Nasal Reconstruction: Current Overview.

The nose, with its conspicuous location, intricate convexities, and delicate 3-dimensional structure, continues to challenge the reconstructive surgeon. Today, there are a myriad of options available for reconstruction. The practitioner must take into account the location of the defect as well as the components needed to be restored. This article addresses the current practices in nasal reconstruction, including the different strategies for skin coverage, nasal lining, and structural support. We discuss both the newest techniques as well as basic principles of this long-standing procedure.

Is the SMARTLock Hybrid Maxillomandibular Fixation System Comparable to Intermaxillary Fixation Screws in Closed Reduction of Condylar Fractures?

Condylar fractures account for one third of all mandibular fractures. Despite being highly prevalent, treatment of these fractures remains controversial because of the sequelae of inadequate closed reduction and the risks associated with open repair. Multiple studies attempt to compare closed reduction with maxillomandibular fixation (MMF), open reduction with internal fixation, and endoscopic reduction with internal fixation. In our practice, we favor closed reduction with MMF except in cases of significantly displaced subcondylar fractures. To decrease operative MMF time, we moved away from traditional arch bars in favor of intermaxillary fixation screws (IMF screws). However, since the advent of the Stryker SMARTLock Hybrid Maxillomandibular Fixation System (Hybrid), we now use this system to maximize the advantages of having an arch bar, with its flexibility of elastic placement and ability to serve as tension band, in addition to the speed and simplicity of application similarly afforded by the IMF screws. The Hybrid system is shown to be cost effective compared with arch bars in a previous study. This is attributed to decreased operating room time. There are no studies comparing its outcomes and cost with IMF screws. In this article, we examine a series of patients treated with closed reduction using either IMF screws or the Stryker SMARTLock Hybrid Maxillomandibular Fixation System. We found similar result in patient outcomes and operative time, but increase cost with the Hybrid system.

The Tessier number 3 cleft: a report of 10 cases and review of literature.

The Tessier number 3 cleft is one of the most intricate and destructive of all facial clefts, presenting surgeons with a difficult task for reconstruction. We present a series of 10 patients with this rare cleft all treated by a single surgeon over 30 years. All patients with Tessier number 3 clefts treated between 1978 and 2008 by the senior surgeon were reviewed. Demographic data and all associated clinical findings including cranial and extracranial anomalies were recorded. Methods used to reconstruct each patient were also noted. Seven males and three females were identified and age at initial treatment ranged from 12 months to 12 years. Mean follow-up was 6.3 years. Multiple craniofacial anomalies were appreciated including other rare facial clefts, hypertelorbitism, lacrimal obstruction, anophthalmia, choanal atresia, and hemifacial microsomia. Amniotic banding was the most prominent extracranial finding noted in these patients. Tessier number 3 clefts can be associated with multiple other craniofacial anomalies making reconstruction challenging. Soft tissue and bony reconstruction must be considered separately, and a variety of tools may be employed to accomplish each goal. As the presentation can be highly variable, an individualized treatment plan must be made to meet each patient's specific needs.

Radiation-induced craniofacial deformities: a new classification and management algorithm.

Little is written about the spectrum of late radiation-induced craniofacial abnormalities and the guidelines for treating these abnormalities. The clinical records of 13 patients (eight males and five females) who received childhood craniofacial radiation between birth and 11 years of age and who subsequently had reconstructive surgery were reviewed. Eleven patients had their irradiation at the age from 1 to 5 years. The other two patients received their treatment at a relatively older age (9 and 11 years). Their deformities ranged from isolated soft-tissue deficiency with no or minimal bony deficiency to cases having osseous deformities with or without soft-tissue deficiency but still the normal or near-normal craniofacial form can be obtained with surgical intervention and the outermost extreme of the deformity is the patients whose normal or near-normal craniofacial form and function cannot be regained even with much sophisticated surgeries. Our new classification is based on two factors: the tissue component of the deformity and the possibility of regaining a normal or near-normal craniofacial form and function with the planned surgical intervention. Based on this classification, a new treatment algorithm was created.

Constructing the philtral column in the secondary cleft lip deformity: utilizing the palmaris longus graft.

