Foot reconstruction using free microvascular muscle flaps with skin grafts.

Free muscle flap transfer with skin graft coverage for extensive foot defects can be a successful form of foot reconstruction in well-selected patients who have overall normal foot innervation and deep pressure sensibility. Cutaneous sensibility does not appear to be necessary to maintain a functional or well-healed foot. The major reconstructive goal in plantar foot reconstruction is the restoration of weight-bearing during normal ambulation using regular foot apparel. Based on this reconstructive goal, the authors present their current approach in the reconstruction of extensive defects of the foot using free microvascular muscle flaps with skin grafts.

Optimal timing of cleft palate closure. Speech, facial growth, and hearing considerations.

We have presented an updated overview of the controversy surrounding the timing of cleft palate closure based upon the goals of cleft palate surgery: attainment of normal speech, maxillofacial growth, and hearing. From a critical analysis of the conflicting literature in these areas, we have developed our own philosophy of the cleft palate closure over the past decade that incorporates these three primary goals in the multidisciplinary care of the cleft palate patient. We feel that only through an objective, long-term, goal-oriented, prospective study of our patients will we be able to obtain realistic data in this controversial area. To date, there are no long-term, prospective, double-blind studies available in the area of cleft palate surgery. In the interim, we must objectively assess our results and, above all, adhere to the primary principle of medicine of doing no harm in the multidisciplinary management of the cleft palate patient.

Use of spreader grafts in the external approach to rhinoplasty.

The challenge for the modern rhinoplasty surgeon is to create a nose that appears natural and balances with the individual's face and ethnicity. The use of spreader grafts in endonasal rhinoplasty as described by Sheen has been expanded by the external approach to (1) straighten and buttress weakened L-struts in a high dorsally deviated septum, (2) recreate dorsal aesthetic lines, (3) reconstruct a narrow middle vault, and (4) restore the internal nasal valve. The advantages of the external approach in the use of septal spreader grafts includes ease of harvest, accurate contouring, and precise placement and suture stabilization to minimize postoperative graft displacement. The versatility of this technique allows the surgeon to attain consistent functional and aesthetic results in the management of dorsal mid-vault problems in primary and secondary rhinoplasty.

Rhinoplasty with advancing age. Characteristics and management.

The aging nose presents several unique challenges to diagnosis and management. Although classically it presents as a drooping nasal tip secondary to loss of tip support with a relative dorsal hump, there are associated changes in the nasal skin, bony architecture, and airway that mandate consideration. Methods of correction emphasize restoration of tip support with nondestructive suture techniques. Use of osteotomies is minimized. Airway patency is improved or maintained by restoring the internal nasal valve, often with dorsal spreader grafts. Finally, special consideration is given to the patients' unique expectations and motivation. Rhinoplasty in the patient with advancing age is a rewarding operative procedure if one follows the guidelines delineated here to optimize the functional and aesthetic results.

Management of the deviated nose. The importance of septal reconstruction.

The key to the correction of severely deviated noses is straightening the nasal septum. An emphasis is placed on conservative management of the external nasal framework while being prepared to perform extensive surgery on the deviated septum. If the septum can be modified and repositioned in the midline without losing support to the nose, consistently good functional and aesthetic results are obtained. Several techniques that we have found to be of value in achieving this goal have been discussed and illustrated and three representative cases have been presented.

Evolving concepts of craniomaxillofacial fracture management.

Few areas in plastic surgery have changed as rapidly as the management of complex facial fractures. This article delineates five principles governing current management of the patient with injuries of the craniomaxilloficial skeleton.

Management of frontal sinus fractures. Changing concepts.

Since the turn of the century, surgeons have handled frontal sinus fractures with a variety of different procedures. The optimal management procedure remains controversial. We have presented a graduated anatomic algorithm for treatment of frontal sinus fractures based on the degree of fracture displacement and nasofrontal duct involvement and presence of CSF leak. Nondisplaced fractures are best handled conservatively, without operative intervention. However, the majority of frontal sinus fractures require operative correction. Uncomplicated anterior table displacement with an aesthetic deformity is treated by fragment reduction and stabilization with miniplates or microplates or wires. Nasofrontal duct obstruction is usually managed by sinus obliteration with spontaneous osteoneogenesis or autologous bone grafting. Finally, comminuted, displaced anterior and posterior table fractures, especially those with persistent CSF leakage and associated nasofrontal duct involvement, are best handled with frontal sinus cranialization. The presented algorithm is simply a treatment guideline. Frontal sinus fracture management must be individualized. However, this graduated anatomic approach provides a pragmatic framework for decision making and understanding this complex and controversial topic.

