Omega incision face-lift approach and SMAS rotation advancement flap in parotidectomy for prevention of contour deficiency and conspicuous scars affecting the neck.

To overcome the disadvantages after the surgical removal of tumours of the parotid gland, especially the depressed facial deformity and conspicuous cervical scar formation subsequent to parotid surgery, we have concentrated on omega face-lift incision in combination with an SMAS rotation advancement flap for the last several years using a lazy omega incision. Nine patients (3 male and 6 female) ranging in age from 43 to 68 years (mean age: 56.3 years) fulfilled the selection criterion of having a clinically benign discrete parotid lump with a benign preoperative fine needle cytology result. Parotidectomy was performed using the modified omega face-lift incision in conjunction with the rotation advancement SMAS flap. All patients underwent follow-up every 3 months in the first year. During the follow-up, the patients were specifically asked about their satisfaction with the post-operative appearance and whether they would consent to the operation again. The vascularized SMAS rotation advancement flap is clinically simple to perform and provides satisfactory cosmetic and functional results in patients undergoing conservative parotidectomy. There are no drawbacks in the use of modified face-lift incision to remove tumours of the parotid gland.

[Renaissance of the Franz König bilateral lip repair procedure - clinical experiences with an one hundred year old technique]. / Die Renaissance des doppelseitigen Lippenspaltverschluss nach Franz König - Klinische Erfahrungen mit einer über hundert Jahre alten Technik -

Surgical correction of bilateral cleft lips is known to have a lot of problems. The surgical principles of treatment of bilateral cleft lips are similar to those of unilateral clefts but differ in the area of the prolabium due to specific anatomical disorders of the orbicularis oris muscle. The postoperative results of simultaneous bilateral cleft lip repair according to König were analysed retrospectively in 15 young children (6.1 +/- 1.1 years) paying special emphasis to the aesthetic and functional postoperative outcome of the upper lip and nose. The mean values were compared with measurements from normal infants at ages 8.3 +/- 1.8 years. Lip height and lip length were in 87 % similar to those of the age-matched normal group. Only two cleft patients showed a slightly shorter lip. Distortions of the lip function were not obvious. Our data show that König's surgical procedure of bilateral cleft lip closure meets the requirements of modern surgical concepts of cleft lip repair and should belong to the armamentarium of modern face surgery.

Subgaleal versus subperiosteal dissection in fronto-orbital advancement procedures.

Extensive cranioorbital surgery for craniosynostosis in young children can produce excessive blood loss. Thus, to overcome the disadvantage of unappropriated blood loss and translocation of the osteosynthesis material, we performed a subgaleal dissection in infants and compared the subperiosteal with the subgaleal surgical approach in 29 children who underwent surgery for craniosynostosis. The treatment goal of correction of the deformity was accomplished in each case. Fronto-orbital deformities were significantly improved in all patients. Blood loss was less in the group with subgaleal elevation of the forehead (mean = 163 ml) compared with the subperiosteal group, which had a mean 266 ml blood loss. The subgaleal dissection caused less bleeding and tethering of the advanced bone.

[Intra-individual comparison of alpha- and beta-TCP ceramics in an animal experiment]. / Intraindividueller Vergleich von alpha- und beta-TCP-Keramik im Tierexperiment.

In the quest for bioinert adaptable alloplastic materials, TCP ceramics have gained a new application in craniofacial bone substitutes. Therefore, a histomorphological, intraindividual, comparative study was conducted on seven adult Goettingen miniature pigs (GMP) to analyze the difference of the degradation and remodelling processes of alpha-TCP and beta-TCP in critical size defects of the proximal tibiae. In addition, primary insertion of dental implants followed to study osseous integration. The critical size defects, which were created in the proximal tibiae in GMPs, were filled on the left side with beta-TCP and on the right side with alpha-TCP. Two GMPs were used as control group. After 4-68 weeks of investigation, the GMPs were sacrificed by narcosis. The histological investigation showed that these ceramics have an osteoconductive effect. It was noted that ossification proceeds centripetally. It could be demonstrated that the degradation of the materials follows a hydrolytical process and that the intratrabecular integrated ceramic remnants follow a dynamic remodelling process. Within 68 weeks after implantation, 90% of the TCP granulae were degraded. Macrophages were found in the marrow space, containing microparticles of TCP, especially after alpha-TCP implantation. In conclusion, defined degradation of these ceramics allows early functional bone regeneration with an additional undisturbed biofunctional unisotrop orientation of new trabeculae. Furthermore, dental implants should be inserted 5-6 months after TCP implantation.

