Incidence of cleft palate fistula: an institutional experience with two-stage palatal repair.

The purpose of this study was to determine the incidence of cleft palatal fistula in a series of nonsyndromic children treated at the authors' institution. This retrospective analysis of 103 patients with cleft palate treated by five surgeons between 1982 and 1995 includes 60 boys and 33 girls, whose median age was 18.4 months at the time of surgery. The median length of follow-up was 4.9 years after primary palatoplasty. Cleft palatal fistula was defined as a failure of healing or a breakdown in the primary surgical repair of the palate. Intentionally unrepaired fistulas of the primary and secondary palate were excluded. Extent of clefting was described according to the Veau classification. Statistical examination of multiple variables was performed using contingency table analysis, multivariate logistic regression, and the Wilcoxon rank sum test. The incidence of cleft palatal fistula in this series was 8.7 percent. All of these fistulas were clinically significant. The rate of fistula recurrence was 33 percent. The incidence of cleft palatal fistula when compared by Veau classification was statistically significant, with nine fistulas occurring in patients with Veau 3 and 4 clefts and no fistulas occurring in patients with Veau 1 and 2 clefts (p = 0.0441). No significant differences between patients with and without fistulas were identified with respect to operating surgeon, patient sex, patient age at palatoplasty, type of palatoplasty, and use of presurgical orthopedics or palatal expansion. All three recurrent fistulas occurred in the anterior palate, two in patients with Veau class 3 clefts and one in a patient with a Veau class 4 cleft. The low rate of clinically significant fistula was attributed to early delayed primary closure, with smaller secondary clefts allowing repair with a minimum of dissection and disruption of vascularity.

Primary correction of the unilateral cleft nasal deformity.

An 18-year experience with the management of the unilateral cleft nasal deformity in 1200 patients is presented. A primary cleft nasal correction was performed at the time of lip repair in infancy; a secondary rhinoplasty was done in adolescence after nasal growth was complete. The technical details of the authors' primary cleft nasal correction are described. Exposure was obtained through the incisions of the rotation-advancement design. The cartilaginous framework was widely undermined from the skin envelope. The nasal lining was released from the piriform aperture, and a new maxillary platform was created on the cleft side by rotating a "muscular roll" underneath the cleft nasal ala. The alar web was then managed by using a mattress suture running from the web cartilage to the facial musculature. In 60 percent of cases, these maneuvers were sufficient to produce symmetrical dome projection and nostril symmetry. In the other 40 percent, characterized by more severe hypoplasia of the cleft lower lateral cartilage, an inverted U infracartilaginous incision and an alar dome supporting suture (Tajima) to the contralateral upper cartilage were used. Residual dorsal hooding of the lower lateral cartilage was most effectively managed with this suture. This primary approach to the cleft nasal deformity permits more balanced growth and development of the ala and domal complex. Some of the psychological trauma of the early school years may be avoided. Also, because of the early repositioning of the cleft nasal cartilages, the deformity addressed at the time of the adult rhinoplasty is less severe and more amenable to an optimal final result.

Porous hydroxyapatite granules for alloplastic enhancement of the facial region.

Hydroxyapatite is a biocompatible alloplast with the same chemical composition as bone. It is readily incorporated into host bone, does not undergo appreciable resorption, does not incite a clinically significant foreign body reaction, and resists infection. This article describes forms of hydroxyapatite, procedures for use, and clinical examples.

Optimal timing of cleft palate closure.

Treatment objectives for the cleft palate patient--normal speech, normal maxillofacial growth, and normal hearing--are closely related. Controversy about the timing of cleft palate surgery is directed at the need for early palatoplasty for improved speech and hearing versus delayed hard palate repair for undisturbed facial growth. This controversy as to the value of early versus delayed closure continues into the present. The authors present an updated argument regarding this controversy along with a comprehensive literature review. They also present a logical algorithm based on the literature and their personal experience.

Total soft-tissue reconstruction of the middle and lower face with multiple simultaneous free flaps in a pediatric patient.

A 2-year-old boy sustained a massive facial soft-tissue wound secondary to a dog attack. Essentially all the soft tissues of the face were absent, including innervation and intraoral lining. We describe the reconstruction of this defect with five simultaneous free tissue transfers. To our knowledge, this is the first report of five simultaneous free flaps in any patient.

Cleft lip: unilateral primary deformities.

