An analysis of 101 primary cosmetic rhinoplasties.

PURPOSE: Primary cosmetic rhinoplasty is one of the most complex of cosmetic surgical procedures in the maxillofacial area that requires precise consideration to both form and function. The complex and variable anatomy, highly visible position of the nose, and distinct patient desires contribute to the complexity of this procedure. This study reports the combined results of 101 consecutive primary cosmetic rhinoplasties at 2 centers. PATIENTS AND METHODS: A retrospective chart review was completed on all patients who had primary cosmetic rhinoplasty with or without septoplasty and who were operated on by the senior authors (S.C.B. and H.M.) from June 2006 through December 2008. A standard physical examination, including photo documentation, was completed on each patient preoperatively. All patients were followed periodically after surgery for at least 12 months. Outcome was measured by both subjective and objective measures of cosmetic and functional (breathing) outcome. The following data were collected and analyzed: age of patient, gender, chief cosmetic and functional complaint, details of surgical procedure (including septoplasty, grafts, and donor sites), complications, and report of subjective outcome at final evaluation. RESULTS: One hundred one patients (n = 101, average age 24.4 ± 6.8 years old) were enrolled in the study. Most patients presented for consultation regarding cosmetic rhinoplasty (80%) versus septorhinoplasty (20%). Although most of the patients (63%) were treated with septorhinoplasty, the open rhinoplasty (transcollumellar) incision was used in 61% of patients versus the closed rhinoplasty (39%) technique. The most commonly performed combination of techniques used was the combination of nasal tip modification, with dorsal reduction and nasal osetotomies (54%), followed by tip modification with dorsal reduction (19%), and dorsal reduction with osteotomies (18%) and no tip modification. In the 50 patients who required a graft, in 80% the donor site was the nasal septum. Spreader grafts were used in 14% of patients, and a combination of shield/tip graft was used in 52%. The following complications were observed: unhappy patient 16%, dehiscence at incision 5%, asymmetry requiring revision 6%, and infection 1%. In the 63 patients that had septoplasty, 6 (9.5%) reported that their breathing was not improved. In this series 11 patients (11%) received a revision rhinoplasty. CONCLUSIONS: Primary cosmetic rhinoplasty is 1 of the more complex facial cosmetic procedures. The vast majority of complications can be avoided with careful and extensive treatment planning. In this series we found a complication and revision rate similar to that reported in the literature.

Microsurgical repair of the inferior alveolar nerve: success rate and factors that adversely affect outcome.

PURPOSE: The objectives of this study were to determine the likelihood of regaining functional sensory recovery (FSR) after microsurgical repair of the inferior alveolar nerve (IAN), and which variables significantly affected the outcome of that surgery in a large series of patients. MATERIALS AND METHODS: This was a retrospective cohort study that evaluated all patients who had undergone microsurgical repair of the IAN by 1 of the senior surgeons (R.A.M.) from March 1986 through December 2005. The requirements for inclusion of a patient in the study included the availability of a complete chart record and a final follow-up visit at least 12 months after surgery. All other patients were excluded. The predictor variables were categorized as demographic, etiologic, and operative. The final outcome variable was the level of recovery of sensory function as determined by standardized neurosensory testing at the last postoperative visit of each patient and based on guidelines established by the Medical Research Council Scale. Risk factors for surgical failure to achieve useful sensory function were determined from analysis of descriptive statistics, including patient age, patient gender, etiology of nerve injury, chief sensory complaint (numbness, pain, or both), time from injury to surgical intervention (in months), intraoperative findings, and surgical procedure. Logistic regression methods and associated odds ratios were used to quantify the association between the risk factors and improvement. Receiver operator characteristic curve analysis was used to find the threshold of those variables that significantly affected patient outcome. RESULTS: In total, 167 patients (41 male and 126 female patients; mean age, 38.7 years [range, 15-75 years]) underwent 186 IAN repairs (19 patients sustained bilateral IAN injuries). The mean time from injury until surgery was 10.7 months (range, 0-72 months). Successful recovery from neurosensory dysfunction (FSR, defined by the Medical Research Council Scale as ranging from useful sensory function to complete sensory recovery) was observed in 152 repaired IANs (81.7%). With increasing duration from date of injury to IAN repair, the likelihood of FSR decreased (odds ratio, 0.898; P < .001). The odds of achieving FSR exhibited a linear decline between the date of nerve injury and its repair, with a significant drop in rate of successful outcome (FSR) occurring beginning at 12 months after injury. There was also a significant negative relationship between increasing patient age and improvement (odds ratio, 0.97; P = .015), with a threshold drop of achieving FSR at 51 years of age. The cause of the injury, the operative findings, and the type of operation performed to repair the nerve had no significant effect on the likelihood of the patient regaining FSR. The presence of pain after nerve injury did not affect the likelihood of achieving FSR after repair in a statistically significant manner (P = .08). In those patients who did not have pain as a major complaint before nerve repair, pain did not develop after microneurosurgery. CONCLUSIONS: Microsurgical repair of an IAN injury resulted in successful restoration of an acceptable level of neurosensory function (FSR) in most patients (152 of 186 repairs [81.7%]) in this study. The likelihood of regaining FSR was inversely related to both time between the injury and its repair and increasing patient age, with significant threshold drops at 12 months after nerve injury and at 51 years of age, respectively.

