Evaluating the length, diameter, and stenosis of deep circumflex iliac artery and neighboring arteries based on digital subtraction angiography.

BACKGROUND: The vascularized iliac bone crest flap offers excellent usable bone in terms of volume and quality. Its nourishing vessel, the deep circumflex iliac artery (DCIA), although relatively short, is reliable vessel. Digital subtraction angiography presents still the gold standard for diagnostic purpose. However, computed tomography (CT) and magnetic resonance imaging (MRI) angiography is used for preoperative planning with low morbidity. The purpose of this study is to evaluate the gainable information using digital subtraction angiography (DSA) as compared to other imaging modalities. MATERIALS AND METHODS: We evaluated information gainable from standard DSA of 130 consecutive patients (average age was 69.5 years [range 18-90 years]) concerning topography, dimension, and condition of the vessel wall. We looked for differences considering gender and side. RESULTS: DCIA could not be followed in the periphery constantly in all cases due to the small, illustrated field. Arteriosclerotic changes showed to be very low in DCIA as compared to the neighboring vessels. Diabetes mellitus and smoking had a significant impact on vessel condition. DCIA branched off into its main two branches early after 40 mm (11%), after 40-60 mm (30%), or late after 60 mm (59%). DCIA showed to be least affected by different risk factors that reported to affect the vessel condition. CONCLUSIONS: We present additional detailed topographic anatomy of DCIA and its variation that can be used intraoperative guide to harvest the flap and teaching purpose. Standard DSA delivers valuable preoperative data regarding stenosis in addition to the topographic anatomy of the flap pedicle. However, imaging of the distal parts of the DCIA, nourishing the skin paddle is limited by the detector field used. For a full imaging of both DCIAs from the origin to the perforators, the intraarterial injection of contrast medium, as applied in DSA, could be combined with different imaging modalities like CT-angiography.

Comparison of Bone Formation After Sinus Membrane Lifting Without Graft or Using Bone Substitute "Histologic and Radiographic Evaluation".

PURPOSE: Sinus floor elevation without using autogenous bone graft or bone substitute will eliminate donor site morbidity and reduce the cost and the risk of infection. We evaluated the bone gain after sinus membrane elevation without graft or using bone substitute in the same maxilla. Dental implants were inserted simultaneously as a 1-stage procedure. PATIENTS AND METHODS: In a split-mouth design, we conducted a randomized double-blinded clinical trial performing sinus lifts and simultaneous implant insertion in 10 healthy patients (n = 20). On the 1 site, we performed graft-less sinus lift (group 1) and on the other site Cerabone was used as bone substitute (group 2), respectively. The quantity and quality of bone gained in each sinus were evaluated and compared radiologically and histomorphometrically. RESULTS: After 6 months, the average gain of bone height was 6.21 and 9.58 mm in group 1 and 2, respectively, as measured radiologically (P < .001, P < .001). Histomorphometric examination showed significantly higher thickness of trabeculae and bone formation in group 1 (P = .003 and P = .002). However, the neovascularization was higher, but not significantly (P = .288). CONCLUSIONS: Radiological bone gain was similar in both groups. However, histomorphometric examination showed superior bone formation in graft-less group as compared to the Cerabone group. The blood clot seems to be an adequate filler and excellent medium for bone formation. More studies in split-mouth design are needed to compare different bone substitutes.

Patient-Specific Topographic Anatomy of the Deep Circumflex Iliac Artery Flap: Comparing Standard and Modified Computed Tomographic Angiography.

