still remains unsolved [3,4]. Stephen's anatomical observations with regard to the course of the nervi erigentes were decisive for the development of his sacrococcygeal technique [10]. However, his technique was considered blind, as it did not ensure accurate placement of the pull through bowel in the center of the muscle complex, and fell into oblivion. It is to the credit of Pena and De Vries who introduced the posterior sagittal anorectoplasty (PSARP) that most pediatric surgeons have found it now easy to repair IA [1,11]. Despite performing a technically "perfect" operation, there are a subset of children that require significant lifelong bowel management for constipation or incontinence [12]. These children are often characterized by a very abnormal sacrum, poor perineal musculature, colonic dysmotility, and deficient pelvic innervation. It is not known whether anything can be done to improve the outcome for children with these poor prognostic factors. However, there is substantial evidence that to emphasize the importance of preservation of the mucosal receptors at the level of the internal sphincter, lowermost part of the rectum and the proprioceptors at perineal skin in maintaining continence [13,14]. The sphincter saving anorectoplasty (SSARP) described in this report provides an opportunity to maximize preservation of all existing continence mechanisms in these children. This small series does highlight several advantages of this approach. 1) A transverse incision, well away from the neoanus and sparing the midline skin minimizes surgical site infection.
2) The skin is not violated in posterior midline sagitally. This preserves the proprioceptive nerves, allowing better sensation which may assist in attainment of continence by providing a "sensory warning zone" [14].
3) Complete preservation of levator muscle ensures integrity of the neurovascular bundle. 4) Central placement of pull through bowel without having to divide the muscle complex in the midline. 5) Finally, the cosmetic appearance of the perineum is satisfactory, resembling the normal surface anatomy (Figure 18). One may argue that dividing the sphincter exactly in the midline, as in PSARP, is relatively safe regarding preservation of the neurovascular bundle, however, violation of this strictly midline approach is common during the "learning curve" for PSARP which may damage the sphincter. Studies have also shown that even cutting the sphincter muscle exactly in the midline was associated with decrease in mean amplitude on EMG of external anal sphincter [15]. Under a technical perspective the only advantage of PSARP is opportunity to directly visualize the muscle complex which assists correct placement of the rectal tube. This aspect is probably the most crucial step in anorectal reconstruction and every effort should be made to correctly place the pull through bowel. SSARP achieves the same goal without having to divide and open the muscle complex. In our study we used CT scan to confirm the correct placement of guide wire preoperatively and the pull through bowel in the postoperative period. Despite the crucial role of a CT scan in this study, the risk of radiation needs to be addressed. Magnetic resonance imaging and intraoperative ultrasound are attractive alternatives to CT scan where these facilities are available. Otherwise strategies to reduce or eliminate unnecessary radiation that children get from CT examinations need to be implemented. These include focused CT examinations by limiting the field of view to the region of interest, and reducing the tube current by 50%. These strategies decrease the radiation dose by 50% without loss of information. Perfect continence is probably not realistic in patients with ARM. The results of clinical evaluation in postoperative patients with anorectal malformations vary depending on the operative methods used by various investigators. In most series continence rates are reported between 8% to 75% and improve with time [3,16]. In our study, sphincter integrity was preserved after SSARP in all the 13 patients who showed EMG activity preoperatively. The remaining three children who had sacral agenesis had no EAS activity on EMG and were found to have fair continence scores. These three children however, have preserved proprioception in the perineum to cold, hot and painful stimuli. It is anticipated that the continence in them will improve with time primarily because of motivation and intact perineal sensation. Fortunately, we did not encounter any case with a high rectum necessitating a laparotomy. However, if the rectum is not found after opening the precoccygeal fascia, the patient can be turned supine and a laparotomy or laparoscopic mobilization of colon can be performed to gain sufficient length to proceed for a SSARP.
Figure 18. A follow up clinical photograph showing a healthy scar well away from the anus, and a cosmetically normal looking perineum.
Conclusion