New Horizons in Imaging and Diagnosis in Rhinoplasty.

Three-dimensional (3D) surface imaging has found its place in aesthetic surgery globally. The first attempt to use 3D surface imaging technique in clinic was in 1944 by Thalmaan, who used stereo photogrammetry to examine an adult with facial asymmetry and a baby with Pierre Robin syndrome. Three-dimensional photography is becoming more common allowing for a more dynamic facial evaluation, although it is associated with increased cost.

Microsurgical repair of the peripheral trigeminal nerve after mandibular sagittal split ramus osteotomy.

PURPOSE: Injuries to the inferior alveolar nerve (IAN) and lingual nerves (LNs) have long been known complications of the mandibular sagittal split ramus osteotomy (SSRO). Most postoperative paresthesias resolve without treatment. However, microsurgical exploration of the nerve may be indicated in cases of significant persistent sensory dysfunction associated with observed or suspected localized IAN or LN injury. We report the demographics and outcome of microsurgical exploration and repair of peripheral branches of the trigeminal nerve injured because of the SSRO. MATERIALS AND METHODS: A retrospective chart review was completed on all patients who had microsurgical repair of peripheral trigeminal nerve injuries caused by mandibular SSRO and were operated on by the senior author (R.A.M.) between March 1986 and December 2005. A physical examination, including standardized neurosensory testing (NST) as described by Zuniga et al, was completed on each patient preoperatively. All patients were followed periodically after surgery for at least 1 year with NST repeated at each visit. NST results obtained at the last patient visit were used to determine the final level of recovery of sensory function. Sensory recovery was evaluated using guidelines established by the Medical Research Council scale. The following data were collected and analyzed: age of patient, gender, nerve injured, chief sensory complaint (numbness, pain, or both), duration (months) from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at final evaluation. Given the retrospective nature of this study, the research was exempt from our institutional review board ethics committee. RESULTS: There were 54 (n = 54) patients (8 males and 46 females) with an average age of 36.9 years (range, 16 to 55 years) and a follow-up of at least 12 months. The most commonly injured/repaired nerve was the IAN (n = 39), followed by the LN (n = 14), and the long buccal nerve (n = 1). In 31 patients (57.4%), the chief sensory complaint was numbness, while 20 patients (37%) complained of pain and numbness, and 3 patients (5.5%) complained of pain without mention of numbness. The average time from nerve injury to repair was 9.4 months (range, 3 to 50 months). The most common intraoperative finding was a discontinuity defect (n = 18, 33.3%), followed by partial nerve severance (n = 15, 27.8%), neuroma-in-continuity (n = 11, 20.3%), and compression injury (n = 10, 18.5%). The most frequent surgical procedure was autogenous nerve graft reconstruction of the IAN using the sural or great auricular nerve (n = 22, 40.7%), followed by excision of a neuroma with or without neurorrhaphy (n = 13, 24.1%). All the LN injuries (n = 14) were partial or complete severances, of which 2 were reconstructed with autogenous nerve grafts and the other 12 underwent neurorrhaphy. The long buccal nerve injury required excision of a proximal stump neuroma without neurorrhaphy. After a minimum of 1-year follow-up, NST showed that 8 nerves (14.8%) showed no sign of recovery; 19 nerves (35.2%) had regained "useful sensory function," and 27 nerves (50%) showed full recovery as described by the Medical Research Council scale. CONCLUSIONS: Microsurgical repair of the IAN or LN injured during the SSRO can be considered in patients with persistent, unacceptable sensory dysfunction in the distribution of the involved nerve. Modifications of surgical technique may be helpful in reducing the incidence of such injuries. Based on our experience, an algorithm for evaluation and treatment is presented.

