Nasal Reconstruction of Large Defects Without a Forehead Flap.

Defects over 2.0 to 2.5 cm may often require repair with a multistaged forehead flap. However, in some such defects, other options may be available. In this article, the author will review some of these options.

The Extended Purse-String Rhytidectomy.

Facelifts remain a critical part of a facial plastic surgeon's cosmetic practice. Techniques continue to evolve, while at the same time patients demand less invasive procedures with less morbidity. The authors present a facelift plication technique using wide purse-string sutures placed into the superficial musculoaponeurotic system and platysma. This is a retrospective review with a level of evidence 3 set at a medical spa and tertiary referral center designed to assess a purse-string suture technique using an inner followed by an outer purse-string, with refinements being made during the timeframe of the review. One hundred and eighteen patients were reviewed and 95 were included in the study given the inclusion criteria of a minimum of 1-year follow-up. Based on the subjective judgment of the primary surgeon, 37 patients were found to have excellent results, while 43 patients were judged as having good results. The judgment was based on the physical exam improvement of the aging aspects of the patient, and patient satisfaction. Ten patients displayed fair results (the patients were marginally happy), and five patients were noted to have poor results (they were notably unhappy). Complications included eight hematomas, five patients with prominent scars, and one patient with skin loss in the temple region. There were no cases of facial nerve injury. The extended purse-string rhytidectomy is a good alternative to traditional facelift techniques. This offers a plication method that results in the vertical vector that is now considered of paramount importance with all facelifts. The authors feel that it is a valuable tool that can be considered in most patients presenting for aging face surgery.

The Role of Transverse Osteotomies in Severe Nasal Trauma.

Facial trauma commonly produces trauma to the nose and perinasal area. In this review, emphasis is on the treatment of the severely deviated nose in terms of excessive shift of the bony dorsum and bony pyramid. In particular, we focus on the problem of centering the severely deviated bony dorsum and when we believe it is helpful to move the entire bony dorsum as a unit, utilizing the transverse osteotomy in addition to traditional osteotomies.

Management of Posttraumatic Pseudotelecanthus.

Injuries to the nose and perinasal region are common. Though the nasal fractures are commonly recognized and properly addressed, injuries to adjacent structures such as the orbit, medial canthus, and midface skeleton can be missed or misdiagnosed leading to improper primary treatment and subsequent secondary deformities. In this discussion, we focus on secondary deformities of the medial canthal region injuries that result from inadequate primary repair of the displaced medial canthal tendon apparatus in naso-orbital-ethmoid fractures. Emphasis is placed on the difference in complexity of the secondary pseudotelecanthus deformity relative to primary fracture treatment. Case examples are used to discuss the complexity of the correction of such deformities.

The Comprehensive AOCMF Classification System: Mandible Fractures- Level 2 Tutorial.

This tutorial outlines the details of the AOCMF image-based classification system for fractures of the mandible at the precision level 2 allowing description of their topographical distribution. A short introduction about the anatomy is made. Mandibular fractures are classified by the anatomic regions involved. For this purpose, the mandible is delineated into an array of nine regions identified by letters: the symphysis/parasymphysis region anteriorly, two body regions on each lateral side, combined angle and ascending ramus regions, and finally the condylar and coronoid processes. A precise definition of the demarcation lines between these regions is given for the unambiguous allocation of fractures. Four transition zones allow an accurate topographic assignment if fractures end up in or run across the borders of anatomic regions. These zones are defined between angle/ramus and body, and between body and symphysis/parasymphysis. A fracture is classified as "confined" as long as it is located within a region, in contrast to a fracture being "nonconfined" when it extents to an adjoining region. Illustrations and case examples of mandible fractures are presented to become familiar with the classification procedure in daily routine.

The Comprehensive AOCMF Classification System: Midface Fractures - Level 2 Tutorial.