[The modern surgery of face lift: indications and results]. / Die moderne Chirurgie des Face liftings. Indikationen und Ergebnisse.

In this retrospective study with a group of 55 patients aged 47.7 +/- 8.3 years, surveyed for a period of 16 months, the results of different face lift techniques--subcutaneous face lift combined with imbrication of the SMAS-Platysma complex versus sub-SMAS-dissection with transposition of the SMAS-Platysma complex--were compared in order to evaluate risks and complication rates of these two techniques. Various indications and different techniques including special features were discussed. A slightly higher complication rate is evident in the patient group treated with the sub-SMAS face lift technique, mainly referring to temporary asthenia of the nervus facialis, which regressed in all cases after 7 months. The post op bleeding rate was 2.3%, within the range given in the literature. Concludingly, the pure subcutaneous face lift with imbrication of the SMAS-Platysma complex still is an established method in modern rhytidectomy treatment.

Surgical removal of intra- and extraoral cavernous lymphangiomas using intraoperative-assisted intralesional fibrin glue injections.

Benign lymphangiomas are encountered frequently in the head and neck region. They may be well circumscribed or diffusely invasive, involving subcutaneous tissue and underlying muscle, and consist of dilated, thin-wall sinuses. Surgical therapy with excision as wide as possible, while taking care to avoid rupturing the lesion, is the treatment of choice. To simplify complete excision, the authors introduce an intraoperative technique--intralesional injection of fibrin glue. Using this technique over period of 10 years in 27 patients (age range, 7-24 years) they removed successfully intra- and extraoral lymphangiomas. There have been no recurrences. This technique helps avoid rupture of the epithelium and bleeding, and makes it easier to remove lymphangiomas surgically and as completely as possible. This technique reduces recurrence remarkably and ensures successful surgical excision.

Inheritance of Hippel-Lindau disease: a rare case of maxillary bone metastasis.

A rare case of familial Hippel-Lindau disease, which is an autosomal dominant disorder with inherited susceptibility to various forms of cancer, is reported in a 46-year-old father and his sons. The father complained of a malignant hypernephroma, which metastasized in the upper jaw 6 months later. As in this patient, renal cell carcinomas are fatal and are exhibited at an early age. Consequentially, patients with familial von Hippel-Lindau disease exhibiting cases of renal cell carcinoma should be examined very carefully in the head and neck region to detect and treat metastases as early as possible.

[Diagnostic and therapeutic concepts of canine fossa abscess. Evaluation of a multicenter study of 55 German-speaking departments of oromaxillofacial surgery]. / Diagnostische und therapeutische Konzepte des Fossa-canina-Abszesses. Auswertung einer multizentrischen Erhebung an 55 deutschsprachigen Abteilungen für Mund-, Kiefer- und Gesichtschirurgie.

A possible complication of fossa canina infections is reactive thrombosis of the vena angularis, which can lead to cavernous sinus phlebothrombosis. According to the literature there are different opinions about the treatment protocol of fossa canina abscesses. Therefore a multicentre study was undertaken in which 55 departments of oral surgery were interviewed using a standardized questionnaire about their procedures. The basis of diagnosis consists of clinical examination (100%), antibiogram (77.1%) and radiography (97.1%). A total of 28.6% use additional imaging procedures. Sonography is used by 20.0% and is found to be helpful in the diagnosis of vena angularis thrombosis. The painful palpation of the medial angle of the eye is of major diagnostic importance (100%) although anatomic variations of the vena angularis have to be considered. Extraoral incisions are not used in most cases (25.7% in exceptional cases) as well as ligations of the vena angularis in case of thrombosis (8.6% in exceptional cases). There is an agreement in the use of antibiotics (elective administration in 14.3%, obligatory administration in 85.7%); 77.1% don't use heparin to treat thrombosis of the vena angularis. In heparin therapy risks such as bleeding complications and thrombocytopenia have to be considered.

What is the best possible design of temporary anterior mandibular osteotomy? A histomorphological animal study.

