Mandibular Angle Implants.

After studying this article, the reader should be able to understand the two basic types of implants for aesthetic augmentation of the jaw angles and the aesthetic goals in using them. The operative steps for surgical placement are described with emphasis on avoiding the common complications of jaw angle implants. The indications for the use of standard versus custom jaw angle implants are also described.

Forehead/Brow Reduction or Augmentation with Custom Implants for Enhanced Facial Profileplasty.

After studying this article, the reader should be able to understand the basic concepts of aesthetic reshaping of the forehead and the different methods to make those upper facial contour changes. The operative techniques for bony forehead and brow bone reduction and biomaterials for forehead and brow bone augmentation are described. Innovations in bony reduction and implant augmentation methods are emphasized.

Chin Reshaping in Profileplasty: Augmentative and Reductive Strategies.

After studying this article, the reader should be able to understand how various implants, osteotomies, and reductive tissue techniques affect the aesthetic outcomes of chin reshaping surgery. The roles of standard versus custom chin implants, the operative steps and indications for a bony genioplasty and the techniques for chin reduction are described with emphasis on proper patient selection and avoiding their common complications.

Facial dog bite injuries in children: treatment and outcome assessment.

Dog bite injuries to a child's face are not an infrequent occurrence. They may require primary and revisional surgery. All result in permanent facial scars. This report describes the treatment and outcomes of dog bites of the face, scalp, and neck based on a case series of 107 children over a 10-year period.The average children's age was 5.9 years. In cases where the dog was identified (95%), it was known to the victim and their family. The events leading to the dog bite were categorized as provoked (77%) in the majority of the cases.The majority of wounds could be closed primarily without a significant risk of wound infection. Complex reconstructions were required in more severe cases. The majority of families (77%) opted for scar revision between 9 and 18 months after initial treatment to improve the aesthetic outcome.Lawsuit actions resulted in 39 of the cases making good documentation an essential part of treatment. Dogbite injuries to the face in children frequently require multiple scar revisions to obtain the best possible aesthetic outcome, and the family should be so counseled at the onset of treatment.

Surgical pocket location for gluteal implants: a systematic review.

BACKGROUND: The safest pocket location for gluteal augmentation surgery using implants still is unknown. This study conducted a systematic review to derive evidence-based recommendations concerning the safest type of pocket location (sub-muscular, subfascial, intramuscular, or intramuscular XYZ method) for silicone implants in terms of acute and long-term complication rates. METHODS: Articles from medline that met predetermined criteria were included in the study. The outcomes of interest included wound dehiscence, wound infection, seroma, hematoma, implant asymmetry, and capsular contracture. Pooling of statistical data was performed when possible. RESULTS: The authors reviewed 30 articles regarding five different types of pocket locations for gluteal implants described since 1969. The most common complications after gluteal augmentation surgery using implants are wound dehiscence (10.29%), seroma (2.49%), wound infection (1.12%), and hematoma (0.24%). Fulfilled expectations after surgery were assessed differently among studies and could not be compared. CONCLUSIONS: The pocket locations for gluteal augmentation surgery with implants that have the lowest complication rates are the following: intramuscular XZY method (13.18%), sub-muscular (17.60%), intramuscular (18.05%), and subfascial (54.84%). LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nonorthodontic orthognathic surgery.

Orthognathic surgery for occlusal improvement commonly requires preoperative and postoperative orthodontic treatments to fine-tune intercuspation. This report focuses on the feasibility, treatment goals, and outcomes of orthognathic surgery in a series of patients with congenital dentofacial anomalies who were considered ineligible for or noncompliant with orthodontic treatment. Despite suboptimal occlusal outcomes, the orthognathic procedures resulted in tangible benefits for the patients. We conclude that surgical treatment without concomitant orthodontics is a viable option in selected patients.

Body contouring with solid silicone implants.

