Changing Mandible Contour Using Computer Designed/Computer Manufactured Alloplastic Implants.

BACKGROUND: The shape of the mandible is the fundamental determinant of the appearance and sexual dimorphism of the lower one-third of the face. Utilization of computer-aided design/computer-aided manufactured (CAD/CAM) alloplastic implants provides unparalleled planning and sophistication in the correction of skeletal deficiencies, irregularities, and asymmetry. OBJECTIVES: This study presented the rationale, indications, techniques, and results of the senior author's (M.J.Y.) 15-year experience employing CAD/CAM alloplastic implants to correct deficiencies and asymmetries of the mandible. METHODS: A retrospective review of a prospectively maintained database was reviewed of all patients who underwent aesthetic augmentation of the mandible employing CAD/CAM alloplastic implants by the senior author. RESULTS: Over a 15-year period, 123 patients underwent mandibular augmentation utilizing CAD/CAM alloplastic implants. The majority of patients were men (76.4%) with an average age of 31 years (range, 24-63 years). All implants were bilateral. Complications included infection requiring implant removal (2.4%) and patient dissatisfaction resulting in either implant revision (4.1%) or implant removal (2.4%). CONCLUSIONS: As described here, CAD/CAM alloplastic implants are an effective modality to augment aesthetic mandible contour deficiencies.

Occult Histopathology and Its Predictors in Contralateral and Bilateral Prophylactic Mastectomies.

BACKGROUND: The last decade has seen an increasing prevalence of prophylactic mastectomies with decreasing age of patients treated for breast cancer. Data are limited on the prevalence of histopathologic abnormalities in this population. This study aimed to measure the prevalence of histopathologic findings in contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM) patients and identify predictors of findings. METHODS: Our institution's prophylactic mastectomies from 2004 to 2011 were reviewed. Breast specimens with prior malignancies were excluded. Patient factors and pathology reports were collected. Independent predictive factors were identified with univariate and multivariate logistic analysis. RESULTS: A total of 524 specimens in 454 patients were identified. Malignancy was found in 7.0% of CPM and 5.7% of BPM specimens. In CPM patients, ipsilateral lobular carcinoma-in situ [odds ratio (OR) 4.0] and mammogram risk group (OR 2.0) were predictive of malignancy. Age group (OR 1.5), ipsilateral lobular carcinoma-in situ (OR 2.3), and prior bilateral salpingo-oophorectomy (OR 0.3) were predictive of moderate- to high-risk histopathology. Only increasing age group was predictive of increased moderate- to high-risk histopathology in BPM patients (OR 2.3). There were no independent predictors of malignancy in BPM. BRCA status was not predictive in either CPM or BPM. CONCLUSIONS: Patients with lobular carcinoma-in situ in the index breast or high-risk mammograms have a higher prevalence of malignancies. Although BRCA patients may benefit from prophylactic mastectomy, the genetic diagnosis does not increase the prevalence of detecting occult pathology. BPM patients can be counseled about relative risk, where occult pathology increases with age.

Cost and outcome analysis of breast reconstruction paradigm shift.

Increased bilateral mastectomy for breast cancer treatment has generated an increased demand for bilateral breast reconstruction. This study examines changing patterns of reconstruction over the last decade to accommodate increased case volume and decreased morbidity associated with reconstruction. A single institution series of 3171 consecutive breast reconstruction cases of more than 10 years was divided into 2 periods, that is, 1999 to 2004 and 2005 to 2010. Bilateral breast reconstruction case volume increased 260% from 1999 to 2004 (n = 237) to 2005 to 2010 (n = 634). Mean patient age at diagnosis decreased by 7 years (P < 0.001). In 2005 to 2010, autologous reconstruction decreased from 60% to 26%, implant-based reconstruction increased from 40% to 74%. There was a noted increase in single-stage implant reconstruction and selective application of perforator flaps for bilateral autologous reconstruction (P < 0.001). Two-staged tissue expander reconstruction accounted for the greatest share of total cost (45%) in the later period. A younger patient demographic and increased case volume were accommodated through increased single-staged and prosthesis-based procedures.