When squamous cell carcinomas in the oral cavity have advanced to the size of T2 to T3 or when they start to encroach on the middle, occasionally it is necessary to divide the mandible at the parasymphysis and swing the hemimandible away from the midline for intraoral exposure of tumor resection. The osteotomy is usually performed in either a straight vertical cut, in a step-cut fashion, or in a dove-tail geometric configuration. The design of the geometric pattern of the osteotomy determines whether or not the postoperative period is prolonged. The authors analyzed the best possible design of temporary anterior mandibular osteotomy. In an animal study of 12 Goettingen minipigs (GMPs) the authors investigated the best possible design of geometric pattern of mandibular osteotomy and the fragment healing process. Their primary interest was directed at the histomorphological bone-healing process after straight vertical bone cut, step-cut fashion, and dove-tail osteotomy of the mandible, and rigid fixation with an osteosynthesis plate. From this study it can be concluded that the dove-tail osteotomy of the mandible is the best possible design of temporary anterior mandibular osteotomy in preventing pseudoarthrosis due to the mainly primary bone contact and gap healing process.

Single lag screw fixation for malar fracture (type B) fixation: reduction of hardware treatment costs.

In an attempt to define the most simple and inexpensive method of achieving postreduction stability in zygomatic fractures, the authors compared two different methods of internal rigid fixation of the frontozygomatic suture line in one group with miniplates and in another group with Panfix lag screws. The randomized study protocol consisted of a control group of 20 patients and 40 patients with laterally displaced body fractures of the zygoma. Statistical differences were not seen between the control subjects and the patients who required open reduction and internal fixation either with one osteosynthesis plate at the frontozygomatic suture line or a lag screw osteosynthesis. Lag screw fixation in malar type B fractures could lower hardware treatment costs and is an alternative method that provides sufficient stability in indicated patients.

Loss of DNA-mismatch repair gene expression in oral melanomas.

The defect of DNA mismatch repair is postulated to be responsible for malignant transformation in many types of tumours. The main aim of this study was to evaluate the expression of DNA mismatch repair proteins in 29 cases of oral melanomas and to relate this to the ploidy status of the lesions. MLH1 expression was found in 4/29, MSH2 in 6/29, PMS2 in 2/29 and PMS1 in 0/29 cases investigated. The range of positively stained cells did not exceed 50% with MSH2, and PMS2, or 5% with MLH1. Loss of the DNA mismatch repair gene expression correlated with high aneuploidy ratio, observed in totally negative cases.

[Animal experiments on the frontal sinus development after craniofacial surgery on the frontal bone in Göttingen miniature pigs]. / Tierexperimentelle Untersuchungen zur Stirnhöhlenentwicklung nach kraniofazialer Austauschplastik des Os frontale beim Göttinger Miniaturschwein.

According to the literature, the development of the frontal sinus is a result of the active immigration of cells from the ethmoidal complex into the os frontale. This migration theory is in contrast to the results in patients with Apert's syndrome. When front-orbital advancement at the age of a few months is performed in these patients--at a time when the frontal suture is not yet closed--a sinus developed despite the distance between nasal root and os frontale, being up to 2 cm. In order to investigate the development of the frontal sinus, an animal study in 12 juvenile Goettingen minipigs (age 5-6 weeks) with histologically pronen un-developed frontal sinus was performed. To exclude the emigration of ethmoidal complex cells into the frontale bone an orthotopical transposition of the frontale bone into the os occipitale was performed. Histologically the development of a frontal sinus in the frontal bone was excluded before transplantation. The macro- and microscopic comparison with a control group revealed that in the orthotopical transplants in the os occipitale an epithelium-lined sinus developed beginning from the 35th week. Based on our histomorphological results, a development scheme for the genesis of the sinus frontalis and a model is drawn.

Loss of growth arrest DNA damage genes expression in oral melanomas.

29 oral melanomas were stained immunohistochemically for the GADD34, GADD45 and GADD153. GADD34 was found in 5/29 melanomas and its expression did not exceed 21%, averaging 4.1% of melanoma cells. GADD45 was observed in 8/29 oral melanomas and cell positivity averaged 2.8%. GADD153 was found in 2/29 melanomas and the percentage of positive cells ranged between 0 and 31%, averaging 1.2%. Not one significant correlation between GADD genes in oral melanomas was found. Loss of GADD gene expression and lack of correlation between them show advanced disturbances in their cooperation, leading to a high genetic instability of oral melanoma cells.

Modified channel retractor simplifies sagittal ramus osteotomy procedure.

A new instrument is described for use in the sagittal ramus split osteotomy by Obwegeser. This modified channel retractor simplifies the sagittal ramus osteotomy procedure, allows clear vision and easy access, and protects adjacent tissues.

[Surgical technique and clinical results of modified endo-dermo-"brassière" breast reduction-plasty]. / Operative Technik und klinische Ergebnisse der modifizierten Endo-Dermo-"Brassière"-Mamma-Reduktionsplastik.