Retrospective review of microsurgical repair of 222 lingual nerve injuries.

PURPOSE: Injury to the lingual nerve (LN) is a known complication associated with several oral and maxillofacial surgical procedures. We have reviewed the demographics, timing, and outcome of microsurgical repair of the LN. MATERIALS AND METHODS: A retrospective chart review was completed of all patients who had undergone microsurgical repair of the LN by one of us (R.A.M.) from March 1986 through December 2005. A physical examination, including standardized neurosensory testing, was completed of each patient preoperatively. All patients were followed up periodically after surgery for at least 1 year, with neurosensory testing repeated at each visit. Sensory recovery was determined from the patient's final neurosensory testing results and evaluated using the guidelines established by the Medical Research Council Scale. The following data were collected and analyzed: patient age, gender, nerve injury etiology, chief sensory complaint (numbness or pain, or both), interval from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at the final evaluation. The patients were classified according to whether they achieved "useful sensory recovery" or better, according to the Medical Research Council Scale, or had unsatisfactory or no improvement in sensation. Logistic regression methods and associated odds ratios (OR) were used to quantify the association between the risk factors and improvement. Receiver operating characteristic curve analysis was used to find the age threshold and duration that maximally separated the patient outcomes. RESULTS: A total of 222 patients (51 males and 171 females; average age 31.1 years, range 15 to 61) underwent LN repair and returned for at least 1 year of follow-up. The most common cause of LN injury was mandibular third molar removal (n = 191, 86%), followed by sagittal split mandibular ramus osteotomy (n = 14, 6.3%). Most patients complained preoperatively of numbness (n = 122, 55%) or numbness with pain (n = 94, 42.3%). The average interval from injury to surgery was 8.5 months (range 1.5 to 96). The most commonly performed operation was excision of a proximal stump neuroma with neurorrhaphy (n = 154, 69%), followed by external decompression with internal neurolysis (n = 29, 13%). Nineteen patients (8.6%) underwent an autogenous nerve graft procedure (greater auricular or sural nerve) for reconstruction of a nerve gap. A collagen cuff was placed around the repair site in 8 patients (3.6%; external decompression with internal neurolysis in 2 and neurorrhaphy in 6). Recovery from neurosensory dysfunction (defined by the Medical Research Council Scale as ranging from "useful sensory function" to a "complete return of sensation") was observed in 201 patients (90.5%; 146 patients with complete recovery and 55 patients with recovery to "useful sensory function"), and 21 patients (9.5%) had no or inadequate improvement. Using the logistic regression model, a shorter interval between nerve injury and repair resulted in greater odds of improvement (OR 0.942, P = .0064); with each month that passed, the odds of improvement decreased by 5.8%. The receiver operating characteristic analysis revealed that patients who waited more than 9 months for repair were at a significantly greater risk of nonimprovement. Statistical significance was observed between patient age and outcome (OR 0.945, P = .0067) representing a 5.5% decrease in the chance of recovery for every year of age in patients 45 years old and older. The odds of a return of acceptable neurosensory function were better when the patient's presenting symptom was pain and not numbness (OR 0.04, P < .001). CONCLUSIONS: Microsurgical repair of LN injury has the best chance of successful restoration of acceptable neurosensory function if done within 9 months of the injury. The likelihood of recovery after nerve repair decreased progressively when the repair occurred more than 9 months after injury and with increasing patient age.

