Effects of endoscopic forehead/midface-lift on lower eyelid tension.

OBJECTIVE: To evaluate and quantify the increase in lower eyelid tension (stress) after endoscopic forehead/midface-lift in a cohort of patients with normal lower eyelid function preoperatively. METHODS: A prospective nonrandomized study was conducted at a private facial plastic surgery practice and ambulatory surgical center on 22 patients who underwent subperiosteal endoscopic forehead/midface-lift from October 2000 to June 2002. Patients were evaluated preoperatively, 4 to 6 months postoperatively, and approximately 12 months postoperatively. RESULTS: Compared with preoperative lower eyelid tension, there was a 4- to 5-fold increase in lower eyelid tension at 3 and 5 mm of distraction immediately after the operation. Four to 6 months after the operation, lower eyelid tension decreased but was still 2 to 3 times that of preoperative values. Twelve-month measurements for the 15 patients who remained in the study (the other 7 patients were lost to follow-up or refused to have measurements taken) showed that lower eyelid tension was 1.7 to 1.9 times preoperative values. CONCLUSIONS: Our results show that lower eyelid tension increases following endoscopic forehead/midface-lift and that this increased tension is long lasting and quantifiable 12 months after surgery.

Reconstruction after resection of sphenoid wing meningiomas.

OBJECTIVE: To review our experience of reconstructing the lateral and superior orbital walls after resection of sphenoid wing meningiomas. We will review the presentation and complications, examine the aesthetic results postoperatively, and compare preoperative and postoperative computed tomographic scans. To our knowledge, a comparative analysis of preoperative defect and postoperative reconstruction has not been performed. METHODS: We conducted a retrospective analysis, with a minimum of 5 months and a maximum of 9 years of follow-up in an academic multidisciplinary skull base center. Twenty-two patients were treated for sphenoid wing meningiomas by resection and reconstruction with split calvarial bone graft and, for more than half of the patients, also with free abdominal fat graft. The main outcome measures were aesthetic evaluation of patients and analysis of tumor control using computed tomographic scans, survival, and complications. RESULTS: A total of 24 resections were performed on 22 patients. The average follow-up was 14.6 months. All patients had meningiomas with similar preoperative presentations, and for 21 of the 22 patients aesthetic reconstruction resulted in the near symmetry of the 2 sides. All patients are currently alive, those who underwent complete resection are without recurrence, and 15 (68.2%) did not incur complications. One patient experienced a worsening of temporal wasting following radiation therapy. CONCLUSION: Reconstruction of the defect with split calvarial bone and free abdominal fat grafts affords the patient excellent aesthetic results as well as good symmetry, as demonstrated by a postoperative computed tomographic scan.

Surgical management of concavities of the distal nose.

Normal topographic anatomy of the distal nose is a reflection of the delicate integration between the lower lateral cartilage, the upper lateral cartilage, the sep-tum, and skin. Understanding these relationships will help the rhinoplasty surgeon diagnose and treat con-cavities of the distal nose. Most patients present with a hybrid of these defects. For example, the patient in Fig. 19 presented for a primary rhinoplasty. A variety of concavities can be noted and include dorsal septal deflection, upper lateral cartilage avulsion on the left,bilateral lower lateral complete concavities, and the beginning of a dorsal depression (Fig. 19A-I). The nasal skeleton and the skin and soft tissue are normally in equilibrium, but trauma and reduction rhino-plasty disrupts this equilibrium. Skeletal distortion can lead to septal deflection, middle vault collapse, or alar buckling [20]. It is important to realize that correction of deflection or depression by excision needs to be balanced with augmentation, which provides balance for the previously disequilibrated skeletal and soft tissue forces. Augmentation can be done with spreader grafts, tip grafts, columellar strut, and dorsal grafts. A patient's soft tissue envelope will also play a major role in the success of a septorhinoplasty. The surgical principles of septorhinoplasty such as judicious resculpting of the cartilaginous framework, respect of major tip support, tip grafting technique, and postoperative tissue contraction still apply and must be placed in conjunction with repairing a pathological topographic concavity.

Expression of urokinase-type plasminogen activator and its receptor in keloids.

BACKGROUND: The urokinase-mediated plasminogen activation (uPA) system plays a central role in a number of cellular processes including tissue remodeling, cell migration, and angiogenesis. Elevated uPA activity has also been seen with tumor invasion and metastasis in a variety of malignancies. Keloids represent an aberrant form of wound healing characterized by uncontrolled growth with invasion beyond the margins of the original wound. The regulation of this cellular process remains poorly understood. We hypothesize that keloids will have increased staining percentage for uPA and its receptor (uPAR) compared with normal scars. To our knowledge, no previous studies have examined the relationship of uPAR in keloid formation. DESIGN: Analysis of uPAR expression by immunohistochemistry in paraffin sections from 20 keloids and 18 normal scars. Expression was graded by a dermatopathologist according to percentage of cells staining for uPAR. SETTING: University Medical Center (Division of Otolaryngology-Head and Neck Surgery) and the Department of Dermatology at the University of Rochester Medical and Dental School, Rochester, NY. RESULTS: Of the 20 keloids, 8 (40%) strongly expressed uPAR (>50% of cells), while only 4 (22%) of 18 normal scars had similar staining. More than half of the normal scars stained minimally for uPAR (<5% staining). There was a strong expression of uPAR in the extracellular matrix in 14 (70%) of the 20 keloids, while no scar showed uPAR in the extracellular matrix. CONCLUSION: Our observation suggests that the uPA system is involved in the expansion of keloids beyond the wound margins in part through the degradation of the extracellular matrix, a finding that is supported by the strong expression of uPAR in the extracellular matrix and collagenous cords in most keloids studied.