BACKGROUND: Body-contouring implants are becoming increasingly popular and more accepted and requested for aesthetic purposes. These implants must be placed in a safe and reproducible plane of anatomic dissection for a successful long-term outcome. Poor implant placement techniques result in greater complications such as asymmetry, implant migration, capsular contracture, and infection. This article discusses (1) the history and the evolution of body-contouring implants, (2) the different techniques and dissection planes in which to put the implants in the calf, gluteal, pectoral, and triceps/biceps areas, and (3) the complications associated with the different implantation techniques. METHODS: The different anatomical areas that have been treated with solid silicone implants are the gluteus, pectoral, calf, deltoids, biceps, triceps, and trapezium. RESULTS: Determining the ideal plane for implant placement is the most important surgical goal for satisfactory aesthetic results. CONCLUSION: Aesthetic contouring of the chest, back, arms, buttocks, and calf can be done safely with solid silicone implants. Proper pocket dissection and location are paramount to successful implant placement and decreased complications.

Utility of Tongue Stitch and Nasal Trumpet in the Immediate Postoperative Outcome of Cleft Palatoplasty.

BACKGROUND: Postoperative airway obstruction is a feared complication following cleft palate repair. The aim of this study was to evaluate the effectiveness of tongue stitches and nasal trumpets that have been used in an attempt to prevent this complication. METHODS: An 8-year (2005 to 2013) retrospective review of palatoplasties performed at a tertiary care center was conducted. Patients were divided into three groups: those with no airway protective measure, those with a tongue stitch only, and a group with nasal trumpet and tongue stitch. Recorded variables included sex, age, Veau classification, and comorbidities. Primary outcomes measured were postoperative respiratory distress, readmission, and reoperation rates. RESULTS: Fifty-eight patients underwent palatoplasties with no airway protective measure, 252 patients had tongue stitch only, and 87 had tongue stitch and nasal trumpet. There were no significant differences between groups with respect to comorbidities except that cleft lip was more prevalent in the no-airway protection group than in the other two groups (p = 0.04). There was no significant difference in the incidence of reintubation, intensive care unit transfer, surgery-related readmissions, or reoperation. Respiratory complications were significantly increased in the nasal trumpet group even after adjusting for age and weight. Length of stay was also significantly (p < 0.01) shortened when comparing no airway protection to those who underwent both nasal trumpet and tongue suture placement. CONCLUSIONS: The use of a tongue stitch, with or without nasal trumpet, did not correlate with improved safety and outcomes. Patients without these airway protective measures had a shorter hospital stay. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cranial reconstruction with computer-generated hard-tissue replacement patient-matched implants: indications, surgical technique, and long-term follow-up.

The aim of this clinical study was to evaluate the effectiveness and safety of using computer-generated alloplastic (hard-tissue replacement) implants for the reconstruction of large defects of the upper craniofacial region. Fourteen patients who had large (> 150 cm2) preexisting defects of the cranium or cranio-orbital region underwent surgical reconstruction. Preoperatively, a three-dimensional computed tomographic scan was obtained from which an anatomic model was fabricated. The defect in the model was then used to create an alloplastic (hard tissue-replacement polymer) implant for reconstruction and surgical placement. At the time of surgery, the implant was secured into position with either metal or resorbable fixation. In cases where the frontal sinus was in proximity to the implant, the frontal sinus was either cranialized and covered with a pericranial flap or obliterated with hydroxyapatite cement. In cases that had been previously irradiated or infected, wide bony debridement and coverage with a vascularized muscle was initially performed, followed by implant reconstruction 6 months later. All implants fit easily into the bone defects, and only four (29 percent) required some minor adjustments to complete the fit. All patients healed uneventfully. With a minimum of 1 year follow-up (average, 3 years) in all cases, excellent contours have been maintained and all patients have remained infection-free. In large cranial defects, custom implants fabricated from porous, hydrophilic hard-tissue replacement polymer provide an exacting anatomic fit and a solid stable reconstruction. This method of reconstruction in these defects is rapid and exact, and significantly reduces operative time. Critical attention must be paid, however, to management of the frontal sinus and preexisting bone infection and the quality of the overlying soft-tissue cover.

