Ear and nose reconstruction in children.

Auricular and nasal deformities can have significant social ramifications; therefore, proper repair of these deformities is critically important to a child's well-being. Moreover, the benefits of reconstruction in the pediatric population must be weighed against added concerns about potential growth restriction on the ear and the nose with any manipulation. This article reviews various methods of auricular and nasal reconstruction and discusses some of the technical pearls for improved outcome. A complete discourse on treatment of total ear and nasal reconstruction is beyond the scope of this article. Attention is focused primarily on partial to subtotal defects.

Cleft nasal deformity and rhinoplasty.

The cleft nasal deformity is a complex challenge in plastic surgery involving the skin, cartilage, mucosa, and skeletal platform. Ever since Blair and Brown first described the intricacies of the cleft pathology in 1931, the appropriate approach has been extensively debated in the literature with respect to timing, technique, and extent of surgical intervention. In this article, the authors review the literature and summarize the various modalities for achieving a successful rhinoplasty in the patient with a cleft nasal deformity.

Perioperative steroids for minimizing edema and ecchymosis after rhinoplasty: a meta-analysis.

BACKGROUND: Minimizing complications after rhinoplasty is a priority for every surgeon performing the procedure. Perioperative steroid administration has been shown to decrease postoperative edema and ecchymosis in a number of prospective randomized trials. OBJECTIVES: In an effort to further elucidate the significance of the data and develop an evidence-based algorithm for steroid administration, the authors offer a meta-analysis of the existing literature. METHODS: A systematic review of the literature was performed. All articles were reviewed for relevant data, which were extracted, pooled, and compared. Seven prospective randomized trials investigating perioperative steroid use in rhinoplasty have been conducted and reported. Four of these studies had the same method of patient edema and ecchymosis assessment, and their data were compared. RESULTS: Based on results from the four relevant studies, perioperative steroid use significantly reduces postoperative edema and ecchymosis of the upper and lower eyelids at one day and seven days postoperatively (P < .0001). Preoperative steroid administration decreases postoperative upper and lower eyelid edema at one day preoperatively, when compared to postoperative administration (P < .05). Extended dosing is superior to one-time dosing (P < .05). CONCLUSIONS: Perioperative steroid use decreases postoperative edema and ecchymosis associated with rhinoplasty. Preoperative administration is superior to postoperative, and extended dosing is superior to singular. Based on these results, evidence-based guidelines for perioperative steroid administration can be given.

General management considerations in pediatric facial fractures.

The treatment of pediatric facial fractures, although similar to that of adults, requires a separate and thorough understanding of the unique developmental issues inherent to this age group. The contribution of several of these factors allows for a large portion of these injuries to be managed more conservatively; however, operative indications still exist. The optimal form of management in these situations must balance the risks of impacting dentition or future skeletal growth versus obtaining acceptable stability and reduction for healing. Although these principles have remained largely unchanged over the years, a more current discussion on the state of resorbable and titanium fixation is offered to highlight evolving management considerations. Although uniquely challenging, the proper management of pediatric facial trauma is possible if the treating physician remains aware of key anatomic, epidemiological, evaluation, and management issues.

A novel autologous scaffold for diced-cartilage grafts in dorsal augmentation rhinoplasty.

BACKGROUND: Diced-cartilage grafts have been used for dorsal nasal augmentation for several years with good results. However, compounds such as Surgicel and temporalis fascia used as a wrap have inherent problems associated with them, predominantly inflammation and graft resorption. An autologous carrier could provide stabilization of cartilage grafts while avoiding the complications seen with earlier techniques. METHODS: In our patients, a malleable construct was used for dorsal nasal augmentation in which autologous diced-cartilage grafts were stabilized with autologous tissue glue (ATG) created from platelet-rich plasma (platelet gel) and platelet-poor plasma (fibrin glue). RESULTS: A prospective analysis of 68 patients, who underwent dorsal nasal augmentation utilizing ATG and diced-cartilage grafts between 2005 and 2008, were included in the study. Although there was notable maintenance of the dorsal height, no complications occurred that required explantation over a mean follow-up of 15 months. CONCLUSION: The use of ATG to stabilize diced-cartilage grafts is a safe, reliable technique for dorsal nasal augmentation. The platelet gel provides growth factors while the fibrin glue creates a scaffold that allows stabilization and diffusion of nutrients to the cartilage graft.

Packing and postoperative rhinoplasty management: a survey report.