Recently, authors have popularized exclusive laparoscopically assisted anorectal pull-through (LAARP) to reduce the amount of posterior dissection required for accurate placement of the bowel into the muscle complex [17,18]. In comparison to the above described technique, the step in the laparoscopic procedure of passage of the trocar through the perineum has the potential of injuring the urinary system. In addition, the incidence of postoperative prolapse is not yet known but may be a concern because of the avoidance of several key PSARP steps, most notably tacking of the rectum to the pelvic muscles [19]. Although the early results of SSARP are encouraging, long-term functional outcome of these patients are awaited. In conclusion, sphincter saving anorectoplasty (SSARP) allows safe, minimally invasive and anatomical reconstruction of the anorectum with a satisfactory function and cosmetic outcome.
References
1.deVries PA, Pena A: Posterior sagittal anorectoplasty.
J Pediatr Surg 1982, 17:638-43. PubMed Abstract | Publisher Full Text
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2.Yuan Z, Bai Y, Zhang Z, Ji S, Li Z, Wang W: Neural Electrophysiological Studies on the External Anal Sphincter in Children With Anorectal Malformation.
J Pediatr Surg 35:1052-57. PubMed Abstract | Publisher Full Text
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3.Pena A: Posterior sagittal anorectoplasty: results in the management of 332 cases of anorectal malformations.
Pediatr Surg Int 1988, 3:94-104.
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4.Peña A, Guardino K, Tovilla JM, Levitt MA, Rodriguez G, Torres R: Bowel management for fecal incontinence in patients with anorectal malformations.
J Pediatr Surg 1998, 33:133-137. PubMed Abstract | Publisher Full Text
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5.Wangensteen OH, Rice CO: Imperforate anus: A method of determining the surgical approach.
Ann Surg 1930, 92:77-80. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
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6.Podnar S, Rodi Z, Lukanovic A, Trsinar B, Vodusek DB: Standardization of anal sphincter EMG: Technique of needle examination.
Muscle Nerve 1999, 22:400-403. PubMed Abstract | Publisher Full Text
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7.Donnelly LF, Emery KH, Brody AS, Laor T, Gylys-Morin VM, Anton CG, Thomas SR, Frush DP: Minimizing radiation dose for pediatric body applications of single-detector helical CT.
AJR Am J Roentgenol 2001, 176:303-306. PubMed Abstract | Publisher Full Text
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8.Cremin BJ: Radiological assessment of anorectal anomalies.
Clin Radiol 1971, 22:239-250. PubMed Abstract | Publisher Full Text
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9.Moore SW: Clinical outcome and long-term quality of life after surgical correction of Hirschsprung's disease.
J Pediatr Surg 1996, 31:1496-1502. PubMed Abstract | Publisher Full Text
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10.Stephens FD: Imperforate rectum. A new surgical technique.
Med J Australia 1953, 1:202. PubMed Abstract
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11.Peña A, deVries PA: Posterior sagittal anorectoplasty: important technical considerations and new applications.
J Pediatr Surg 1982, 17:796-811. PubMed Abstract | Publisher Full Text
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12.Hedlund H, Pefia A, Rodriguez G, Maza J: Long-term anorectal function in imperforate anus treated by a posterior sagittal anorectoplasty: Manometric investigation.
J Pediatr Surg 1992, 27:906-909. PubMed Abstract | Publisher Full Text
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13.Arhan P, Faverdin C, Devroede G, Dubois F, Coupris L, Pellerin D: Manometric assessment of continence after surgery for imperforate anus.
J Pediatr Surg 1976, 11:157-166. PubMed Abstract | Publisher Full Text
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14.Nagashima M, Iwai N, Yanagihara J, Iwata G: Sensation in the anal region and rectum after surgery for anorectal malformations.
Eur J Pediatr Surg 1995, 3:167-169.
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15.Kubota M, Suita S: Assessment of Sphincter Muscle Function Before and After Posterior Sagittal Anorectoplasty Using a Magnetic Spinal Stimulation Technique.
J Pediatr Surg 2002, 37:617-622. PubMed Abstract | Publisher Full Text
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16.Langemeijer RATM, Molenaar JC: Continence after posterior sagittal anorectoplasty.
J Pediatr Surg 1991, 26:587-590. PubMed Abstract | Publisher Full Text
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17.Georgeson KE, Inge TH, Albanese CT: Laparoscopically assisted anorectal pull-through for high imperforate anus-A new technique.
J Pediatr Surg 2000, 35:927-931. PubMed Abstract | Publisher Full Text
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18.Sydorak RM, Albanese CT: Laparoscopic repair of high imperforate anus.
Semin Pediatr Surg 2002, 11:217-225. PubMed Abstract | Publisher Full Text
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19.Belizon A, Levitt MA, Shoshany G, Pena A: Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations.
J Pediatr Surg 2005, 40:192-196. PubMed Abstract | Publisher Full Text
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20.Bajpai [http://paediatric-urologyonline.com] webcite

