Surgical correction of late sequelae from facial bone fractures.

This study has described the UCLA experience over a 5 year period in the treatment of secondary traumatic deformities utilizing the craniofacial techniques originally proposed by Tessier. Because of scarring, absent parts, and the malposition of segments, correction of long-standing traumatic deformities remains difficult and treatment results remain less than ideal. Primary correction utilizing the principles we have described herein still provides the best functional and aesthetic results. Facial fractures can no longer be considered as an independent and unrelated entity when dealing with the traumatized patient. If primary reconstruction continues to be compromised, correction of residual disfigurement will result in unnecessary patient morbidity and disturbances of facial form and function.

Enophthalmos revisited.

As an alternative to the conventional craniofacial approach with its coronal incision, a limited access technique has evolved. Its advantages and disadvantages are discussed. The method should not be used unless one is well versed in the correction of enophthalmos and has previous experience using the traditional craniofacial approach.

Saddle nasal deformity.

Correction of the saddle nasal deformity requires generous elevation and mobilization of the overlying soft tissue, the restoration of skeletal support, and the provision of nasal mucosa lining ("the forgotten link"). For moderate to severe saddle deformities, calvarial bone grafts serve well to reconstruct the disrupted skeletal framework.

Craniofacial biostereometrics.

We believe that biostereometrics can be useful to the craniofacial surgeon in providing a highly accurate, reproducible diagnostic and presurgical tool that is inexpensive and noninvasive. It can help visualize complex pathologic bony abnormalities, resolve ambiguous CT scans, and predict soft-tissue changes secondary to alterations in bony contours when used in conjunction with CT scans and cephalograms.

Correction of major defects of the vermilion with a cross-lip vermilion flap.

A method is described to correct major vermilion defects by using a transverse, cross-lip, vermilion flap. Sizable defects can be easily filled in to obtain an upper lip with better contour and simultaneously reduce the unpleasant fullness of the lower lip to produce better balance between the two lips.

Late posttraumatic enophthalmos: a correctable deformity?

Long-established posttraumatic enophthalmos with a seeing eye is a correctable deformity. A method utilizing principles of craniofacial surgery is described that provides the advantages of (1) wide exposure, (2) free mobilization of the displaced zygoma, (3) direct inspection of the orbital defect, and (4) restoration of the balance between the orbital contents and bony surroundings, which allows (5) the permanent correction of traumatic enophthalmos using autogenous material.

Elective osteotomies and bone grafting of irradiated midfacial bones.

Elective osteotomies of post-irradiated midfacial bones to correct the resulting facial deformities can be safely performed. When there is an associated radiation-induced enophthalmos, improvement in appearance can be achieved, but the results often falls short of an ideal restoration. Transposing a temporalis flap into the orbit is an excellent means of freeing the irradiated, contracted, enucleated orbital socket.

A self-retaining method to maintain vertical position of the maxilla during Le Fort I osteotomies.

A simple technique that relies on a fine wire to maintain vertical relationships of the maxilla during Le Fort I osteotomy is described. The advantages are (1) the hands of the assistant are free to help adapt plates, (2) it decreases the assistant's need to maintain a pose, and (3) the time of the operation decreases.

The free tongue graft for correction of secondary deformities of the vermilion in patients with cleft lip.

From January of 1985 to January of 1990, 31 patients with repaired cleft lip and secondary vermilion defects underwent 45 revisional procedures. A free tongue graft was utilized seven times in six patients (19 percent). Indications for its use were a V-shaped vermilion deficit or a "whistling" deformity associated with a sagittal vermilion deficiency and normal or insufficient lateral vermilion bulk. Of the seven free tongue grafts, none was lost. Three patients have required revisions, including repeat free tongue graft in one. Proper positioning of the graft along the free vermilion border has made color and texture match satisfactory. The free tongue graft is a simple and reliable means of transferring both vermilion bulk and surface mucosa. Introduction of the free tongue graft has eliminated the need for more cumbersome procedures, such as the Abbé flap or the tongue flap, in properly selected patients.