The AOCMF Classification Group developed a hierarchical three-level craniomaxillofacial classification system with increasing level of complexity and details. The highest level 1 system distinguish four major anatomical units including the mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94). This tutorial presents the level 2 system for the midface unit that concentrates on the location of the fractures within defined regions in the central (upper, intermediate, and lower) and lateral (zygoma, pterygoid) midface, as well as the internal orbit and palate. The level 2 midface fracture location outlines the topographic boundaries of the anatomical regions. The common nasoorbitoethmoidal and zygoma en bloc fracture patterns, as well as the time-honored Le Fort classification are taken into account. This tutorial is organized in a sequence of sections dealing with the description of the classification system with illustrations of the topographical cranial midface regions along with rules for fracture location and coding, a series of case examples with clinical imaging and a general discussion on the design of this classification. Individual fracture mapping in these regions regarding severity, fragmentation, displacement of the fragment or bone defect is addressed in a more detailed level 3 system in the subsequent articles.

The Comprehensive AOCMF Classification System: Mandible Fractures-Level 3 Tutorial.

This tutorial outlines the details of the AOCMF image-based classification system for fractures of the mandibular arch (i.e. the non-condylar mandible) at the precision level 3. It is the logical expansion of the fracture allocation to topographic mandibular sites outlined in level 2, and is based on three-dimensional (3D) imaging techniques/computed tomography (CT)/cone beam CT). Level 3 allows an anatomical description of the individual conditions of the mandibular arch such as the preinjury dental state and the degree of alveolar atrophy. Trauma sequelae are then addressed: (1) tooth injuries and periodontal trauma, (2) fracture involvement of the alveolar process, (3) the degree of fracture fragmentation in three categories (none, minor, and major), and (4) the presence of bone loss. The grading of fragmentation needs a 3D evaluation of the fracture area, allowing visualization of the outer and inner mandibular cortices. To document these fracture features beyond topography the alphanumeric codes are supplied with distinctive appendices. This level 3 tutorial is accompanied by a brief survey of the peculiarities of the edentulous atrophic mandible. Illustrations and a few case examples serve as instruction and reference to improve the understanding and application of the presented features.

Revision of severe nasal trauma.

Facial trauma commonly includes injury to the nose and perinasal area. In this review, we will focus on the sequelae of severe nasal trauma and provide examples of correction of the severely deviated nose, the severely collapsed nose, and revision of a traumatic deformity after prior rhinoplasty. We will then discuss coexistent deformities of perinasal regions in addition to functional and posttraumatic nasal correction, including posttraumatic periorbital deformities.

Avoiding and correcting complications in perinasal trauma.

Injuries to the nose and perinasal region are common. Although the nasal fractures are commonly recognized and properly addressed, injuries to adjacent structures such as the orbit, medial canthus, and midface skeleton can be missed or misdiagnosed, leading to improper primary treatment and subsequent secondary deformities. In this discussion, three common injuries will be discussed, including nasomaxillary fractures, limited naso-orbital-ethmoid fractures, and severe central facial injuries with naso-orbital-ethmoid fractures. For instructional purposes, a case example of inadequate primary diagnosis and subsequent delayed or secondary management will be followed by a case example of proper initial diagnosis and proper primary management.

Reconstruction of periparotid defects using temporoparietal fascia flap with layered acellular human dermal allograft.

Excision of lesions in the periparotid area can leave a sizable concavity of the preauricular area with skeletonization of the mandible. To achieve the bulk necessary to fill this defect, we propose using a composite graft. Acellular human dermal allograft provides the thickness of the graft, and the temporoparietal fascia flap provides blood supply to the dermal graft. Our hypothesis is that vascularization of the graft will promote greater ingrowth of native tissue and prevent breakdown and absorption of the graft. Four representative patients are described.

Reconstruction of complex nasal dorsal and sidewall defects: is the nasal sidewall subunit necessary?