The understanding and management of all aspects of unilateral cleft lip deformities continue to evolve. Just as we are entering the era of exciting advances in the understanding of the pathogenesis of craniofacial disorders, expansion of our understanding of the dynamic relationships of the structural and soft-tissue components of cleft deformities has assisted surgeons in achieving progressively improved and consistent outcomes for these patients. The anatomic and physiologic complexity of unilateral cleft lip deformities has been recognized for centuries, and generations of researchers have cumulatively contributed to our current understanding. This article examines the history, classification, anatomy, and controversies in the surgical management of unilateral cleft lip deformities, allowing surgeons to formulate a reasoned, longitudinal management plan for their patients on the basis of the available current data.

Long-term assessment of CO2 facial laser resurfacing: aesthetic results and complications.

Several series have documented the ability of the carbon dioxide laser to smooth facial rhytids; however, follow-up has been limited to several months. Since 1995, more than 600 full or partial facial resurfacings were performed with the pulsed CO2 laser. To assess the long-term efficacy and safety of this procedure, the results of 211 resurfacings were retrospectively reviewed using a custom-designed database. Variables that were input included patient demographics, Fitzpatrick skin type, smoking history, prior and concurrent facial procedures, laser pass data, and postoperative complications. Short and long-term aesthetic results were graded by a blinded panel of plastic surgery reviewers (none of whom performed the laser resurfacing) using a standardized photographic rhytid scale. For each facial region, this scale consisted of eight high-resolution photographs depicting increasingly severe wrinkling. Facial rhytids were almost completely ablated at the 3 and 6 month follow-up. Some relapse was seen at 1 year, but the overall aesthetic result remained very good. Regions with dynamic rhytids (e.g., the perioral region) showed more recurrence. The best and most durable results were seen in the cheeks. Infection and scleral show each occurred in 13 patients (6 percent). Forty-five patients (21 percent) developed postprocedure hyperpigmentation, but the overwhelming majority of this group were treated before our postoperative antipigment regimen. Hypopigmentation was noted in 17 patients (8 percent) in this early follow-up group. Two patients (1 percent) developed postoperative scarring. It is hoped that these data will serve to provide additional information on the long-term results of laserbrasion.

Maxillary reconstruction: functional and aesthetic considerations.

Maxillary reconstruction is a challenging endeavor in functional and aesthetic restoration. Given its central location in the midface and its contributions to the key midfacial elements--the orbits, the zygomaticomaxillary complex, the nasal unit, and the stomatognathic complex--the maxilla functions as the keystone of the midface and unifies these elements into a functional and aesthetic unit. Maxillary defects are inherently complex because they generally involve more than one midfacial component. In addition, most maxillary defects are composite in nature, and they often require skin coverage, bony support, and mucosal lining for reconstruction. In the reconstruction of maxillary defects secondary to trauma, ablative tumor surgery, or congenital deformities, the following goals must be met: (1) obliteration of the defect; (2) restoration of essential functions of the midface, such as mastication and speech; (3) provision for adequate structural support to each of the midfacial units; and (4) aesthetic reconstruction of the external features. This review will discuss the pertinent anatomic considerations, the historical approaches to maxillary reconstruction, and the merits of the techniques in use today, with an emphasis on state-of-the-art reconstruction and dental rehabilitation of extensive maxillary defects.

Correction of the crooked nose.

Correcting the crooked nose remains one of the most challenging problems in rhinoplasty. When faced with a twisted nose, rhinoplasty surgeons tend to be divided into those who perform an anatomic reconstruction and those who prefer camouflage techniques. Regardless of the approach used, the revision rate remains fairly high. An anatomic correction of the twisted nose through an open approach was performed. The septum was freed from the extrinsic forces of the deformed nasal bones and upper and lower lateral cartilages. The residual true septal injury was then evaluated. The septal deformity was addressed through quadrangular cartilage resection, repositioning of the caudal septum in the anatomic midline, and correction of the dorsal septal deformity with horizontal control sutures. The skeletal support was then reconstructed with the use of a spreader-extension graft on the concave side and a batten graft on the opposite side. The nasal tip was set relative to the dorsum by fixation to the extension grafts. Residual lateral crus deformities were corrected by a combination of lateral crural spanning sutures or alar spreader grafts. With this approach, straightening the crooked nose without compromising skeletal support or nasal aesthetics was successful.

Fever after craniofacial surgery in the infant under 24 months of age.