BACKGROUND: Postoperative management following rhinoplasty varies greatly among aesthetic surgeons. Few studies have addressed practice trends in postoperative rhinoplasty care or questioned the frequency of packing and splinting. Many conventional postoperative techniques remain controversial (eg, packing). OBJECTIVE: To investigate current postoperative practices in the United States, correlating the results with surgical education, practice type, and complication rates. METHODS: An online survey was distributed to members of the American Society for Aesthetic Plastic Surgery. Respondents were polled about their background, route of education, type of practice, frequency and preference of postoperative nasal care, and most frequent rhinoplasty complications. Statistical analysis was performed with the χ(2) test. RESULTS: Of the 1550 total surveys sent, 126 responses were received (8.1%). The majority of respondents were in private practice (86%) and trained in plastic surgery (83%). Approximately 33% continue to regularly employ packing following rhinoplasty, but data show that surgeons performing 21 or more rhinoplasties per year were less likely to utilize packing (P = .06). Those surgeons with higher rhinoplasty case volumes were significantly more likely to utilize a secondary therapy (eg, steroids, arnica) in combination with ice packs (P = .03) to prevent postoperative ecchymosis. Finally, surgeons with lower rhinoplasty case volumes reported more frequent postoperative nasal tip deformities (P = .01). CONCLUSIONS: Postoperative rhinoplasty care varies greatly among practicing aesthetic surgeons. Importantly, a high percentage of private practice aesthetic surgeons continue to utilize nasal packing following rhinoplasty. However, these numbers trend downward in surgeons who perform rhinoplasties more frequently.

Nonsyndromic cleft lip and palate: CRISPLD genes and the folate gene pathway connection.

BACKGROUND: Nonsyndromic cleft lip with or without cleft palate (NSCLP) is a common birth defect that has a multifactorial etiology. Despite having substantial genetic liability, <15% of the genetic contribution to NSCLP has been delineated. In our efforts to dissect the genetics of NSCLP, we found that variation in the CRISPLD2 (cysteine-rich secretory protein LCCL domain containing 2) gene is associated with NSCLP and that the protein is expressed in the developing murine craniofacies. In addition, we found suggestive linkage of NSCLP (LOD > 1.0) to the chromosomal region on 8q13.2-21.13 that contains the CRISPLD1 gene. The protein products of both CRISPLD1 and CRISPLD2 contain more cysteine residues than comparably sized proteins. Interestingly, the folic acid pathway produces endogenous cysteines, and variation in genes in this pathway is associated with NSCLP. Based on these observations, we hypothesized that variation in CRISPLD1 contributes to NSCLP and that both CRISPLD genes interact with each other and genes in the folic acid pathway. METHODS: Single nucleotide polymorphisms (SNPs) in CRISPLD1 were genotyped in our non-Hispanic white and Hispanic multiplex and simplex NSCLP families. RESULTS: There was little evidence for a role of variation for CRISPLD1 alone in NSCLP. However, interactions were detected between CRISPLD1/CRISPLD2 SNPs and variation in folate pathway genes. Altered transmission of one CRISPLD1 SNP was detected in the NHW simplex families. Importantly, interactions were detected between SNPs in CRISPLD1 and CRISPLD2 (15 interactions, 0.0031 ≤p < 0.05). CONCLUSION: These novel findings suggest that CRISPLD1 plays a role in NSCLP through the interaction with CRISPLD2 and folate pathway genes.

Folate pathway and nonsyndromic cleft lip and palate.

BACKGROUND: Nonsyndromic cleft lip with or without cleft palate (NSCLP) is a common complex birth defect. Periconceptional supplementation with folic acid, a key component in DNA synthesis and cell division, has reduced the birth prevalence of neural tube defects and may similarly reduce the birth prevalence of other complex birth defects including NSCLP. Past studies investigating the role of two common methylenetetrahydrofolate reductase (MTHFR) single-nucleotide polymorphisms (SNPs), C677T (rs1801133) and A1298C (rs1801131), in NSCLP have produced conflicting results. Most studies of folate pathway genes have been limited in scope, as few genes/SNPs have been interrogated. Here, we asked whether variations in a more comprehensive group of folate pathway genes were associated with NSCLP, and were there detectable interactions between these genes and environmental exposures? METHODS: Fourteen folate metabolism-related genes were interrogated using 89 SNPs in multiplex and simplex non-Hispanic white and Hispanic NSCLP families. RESULTS: Evidence for a risk association between NSCLP and SNPs in NOS3 and TYMS was detected in the non-Hispanic white group, whereas associations with MTR, BHMT2, MTHFS, and SLC19A1 were detected in the Hispanic group. Evidence for over-transmission of haplotypes and gene interactions in the methionine arm was detected. CONCLUSIONS: These results suggest that perturbations of the genes in the folate pathway may contribute to NSCLP. There was evidence for an interaction between several SNPs and maternal smoking, and for one SNP with gender of the offspring. These results provide support for other studies that suggest that high maternal homocysteine levels may contribute to NSCLP and should be further investigated.