PURPOSE: Computed tomographic angiography (CTA) is reported to give insight into patient-specific anatomy of the flap pedicle preoperatively. We compared information available from standard CTA (s-CTA) with that gained by modifying the conventional CTA technique (modified CTA [m-CTA]). Dissected cadavers served as the control group. MATERIALS AND METHODS: We evaluated 16 s-CTA scans (32 deep circumflex iliac arteries [DCIAs]) and 12 m-CTA scans (17 DCIAs) using 3-dimensional software (Vesalius; ps-medtech, Amsterdam, The Netherlands). We dissected 17 cadavers (n = 34 DCIAs) to serve as the control group. The positions of 4 landmarks (anterior superior iliac spine, origin of DCIA, origin of ascending branch, and crossing of horizontal branch and iliac crest) were defined in a 3-dimensional coordinate system. RESULTS: We found significant differences concerning the distances from the origin of the DCIA to the femoral bifurcation (P < .05) and the anterior superior iliac spine to the crossing point of the horizontal branch with the iliac crest (P < .05) between CTA scans and cadaveric studies. The imaging quality of the m-CTA scans was shown to be more consistent than and superior to that of the s-CTA scans. The visible length of the DCIA was longer on m-CTA scans (mean, 134.32 mm) than on s-CTA scans (mean, 73.62 mm). We could evaluate the branching off of perforators and the relation of the pedicle to the surrounding bone and soft tissue in more detail on m-CTA scans. Standard CTA allowed the bilateral evaluation of the pedicle, whereas m-CTA allowed the evaluation of the injected side only. CONCLUSIONS: The quality and quantity of information available from CTA could be improved by modifying the s-CTA examination by injection as close as possible to the target vessel. Standard CTA delivered information about both sides, whereas m-CTA may need an additional injection for contralateral-side imaging.

Three-Dimensional Analysis of the Ear Morphology.

BACKGROUND: For surgical treatment of the face, detailed surgical planning is necessary to avoid later unaesthetic results. Most of the studies in the literature concentrate on the ears' anatomy during childhood and adolescence. Nearly no study evaluates the anatomy of ears of people aged 50 or older. It was our aim to measure and evaluate the ear's anatomy in Caucasians between the ages of 21 and 65. METHODS: Three-dimensional scans of 240 volunteers were taken. The subjects were divided into groups of males and females and each of them into three groups by age (21-35, 36-50, 51-65). Landmarks were placed in these scans. Distances, relations and angles between them were recorded. RESULTS: The distance between the subaurale and superaurale significantly increases (p < 0.001) during the aging process in males and females. Also, the width of the ear, measured between the preaurale and postaurale, significantly increased (p = 0.007) with advancing age. When the length of the ear is divided into four parts by anatomical landmarks, it extended the most in the lower quadrant with increasing subject age. CONCLUSION: The ear of Caucasians does not stop changing its shape during adulthood. Even after the body has stopped growing, the ear still does. With the measured values in this study, it should be possible for the surgeon to plan the operation in advance and achieve satisfactory aesthetic outcomes. LEVEL OF EVIDENCE V: 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 .

Comparison of the Effect of Dexamethasone and Tranexamic Acid, Separately or in Combination on Post-Rhinoplasty Edema and Ecchymosis.

BACKGROUND: Dexamethasone and tranexamic acid are used to decrease post-rhinoplasty periorbital edema and ecchymosis. We compared the impact of each medication separately or in combination in this regard. METHODS: A prospective, randomized triple-blinded study was undertaken on 60 patients who underwent primary open rhinoplasty. They were divided into four groups: Group D (n = 15) received 8 mg dexamethasone, group T (n = 15) received 10 mg/kg tranexamic acid, group DT (n = 15) received both 8 mg dexamethasone and 10 mg/kg tranexamic acid, and group P (n = 15) received neither medication and served as the placebo control group. The medications were given intravenously (IV) 1 h before and three doses every 8 h postoperatively. Digital photographs were taken on the first, third and seventh postoperative days. One expert examiner blinded to the study evaluated the periorbital edema and ecchymosis on a scale of 0-4. Periorbital edema and ecchymosis were examined in all groups. RESULTS: In group D, group T and group DT, periorbital edema and ecchymosis ratings were significantly lower compared with the control group (p < 0.01). No statistically significant difference was seen in preventing or decreasing both periorbital edema and ecchymosis among group D, group T and group DT. CONCLUSION: Tranexamic acid and dexamethasone, separately or in combination, had similar effects in reducing periorbital edema and ecchymosis in open rhinoplasty. Combined application did not show a significantly higher beneficial effect in this regard. LEVEL OF EVIDENCE III: 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 .