Resorbable PLLA-PGA plate and screw fixation in pediatric craniofacial surgery: clinical experience in 1883 patients.

The need to provide rigid bony fixation in the surgical treatment of craniofacial deformities has inspired an on-going evolution of surgical innovations and implants. Because of the young age of many treated craniosynostosis patients and the unique pattern of cranial vault growth, the extensive implantation of metal devices is potentially problematic. The use of resorbable plate and screw devices offers all of the benefits of rigid fixation without many of their potential risks. Since the introduction of resorbable plate and screw devices in 1996, tens of thousands of craniofacial patients have received implants, but long-term results from a large series have yet to be reported. A combined prospective and retrospective analysis was done on 1883 craniosynostosis patients under 2 years of age treated by 12 surgeons from seven different geographic locations over a 5-year period who used the same type of resorbable bone fixation devices (poly-L-lacticpolyglycolic copolymer). Specifically, the incidence of postoperative infection, fixation device failure, occurrence of delayed foreign-body reactions, and the need for reoperation resulting from device-related problems were determined. Technical difficulties and trends in device use were also noted. From this series, significant infectious complications occurred in 0.2 percent, device instability primarily resulting from postoperative trauma occurred in 0.3 percent, and self-limiting local foreign-body reactions occurred in 0.7 percent of the treated patients. The overall reoperation rate attributable to identifiable device-related problems was 0.3 percent. Improved bony stability was gained by using the longest plate geometries/configurations possible and bone grafting any significant gaps across plated areas that were structurally important. The specific types of plates and screws used evolved over the study period from simple plates, meshes, and threaded screws to application-specific plates and threadless push screws whose use varied among the involved surgeons. This report documents the safety and long-term value of the use of resorbable (LactoSorb) plate and screw fixation in pediatric craniofacial surgery in the infant and young child. Device-related complications requiring reoperation occurred in less than 0.5 percent of the implanted patients, which is less frequent than is reported for metallic bone fixation. Resorbable bone fixation for the rapidly growing cranial vault has fewer potential complications than the traditional use of metal plates, screws, and wires.

Easing Botox administration with EMLA cream.

The author's study demonstrates that application of EMLA cream to treatment sites significantly reduces needle pain during Botox administration. Twenty patients receiving 200 Botox injections in the glabellar area experienced a 60% reduction in pain in EMLA-pretreated sites compared with that in matched control sites.

Adipose stromal cells and platelet-rich plasma therapies synergistically increase revascularization during wound healing.

BACKGROUND: The authors examined the efficacy of adipose stem cells, when supplied either alone or in platelet-rich fibrin gels, to improve wound healing. METHODS: A porcine full-thickness wound model was used to compare six topical treatments: platelet-poor plasma; platelet-rich plasma; autologous adipose stem cells plus platelet-poor plasma; autologous adipose stem cells plus platelet-rich plasma; allogeneic adipose stem cells containing green fluorescent protein plus platelet-poor plasma; and saline (control). One week after isolation, adipose stem cells were applied to full-thickness wounds on the paraspinal and thoracic regions of three pigs (44 wounds per pig; each treatment was applied to eight separate wounds). Each wound was monitored over 21 days for closure, cosmesis, and histopathology. RESULTS: There was no significant difference in the reepithelialization rate, but treatments containing adipose stem cells demonstrated increased microvessel densities (31.75 +/- 5.73 vessels/cm2 versus 7.93 +/- 3.61 vessels/cm2) compared with groups without adipose stem cells. Wound cosmesis was improved in the adipose stem cell plus platelet-rich plasma group compared with other treatment groups (p < 0.05). Vascular endothelial growth factor levels detected in matrices containing adipose stem cells were approximately 7-fold higher compared with platelet-rich plasma or platelet-poor plasma (p < 0.05). Localization of transgenic green fluorescent protein plus adipose stem cells indicated incorporation near neovasculature. CONCLUSIONS: In normal healing wounds, adipose stem cells appear to enhance the healing process only when provided in a fibrin gel vehicle containing a number of complementary wound-healing trophic factors. Perivascular adipose stem cell localization suggests a function in enhancing blood supply through providing physical and paracrine support to newly forming vessels.