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Stapled Hemorrhoidopexy (PPH Procedure)

Also known as Procedure for Prolapse & Hemorrhoids (PPH), Stapled Hemorrhoidectomy, and Circumferential Mucosectomy



PPH is a technique developed in the early 90's that reduces the prolapse of hemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane with the use of a circular stapling device. In PPH, the prolapsed tissue is pulled into a device that allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled. This restores the hemorrhoidal tissue back to its original anatomical position.
The introduction of the Circular Anal Dilator causes the reduction of the prolapse of the anal skin and parts of the anal mucous membrane. After removing the obturator, the prolapsed mucous membrane falls into the lumen of the dilator.
The Purse-String Suture Anoscope is then introduced through the dilator.
This anoscope will push the mucous prolapse back against the rectal wall along a 270° circumference, while the mucous membrane that protrudes through the anoscope window can be easily contained in a suture that includes only the mucous membrane. By rotating the anoscope, it will be possible to complete a purse-string suture around the entire anal circumference.
The Hemorrhoidal Circular Stapler is opened to its maximum position. Its head is introduced and positioned proximal to the purse-string, which is
then tied with a closing knot.
The ends of the suture are knotted externally. Then the entire casing of the stapling device is introduced into the anal canal. During the introduction, it is advisable to partially tighten the stapler.
With moderate traction on the purse-string, a simple maneuver draws the prolapsed mucous membrane into the casing of the circular stapling device. The instrument is then tightened and fired to staple the prolapse. Keeping the stapling device in the closed position for approximately 30 seconds before firing and approximately 20 seconds after firing acts as a tamponade, which may help promote hemostasis.
Firing the stapler releases a double staggered row of titanium staples through the tissue. A circular knife excises the redundant tissue. A circumferential column of mucosa is removed from the upper anal canal. Finally, the staple line is examined using the anoscope. If bleeding from the staple line occurs, additional absorbable sutures may be placed.
What are the Benefits of PPH over other Surgical Procedures?
1) Patients experience less pain as compared to conventional techniques.
2) Patients experience a quicker return to normal activities compared to those treated with conventional techniques.
3) Mean inpatient stay was lower compared to patients treated with conventional techniques.
What are the Risks of PPH?
Although rare, there are risks that accompany PPH:
4) If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall.
5) The internal muscles of the sphincter may stretch, resulting in short-term or long-term dysfunction.
6) As with other surgical treatments for haemorrhoids, cases of pelvic sepsis have been reported following stapled haemorrhoidectomy.
7) PPH may be unsuccessful in patients with large confluent hemorrhoids. Gaining access to the anal canal can be difficult and the tissue may by too bulky to be incorporated into the housing of the stapling device.
8) Persistent pain and fecal urgency after stapled hemorrhoidectomy, although rare, has been reported.
9) Stapling of hemorrhoids is associated with a higher risk of recurrence and prolapse than conventional hemorrhoid removal surgery; according to a Canadian study of 537 participants.

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Microtia

Microtia: A Common Birth Defect
Every year one of every seven to eight thousand children is born with a common birth defect referred to as "Microtia." Not a life-threatening condition, microtia typically occurs in one ear, but can affect both ears.

While many children born with microtia are normal in all other respects, some have other health conditions including defects of the face and head. Microtia can be, but is not always, a hereditary condition.

Often a mother exposes the fetus to foreign substances without knowing they may harm the developing fetus. Accutane, a drug prescribed to relieve acne for example, if taken in the early weeks of pregnancy may result in microtia or other birth defects. There are likely other toxins doctors do not know of that may result in microtia.
http://www.microtia.com/_fileCabinet/GRBT108-2245G-30-297-312.pdf

Usually the ear forms during the early weeks of the first trimester, when the fetus is most at risk for birth defects. Sometimes doctors do not know the cause or causes for microtia. For some, the causes for microtia remain a mystery.

What is Microtia?
When a normal ear develops, it includes an external ear fully formed, and a middle ear that carries sound waves to the brain. Patients with microtia do not have a normal external ear. Instead, many come into this world with a small nub or nodule where the ear should exist.

Usually this occurs when the outer ear partially forms during fetal development. Because the internal ear canal becomes blocked, most patients experience difficulty hearing. Some may hear distorted sounds, while others may not hear at all. This is more common among children born with microtia affecting both ears.
There are four distinct grades of microtia, ranging from mild to moderate.

* Grade I microtia results when a child develops an almost normal looking ear that is smaller than normal, but functioning.


