Nasal Reconstruction of Large Defects Without a Forehead Flap.

Defects over 2.0 to 2.5 cm may often require repair with a multistaged forehead flap. However, in some such defects, other options may be available. In this article, the author will review some of these options.

The Extended Purse-String Rhytidectomy.

Facelifts remain a critical part of a facial plastic surgeon's cosmetic practice. Techniques continue to evolve, while at the same time patients demand less invasive procedures with less morbidity. The authors present a facelift plication technique using wide purse-string sutures placed into the superficial musculoaponeurotic system and platysma. This is a retrospective review with a level of evidence 3 set at a medical spa and tertiary referral center designed to assess a purse-string suture technique using an inner followed by an outer purse-string, with refinements being made during the timeframe of the review. One hundred and eighteen patients were reviewed and 95 were included in the study given the inclusion criteria of a minimum of 1-year follow-up. Based on the subjective judgment of the primary surgeon, 37 patients were found to have excellent results, while 43 patients were judged as having good results. The judgment was based on the physical exam improvement of the aging aspects of the patient, and patient satisfaction. Ten patients displayed fair results (the patients were marginally happy), and five patients were noted to have poor results (they were notably unhappy). Complications included eight hematomas, five patients with prominent scars, and one patient with skin loss in the temple region. There were no cases of facial nerve injury. The extended purse-string rhytidectomy is a good alternative to traditional facelift techniques. This offers a plication method that results in the vertical vector that is now considered of paramount importance with all facelifts. The authors feel that it is a valuable tool that can be considered in most patients presenting for aging face surgery.

The Role of Transverse Osteotomies in Severe Nasal Trauma.

Facial trauma commonly produces trauma to the nose and perinasal area. In this review, emphasis is on the treatment of the severely deviated nose in terms of excessive shift of the bony dorsum and bony pyramid. In particular, we focus on the problem of centering the severely deviated bony dorsum and when we believe it is helpful to move the entire bony dorsum as a unit, utilizing the transverse osteotomy in addition to traditional osteotomies.

Management of Posttraumatic Pseudotelecanthus.

Injuries to the nose and perinasal region are common. Though the nasal fractures are commonly recognized and properly addressed, injuries to adjacent structures such as the orbit, medial canthus, and midface skeleton can be missed or misdiagnosed leading to improper primary treatment and subsequent secondary deformities. In this discussion, we focus on secondary deformities of the medial canthal region injuries that result from inadequate primary repair of the displaced medial canthal tendon apparatus in naso-orbital-ethmoid fractures. Emphasis is placed on the difference in complexity of the secondary pseudotelecanthus deformity relative to primary fracture treatment. Case examples are used to discuss the complexity of the correction of such deformities.

Revision of severe nasal trauma.

Facial trauma commonly includes injury to the nose and perinasal area. In this review, we will focus on the sequelae of severe nasal trauma and provide examples of correction of the severely deviated nose, the severely collapsed nose, and revision of a traumatic deformity after prior rhinoplasty. We will then discuss coexistent deformities of perinasal regions in addition to functional and posttraumatic nasal correction, including posttraumatic periorbital deformities.

Avoiding and correcting complications in perinasal trauma.

Injuries to the nose and perinasal region are common. Although the nasal fractures are commonly recognized and properly addressed, injuries to adjacent structures such as the orbit, medial canthus, and midface skeleton can be missed or misdiagnosed, leading to improper primary treatment and subsequent secondary deformities. In this discussion, three common injuries will be discussed, including nasomaxillary fractures, limited naso-orbital-ethmoid fractures, and severe central facial injuries with naso-orbital-ethmoid fractures. For instructional purposes, a case example of inadequate primary diagnosis and subsequent delayed or secondary management will be followed by a case example of proper initial diagnosis and proper primary management.

Reconstruction of periparotid defects using temporoparietal fascia flap with layered acellular human dermal allograft.

Excision of lesions in the periparotid area can leave a sizable concavity of the preauricular area with skeletonization of the mandible. To achieve the bulk necessary to fill this defect, we propose using a composite graft. Acellular human dermal allograft provides the thickness of the graft, and the temporoparietal fascia flap provides blood supply to the dermal graft. Our hypothesis is that vascularization of the graft will promote greater ingrowth of native tissue and prevent breakdown and absorption of the graft. Four representative patients are described.