Identifying a safe zone for midface augmentation using anatomic landmarks for the infraorbital foramen.

BACKGROUND: Midface augmentation is commonly used to improve the appearance of concave faces and to achieve balance in the facial contour. It can also be an adjunct to orthognathic or reconstructive surgery. However, an inherent risk of midface augmentation is injury to the infraorbital nerve where it exits the infraorbital foramen (IOF). This can result in significant morbidity, including loss of sensation to the midface, nasal sidewall, upper lip, and lower eyelid. OBJECTIVES: The authors identify a safe zone of dissection in the midface for subperiosteal placement of infraorbital, paranasal, malar, and submalar implants, which avoids injury to the infraorbital nerve. METHODS: Given the popularity of transconjuctival and intraoral access to the midface skeleton, the authors identified relevant bony and dental landmarks from radiographic images and measured distances between the IOF and these landmarks. Forty-four computed tomography scans of adult hemifaces were used to accurately locate the IOF in relation to the anatomic landmarks. RESULTS: Most often, the IOF's location correlated with the second premolar on a vertical axis. The average distance between the IOF and the infraorbital rim, piriform aperture, tip of the second premolar cusps, and lateral orbital rim was approximately 8.61, 17.43, 41.81, and 25.93 mm (respectively) in men and 8.25, 15.69, 37.33, and 24.21 mm (respectively) in women. CONCLUSIONS: A safe zone of dissection for midface augmentation has been identified, which differs from previous findings. Awareness of this zone may help clinicians locate the IOF and avoid injury to the nerve.

Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy.

BACKGROUND: An estimated 116 086 facelifts were performed in 2011. Regardless of the technique employed, facial flap elevation carries with it anatomical pitfalls of which any surgeon performing these procedures should be aware. Injury to the great auricular nerve (GAN) is the most common of these injuries, occurring at a rate of 6% to 7%. OBJECTIVES: We report our findings on the location of the GAN on the basis of anatomical landmarks to aid surgeons with planning their surgical approach for safe elevation of rhytidectomy skin flaps in the lateral neck region. METHODS: Sixteen fresh cadaveric heads were dissected under loupe magnification. All specimens were dissected in a 45-degree (facelift) position in which a mid-sternocleidomastoid (SCM) incision was used for exposure. Measurements from the bony mastoid process, bony external auditory canal, external jugular vein, and anterior border of the SCM to the GAN were taken in each cadaver. RESULTS: The GAN follows a consistent course over the mid-body of the SCM before bifurcating into anterior and posterior branches and terminal arborization. Regardless of the length of the SCM, the GAN at its most superficial location was found to be consistently at a ratio of one-third the distance from either the mastoid process or the external auditory canal to the clavicular origin of the SCM. CONCLUSIONS: Knowledge of the anatomy, course, and location of the GAN along the surface of SCM muscle based on anatomic landmarks and distance ratios can facilitate a safer dissection in the lateral neck during rhytidectomy procedures.

Modified Gillies approach for zygomatic arch fracture reduction in the setting of bicoronal exposure.

Zygomatic arch fractures are common injuries, occurring in isolation in 5% of all patients with facial fractures and in 10% of patients with any fracture to the zygomaticomaxillary complex. Isolated noncomminuted depressed zygomatic arch fractures are easily treated with the minimally invasive Gillies approach, which most often provides long-term stability. However, zygomatic arch fractures often occur in conjunction with zygomaticomaxillary complex, Le Fort, calvarial, and naso-orbitoethmoid fractures. In situations requiring a bicoronal incision to address concomitant injuries, zygomatic arch fractures are frequently treated with wide dissection and rigid fixation. Using principles obtained from isolated arch fractures, we present for the first time to our knowledge the use of a modified Gillies approach to noncomminuted zygomatic arch fractures in a case requiring a bicoronal incision. With the deep temporal fascia exposed from the reflected bicoronal flap, a 1-cm horizontal incision is made within the deep temporal fascia allowing a Gillies elevator to easily reduce the arch fracture in a plane between the deep layer of the deep temporal fascia and the temporalis muscle. This technique exploits the advantages of the traditional Gillies approach, preserving fascial attachments, avoiding neurovascular injury, and obviating the need for rigid fixation. Moreover, this method saves time and money and decreases morbidity. Our modified Gillies approach to zygomatic arch fractures in the setting of a bicoronal incision can be applied to a wide range of cases because of the frequency with which arch fractures occur with concomitant craniomaxillofacial injuries requiring wide exposure.