The variety of techniques feasible for reduction mammaplasty depends on the patient's anatomy. The inferior pedicle technique and its manifold variations have been described by several authors, probably being the most popular breast reduction technique. The advantages include the ease of performance, good preservation of the neuro-vascular supply of the nipple, new configuration of the breast and fixation like an endo-brassière. Here we present the method of breast reduction, as we currently use it, as well as the principles and the technical considerations necessary to achieve an optimal outcome. Additionally, a retrospective study of selected patients is performed. Results have been very gratifying, not only concerning the esthetical appearance of the breast, but also the long-term preservation of it's new shape. Complications like necrosis of the NAC complex were not observed till yet.

Significance of the periosteum in onlay craniofacial augmentation.

In the quest for bioinert, easily applicable, and individually adaptable alloplastic materials, hydroxyapatite (HA) has gained a new application in onlay craniofacial augmentation. On the basis of clinical and experimental proof that intraosseous translocation of HA occurs after HA onlay augmentation, we conducted an animal study on 16 adult Goettingen minipigs in which HA, as blocks or granular, was implanted for a maximum time of 72 weeks. Our aim was to study the difference between periosteal and subperiosteal onlay augmentation of two different HA forms by comparing HA-bone interface on the intact frontal bone treated with a block form of HA versus granular HA, with special emphasis on the periosteum. Within a few weeks after subperiosteal augmentation, subimplant changes in the grafted bone became evident to such an extent that within 72 weeks the granules migrated into the frontal sinus. In contrast, in epiperiosteal HA onlay augmentation, no intraosseous migration of HA particles was observed, regardless of the type of HA implants. The HA particles were integrated within the connective tissue, and the connective tissue infiltrated the interstitial spaces. For the most part, the location and the shape of the implant remained stable. The periosteum assumed the function of a limiting membrane. We recommend that epiperiosteal onlay augmentation with HA be performed only if previous studies have proven that shape and location are stable. The periosteum should be preserved because it functions as a limiting membrane, retaining the HA and preventing it from migrating into the subimplant bone.

[Indications and technique of the M-U abdominal incision and initial clinical results of modified abdominoplasty]. / Indikation und Technik der M-U-Abdominalinzision sowie erste klinische Ergebnisse der modifizierten Abdominoplastik.

The M-U-abdominoplasty introduced here has been developed to generate an even tightening of the central and the lateral parts of the abdominal wall. In contrary to the standard method, a more pronounced accentuation of the waist and an aesthetically more advantageous course of the scars can be achieved. Application of the M-U-abdominoplasty is especially recommended in cases of previous liposuction or undermining of the abdominal wall, resulting in a stronger relaxation of the lateral than the central parts. A stressed tightening of the lateral abdominal wall can be achieved by a soft coursed, M-shaped, cranial incision line, which is united with a broad U-shaped caudal incision line. The length of the U-incision determines the length of the M-shaped incision. Only a limited undermining of the abdominal wall above the umbilicus is needed, which minimises the risk of wound-healing impairment caused by nutrition defects.

Avoidance of implicit hazards: the realignment of maxillary and mandibular arches in comminuted and facial fractures.

The authors introduce an attempt to elevate the problem of proper realignment of the maxillary and mandibular arches to achieve an exact transversal width of the lower third of the face with an index of the sum of the maxillary and mandibular central incisors, together with a new Artex-Callotte System (Karl Storz GmbH, Tuttlingen, Germany). This allows individual and anatomically correct restoration of the dental arches. This is especially helpful if either a large number of teeth or portions of dental alveolar processes have been lost in comminuted panfacial fractures. In addition, a sequential, step-management concept of comminuted panfacial fractures is described and illustrated. The goals of treatment with this method are to reestablish the midfacial height and projection and the occlusion, and reestablish the integrity of the nose, the orbit, and the transversal dimension of the lower jaw. This simple method is not yet well appreciated.

A de novo discharging sinus of the fronto-orbital suture: a rare presentation of a dermoid cyst.

Dermoid cysts are developmental anomalies, resulting primarily from trapped germinal epithelium. In the neck and head region, the most common location is the fronto-orbital upper outer quadrant of the orbit. Because only a few cases of dermoid cysts with discharging sinus of the fronto-orbital area have been reported in the literature, the authors present an unusual case of a frontozygomatic suture dermoid cyst, presenting as a sinus, in an 56-year-old man. The histologic report confirmed that the cystic lesion was a dermoid cyst with a tract. Diagnosis and management are discussed.