A retrospective review was undertaken of 126 consecutive craniofacial procedures involving a transcranial component, performed at the Children's Medical Center at Dallas, between 1990 and 1994. Standard postoperative axillary temperature measurements were recorded until discharge. Age at surgery of less than 24 months correlated very strongly with a postoperative temperature of greater than 38 degrees C (r = -0.92). The incidence of postoperative fever was high in all age groups, yet there was still a significant difference between the group younger than 2 years and the group in which surgery was performed after the age of 2 years across all postoperative temperature ranges, from >38 degrees C to >39.5 degrees C (p < 0.001, chi-square test). The white blood cell count was elevated above the age-related normal in 67 percent of febrile patients. There was no correlation between type or duration of surgical procedure, length of intensive care or hospital stay, or the need for blood transfusion and the development of a significant postoperative fever. There were minor infectious complications in four patients (3 percent), only one of which was a wound problem related to the surgery. All infectious complications were easily identifiable clinically. There was no mortality or serious infections. The development of postoperative fever, and an elevated white blood cell count, is to be expected in pediatric patients undergoing craniofacial procedures. The routine laboratory investigation of postoperative fever in pediatric craniofacial patients under 2 years of age without procedures involving transgression of the paranasal sinuses is not warranted unless there are associated clinical indicators.

Septal extension grafts: a method of controlling tip projection shape.

Failure to control the projection, shape, and rotation of the nasal tip is a common occurrence among patients with weak lower lateral cartilages. These patients' noses are characterized by a weak midvault, a plunging tip with "Polly beak," and drawn-up alae. The purpose of our study was to identify methods for controlling the position and shape of the nasal tip in these high-risk patients. Twenty patients at risk of losing nasal tip projection were retrospectively identified, and measurements made from their preoperative and postoperative photographs were compared. Loss of tip projection occurred in all but one patient whose columella strut was fixed to the caudal septum. Prompted by these failures, we studied the relationship between the dorsum and tip in cadaveric specimens with and without a supratip break. From our observations, a structural extension of the septum-an anterior septal extension graft-was developed to predictably control this relationship. The clinical application of septal extension grafts in open rhinoplasty was subsequently evaluated in 20 patients who were deemed to be at risk of losing tip projection. Postoperative photographic analysis showed nasal tip projection to be maintained or increased in all but one patient with the use of septal extension grafts. A stable caudal septum is essential to the success of the technique.

The extended browlift.

The endoscopic extended browlift adds to the armamentarium against aging, serving as an excellent stand alone procedure in the younger patient in whom the lower face and neck are minimally affected. It accomplishes a repositioning of the orbital portion of the orbicularis oculi muscle thereby minimizing resection of eyelid skin, muscle, and fat. Its lift of the malar pad causes a pleasing transition onto the upper face blending nicely into the lower face. In more advanced aging, the extended browlift serves as a powerful adjunct to procedures on the eyelids, lower face, and neck. It corrects troublesome orbital festoons and malar bags and reduces the upper third of the nasolabial fold. Its transition effect in the lower face has allowed an alternative procedure with more limited SMAS-skin undermining to be performed in smokers. The primary disadvantage of the procedure is the necessity of thoroughly understanding and familiarizing oneself with the somewhat confusing temporal anatomy, the location of the retaining ligaments of the cheek, and the relationship of the facial nerve to the deep plane. A failure to recognize and release the retaining structures will limit significantly the outcome of the procedure. Careless or misdirected dissection over the zygomaticus major muscle may directly injure the muscle or the nerve branches to the orbicularis oculi muscle. Forty-two patients who underwent an endoscopic extended browlift now have been followed from 6 to 18 months. The patient representing the first endoscopic attempt had unilateral weakness of the forehead and bitemporal fat atrophy. The forehead weakness resolved at 4 weeks postoperatively. The temporal fat atrophy was corrected at 1 year postoperatively with micro fat grafts. A second patient done as a demonstration at another institute had forehead weakness and excessive tension on one side. The weakness and tension reportedly resolved at 3 months. No patients have had permanent weakness. The most frequent occurrence following the procedure was the return of brow asymmetry that was present before surgery. Attempts at correcting this preoperative finding were generally unsuccessful.

Risk factors for complications in pediatric tissue expansion.

Tissue expansion in children has been associated with complication rates of 20 to 40 percent. A critical analysis of 6 years' (1988-1993) experience with 180 expanders placed in 82 consecutive children was performed to identify those factors which predispose to complications. Major and minor complications each occurred in 9 percent of patients. The factors associated with a statistically significant increase in complications were burns and soft-tissue loss, patient age under 7 years, use of internal expander ports, and a history of two or more prior expansions. In addition, complications were significantly more likely to occur within the first 90 days than during any subsequent expansion. Factors that did not influence complication rate included patient gender, wound drainage upon expander insertion or removal, intraoperative use of antibiotic irrigation, number of expanders placed, use of customized expanders, and operating surgeon.