Bioabsorbable plate and screw fixation in orthognathic surgery.

This paper describes the author's 10-year experience in using resorbable polymeric plates and screws in select cases of orthognathic surgery as well as a comprehensive review of all published reports on this technology for similar applications.

An experimental study of heat adaptation of bioabsorbable craniofacial meshes and plates.

Intraoperative heating of bioabsorbable plates and mesh panels to above the glass transition temperature is commonly performed to assist their adaptation to bone. Some studies suggest that once heat-adapted, such implants under certain conditions tend to partially revert to their preadapted shape, termed a "memory effect." We investigated this phenomenon by using heat-adapted 82:18 poly-L-lactic acid:polyglycolic acid copolymer mesh panel and plate specimens with a glass transition temperature of 57 degrees C. The specimens retained limited malleability even at temperatures as low as 45 degrees C, substantially below the nominal glass transition temperature, as measured by shape relaxation experiments. At 40 degrees C to 42 degrees C, however, shape relaxation was not observed. A three-dimensional synthetic bone construct was also fixated using 90 degrees C heat-adapted plates, then incubated in a 37 degrees C buffer bath for 4 weeks, with periodic measurement of the shape of the construct. No changes in shape were recorded over this interval, suggesting that heat-adapted bioabsorbable implants forming a three-dimensional fixation network with multiple bone fragments cannot independently shape relax with the overall interconnectedness of the network ensuring its stability over time.

In vitro characteristics of a bioabsorbable suspension screw and suture system for endoscopic brow lift surgery.

The time requirement for endoscopic subperiosteal brow lift fixation is as little as 10-14 days. Many types of bioabsorbable fixation have been applied to this procedure, including bioabsorbable suture coupled with a bioabsorbable bone anchor, with excellent outcomes. Typically, the anchor and suture materials differ, each having their own hydrolytic strength loss profile. The dynamic relationship between the instantaneous state of degradation of the bone anchor and the suture components can affect fixation strength and failure mode, a poorly understood phenomenon. We examined the use of 2x5 mm PLLA-PGA (82:18) copolymer screws containing a suture eyelet in the head, paired with one of four types of bioabsorbable suture (2-0 and 3-0 Vicryl and 2-0 and 3-0 PDS-II), in a model system designed to mimic brow lift fixation. Constructs were inserted into a synthetic bone substrate and incubated in pH 7.4 buffer at 37 degrees C for up to 3 weeks, then loaded to failure. Initial failure loads were dependent upon suture size but not suture material, with 2-0 suture constructs (63-70N) failing at twice the load of the 3-0 suture constructs (30-35N). The following 3 week strength retentions were obtained: 40-55% for 2-0 and 3-0 Vicryl suture, 100% for 3-0 PDS-II suture, and 58% for 2-0 PDS-II suture constructs. The predominant failure mode was suture breakage at the knot, with the later intervals utilizing 2-0 PDS-II suture including some screw head failures. This suspension screw, when coupled with an appropriate suture, appears to have suitable mechanical properties for endoscopic brow lift fixation.

Mandibular coronoid hyperplasia in pediatric patients.

Bilateral coronoid hyperplasia is a relatively rare condition in the pediatric population and yet may be an unrecognized cause of limited mouth opening in children. There are multiple theories as to the causes of the hyperplasia, which include temporalis hyperactivity, hormonal stimulus, and genetic inheritance. The resulting excess growth of the coronoids results in impingement on the zygomatic processes leading to mandibular hypomobility. The diagnosis is confirmed with plain films and computed tomography scans. Treatment involves bilateral coronoidectomies to relieve impingement on the zygoma. Postoperative physical therapy is crucial for success; the therapy focuses on maintaining the mouth opening achieved at the time of surgery. Outcome reports have been variable despite good physical therapy, suggesting that the exact pathology of the condition is not well understood.