Microsurgical repair of peripheral trigeminal nerve injuries from maxillofacial trauma.

PURPOSE: Injuries to the peripheral branches of the trigeminal nerve from maxillofacial trauma can have distressing sensory or functional sequelae. The present study reports the results of trigeminal microneurosurgical repair in a series of patients with maxillofacial trauma. MATERIALS AND METHODS: A retrospective chart review was completed of all patients who had undergone microneurosurgical repair of peripheral trigeminal nerve injuries caused by maxillofacial trauma and who had been treated by one of us (R.A.M.) from March 1986 through December 2005. A physical examination, including standardized neurosensory testing, was completed on each patient preoperatively. All patients were followed up periodically after surgery for at least 1 year with neurosensory testing repeated at each visit. Sensory recovery was evaluated using the guidelines established by the Medical Research Council. The following data were collected and analyzed: patient age, gender, nerve injured, etiology (location of fracture), chief sensory complaint (ie, numbness or pain, or both), interval from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at the final evaluation. RESULTS: A total of 42 patients (25 males and 17 females) with average age of 37.1 years (range 11 to 61) and a follow-up of at least 12 months were included in the study. The most commonly injured/repaired nerve was the inferior alveolar nerve caused by mandibular angle fracture (n = 21), followed by the mental nerve due to mandibular parasymphysis fracture (n = 12), the infraorbital nerve from zygomaticomaxillary complex fracture (n = 7), and lingual nerve and long buccal nerve from mandibular body fracture (n = 1 each). In 17 patients, the chief sensory complaint was numbness, and 25 patients complained of pain with or without mention of numbness. The average interval from nerve injury to repair was 12.5 months (range 2 to 24). The most common intraoperative finding was a compression injury (n = 19), followed by partial nerve severance (n = 9). The most frequent surgical procedure was external decompression/internal neurolysis (n = 20). Ten injured nerves required reconstruction of a discontinuity defect with an autogenous nerve graft (donor sural or great auricular nerve), all of which were associated with mandibular angle or parasymphysis fractures. After a minimum of 1 year of follow-up, neurosensory testing demonstrated that 6 nerves (14%) showed no sign of recovery, 23 nerves (55%) had regained "useful sensory function," and 13 nerves (31%) showed full recovery as described by the Medical Research Council scale. CONCLUSIONS: Microsurgical repair of peripheral branches of the trigeminal nerve injured by maxillofacial trauma produced significant improvement or complete recovery in 36 (86%) of 42 patients. These results compare favorably with the microsurgical repair of peripheral trigeminal nerve injuries resulting from other causes.

Overdose, adverse effects, and safety of oral medications.

Overdose of oral medications can be a major concern. This article reviews the clinical presentations, toxic dosages, adverse effects, and the recommended treatments for the most commonly used oral medications in dentistry. Clinicians need to be aware of the toxicities and adverse effects of the most commonly used oral medications, and recognize the signs and symptoms as early as possible for expedient treatment and referral.

Extraction versus nonextraction management of third molars.

Surgical removal of impacted third molars is the most commonly performed procedure by oral and maxillofacial surgeons. The removal of diseased or symptomatic third molars has not been an issue of controversy. The risk of surgery and associated complications are justified and uniformly accepted by most surgeons when the teeth are associated with chronic or acute pathologic processes, including caries, nonrestorable teeth, fractured roots, resorption, associated pathologic conditions (cysts, tumors), periapical abscesses, odontogenic infections, osteomyelitis, removal before reconstructive or ablative surgery, and radiation therapy.

Rhinoplasty: initial consultation and examination.

Many cosmetic surgeons consider rhinoplasty to be the most complex surgical and artistically challenging of all aesthetic surgery today. It is the most common facial procedure performed for women and the second most common for men. The art and science of cosmetic rhinoplasty begins with the initial examination. The surgeon must visualize and predict like Leonardo Da Vinci, be a sculptor like Michelangelo, and be an analyzer like Einstein. This article describes the components and complexities of the initial examination in cosmetic rhinoplasty.