Idiopathic midline granuloma--current classification and management controversies.

Midline granuloma is a mutilating process produced by a number of diseases that progressively destroy the nose, paranasal sinuses, and palate. Infectious, neoplastic, and idiopathic forms of this disease have been described. The specific diagnoses must be ascertained, as the treatment is different depending on the etiology of the disease. Radiation therapy is the treatment of choice for idiopathic midline destructive disease, while cytoxan is appropriate for Wegener's granulomatosis, polymorphic reticulosis, and primary nasal lymphomas. When the diagnosis is uncertain, the least-toxic therapy should be used. If the treatment is failing, an alternate therapy should be tried. This article reviews the history of idiopathic midline granuloma, describes the current classification of the disease, and discusses controversial issues demonstrated by two patient presentations.

The deep temporal lift: a multiplanar, lateral brow, temporal, and upper face lift.

An extended brow upper facelift technique employing a multiplanar, temporal approach is described. Fresh cadaver dissections are utilized to demonstrate the anatomic basis of the approach. A complete mobilization of the orbital portion of the orbicularis oculi muscle away from the orbital rim is described. Release of the malar orbicularis (zygomatic cutaneous ligament) above the zygomaticus major muscle and over the origin of the masseter muscle is emphasized. Indications and patient selection are reviewed and the clinical benefit to the brow, lateral canthus, lower lid, and malar orbicularis cheek pad is demonstrated in different patient groups.

Alloplastic nasal and perialar augmentation.

Our favorable experience with use of porous hydroxyapatite granules to augment the craniofacial skeleton (more than 200 patients during an 8-year period) has led us to use this method to augment the nasal skeleton in selected cases. Extensive experience has been achieved in augmenting the perialar, maxilla, and glabellar area with very favorable results. A much more limited experience has been gained in augmenting the nasal dorsum, and this method must be considered investigatory at present.

Abdominal-wall reconstruction with expanded musculofascial tissue in a posttraumatic defect.

An anatomic basis for expansion of the abdominal wall is presented and clinically demonstrated in an adult man with a posttraumatic defect. The patient demonstrates an intact, functional abdominal wall 4 years after the procedure. The procedure provides autogenous, innervated, well-vascularized, contractile tissue for repair of abdominal-wall hernias. Large tissue expanders are placed between the external oblique and internal oblique muscles. A small incision in the posterior rectus sheath is made in order to gain access to the potential space between these muscles. The incision in the posterior rectus sheath is kept small to minimize risk of denervation of the rectus abdominis muscle. Tissue expansion is carried out over several weeks. After removal of the expanders, abundant musculofascial tissue is available for reconstruction of the abdominal wall. The abdominal wall is then reconstructed with innervated, functioning tissue.

Rhinoplasty: a practical guide for surgical planning.

A method for determining the aesthetically proportioned nasal length, tip projection, and radix projection in any given face is described. The proportioned nasal length is two-thirds (0.67) the midfacial height and exactly equal to chin vertical. Tip projection is two-thirds (0.67) the surgically planned or ideal nasal length. Radix projection, measured from the junction of the nasal bones with the orbit, is one-third (0.33) the ideal nasal length. The preferred clinical reference for measuring radix projection is the plane of the corneal surface; the radix projects 0.28 times the ideal nasal length from this surface (range: 9-14 mm). These-dimensional relationships were confirmed from direct clinical measurements taken from 87 models and subsequently applied in 126 consecutive rhinoplasties. The significance of this dimensional approach to rhinoplasty lies in the fact that planned nasal dimensions are based on facial measurements that allow the nose to vary in size directly with the face. Furthermore, it removes the dorsum as the primary focus in dimensional assessment. Rather, the dorsal prominence may be consistently described relative to a plane connecting the "ideal" radix and tip.

Augmentation of the craniofacial skeleton with porous hydroxyapatite granules.

Augmentation of the craniofacial skeleton with porous hydroxyapatite granules (Interpore 200) has been performed in 52 sites on 43 patients. Follow-up extends to 5 years, and 26 patients have been followed for greater than 1 year with excellent results. The procedure has been used for reconstruction of congenital and posttraumatic deformities and for purely aesthetic purposes. Areas that have benefited from hydroxyapatite augmentation include the skull, zygomaticomaxillary region, lateral mandible, perialar region, periorbital area, and temporal region. There have been no cases of infection, and only two patients have required minor revisions. Resorption has not occurred.