Le Fort-based maxillofacial transplantation: current state of the art and a refined technique using orthognathic applications.

Following encouraging results from the first 6 maxillofacial allotransplants, there has been a dramatic rise in interest worldwide. Numerous groups are now devoting resources to increase the frequency of these complex procedures, and with this, the craniomaxillofacial surgeon should become familiar with the emerging state of the art. This article reviews the evolution of Le Fort-based cadaveric studies pertaining to maxillofacial allotransplantation, briefly describes the clinical reports through 2010, and introduces a refined technique applying orthognathic applications. Preliminary studies over the last 5 years have highlighted the challenges associated with transplanting skeletal components, and clinical results presented thus far have been extremely promising. However, a notable area for improvement is suboptimal facial-skeletal harmony and profile in the context of sagittal skeletal projection and maxillomandibular relation. To our knowledge, orthognathic planning as applied to osteocutaneous face transplantation has not been described. Many recipients seen thus far demonstrate some degree of malocclusion and suboptimal harmony, as expected, given the donor-to-recipient skeletal/jaw discrepancies. Given that the goal is to improve function as well as form, the importance of orthognathic planning cannot be overstated with respect to optimizing harmony, profile, and occlusion. Preoperative planning, including generation of donor/recipient dental cast models, as described herein for the first time, is essential.

Improving Male Chin and Mandible Eesthetics.

The size and shape of the chin and mandible are fundamental to sexual dimorphism. Deficiencies in these structures distract from the male facial esthetic. When deficient, these areas of the facial skeleton can be augmented by alloplastic augmentation or skeletal rearrangement. This article discusses these alternatives with emphasis on the design and techniques of alloplastic skeletal augmentation.

Temporal augmentation with methyl methacrylate.

Concavity in the temporal area reflects a deficiency in the bulk of the temporalis muscle or overlying temporal fat pad. It may be a reflection of senescence, low body fat, exaggerated adjacent skeletal or soft-tissue contours, idiopathic progressive atrophy, or postsurgical deformities. The authors describe the application of methyl methacrylate (MMA) to fill depressions in the temporal area. In instances in which no previous surgery has been performed or when the temporal area has served as a dissection plane for surgery in adjacent areas (eg, a subperiosteal facelift), the implant material is placed beneath the temporal muscle through a limited incision in the hair-bearing scalp. When previous reconstructive surgery has been performed in the temporal area, the area of depression is accessed through existing surgical incision scars to place MMA over the temporal muscle. These operative techniques have been reliable, durable, and relatively free of complications.

Role of the Pedicled Mentalis Muscle Flap in Closure of Chin Implants in Genioplasty.

With the purpose of obtaining an aesthetically pleasing chin appearance, genioplasty or chin augmentation can be performed through osteotomy or chin implantation, with the latter available in different sizes and materials such as silicone and porous polyethylene. The implants are traditionally placed in a subperiosteal or supraperiosteal plane with different advantages and disadvantages to each. This procedure has evolved through time with many techniques and modifications; and this article is an addition to this ongoing refinement by advocating for closure of the mentalis muscle (a paired chin muscle originating from the incisor fossa to the chin skin) over the implant after securing its position with screws (in the case of porous polyethylene) or creating a snug pocket (in the case of silicone). In this retrospective analysis, 15 patients underwent this procedure with an excellent outcome. A single patient developed numbness in the mandibular nerve territory, while another one developed a fistulating radicular cyst that was unrelated to this technique. In addition to the simple learning curve, the potential advantages of this technique include less chances of fistula formation, implant exposure, infection, extrusion, or malpositioning. Prospective studies with more subjects are required to cement our findings.