Ethnic heterogeneity of IRF6 AP-2a binding site promoter SNP association with nonsyndromic cleft lip and palate.

OBJECTIVE: The goal of this study was to confirm the reported association between a noncoding SNP (rs642961) in IRF6 and nonsyndromic cleft lip and palate. DESIGN, SETTING, AND PARTICIPANTS: Two SNPs in IRF6 (rs2235371 and rs64296) were genotyped in Hispanic and non-Hispanic white multiplex (122) and simplex (308) nonsyndromic cleft lip and palate families. Linkage and family-based association analyses were performed on the individual SNPs as well as the 2-SNP haplotype. RESULTS: Only modest evidence was found for an association with rs642961 and the 2-SNP haplotype. In contrast, strong evidence was found for the association with rs2235371; this was most evident in the non-Hispanic white simplex families. CONCLUSIONS: Although it is confirmed that variation in IRF6 is associated with nonsyndromic cleft lip and palate, the results do not support the reported association with SNP rs64296. Importantly, the association varies between ethnic groups. This finding underscores the need for evaluating additional variations in IRF6 across multiple populations to better determine its role in nonsyndromic cleft lip and palate.

Contemporary techniques in inferior turbinate reduction: survey results of the American Society for Aesthetic Plastic Surgery.

BACKGROUND: Nasal airway obstruction is a frequently-encountered problem, often secondary to inferior turbinate hypertrophy. Medical treatment can be beneficial but is inadequate for many individuals. For these refractory cases, surgical intervention plays a key role in management. OBJECTIVE: The authors evaluate the current trends in surgical management of inferior turbinate hypertrophy and review the senior author's (SS) preferred technique. METHODS: A questionnaire was devised and sent to members of the American Society for Aesthetic Plastic Surgery (ASAPS) to determine their preferred methods for assessment and treatment of inferior turbinate hypertrophy. RESULTS: One hundred and twenty-seven physicians responded to the survey, with 85% of surveys completed fully. Of the responses, 117 (92%) respondents were trained solely in plastic surgery and 108 (86.4%) were in private practice. Roughly 81.6% of respondents employ a clinical exam alone to evaluate for airway issues. The most commonly-preferred techniques to treat inferior turbinate hypertrophy were a limited turbinate excision (61.9%) and turbinate outfracture (35.2%). CONCLUSIONS: Based on the results of this study, it appears that limited turbinate excision and turbinate outfracture are the most commonly-used techniques in private practice by plastic surgeons. Newer techniques such as radiofrequency coblation have yet to become prevalent in terms of application, despite their current prevalence within the medical literature. The optimal method of management for inferior turbinate reduction should take into consideration the surgeon's skill and preference, access to surgical instruments, mode of anesthesia, and the current literature.

Facial trauma: general principles of management.

Facial fractures are common problems encountered by the plastic surgeon. Although ubiquitous in nature, their optimal treatment requires precise knowledge of the most recent evidence-based and technologically advanced recommendations. This article discusses a variety of contemporary issues regarding facial fractures, including physical and radiologic diagnosis, treatment pearls and caveats, and the role of various synthetic materials and plating technologies for optimal facial fracture fixation.

Bilateral cleft lip revisions: the Abbe flap.

BACKGROUND: Secondary deformities of the bilateral cleft lip are unfortunately very common, and severe cases can involve scar contracture, vermilion deficiency, and a tight upper lip. In these cases, reconstruction often requires replacement of the central philtral unit with full-thickness tissue, including vermilion, orbicularis oris, and skin. The Abbe flap offers full-thickness reconstruction of the central aesthetic unit of the upper lip by replacing the deficient and scarred tissue and restoring functional competence to the oral sphincter. METHODS: A review was performed of the authors' operating room video files to evaluate their technique for performing secondary bilateral cleft lip revision using the Abbe flap. RESULTS: The Abbe flap has been used successfully for secondary revisions of the bilateral cleft lip at the Texas Children's Hospital. A technique video was made using video clips from two secondary bilateral cleft lip revisions. CONCLUSIONS: Results of bilateral cleft lip repair are often poor because of inappropriate use of the hypoplastic prolabial tissue, failure to anatomically reunite the orbicularis muscle, and scarring. The Abbe flap is an effective tool for reconstruction of the philtral landmarks, reconstitution of oral competence of the orbicularis, and recreation of Cupid's bow and the central pout. Although this procedure is relatively straightforward, special attention to designing the new philtrum, marking intact landmarks, and careful dissection of the labial artery are required for successful reconstruction.

Problems in rhinoplasty.