* Grade II microtia involves developing a partial external ear, resulting in partial loss of hearing. Patients with grade II microtia may have a closed external ear canal, allowing them to hear only muffled sounds.


* Grade III microtia, the most common form of microtia, involves the lack of an external ear and ear canal, as well as eardrum. Patients with Grade III microtia often have a tiny nub or piece of skin where the external ear should reside.


* Grade IV microtia is the most severe form of the defect, where patients have no ear and accompanying anatomical structures of the ear.

Thanks to modern technology, for patients with partial hearing, and part of the ear or a nub may undergo surgery to produce a normal-looking ear. Typically, children make better candidates for surgery than adults.

How Microtia Affects Children
For most children, having a birth defect as small as results in few problems, until the child reaches the school years. When children are five and older, they start realizing their ear is different from that of their peers.

Many children become the target of cruel taunting or unwelcome stares from other children and even adults that are not familiar with the defect. With time, children with microtia often become self-conscious and may suffer from low self-esteem or other emotional problems.

Despite a parent's best efforts at helping their child feel normal, for most children, it is difficult to live in a world where you "look" different and subsequently "feel" different from your peers.

New Treatments For Microtia
In the past, doctors had few tools available to help children born with microtia. Many doctors recommended patients do nothing, and suggested parents work closely with their child and a psychologist to overcome the stigma associated with a birth defect.

Some patients preferred to cover their deformity in times of old. For many, wearing an artificial ear or prosthesis felt better than showing the world their deformed ear. Unfortunately, prosthetic devices created for the ear can be cumbersome. Most patients must replace them a minimum of twice each year as the child grows. For adults, wearing the prosthesis is less of a problem.

Thanks to modern technology and the work of an innovative plastic surgeon, Dr. Robert Ruder, children can now undergo surgery that essentially creates a new ear.

How To Create The Human Ear
Patients interested in surgery must undergo a several tedious surgeries. Surgery to correct microtia occurs in distinct stages over two years. However, once completed, most patients report they are happy with the results.

Many patients not only look normal, they also hear better because microtia may not affect the inner ear canal. Dr. Ruder created a procedure that allows a new ear to be crafted from grafts of human skin and a tiny piece of the patient's rib.

Sound like a miracle? For many this new surgery is, changing the lives of hundreds of patients suffering from microtia. While expensive, some insurance companies cover part or all the cost of surgery.

Microtia surgery is ideal for young children, but does present complications for adult patients interested in the surgery. While a doctor may rebuild an ear in an older patient, often the result is less aesthetically pleasing as it might be in a child. Regardless, children and adults alike are eager to take advantage of the latest technologies.
Microtia surgery can help children grow up to lead normal, happy and confident lives.
Microtia refers to a condition in which the ear is underdeveloped. Microtia occurs in about one out of every 7,000 to 8,000 births. No one can say for sure why microtia occurs. It usually affects one ear, but may affect both ears. Often microtia is associated with other conditions or syndromes that disfigure the face or head. Even if one or both parents have microtia, the condition is not necessarily passed on to their children.

Like the external ear, the middle ear, which transmits the sounds that are heard, may also be incompletely formed. As a result, hearing in the microtic ear may be markedly distorted or completely absent. As a rule, the degree of hearing impairment is usually associated with the severity of the microtia. It is a good idea to have your child's hearing evaluated and monitored regularly by an otolaryngologist.

Even though your child may not seem to be bothered by the malformed ear, feelings of self-consciousness may potentially develop. The deformity of the outer ear often draws attention from others, especially children. Children generally become very aware and curious of differences in their bodies around the age of 4 or 5. By age 6 or 7, children begin to tease other children who do not look 'normal'. As a result, the child with a microtic ear may not be accepted by other children of the same age. This can produce feelings of self-consciousness and inadequacy.

There are three possible treatment options for the child with microtia. The first option is to do nothing, however, the potential to develop psychological scars remains. The second option is to cover up the deformity. An artificial ear, called prosthesis, can be worn to hide the microtic ear. The ear prosthesis requires replacement about twice a year to keep the size and color matched to the child's growth. The third option is to surgically correct the deficit. Surgical correction is done in a series of stages and can be completed within two years. These options can be discussed with the doctor to help you choose which option is best for your child.

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Surgeries for Lips and Chin

Thick Lips
Thick or fat lips are reduced in size by removing a strip of the red mucosa of the lip along with the underlying tissue from one end to the other end.
This surgery is done under local anesthesia without any hospital stay.Both the lips can be reduced at the same time.This procedure also can be combined with other facial surgeries.