Two-Step Reconstruction of Non-Marginal Auricular Defects.

PURPOSE: Auricular reconstruction is an extensively discussed topic in facial reconstructive surgery and poses an immense challenge to the reconstructive surgeon. This report describes a 2-stage technique to repair non-marginal full-thickness defects of the auricle. MATERIALS AND METHODS: Thirteen patients underwent surgery after partial to complete loss of the auricular concha using an improved and refined method. Tissue from the pre- and retroauricular regions was used to replace nonhelical auricular tissue loss in 2 surgical steps. All procedures were performed in an ambulatory setting using local anesthesia. RESULTS: All 13 patients (age range, 37 to 82 yr; mean age, 68 yr; 4 women and 9 men) had excellent esthetic outcomes with low surgical morbidity and were satisfied with the achieved results. No flap necrosis was observed. Auricular vertical and horizontal dimensions changed minimally (0 to 4 mm). A tension-free closure of the donor-site defects could be achieved primarily. CONCLUSION: The present method uses 2 separate donor sites to reconstruct centrally located full-thickness defects of the auricle. It is straightforward to perform, minimizes the surgical steps required, shows excellent outcomes, and allows easier closure of the donor site because of the distribution of the harvested tissue.

Histopathological Differences of the Pedicle Artery in Commonly Used Free Flaps: The Influence of Age, Gender, and Side.

PURPOSE: The increasing use of vascularized free flaps has increased the demand for a specified flap selection. This study investigated histologic differences in the arterial wall of the pedicle for commonly used free flaps and the effect of age, gender, and anatomic side on these differences. MATERIALS AND METHODS: Light microscopic examinations of vessel walls were performed on 245 specimens of the nourishing artery of commonly used free vascularized flaps in preserved cadavers. The peroneal artery (PA), radial artery (RA), inferior epigastric artery (IEA), deep circumflex iliac artery (DCIA), and circumflex scapular artery (CSA) were examined. Differences of histologic changes in the arterial wall and the effect of age, gender, and body side were investigated. RESULTS: All examined vessel specimens (age range, 62 to 98 yr; mean age, 83 yr; 15 female and 12 male) displayed mostly Class II changes. PA showed the greatest atherosclerotic changes, followed by the RA, IEA, DCIA, and CSA. Age had a meaningful effect on PA and RA. Anatomic side was important for PA and DCIA, whereas gender had a minor influence on vessel condition. CONCLUSION: The vessel wall of different flaps showed different atherosclerotic changes depending on age, anatomic side, and gender. These differences should be considered in flap selection.

Acellular Dermal Graft in Secondary Cleft Lip Deficiencies: Assessment of Results With a Reproducible Quantitative Technique.

PURPOSE: Considering the little evidence around acellular dermal graft application in secondary lip reshaping, this study is aimed to quantitatively examine the effect of acellular dermal graft in combination with Z-plasty technique in secondary defects of cleft lip. METHODS: In this clinical investigation, patients with secondary unilateral cleft lip deformity were selected. Standard photographs were prepared for each patient. Subsequent to scar revision, submucosal tunneling and Z-plasty, implantable human acellular dermal graft was placed and fixed in submucosal pocket. Quantitative parameters included angle of symmetry , dimension of symmetry (DS), defect height (DH), parallel lines, and lip thickness were measured presurgically and 1 year after treatment. Pre and post-operative pictures were compared and the changes were documented according to the criteria. P value less than 0.05 were considered as significant. RESULTS: Eighteen patients were included in this study. The difference of "DS" between normal side and cleft side was 3.1 ± 1.5 mm presurgically and 1.1 ± 1.8 mm postsurgically. The change was significant (P value < 0.05). The difference between pretreatment and posttreatment measures of "DS", "DH", and "Lip Thickness" were 2.75 ± 4.55, 3.43 ± 4.82, and 2.66 ± 3.04 mm, respectively. The results were significant (P value<0.05). CONCLUSIONS: Based on the results, acellular dermal graft in combination with Z-plasty was able to improve lip deformity in patients with secondary defects of cleft lip. Further studies are recommended regarding the application of this technique in patients with bilateral cleft lip and severe "DH."