Late infection following aesthetic malar augmentation with proplast implants.

Two cases of late infection following aesthetic malar augmentation with Proplast implants are described. The etiology appears to be contamination because of erosion of the implants through the thin wall of the anterior maxilla. This problem might be avoided by confining placement of the implant over the thick portion of the zygoma.

Surgical correction of exophthalmos secondary to Graves' disease.

Graves' disease has been recorded in the medical literature for more than 150 years. Despite introduction of iodine into the diet, Graves' disease still remains the most important disorder of the thyroid gland. Clinically, Graves' disease is a multisystem disorder of unknown etiology characterized by the clinical triad of infiltrative pretibial dermopathy, thyroid glandular hyperplasia, and ophthalmopathy. Expansion of the bony orbital volume is an effective method of treating moderate to severe exophthalmos. Our experience with a simplified version of a three-wall orbital decompression to correct exophthalmos secondary to Graves' disease is presented.

Infection of proplast malar implants following dental injections.

Two cases of late infections of malar implants are reported following dental work. Inadvertent inoculation of the implants by mouth organisms during injections for local dental anesthesia is implicated as the causative factor. Patients should warn their dentists that a malar alloplast has been inserted. Alternative techniques of maxillary dental anesthesia should be entertained, and antibiotic prophylaxis should be considered.

Evolving thoughts on correcting posttraumatic enophthalmos.

Posttraumatic enophthalmos, though a difficult problem, is correctable by traditional craniofacial techniques. Based on considerable experience with these wide exposure operations, our surgical strategy has evolved and has been distilled into one of limited exposure via lateral upper blepharoplasty, transconjunctival without canthotomy and intraoral incisions. The advantages of this approach are reduced morbidity and hospital stay, shorter operating time, and avoidance of blood transfusions. However, this technique should be reserved until valuable insight is gained using the more conventional coronal approach.

Carotid thrombosis following surgical release of temporomandibular ankylosis.

Temporomandibular ankylosis frequently involves massive bony proliferation which can approach the carotid artery at the base of the skull. During the resection of the bony ankylosis, the artery can be injured. The first such case is reported which led to a thrombosis and hemispheric stroke.

A histologic evaluation of fracture repair in the midface.

Although much has been written regarding the treatment of facial bone fractures, at the present time there are no available investigations of human microscopic sections to verify the exact nature of the healing process. The consensus in the literature is that following fractures of the midface, the bone segments are united by fibrous union. Biopsies of the healed fracture sites were obtained in 10 consecutive patients who underwent secondary reconstructive procedures to correct residual deformities. Clinical assessment confirmed that the fractures were completely healed and stable. Histologic sections were obtained across the healed fracture sites, sent for H&E staining, and then examined by light microscopy. All specimens showed that the defects between the segments were obliterated by the formation of a mature compact bone. This bridging bone was characterized by concentric lamellae surrounded by a typical bony architecture. From this study it can be concluded that fractures of the midface heal by direct bony union.

Rare craniofacial clefts: Tessier no. 4 clefts.

A major difficulty in understanding rare craniofacial clefts arises from the fact that previous reports have focused on a single case or have grouped together different types of rare clefts. Less than 50 Tessier no. 4 clefts have been reported. This paper examines our experience with eight patients treated primarily or secondarily for Tessier no. 4 clefts. A treatment plan is recommended. The primary early concern is protection of the eye. Early correction of soft-tissue deformities should include skin, muscle, and lining of the orbit, cheek, and oral cavity. Contrary to the dictum that all soft tissue must be preserved, the medial portion of the upper lip from the cleft to the philtral ridge must be resected to prevent poorly camouflaged scars, muscle deficiency, and macrostomia. Bone grafting should be undertaken at an early age using calvarial bone. Late operations will be necessary for correction of medial and lateral canthal position, epiphora, lower eyelid skin deficiency, and further bony augmentation.