BACKGROUND: The philtrum and the Cupid's bow are the most prominent features of the upper lip and are crucial for normal appearance. Unfortunately, projection of the philtral column is a common deficiency of the repaired cleft lip. Although a multitude of methods for constructing the philtral dimple and ridge have been described, no single procedure has achieved complete satisfactory results. The authors describe their technique for construction of the philtral column using palmaris longus tendon. METHODS: Between 1998 and 2009, a retrospective study was performed for identifying patients with depression of the philtral scar following cleft lip repair. Pre- and postoperative photographs were taken with at least 6 months follow-up. Postoperative patient satisfaction and occurrence of complications are reported. RESULTS: In all, 17 patients who developed depression of the philtral ridge following cleft lip repair underwent philtral reconstruction utilizing palmaris longus tendon grafts by the senior author (H.K.K.). At the time of surgery, average age for 11 females and 6 males was 18.5 years. The follow-up period ranged from 6 to 126 months, with an average of 42.3 months. In the early postoperative period, 2 complications in the form of graft exposure occurred. However, both cases were successfully managed with preservation of the graft. All patients were satisfied with their long-term results, and none required further surgery. CONCLUSIONS: The use of palmaris longus tendon graft is an effective, reproducible, and safe method by which to construct the philtral column in the secondary cleft lip deformity.

Humanitarian cleft care in Southeast Asia: military-civilian partnerships and the role of the US Navy ship Mercy.

The primary mission of the US Navy (USN) is to maintain superior naval forces capable of winning wars, deterring aggression, and maintaining freedom of the seas. However, a major core capability of the present-day USN includes the ability to effectively and rapidly provide humanitarian assistance and disaster response whenever the need arises. Occurring annually since 2006, Pacific Partnership is an ongoing USN operation that aims to strengthen regional alliances and improve delivery of humanitarian assistance and disaster relief. A major focus of Pacific Partnership 2010 was the delivery of medical care to underserved communities in the region. A significant portion of the medical mission was specifically directed toward the treatment of patients with cleft lip and palate. As the main operational platform, the USN Ship Mercy provided an unparalleled environment in which to provide state-of-the-art multidisciplinary treatment to patients with cleft lip and palate. With the cooperation of host nations and locally active nongovernmental organizations, a sustainable model for providing treatment for cleft lip and palate can be developed.

Evaluation and treatment of surgical management of silicone mastitis.

Injected liquid silicone continues to be employed by unscrupulous practitioners in many parts of the world for the purpose of breast augmentation. Complications vary; however, inflammation, foreign body reaction, and granuloma formation often lead to painful and disfigured breasts. Furthermore, migrations of silicone to remote tissues cause additional problems. We present a review of cases and propose an updated algorithm for the diagnosis and management silicone mastitis. We describe two representative cases of mastitis cause by injected liquid silicone. Patients uniformly developed inflammation and granuloma formation causing painful and disfigured breasts. Each patient required bilateral mastectomy and breast reconstruction. Although injection of liquid silicone has been condemned by the legitimate medical community for the purpose of breast augmentation, it continues to be illicitly performed and there exists a sizable patient population suffering from the complications of this procedure. Accurate identification requires a high index of suspicion in patients presenting with firm and painful breasts. An aggressive management strategy is recommended in the setting of silicone mastitis due to the risk of obscuring malignancy.

Autologous fat transplantation in the craniofacial patient: the UCLA experience.

Patients with congenital craniofacial malformations present with complex challenges for reconstruction. Successful management requires individualized treatment often involving rebuilding the facial skeleton de novo, as well as correcting the overlying soft-tissue deficiencies in the final stages. At the University of California, Los Angeles (UCLA) Craniofacial Clinic, serial autologous fat transplantation performed during staged reconstruction is the preferred method.A total of 27 patients with a diagnosis of either craniofacial microsomia/Goldenhar (CM) (n = 19) or Treacher Collins syndrome (TC) (n = 8) were treated at the UCLA Craniofacial Clinic by autologous fat transfer between July 1999 and February 2009. Two-dimensional analysis was conducted on standardized preoperative and postoperative photographs to determine facial symmetry for every patient. Results was grouped based on pathology and analyzed by comparing adipocyte donor site (abdomen vs other).The mean ages at the time of first fat transfer were 17 years for the CM group and 15 years for the TC group. The average numbers of fat transfers per patient were 2.05 (CM) and 2.12 (TC). A mean of 3.74 procedures other than fat grafting was performed in each CM patient, whereas 4.38 other procedures were performed in each TC patient. In CM patients, less than 10.5 months between procedures resulted in improved symmetry. There was an average 6.63% improvement in facial symmetry in the CM group, and a 7.67% improvement in the TC group.Based on the UCLA experience, the durability of facial asymmetry and contour correction with fat transplantation is attainable in the craniofacial patient but may also require concomitant skeletal correction in the most severe cases.