Regions of ilium and fibula providing clinically usable bone for mandible reconstruction: "A different approach to bone comparison".

A variety of donor sites are available for mandibular reconstruction. We present here a different way of comparing two commonly-used bone flaps. The lengths of the usable parts in a total of 241 coxal bones, 91 mandibles and 60 fibulas were measured. The mandible was measured from condyle-to-condyle and the harvestable bone length (HBL) and usable (UBL) bone lengths in fibula and ilium were also measured. The bone thickness (BT) in 60 iliac crests was measured in two parallel lines from the anterior superior iliac spine (ASIS) along the iliac crest. The mandible was 32.17 mm shorter in females than in males. The total ilium UBL was 171.12 mm in females and 178.80 mm in males. The mean HBL of the fibula was 22.6 mm shorter in females than in males. However, in some fibulas in both females and males, only 4.2% and 21.1% of the HBL respectively could be used if the ultimate goal was to insert dental implants. We found significant correlations between BT and gender in both fibula and ilium (P≤ 0.05). The ilium offers constant BT throughout the usable bone area with a similar bone length to the fibula. In contrast, the fibula showed variable bone dimensions, so not all of it is clinically usable. This should especially be considered in females when a mandibular reconstruction is planned with the goal of occlusal rehabilitation. Clin. Anat. 29:773-778, 2016. © 2016 Wiley Periodicals, Inc.

The use of mobile 3D scanners in maxillofacial surgery.

There are many possibilities for the use of three-dimensional (3D) scanners in maxillofacial surgery. This study aimed to investigate whether the bundling and syncing of two 3D scanners has advantages over single-scanner acquisition in terms of scan quality and the time required to scan an object. Therefore, the speed and precision of 3D data acquisition with one scanner versus two synced scanners was measured in 30 subjects. This was done by analyzing the results obtained by scanning test objects attached to the forehead and cheeks of the subjects. Statistical methods included the Student t test for paired samples. Single-scanner recording resulted in significantly lower mean error of measurement than synced recording with two scanners for length (P < 0.001), all frontal/lateral plane angles (P = 0.034, P < 0.001, P = 0.002, P = 0.003), and side/side plane angles (P = 0.014, P < 0.001, P = 0.015, P = 0.011) of the test object on the cheek. Likewise, the single-scanner method resulted in a significantly lowermean error of measurement than the two-scanner method for frontal/lower plane angles (P < 0.001), right/lower plane angles (P < 0.001), and left/lower plane angles (P = 0.002). Conversely, synced recording of data with two scanners resulted in a significant reduction of scanning time (P < 0.001). Compared to data acquisition with a single 3D scanner, the bundling of two 3D scanners resulted in faster scanning times but lower scan quality.

Repairing a non-marginal full-thickness auricular defect using a reversed flap from the postauricular area.

PURPOSE: Different methods for auricular reconstruction have been introduced over time. To minimize stress on the flap and offer an excellent wound control, the anterior pedicled retroauricular flap (APRF) was described in 2012. It offers an excellent alternative for reconstructing different parts of the ear helix. The authors also apply the APRF to repair centrally located perforating defects of the ear. MATERIALS AND METHODS: The APRF was used to reconstruct nonhelical full-thickness defects of the auricle in 11 patients. The operations were performed under local anesthesia and in an ambulatory setting in 3 operative steps. RESULTS: The repair of full-thickness conchal defects was successfully performed in 11 patients, with good esthetic outcome, minimal donor site morbidity, and high patient satisfaction. CONCLUSION: An APRF from the postauricular area is a simple and effective method to reconstruct a full-thickness non-marginal auricular defect.

The short-term effects of face mask and fixed tongue appliance on maxillary deficiency in growing patients--a randomized clinical trial.