Reconstruction of complex nasal dorsal and sidewall defects: is the nasal sidewall subunit necessary?

OBJECTIVE: To demonstrate that by the extended use of cheek advancement flaps, the need to maintain the nasal dorsal side unit is obviated. DESIGN: Retrospective case series. SETTING: Tertiary care clinic and hospital. PATIENTS: Twelve patients aged 48 to 88 years who underwent Mohs micrographic surgery for nasal skin neoplasms, presenting with dorsal sidewall and nasal dorsal cutaneous defects. INTERVENTION: All patients underwent nasal reconstruction with adjacent tissue cheek advancement flaps with or without contralateral nasal dorsal and sidewall advancement flaps. MAIN OUTCOME MEASURES: Avoidance of ipsilateral nasal sidewall scars to allow a natural-appearing transition between the cheek and nose and avoidance of forehead flap morbidity. Results Satisfactory results were achieved in all but 1 patient who had partial flap necrosis. CONCLUSIONS: To maintain the nasal dorsal sidewall unit, superior, central dorsal, and nasal sidewall defects have traditionally been reconstructed using a variety of techniques, including skin grafts and regional flaps, such as glabellar flaps and frontal flaps. We demonstrate that creation of the nasal dorsal sidewall unit is often not necessary, and excellent results can be achieved through the expanded use of cheek advancement flaps.

Dealing with the difficult trauma and reconstructive surgery patient.

Many of the issues that exist for cosmetic surgery patients exist for noncosmetic patients in areas such as reconstructive surgery and trauma. Although cosmetic and noncosmetic patients usually are considered separate in terms of elective versus nonelective, there are other issues in dealing with reconstructive surgery patients versus those undergoing cosmetic surgery. This article reviews a variety of issues specific to noncosmetic reconstructive surgical patients and discusses issues unique to pediatric patients, craniomaxillofacial trauma patients, patients who have skin cancer defects, scar revision patients, and major reconstruction after cancer resections and craniomaxillofacial trauma.

Computer-designed implants for fronto-orbital defect reconstruction.

Patients with complex defects of the frontal and orbital regions present a myriad of problems for the reconstructive surgeon. In this review, options that allow state-of-the-art reconstruction using computer-assisted implants will be illustrated. The advantages of such implants created with computer assistance will be reviewed as well as indications for their use.

Eyebrow position recognition and correction in reconstructive and cosmetic surgery.

OBJECTIVES: To improve (1) recognition of eyebrow ptosis, asymmetry, or deformity and (2) selection of the appropriate surgical technique based on the patient's underlying etiology. DESIGN: Nonrandomized, retrospective study of patients undergoing surgical correction of eyebrow asymmetry. Forty consecutive patients were identified as having asymmetric eyebrow ptosis or deformity. Varying etiologies included those that were congenital, posttraumatic, age-related, iatrogenic, or idiopathic, with or without facial nerve paralysis. Patients underwent a variety of surgical approaches for correction of the eyebrow malposition, including transblepharoplasty, midforehead, coronal, and endoscopic procedures. Preoperative evaluation of patients, identification of patient-specific appropriate surgical technique, and photographs and grading of postoperative results are discussed. RESULTS: All patients had a minimum follow-up period of at least 4 months (mean, 15 months; range, 4 months to 3 years). Preoperative and postoperative photographs were obtained and graded. Complete symmetry was achieved in 8 patients (20%), considerable improvement in 23 patients (57%), modest improvement in 7 patients (18%), and no improvement in 2 patients (5%). No notable postoperative complications were reported. Recommendations for improving results are included. CONCLUSIONS: The key to correction of eyebrow ptosis in patients undergoing reconstructive and cosmetic surgery is to first recognize the asymmetry. It is also important to note the effect of reconstructive and cosmetic surgical procedures on eyebrow position in order to limit the need to perform additional procedures to correct resultant eyebrow asymmetries and deformities. Finally, the surgeon must consider which eyebrow-lift technique is optimal for the patient's underlying etiology to improve postoperative results and patient satisfaction.

Evaluation and treatment of deformities of the chin.