Double Chin
Double chins are corrected by removing the excess of fat under the jaw bone by suctioning method or by open method through a small cut under the jaw bone.
The latter method is preferred if the muscles also have to be tightened. Double chins can be corrected under local anesthesia without any hospital stay.This can also be done along with face lift.
Receded Chin
Patients with a receding chin but with normal dental bite (Dental Occlusion) are good candidates for augmentation of the chin. If there will be an abnormal dental bite, that should be corrected first and then the chin should be revaluated for augmentation.
A cut is usually made inside the mouth just below the gum or under the chin on the outside skin and a silicone implant is placed in front of the chin bone. This surgery is done under local anesthesia and requires no hospital stay.
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The Cosmetic Surgery Center of Ohio - Breast Augmentation

Breast augmentation:
Enlargement of the breasts. Augmentation of the breast typically consists of insertion of a silicone bag (prosthesis) under the breast (submammary) or under the breast and chest muscle (subpectoral) and then filling the bag with saline (salt water). This prosthesis expands the breast area to give a fuller breast (increased cup size), give a better contour, and give more cleavage.


The ultimate size of the breast is mainly a personal decision by the patient. Cup size is an inexact estimate of the final size since cup sizes vary with the bra manufacturer and how tight or loose the patient wears her bra as well as how much breast tissue is already present. Describing the preferred cup size does aid the surgeon, but it also helps to look at pictures or photos to show the physician the desired final look.
The most accurate method of estimating the implant size (in ounces) is to fill a plastic bag with measured amounts of water and place in a bra with the patient's estimated cup size. One can see with the bra on and covered by a sweater what the final result will approximate.
Patients most often comment that, "I wish I had gone larger," although there is a rare patient who feels she is too large.

The incision (cut) may be placed at various locations such as: under the breast at the breast fold; periareolar which is at the edge of the areola (brown area consisting of nipple and areola); within the areola; in the armpit (axillary); or in the umbilical area.
The thinnest scar is usually in the areola. The umbilical incision approach is used with an endoscope (tube with a light for visualization and placement of the breast implant).
The smooth surface implant requires a large pocket and is associated with a 10% incidence of capsule contracture (tightening of the scar around the implant causing firmness or hardness). The smooth implant has only an occasional occurrence of rippling or wrinkling which gives the overlying skin a wavy appearance.

A textured (roughened surface) implant is associated with a 3% incidence of capsule contracture but has a 7-9% occurrence of rippling.
What are the choices of implant positions? The easiest surgical placement of the implant is under the breast tissue (submammary).
A slightly more difficult surgical placement is under the chest muscle (submuscular or subpectoral) but this position is associated with a lower incidence of capsule contracture and slightly less occurrence of rippling. There is more pain postoperatively than with a submammary placement.

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Eyelid Surgery (Blepharoplasty)

Eyelid surgery (blepharoplasty) is a popular cosmetic plastic surgery to remove excess skin, fat, or muscle from the upper and lower eyelids. Blepharoplasty cosmetic surgery improves baggy skin under the eyes, sinking upper eyelids, or drooping eye lashes that impair vision. The surgery may also be performed to treat a medical condition called ptosis (drooping eyelid), which is caused by poor muscle tone or nerve damage. Ptosis causes the eyelids to hang very low and block vision.

Blepharoplasty treats drooping eyelids, but not drooping eyebrows or wrinkles. Blepharoplasty is often performed with another cosmetic surgery such as abrow-lift or facelift to improve droopy eyebrows, crow's feet, and facial sagging.



Why Blepharoplasty?

As we age, excess skin forms in the eye area and the skin loses elasticity. Fatty tissue can accumulate under the skin. Your eyes will "look older" because these aging processes leave the eyes appearing tired, wrinkled, or puffy. Even with a good skincare and eyecare regimen, wrinkles, puffiness, and drooping eyelids will catch up to you. Genetic factors and body chemistry can cause these aging effects in younger people. Plastic surgery may restore a youthful and refreshed appearance to your eyes.
Is Blepharoplasty Right for Me?

The best candidates for blepharoplasty are physically healthy, emotionally stable, and well-informed about the procedure. Ideal candidates are typically at least 35 (although genetic factors may indicate treatment for younger patients). Candidates may be excluded if they suffer from any of the following conditions: dry eyes, high blood pressure, hypothyroidism, cardiovascular disease, diabetes, glaucoma, or Graves' disease. Personal anatomy issues, including bone and supporting structure, may also affect your candidacy.
The Blepharoplasty Procedure

Incisions are made along the line creases of the upper eyelid and possibly along the outer lower rim of the eye's skin. When removing fatty tissue, but not skin, the surgeon may perform a transconjunctival blepharoplasty with an incision inside the lower rim of the eye's skin. These incisions often reach the outer corners of the eyes. The surgeon then divides the fatty tissue and muscle from the skin so that excess skin, fat, or muscle can be removed.