BACKGROUND: The purpose of this single blind, prospective, parallel randomized trial study was to compare the effects of face mask and fixed tongue appliance in treatment of Class III malocclusion with maxillary deficiency in growing patients. METHODS: 88 patients with maxillary deficiency were selected. 60 fulfilled the study requirements. The patients were randomly assigned to 2 groups by computer generated tables. One group was treated with removable face mask and the other group was treated by fixed tongue appliance. 4 of the patients dropped out of study leaving a final number of 56 patients. Thus, the face mask group included 30 patients (13 males, 17 females) with the mean age of 8.5 (SD 1.4) years and the fixed tongue appliance group included 26 patients (13 males, 13 females) with the mean age of 8.9 (SD 1.7) years. The patients Lateral cephalograms obtained at the beginning and end of the study were analyzed. RESULTS: Paired t-tests showed that SNA increased by 1.3° (SD 1.1°) in face mask group (P<0.001) and it increased by 1.8° (SD 0.9°) in fixed tongue appliance group (P<0.001). T-test showed that there were no statistically significant differences between the two groups except for SNB. IMPA decreased significantly in both groups. CONCLUSIONS: Both treatment modalities were successful in moving the maxilla forward and improving the profile of the patients; however, the bulky size of face masks might reduce patients' compliance and make them less favorite choice of treatment.

Management of perforations of the nasal septum: can extracorporeal septoplasty be an effective option?

PURPOSE: Perforation of the nasal septum is a frustrating problem frequently reported in the literature. Surprisingly, in most reports, iatrogenic perforation during septoplasty and electrocautery are the leading causes of this complication. This article presents the management of septal perforations and the indications for an extracorporeal approach. MATERIALS AND METHODS: Fourteen patients with septal perforations were referred for treatment. Treatment was chosen based on defect size. Flaps, extracorporeal repair, or no treatment was used as indicated. RESULTS: Two of 14 perforations were small and were repaired by local flaps, 5 cases were treated by extracorporeal repair, and the 7 remaining cases required no surgical procedure. CONCLUSIONS: The extracorporeal technique, when indicated, can be used effectively for the repair of nasal septum perforations in selected cases.

Enoxaparin prevents steroid-related avascular necrosis of the femoral head.

Nontraumatic osteonecrosis of the femoral head is still a challenging problem in orthopedic surgery. It is responsible for 10% of the 500,000 hip replacement surgeries in the USA and affects relatively young, active patients in particular. Main reasons for nontraumatic osteonecrosis are glucocorticoid use, alcoholism, thrombophilia, and hypofibrinolysis (Glueck et al., 1997; Orth and Anagnostakos, 2013). One pathomechanism of steroid-induced osteonecrosis is thought to be impaired blood flow to the femoral head caused by increased thrombus formation and vasoconstriction. To investigate the preventive effect of enoxaparin on steroid-related osteonecrosis, we used male New Zealand white rabbits. Osteonecrosis was induced by methylprednisolone-injection (1 × 20 mg/kg body weight). Control animals were treated with phosphate-buffered saline. Treatment consisted of an injection of 11.7 mg/kg body weight of enoxaparin per day (Clexane) in addition to methylprednisolone. Four weeks after methylprednisolone-injection the animals were sacrificed. Histology (hematoxylin-eosin and Ladewig staining) was performed, and empty lacunae and histological signs of osteonecrosis were quantified. Histomorphometry revealed a significant increase in empty lacunae and necrotic changed osteocytes in glucocorticoid-treated animals as compared with the glucocorticoid- and Clexane-treated animals and with the control group. No significant difference was detected between the glucocorticoid and Clexane group and the control group. This finding suggests that cotreatment with enoxaparin has the potential to prevent steroid-associated osteonecrosis.

Osteotomy of the nasal wall using a newly designed piezo scalpel--a cadaver study.