Chin deformities present commonly to the facial plastic surgeon. Proper evaluation of the face is essential to allow the surgeon to counsel the patient properly regarding optimal management of chin deformities. This article reviews such analysis and discusses treatment modalities, including both the use of chin implants and osseous genioplasty.

Salvage of partial facial soft tissue avulsions with medicinal leeches.

BACKGROUND: Medicinal leeches have been demonstrated to be extremely useful and safe in the salvage of venous outflow compromised tissue, particularly in digit replants and various forms of flaps. OBJECTIVE: To demonstrate the utility of medicinal leeches in the salvage of venous outflow-compromised traumatic soft tissue avulsions in key facial structures. METHODS: A retrospective review of 4 cases involving the external ear, nose, lip, and scalp in which apparent venous outflow compromise was present. Medicinal leeches were applied acutely in each of these 4 cases, salvaging each of the partially avulsed soft tissue segments. RESULTS: Complete or near complete salvage of each soft tissue segment after using medicinal leeches. CONCLUSIONS: Although it is unusual for a partial soft tissue avulsion of the face to require medicinal leech therapy, situations may occur in which there is adequate arterial inflow but inadequate venous outflow. In such cases, medicinal leeches may play a very important role in salvaging the soft tissue segment. This is particularly important in vital structures such as the ear, nose, lip, and eyelid in which acute or secondary reconstruction is complex. EBM RATING: C.

Evaluation and treatment of vertical microgenia.

OBJECTIVE: To evaluate treatment of vertical microgenia in patients with chin deformities. METHODS: Twenty-one patients were included in this retrospective review. The 3 authors performed a lengthening genioplasty with or without interpositional grafting on each patient in either an academic or a private practice setting. RESULTS: Subjective analysis suggests a substantial improvement of lower face aesthetics in all patients. The degree of subjective change depended on the type of deformity, whether there was vertical microgenia alone or in combination with a sagittal (horizontal) deficiency, and the morphologic characteristics of the labiomental sulcus. There were no significant complications. CONCLUSION: Vertical lengthening of the chin should be considered in patients with the combination of a vertically short lower facial height, deepened labiomental fold, recessive chin, and recessive and/or procumbent lower lip.

Reconstruction of complex scalp defects: the "Banana Peel" revisited.

OBJECTIVE: To demonstrate the use of multiple, large, local flaps in the reconstruction of large scalp defects. METHODS: A retrospective review of 4 cases in which the "banana peel" method of scalp reconstruction, originally described by Orticochea, was used as a method for closure of moderately large to extensive scalp defects. RESULTS: In all 4 cases, closure of the scalp defects was accomplished. Major morbidity included hair-bearing skin in the forehead in 1 patient, an inconsequential small flap dehiscence requiring closure in the same patient, and a partial loss of a small skin graft to a donor site defect in 1 patient. CONCLUSIONS: While other techniques may be optimal for the management of most scalp defects, such as 1- to 2-flap rotation-advancement flaps in small to moderate-size defects and microvascular free tissue transfer and secondary tissue expansion for larger defects, we conclude that the multiple-flap reconstruction method as described by Orticochea may be useful in a small subset of patients. The latter includes older, severely debilitated patients who would be optimally treated with microvascular tissue transfer but cannot tolerate lengthy general anesthesia and young patients who will not accept a significant area of alopecia that might exist with other techniques, such as secondary intention, skin grafts, or free flaps.

Local anesthetics for facial plastic procedures.

The use of local anesthetic in facial plastic surgical procedures is well established as an effective and safe mode of anesthesia delivery. Local infiltration of anesthesia may be used alone for minor surgical procedures, or it may be used with general anesthesia or intravenous sedation and analgesia for more complex, lengthy procedures. When considered independently, the use of local anesthetic agents has undeniable limitations. Local anesthetics can cause toxicity and side effects. Injection of local anesthetics for subcutaneous infiltration frequently is painful until sensory anesthesia occurs. Local anesthetics have limited efficacy with respect to the intensity and duration of sensory blockade that can be achieved. In some situations, use of local anesthesia with the maintenance of an awake patient also may be undesirable for the surgeon and impractical for the patient. Despite these shortcomings, local anesthetics are fundamentally ideal for use in facial plastic surgery.