Periorbital marginotomies: anatomy and applications.

The application of craniofacial techniques has led to a greater variety of methods for operative exposure. In the orbital region, the inferior marginotomy of Tessier is a valuable adjunct in the reconstruction of severe orbital floor fractures and their sequelae. This concept has been extended to the superior, lateral, and medial orbital rims to improve the exposure of the respective orbital wall. These marginotomies have been used for a variety of problems. There have been no complications related to the inclusion of a periorbital marginotomy, and its use in appropriate patients is strongly recommended.

Care of maxillofacial injuries: survey of plastic surgeons.

The purpose of this survey was to evaluate the current trends in the care of facial trauma. Data were obtained through the responses of a survey mailed to all those members and candidates listed in the 1989 American Society of Plastic and Reconstructive Surgeons Directory. A total of 2777 questionnaires were sent, with 1113 (40 percent) returned by means of a self-addressed envelope. Demographic results show that over 70 percent of the treating plastic surgeons fall within the age range 30 to 50 years. Although significant advances have occurred, treatment goals have remained unchanged. These center around the principles of accurate reduction and precise stabilization of fracture segments. The results of this survey reveal that a number of acceptable techniques were employed in the surgical repair of mandibular and zygomatic complex fractures. In the care of Le Fort III fractures, 59 percent of the respondents preferred the use of miniplates and screws for stabilization. Only 26.8 percent believed that facial fracture repair should be performed within the initial 24 hours. With frontal sinus fractures, the vast majority of plastic surgeons (82.1 percent) obtained a neurosurgical consultation. When the posterior wall was involved, 45.6 percent favored removal of the sinus mucosa, 29.7 percent obliterated the frontal sinus with a variety of autogenous materials, while 20.5 percent preferred cranialization. In summary, this survey shows a wide variation in the practice of facial fracture management within the plastic surgical community.

Analysis and results of treatment of established posttraumatic facial deformities.

The clinical records of 125 patients undergoing treatment for posttraumatic facial deformities (PTFD) from 1979 to 1990 were retrospectively reviewed. Patients with complex fractures had a combination of at least three of the major fracture categories [Le Fort I, II, III; naso-orbital-ethmoid (NOE); zygomatic; frontobasilar; and mandibular]. Twenty-five patients (20 percent) were found to have severe posttraumatic facial deformities resulting from a complex facial fracture pattern. Sixteen were males and nine were females, and their ages at the time of our first reconstructive procedure ranged from 22 to 64 years (mean 33 years). All patients presented to our clinic with severe posttraumatic facial deformities from 1 month to 26 years (mean 5 years) after original injury. The number of prior reconstructive attempts averaged two (range 0 to 9). Arbitrary severity scores assigned by us were mild in 4, moderate in 12, and severe in 9 patients. Once treatment was initiated in our clinic, the average number of operations was 3.76 until completion (range 1 to 15). Surgical treatment was aimed first at reestablishing proper skeletal, vertical, transverse, and sagittal proportions. Once skeletal foundations were reset, the more delicate naso-orbital-ethmoid and lateral canthal relations were addressed. Of the 25 patients, 13 (52 percent) suffered a complication at some point during their surgical management. In these 13 patients, 20 complications occurred in a total of 94 operations for an overall complication rate of 21 percent. Fifteen of the 20 complications were related to infection. Skeletal abnormalities in patients with posttraumatic facial deformities can generally be corrected with current craniomaxillofacial techniques. Ultimately, an excellent result in terms of skeletal reconstruction is compromised by the status of the surrounding soft tissue. More in-depth knowledge of the nature and magnitude of the initial and subsequent soft-tissue injury will contribute to our ability to treat these disfiguring posttraumatic sequelae.

Pseudomeningocele: an unusual complication of craniofacial surgery.

A previously unreported complication of pseudomeningocele following monoblock frontofacial advancement is described. The defect was repaired by means of an extracranial approach with a satisfactory outcome.