PURPOSE: Achieving the desired outcome in rhinoplasty depends on many factors. Osteotomy and adjustment of the lateral nasal wall are important steps that necessitate careful planning and execution. A cadaver study was performed to evaluate the osteotomy result obtained with a newly designed piezoelectric-based scalpel. MATERIALS AND METHODS: Twenty lateral osteotomies of the nasal wall were performed in 10 human cadaver noses. The osteotomies were conducted in 6 female and 4 male cadavers (age range, 65 to 83 yr; mean age, 74.8 yr). A specially designed Piezosurgery-based scalpel was used endonasally to perform the lateral osteotomy. Cutting of the bony nasal wall was performed subperiostally along the planned osteotomy route under tactile control. Digital infracturing was accomplished by applying gentle pressure. After completing the osteotomy, the osteotomy line and nasal mucosa were examined endoscopically. The skin cover was removed to examine the lateral bony nasal wall for the shape and amount of bone fragments, the osteotomy path, and mucosa involvement. RESULTS: Using the Piezosurgery-based scalpel required a learning curve, but the handling was easy. It allowed an exact performance of the osteotomy and caused no mucosal tearing. If excessive force was used, the piezo tip stopped working. There was no comminuted fracture pattern and the lateral nasal wall remained in 1 piece. The duration of the osteotomy was 5 to 10 minutes on each side. CONCLUSION: The piezoelectric-based scalpel is a useful tool, which can be used to perform osteotomy of the nasal wall. In addition, this specifically designed tool tip allows an endonasal approach, is easy to handle, and allows effective irrigation of the osteotomy region.

Esthetic outcome after soft tissue reconstruction of the face using deep dissection and composite facelift technique.

PURPOSE: Large defects in the face resulting from the excision of malignant tumors, trauma, and congenital malformation pose a significant challenge to reconstructive surgeons. Achieving good esthetic and functional outcomes is often very demanding. PATIENTS AND METHODS: A facelift technique was used in 47 patients (25 female, 22 male; age range, 17.5 to 82.3 years; mean age, 49.3 years) to replace lost tissue of the face from 2009 through 2012. The minimum defect size was 2 cm in diameter and the maximum was 8 cm. To achieve tension-free coverage with a reliable blood supply, a deep-plane dissection, including the skin and superficial musculoaponeurotic system (SMAS), was performed. The deep sub-SMAS dissection was extended into the neck and the contralateral part, as needed. A thick flap was created and composite lifting was performed. RESULTS: No significant deformity concerning the lower eyelids, nose, and lip was registered. Most scars could be placed in hidden regions and became undetectable after a year. The facial nerve function remained intact in all patients. CONCLUSION: Using these facelift techniques, including the incision, sub-SMAS dissection for volumetric positioning of the skin, and the SMAS flap, the closure of extensive facial defects with excellent functional and esthetic results is conceivable.

Surgical management of auricular defect depending on the size, location, and tissue involved.

PURPOSE: Auricular reconstruction is a challenging surgical intervention that requires perfect surgical skills, exact planning, and esthetic knowledge. It is necessary to use a suitable method of reconstruction for each patient. From 10 years of experience, the authors have developed a general concept for auricular reconstruction. PATIENTS AND METHODS: Seventy-five patients (62 male, 13 female; age range, 8 to 92 yr; mean age, 65.9 yr) underwent partial to total auricular reconstruction. Tissue loss occurred from different causes: 19 cases of squamous cell carcinoma (25.3%), 18 cases of basal cell carcinoma (24%), 14 cases of Bowen disease (18.7), 11 cases of malignant melanoma (14.7%), 7 cases of trauma (9.3%), 3 different malignant tumors (4%), and 3 cases of congenital deformity (4%). RESULTS: Defects smaller than one fourth the vertical auricular size (15 to 20 mm) could be treated by primary closure. A larger defect closed by this method caused visible deformity. In defects larger than one to three fourths the vertical auricular size (40 to 55 mm), a reversed retroauricular flap was used successfully if there was no contraindication or rejection. This flap can be combined with other flaps, depending on the flap location, size, and tissue involved. In defects exceeding three fourths the vertical auricular size, an implant-retained prosthesis was preferred. CONCLUSION: The location and size of a defect, the medical condition of the patient, and the desired esthetic outcome play an important role in choosing the appropriate method. According to the authors' experience, the only contraindications for the reversed retroauricular flap are medical condition, poor prognosis, and patient refusal.

Microsurgical free flap reconstructions of head and neck region in 406 cases: a 13-year experience.