OBJECTIVE: To demonstrate that by the extended use of cheek advancement flaps, the need to maintain the nasal dorsal side unit is obviated. DESIGN: Retrospective case series. SETTING: Tertiary care clinic and hospital. PATIENTS: Twelve patients aged 48 to 88 years who underwent Mohs micrographic surgery for nasal skin neoplasms, presenting with dorsal sidewall and nasal dorsal cutaneous defects. INTERVENTION: All patients underwent nasal reconstruction with adjacent tissue cheek advancement flaps with or without contralateral nasal dorsal and sidewall advancement flaps. MAIN OUTCOME MEASURES: Avoidance of ipsilateral nasal sidewall scars to allow a natural-appearing transition between the cheek and nose and avoidance of forehead flap morbidity. Results Satisfactory results were achieved in all but 1 patient who had partial flap necrosis. CONCLUSIONS: To maintain the nasal dorsal sidewall unit, superior, central dorsal, and nasal sidewall defects have traditionally been reconstructed using a variety of techniques, including skin grafts and regional flaps, such as glabellar flaps and frontal flaps. We demonstrate that creation of the nasal dorsal sidewall unit is often not necessary, and excellent results can be achieved through the expanded use of cheek advancement flaps.

Dealing with the difficult trauma and reconstructive surgery patient.

Many of the issues that exist for cosmetic surgery patients exist for noncosmetic patients in areas such as reconstructive surgery and trauma. Although cosmetic and noncosmetic patients usually are considered separate in terms of elective versus nonelective, there are other issues in dealing with reconstructive surgery patients versus those undergoing cosmetic surgery. This article reviews a variety of issues specific to noncosmetic reconstructive surgical patients and discusses issues unique to pediatric patients, craniomaxillofacial trauma patients, patients who have skin cancer defects, scar revision patients, and major reconstruction after cancer resections and craniomaxillofacial trauma.

Computer-designed implants for fronto-orbital defect reconstruction.

Patients with complex defects of the frontal and orbital regions present a myriad of problems for the reconstructive surgeon. In this review, options that allow state-of-the-art reconstruction using computer-assisted implants will be illustrated. The advantages of such implants created with computer assistance will be reviewed as well as indications for their use.

Eyebrow position recognition and correction in reconstructive and cosmetic surgery.

OBJECTIVES: To improve (1) recognition of eyebrow ptosis, asymmetry, or deformity and (2) selection of the appropriate surgical technique based on the patient's underlying etiology. DESIGN: Nonrandomized, retrospective study of patients undergoing surgical correction of eyebrow asymmetry. Forty consecutive patients were identified as having asymmetric eyebrow ptosis or deformity. Varying etiologies included those that were congenital, posttraumatic, age-related, iatrogenic, or idiopathic, with or without facial nerve paralysis. Patients underwent a variety of surgical approaches for correction of the eyebrow malposition, including transblepharoplasty, midforehead, coronal, and endoscopic procedures. Preoperative evaluation of patients, identification of patient-specific appropriate surgical technique, and photographs and grading of postoperative results are discussed. RESULTS: All patients had a minimum follow-up period of at least 4 months (mean, 15 months; range, 4 months to 3 years). Preoperative and postoperative photographs were obtained and graded. Complete symmetry was achieved in 8 patients (20%), considerable improvement in 23 patients (57%), modest improvement in 7 patients (18%), and no improvement in 2 patients (5%). No notable postoperative complications were reported. Recommendations for improving results are included. CONCLUSIONS: The key to correction of eyebrow ptosis in patients undergoing reconstructive and cosmetic surgery is to first recognize the asymmetry. It is also important to note the effect of reconstructive and cosmetic surgical procedures on eyebrow position in order to limit the need to perform additional procedures to correct resultant eyebrow asymmetries and deformities. Finally, the surgeon must consider which eyebrow-lift technique is optimal for the patient's underlying etiology to improve postoperative results and patient satisfaction.

Skin rejuvenation in facial surgery.

The treatment of the aging face has evolved to increasingly incorporate minimally office-based procedures. The importance of recognizing and treating facial rhytids has always been recognized as important, but an increasing number of modalities have been developed for this purpose. Similarly, there has been an increase of emphasis in the recognition of dyschromias, solar keratoses, and other skin abnormalities. In this article, an overview of many of the minimally invasive office-based procedures that we favor in our practice will be briefly reviewed.

Evaluation and treatment of deformities of the chin.

Chin deformities present commonly to the facial plastic surgeon. Proper evaluation of the face is essential to allow the surgeon to counsel the patient properly regarding optimal management of chin deformities. This article reviews such analysis and discusses treatment modalities, including both the use of chin implants and osseous genioplasty.