The blepharoplasty procedure is often performed under local anesthesia — while you are sedated, numbed, and awake — in an outpatient surgery center, surgeon's office, or hospital. General anesthesia (while you are asleep) may be used. Be sure to discuss the appropriate type of anesthesia with your doctor and the anesthesia provider. Depending upon the number of eyelids and extent of the procedure, time in surgery may be up to three hours. Patients return home typically within hours of the surgery.
After Blepharoplasty Surgery

The eyes will often be lubricated and covered with bandages after surgery. Pain and discomfort can be managed with oral medications. Unmanageable pain should be reported to your doctor immediately. The doctor will also prescribe an antibiotic to prevent infection. You will receive a list of instructions to follow for a number of days, including

* the proper way to clean your eyes
* use of cold compresses
* use of lubricating eye drops
* head elevation
* no makeup
* no alcohol
* no television
* no contact lenses

Stitches are removed about a week after surgery. Bruising and swelling will continue to decrease after stitches are removed. Sunglasses and a protective sun block are required for several weeks. Normal activities can be resumed after about ten days. Strenuous activities such as lifting, bending, or exercise can be resumed after about three weeks.
Complications and Risks of Blepharoplasty

Following surgery, patients may experience tearing, itchy, burning eyes, dry eyes, light sensitivity, and blurred or double vision, which can persist for several days. These complications can be relieved with lubricating eye drops. There will also be some swelling around the eyes. Scarring is another possible complication. Sometimes patients will have difficulty closing their eyes when asleep: although very uncommon, this complication can be permanent. The lower lids may appear to be pulled down: this rare condition, called ectropion, may require additional surgery. There also may be some asymmetry to the eyes.

As with any surgery, there is risk of complications related to infection or reaction to anesthesia. You can avoid most complications by selecting the right plastic surgeon and following pre- and postoperative instructions. With proper precautions by the surgical team, complications are typically minimized or prevented. During consultation with a qualified plastic surgeon and ophthalmologist, your medical history and vision will be evaluated to assess candidacy and risks.
Consult a Qualified Surgeon

Before deciding on blepharoplasty, be sure to discuss the options with aboard-certified plastic surgeon and an ophtalmologist. The plastic surgeon and eye surgeon should have extensive experience performing blepharoplasty. Surgeons can show you the photos of other blepharoplasty patients with similar eyelids. You can look at these pictures to help create your individual surgical plan, as well as get a better idea of what to expect from plastic surgery.

Here are some guidelines to consider when consulting a plastic surgeon:

* Ask about credentials, training, and the number of times the treatment has been performed in the practice.
* Discuss the type of anesthesia to be used.
* Find out where surgery will be performed (surgical suite, hospital, other facility).
* Ask about the extent of the eyelid reshaping, and any associated procedures you may be having.
* Ask about the recovery period and limitations on your activities.
* Ask for an explanation of risks, possible complications, and likely results.

Blepharoplasty Costs

Since blepharoplasty may be performed to reduce fatty tissue, skin, and muscle, the extent of the procedure can vary, which makes it difficult to give a range or an average cost. Each eye may have a different cost. The average cost for blepharoplasty is hard to estimate accurately until you are examined by a surgeon and have discussed a surgical plan.

Blepharoplasty plastic surgery comprises three costs: anesthesia fees, facility fees, and surgeon's fees. Since blepharoplasty is often performed during a brow-lift, facelift, or chemical peel, anesthesia and facility fees can be combined with the other procedures. The total fees can range from $2,000 to $5,000 or more, depending on the extent of the procedure.

Some of the cost can be covered by insurance if the blepharoplasty is related to ptosis or other medical necessity. Be sure to ask your surgeon about filing for insurance. Blepharoplasty for purely cosmetic reasons is not covered. If you are having a medically necessary procedure, and want to add on a cosmetic procedure performed at the same time, you can save out-of-pocket cost by combining the necessary and cosmetic procedures into the same facility and anesthesia fees.
Payment

If the cost is more than you can pay at once, ask your surgeon about monthly payments. For financing options and tips, continue reading about Patient Financing.

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