Optimizing the management of orbitozygomatic fractures.

Our understanding of the biomechanics and current management of orbitozygomatic fractures has evolved with the development of craniomaxillofacial surgery. Early management was minimal, with reduction alone as the uniform treatment, and the only variation was the approach used. However, a critical review of the literature using these methods revealed that many of these fractures were unstable after simple reduction alone. Using the principles of craniofacial surgery, our clinical experience, and the data presented in this article, a pragmatic algorithm for optimizing the management of orbitozygomatic fractures is presented. Our approach to this problem has been graduated, with orbitozygomatic fractures being divided into two general categories: nondisplaced and displaced. The nondisplaced orbitozygomatic fracture is treated nonoperatively, with close patient follow-up to detect signs of malunion. Displaced fractures are openly reduced and rigidly fixed internally with mini- and/or microplates. The orbit is routinely explored, especially in high-velocity injuries. The orbit is anatomically as well as volumetrically reconstructed with bone grafts, if needed, to prevent postoperative enophthalmos.

Ultrasound-assisted lipoplasty. Basic science and clinical research.

A review of the basic science, clinical research, and clinical studies involving ultrasound-assisted lipoplasty is provided. The tissue effects of ultrasonic fragmentation are discussed as are the key elements that led to the use of ultrasound energy in medicine.

Patient evaluation and indications for ultrasound-assisted lipoplasty.

Ultrasound-assisted lipoplasty (UAL) is an important adjunctive technique to traditional lipoplasty that permits true circumferential body contouring of the trunk and thighs. Its effectiveness is realized in those patients demonstrating diminished skin tone, skin irregularities, and fibrous areas of lipodystrophy. Patient evaluation and selection, indications for UAL, and operative strategy beginning with the initial consultation are discussed.

Operative principles for optimizing results in circumferential body contouring with ultrasound-assisted lipoplasty.

The optimization of results in body contouring requires simultaneous visualization of all body regions. This goal is achieved through a circumferential and balanced surgical approach. Adjacent areas must blend together to evoke a smooth contour silhouette. The anatomic differences between men and women, patient selection, markings, access incisions, and technique must all be addressed.

Comparison of rigid plate versus wire fixation in the management of zygoma fractures: a long-term follow-up clinical study.

We evaluated retrospectively 101 patients to assess clinically the results of fixation methods on isolated unilateral zygoma fractures (mean follow-up 3.2 years). All patients were examined by an investigator who was blinded to the initial fixation method. Ninety-two patients were treated with wire or plate fixation alone. The major clinical parameters assessed were globe position abnormalities (enophthalmus and dystopia), malar projection, and cheek sensation. Rigid plate fixation achieved statistically better long-term malar symmetry (p = 0.002) and approached statistical significance in the achievement of more normal globe position (p = 0.06) compared with wire fixation alone. Cheek sensation showed a nonsignificant trend (p = 0.13) toward improvement with plate fixation. Other parameters that were evaluated were anatomic location of fixation points, number of fixation points, surgical approach and exposure, and breakdown of fixation dates by specialty. None of these factors showed any significant influence on outcome. The present study confirms what we have known to be true from our clinical experience--that rigid internal fixation is superior in minimizing or preventing long-term sequelae of facial fractures.

Frontal sinus obliteration: in search of the ideal autogenous material.

The controversies concerning obliteration of the frontal sinus in response to trauma, infection, or tumor growth are long-standing (1913 to the present) and related to the field of training of the surgeon. Successful frontal sinus obliteration requires (1) meticulous removal of the frontal sinus mucosa, (2) removal of the inner cortex of the sinus wall, and (3) permanent occlusion of the nasofrontal duct. It is significant to note that most of the clinical literature relates to management of infected sinuses (sinusitis) and most experimental studies are done on uninfected, unfractured feline models. Therefore, no direct reference can be made to the management of the fractured frontal sinus. The techniques in current use are autologous implantation of fat, bone, and muscle, along with the technique of spontaneous osteogenesis. These techniques are all effective when the preceding guidelines are followed, with the only real advantage being that the spontaneous osteogenesis avoids the problem of donor-site morbidity, which has been as high as 5 percent. This factor makes the osteogenesis technique the method of choice for frontal sinus obliteration. This literature review provides the surgeon with the objective data available for optimal frontal sinus obliteration.

Evaluation of the patient with silicone gel breast implants and rheumatic complaints.

