Columellar flap for secondary cleft rhinoplasty with esthetic improvement of Millard's unilateral cheiloplasty scar.

INTRODUCTION: Columellar cartilage graft helps improve esthetic results in secondary cleft rhinoplasty for patients presenting with cleft lips. However, inadequate skin coverage of the cartilaginous graft can result in columellar necrosis and graft loss. Moreover, the scar after Millard's primary cheiloplasty may not be esthetic. The aim of this article was to present the columellar flap technique to cover the columellar graft and to improve the scar after unilateral Millard's cheiloplasty. TECHNICAL NOTE: The triangular flap is drawn on the edge of Millard's cheiloplasty scar. It is then moved in a V-Y fashion so as to cover the cartilaginous graft and improve the esthetic aspect of the new columella. DISCUSSION: Four hundred and twelve teenage/adult rhinoplasties were performed in our department over 10 years (October 2001 to October 2011). This flap was used in 10 patients who were followed-up for at least 1 year. There were no severe postoperative complications. Millard's unilateral cheiloplasty scar was less visible. A prospective study is ongoing.

Fibular flap for mandibular reconstruction: are there old tricks for an old dog?

Fibular free flap is considered as an "old dog" in reconstructive surgery because it was first described by Taylor and his colleagues in 1975, and was then introduced for mandibular reconstruction by Hidalgo in 1989. There are some "tricks" for fibular free flap that have been used and recognized in many European maxillofacial surgical units over the past decade. These include: 1) harvesting the distal fibula when recipient vessels are distant; 2) flap selection based on the anatomy of perforators; 3) use of the skin paddle for postoperative flap monitoring; 4) protection of the flap's soft-tissue cuff; 5) preventing venous thrombosis which is essential to reduce flap complications; 6) aligning fibular struts and protecting the vascular pedicle when the double-barrel technique is used; 7) minimizing the gap between the double-barrel struts and implementing a long-term follow-up of dental implants; 8) selecting osteosynthesis materials; and 9) learning curve and clinical competence in microvascular reconstruction. We also reviewed current data from the literature, which would be useful for maxillofacial reconstructive surgeons. With these tricks, one can teach an "old dog" "old tricks".

[Iliac crest bone graft with vascular pedicle after Caldwell-Luc procedure]. / Mikrochirurgischer Beckenkammtransfer nach erfolgter Caldwell-Luc-Operation.

The standard Caldwell-Luc procedure includes the removal of most of the maxillary sinus mucosa and the introduction of an inferior meatal antrostomy to promote sinus drainage. Pain, chronic relapsing inflammation and loss of volume are typical sequels of this procedure. Partial maxillary resection and iliac crest bone graft harvesting is a new concept and treatment option in such cases. The case of a 64-year-old woman who had previously undergone several unilateral sinus operations is presented. Fluorescein imaging was used to detect bone areas of low blood perfusion in the sinus walls. All affected bone and granulation tissue were removed. After resection, an iliac crest bone graft with vascular pedicle was performed to reconstruct the maxillary defect. Postoperative CT and scintigraphic imaging revealed a vital transplant. At the 10-month follow-up, no inflammation was observed and chronic pain was significantly reduced. The results clearly demonstrate that maxillary resection and iliac crest bone graft harvesting might be an option to treat severe cases of chronic sinusitis. Further prospective studies are necessary to confirm the advantages of this technique.

[Nasal dermoid sinus cyst: accidental coincidence or syndrome association?]. / Nasendermoide bei Peters-Plus-Syndrom: Zufall oder Syndromexpression?

BACKGROUND: Peters anomaly is a rare congenital glaucoma disease. The Peters' plus syndrome is characterized by distinct malformations. As some of the common craniofacial malformations like cleft lip and palate are frequent in Peters' plus syndrome, no nasal dermoid sinus cysts has been reported so far. Nasal dermoid sinus cysts usually present in isolation, although associations to other anomalies or syndromes are possible. The occurrence of such an anomaly may be either accidental, or present a syndrome association. PATIENTS AND METHOD: One patient with an unilateral cleft lip and Peters' plus syndrome had undergone removal of nasal dermoid sinus cyst previously and was referred for management of recurrent disease. Complete surgical removal and plastic reconstruction was performed. RESULTS: Concerning the common (lateral) cleft lip nasal deformity with no midline nasal masses, there are reasons for the assumption that a coincidence of both anomalies might be accidental. Especially in Peters' plus syndrome no occurrence of nasal dermoids has thus far been documented. However, the embryological pathway of the frontonasal region differs from lip and palate development in time and location: So unique formation of both lesions seems inconsistent. Complete surgical removal and plastic reconstruction simultaneously or in a second step are recommended. CONCLUSION: As two cases of arhinia and Peters anomaly have been described in 1978, midline nasal masses might be a possible appearance of Peters' plus syndrome.

[Nasal dermoid and sinus cysts in patients with cleft malformations]. / Nasenfisteln und -zysten bei Patienten mit Lippen-Kiefer-Gaumen-Spalten.

BACKGROUND: Nasal dermoid sinus cysts are uncommon congenital lesions. They are usually isolated occurrences and are not associated with syndromes or additional malformations. The coincidence of both, cleft malformations and nasal dermoid sinus cysts, has seldom been reported. CASE REPORTS: Within the last 2 years two patients with reconstructed cleft lip and palate and additional nasal dermoid sinus cysts underwent surgical removal. One patient with bilateral complete cleft lip exhibited a fistula from the medial third of the nasal dorsum up to the glabella. Another patient with unilateral cleft lip and Peters' plus syndrome had undergone removal of a nasal dermoid sinus cyst 12 years ago and was referred for management of recurrent disease. DISCUSSION: Concerning the common cleft-dependent nose malformations with no midline nasal masses, there are reasons for the assumption that a coincidence of both anomalies might be accidental. Especially in Peters' plus syndrome no frequent occurrence of nasal dermoids has thus far been documented. However, the proximity and temporal closeness of an embryological pathway of the frontonasal region and lip development could also argue for a unique formation of both lesions. Complete surgical removal and plastic reconstruction simultaneously or in a second step are recommended.

[Restoration of lid function in peripheral facial palsy by implanting gold weights]. / Rehabilitation der Lidfunktion bei peripherer Fazialisparese mit Goldgewichtimplantaten.

BACKGROUND: Lagophthalmos is a common functional and aesthetic problem in patients with facial palsy. The implantation of a rigid gold weight is one technique to improve eyelid closure. The effectiveness of lid loading was investigated, taking into consideration complications ascribed to rigid implants. PATIENTS AND METHODS: We present 11 patients with facial palsy treated with that technique between April 2001 and October 2005. Before and after operation ophthalmological investigations were performed. The patients were questioned about their subjective satisfaction, and the remaining eye lid gap in the closed state was assessed. RESULTS: A good up to perfect lid closure could be achieved. Of the 11 patients, 9 reported being very contented with the result. Except for one case of extrusion, disturbed healing processes did not occur. We did not observe any occurrence of astigmatism as a result of the rigid lid load. All patients reduced their use of eye ointment and eye covers. We observed a visible bulging of the implant contour in 4 of 11 patients. However, not one of them felt discontented. All patients stated that they would undergo the lid loading procedure again. CONCLUSIONS: The implantation of rigid gold weights for lid loading in patients suffering from lagophthalmos due to peripheral facial palsy is considered a simple and effective treatment for improving eyelid closure. Whether or not flexible implants will lead to better results needs to be further investigated.