PURPOSE: The reconstruction of extended soft tissue and bony defects in the maxillofacial region with microsurgical flaps is considered to be the therapy of first choice. The aim of this retrospective study was to detect different influencing factors concerning flap survival. MATERIALS AND METHODS: We examined the data of 406 patient cases (121 female and 285 male cases; mean age, 57 years) undergoing reconstruction with a microsurgical flap in our facility between 1998 and 2010. In these cases 326 soft tissue flaps (radial forearm flap, scapula flap, latissimus dorsi flap, anterolateral thigh flap, lateral arm flap, and jejunum flap) and 80 bony flaps (fibula flap and deep circumflex iliac artery flap) were examined. Evaluated parameters were, among others, the timing of reconstruction, defect localization, and recipient vessels used (external vs internal jugular system), as well as anticoagulative management. We statistically analyzed data by means of a χ(2) test, taking account of the odds ratio with P < .05, which was deemed significant. RESULTS: The overall flap survival rate was approximately 92%, without any gender- or age-specific differences. Primary reconstructions proceeded distinctly more successfully than secondary reconstructions (P < .01). Likewise, the defect localization exerted a significant effect on the survival rate (P = .01), with a more caudal localization affecting flap survival positively. Finally, neither the anticoagulation regimen nor the choice of recipient vein system exercised an influence on the survival rate. CONCLUSIONS: Microsurgical tissue transfer is a convenient and reliable method in maxillofacial surgery, provided that one is aware of the determining factors for success.

Variants of the supplying vessels of the vascularized iliac bone graft and their relationship to important surgical landmarks.

The iliac bone crest is one of the most valuable regions for harvesting bone grafts, both vascularized and nonvascularized. Since the first commendable description of this region as a possible source for vascularized bone flaps by Taylor, little relevant information concerning the variations of the deep circumflex iliac vessels and their relationship to the neighboring structures has been published. The purpose of the current study was to examine this region clinically and anatomically, taking into consideration the former description by Taylor. We gathered all our findings on 216 iliac regions and proposed a new classification. In addition we measured the relationships between the deep circumflex iliac artery and important surgical landmarks. A comparison of our finding with other studies showed similarities and differences but was far more complete. Generally (92%) the deep circumflex iliac artery (DCIA) originated from external iliac artery (EIA) behind the inguinal ligament (IL) and passed cranio-laterally toward the anterior superior iliac spine, where it divided into two important branches. Four variations were observed of the DCIA. The deep circumflex iliac vein (DCIV) ran over (82.5%) or under (17.5%) the EIA. The superficial circumflex iliac vein (SCIV) was observed draining into the DCIV in some dissections. Three different variations of the superficial circumflex iliac artery (SCIA) were observed. The anatomical knowledge of these variations and their correlation to important surgical landmarks can help in harvesting the DCIA flap more safely and thus increasing the success rate while reducing donor site morbidity.

The intraoral approach to lateral osteotomy: the role of a diamond burr.

UNLABELLED: Lateral osteotomy is one of the most traumatic but critical steps in rhinoplasty and can dictate the aesthetic and functional outcomes. Many techniques and instruments to perform it have been suggested, with the objectives of increasing predictability, reliability, and easiness of this invasive approach. We used a 1.5-mm diamond burr via an intraoral approach to thin out the base of the nasal wall along the nasofacial crease in 24 patients. This technique was performed in patients seeking primary rhinoplasty (n = 6), correction of cleft nose deformities (n = 4), deformities due to trauma (n = 9), and secondary nose correction (n = 5). A high mucosal incision paranasally allowed easy access to the osteotomy line. The digital in-fracturing could be performed with light pressure and without extensive manipulation at any time during the rhinoplasty. The osteotomy took on average of 14.5 min (range = 11.00-19.80) and endoscopic examination showed no mucosal tearing. Postoperative swelling and hematoma were comparable to those of other techniques. Using a diamond burr via an intraoral approach is an easy, safe, and reliable method leading to predictable outcomes. LEVEL OF EVIDENCE V: 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 http://www.springer.com/00266 .