By utilizing a systematic approach to evaluate patients with implants and musculoskeletal complaints, patients can be categorized into either those with a true connective-tissue disease (scleroderma, systemic lupus erythematosus, Sjögrens) or those with nonspecific muscle and joint findings consistent with fibromyalgia. This latter subgroup represents the majority of patients who present with musculoskeletal complaints and have no evidence of a serious connective-tissue disease. Patients with silicone gel breast implants suffer great anxiety and fear over the possible association of implants and disease. Unfortunately, most of the information provided to the patient is through the media, support groups, or the legal system. Many patients are unable to evaluate this issue in an objective fashion and present to the plastic surgeon convinced that the implants are causing their problems. Consultation with a rheumatologist interested in the silicone gel implant controversy would serve to educate the patient regarding the diagnosis, as well as provide an independent source of information regarding the relationship between implants and disease. Until proper case-control studies are performed, the controversy over silicone gel implants and connective-tissue disease will persist.

Augmentation rhinoplasty: dorsal onlay grafting using shaped autogenous septal cartilage.

We describe our experience with autogenous septal cartilage onlay grafts for augmentation of the nasal dorsum in primary and secondary rhinoplasty cases. After careful nasofacial analysis, the grafts are custom-shaped into inverted-V-frame, A-frame, or inverted-U-frame grafts, depending on the type and degree of augmentation desired. The dorsal elevation is thus tailored to fit the imperfection at hand, resulting in a smooth, natural-looking nasal contour. The indications for each type of graft are reviewed, and the surgical technique of graft harvesting and carving is detailed and illustrated.

Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery.

The use of tobacco is a significant contributor to preventable morbidity and mortality in the United States. A significant proportion of cardiovascular diseases, various oral and pulmonary neoplasms, nonmalignant respiratory diseases, and peripheral vascular disorders can be attributed to the use of cigarettes. Surgical outcomes can also be adversely affected as a result of cigarette smoking with intraoperative and postoperative pulmonary, cardiovascular, and cerebrovascular complications as well as increased wound healing complications. These are found across the entire spectrum of surgical specialties. Tissue ischemia and wound-healing impairment secondary to the influence of tobacco is particularly problematic for the plastic surgeon, especially during elective facial aesthetic procedures, cosmetic and reconstructive breast operations, abdominoplasty, free-tissue transfer, and replantation procedures. By educating and providing guidelines to those patients who smoke and by refusing to operate on individuals who fail to abstain, tobacco-associated surgical morbidity in the plastic and reconstructive surgery patient can be eliminated.

The boxy nasal tip: classification and management based on alar cartilage suturing techniques.

The boxy nasal tip is characterized by a broad, rectangular appearance of the tip lobule on basal view. This manifests anatomically as one of three types: type I, which features an increased intercrural angle of divergence (greater than 30 degrees) and normal domal arc (4 mm or less) manifesting as the tip-defining points; type II, which features an increased angulation of the domes of the lower lateral segments of cartilage, creating a widened domal arc (greater than 4 mm) and normal angle of divergence (30 degrees or less); and type III, which features a combination of increased angle of divergence (greater than 30 degrees) and widened crural domal arc (4 mm or greater). In this article, the available techniques for correction of the boxy tip are reviewed and an algorithmic approach for the management of this problem is demonstrated using the open approach to rhinoplasty. Using an individualized algorithmic approach with intraoperative nasal tip analysis and three nasal tip suture reshaping techniques, consistent aesthetic results can be obtained in the correction of the boxy nasal tip.

Preventing hairline elevation in endoscopic browlifts.

An endoscopic-assisted method of brow elevation using galea aponeurosis plication with direct suture fixation is presented. This technique does not elevate the hairline, nor is any skin or scalp resected. Dissection is easy because it is limited to the subgaleal plane of the forehead.

A simplified algorithm for the use of Z-plasty.

For the neophyte, the Z-plasty maneuver can be a surgical procedure veiled in intrigue. The theoretical mechanics of Z-plasty geometry are described, establishing that the new length of the central limb in a 60-degree Z-plasty is square root(3) of its original length. Factors such as skin tension, flap thickness, and flap location can, in application, distort the desired outcome. An algorithm is established that describes the indications and simplifies the execution of this technique.

External approach for secondary rhinoplasty.

A systematic approach, using the external rhinoplasty technique, is presented to aid the plastic surgeon in obtaining improved aesthetic and functional results in patients with postoperative nasal deformities. In over 100 external rhinoplasties, there were no problems with the stairstep transcolumellar incision used to provide complete visualization of the underlying nasal framework. The external approach allows for a more accurate intraoperative anatomic diagnosis and subsequent complete correction of the nasal deformity. Three case reports are presented to demonstrate the indications and versatility of the external approach in secondary rhinoplasty.