In this review, the complications of rhinoplasty are examined in terms of their timing of presentation. An algorithmic approach to postoperative problems is discussed. Complications can frequently be avoided by meticulous technique, recognition of pitfalls, and early attention to perioperative morbidity. Reoperative rates can be minimized with good patient education and proper command of the postoperative situation, so that unnecessary procedures are not undertaken.

Family-based study shows heterogeneity of a susceptibility locus on chromosome 8q24 for nonsyndromic cleft lip and palate.

BACKGROUND: Nonsyndromic cleft lip with or without cleft palate is a common birth defect. Although a number of susceptibility loci have been reported, replication has often been lacking. This is likely due, in part, to the heterogeneity of datasets and methodologies. Two independent genome-wide association studies of individuals of largely western European extraction have identified a possible susceptibility locus on 8q24.21. METHODS: To determine the overall effect of this locus, we genotyped six of the previously associated single nucleotide polymorphisms in our Hispanic and non-Hispanic white family-based datasets and evaluated them for linkage and association. In addition, we genotyped a large African American family with nonsyndromic cleft lip with or without cleft palate that we had previously mapped to the 8q21.3-24.12 region to test for linkage. RESULTS: There was no evidence for linkage to this region in any of the three ethnic groups. Nevertheless, strong evidence for association was noted in the non-Hispanic white group, whereas none was detected in the Hispanic dataset. CONCLUSION: These results confirm the previously reported association and provide evidence suggesting that there is ethnically based heterogeneity for this locus.

Evaluation and reduction of nasal trauma.

Nasal trauma plays a large and important role in the field of craniofacial trauma. The resulting aesthetic, structural, and functional sequelae associated with these injuries necessitate a thorough understanding of the topic. This includes an appreciation for the unique anatomic features of the region, the important aspects of the initial history and examination, nasal injury classification, and subsequent treatment timing and options. While a large body of literature has accumulated on the topic, the purpose of this article is to focus on both clinically relevant information and pearls of management. Additionally, age-specific concerns, secondary procedures, and nasal fracture grafting, will be addressed as well.

Treatment of prominent and constricted ear anomalies.

Although the physiologic effects of ear deformity are negligible, the aesthetic and psychological impact on the patient can be profound. Significant ear malformations are prevalent in today's society and affect more than 5 percent of the population. Although the prominent ear results from either underdevelopment of the antihelix or an enlarged conchal bowl, the constricted ear is a product of helical down-folding and height deficiency. After a thorough evaluation, surgical management of the prominent ear must be approached in a careful, rational fashion. Although the surgeon may enjoy the wide latitude that hundreds of corrective techniques offer, he or she must always proceed with an algorithmic application of technique best suited to the specific auricular deformity. By using this approach, correction of the prominent ear can go beyond patient satisfaction to predictably maximize outcome in both form and symmetry. From the clinical evaluation and anatomical basis to surgical management of the deformed ear, the true art of otoplasty is in the surgeon's ability to thoroughly understand auricular structure and appropriately apply technique for maximal aesthetic outcome.

Fifty years of the Millard rotation-advancement: looking back and moving forward.

Of all the methods for repair of the unilateral cleft lip, none has gained as much popularity as the rotation-advancement. Millard's original principle of 50 years ago continues to guide surgeons in closure of the cleft lip. Unlike earlier procedures, the brilliance of the rotation-advancement is that it permits individual manipulation and modifications while maintaining Millard's original surgical and anatomical goals. Millard and many other surgeons have made modifications to adjust the procedure to each specific patient, to address some of its faults, and to gain new advantages. In this article, the authors review the techniques of Drs. Ralph Millard, Steve Byrd, Court Cutting, John Mulliken, and Samuel Stal. The variations from Millard's original technique are highlighted, including a discussion of the benefits of each modification.

Genomic screening identifies novel linkages and provides further evidence for a role of MYH9 in nonsyndromic cleft lip and palate.

Nonsyndromic cleft lip with or without cleft palate (NSCLP) is a common birth anomaly that requires prolonged multidisciplinary rehabilitation. Although variation in several genes has been identified as contributing to NSCLP, most of the genetic susceptibility loci have yet to be defined. To identify additional contributory genes, a high-throughput genomic scan was performed using the Illumina Linkage IVb Panel platform. We genotyped 6008 SNPs in nine non-Hispanic white NSCLP multiplex families and a single large African-American NSCLP multiplex family. Fourteen chromosomal regions were identified with LOD>1.5, including six regions not previously reported. Analysis of the data from the African-American and non-Hispanic white families revealed two likely chromosomal regions: 8q21.3-24.12 and 22q12.2-12.3 with LOD scores of 2.98 and 2.66, respectively. On the basis of biological function, syndecan 2 (SDC2) and growth differentiation factor 6 (GDF6) in 8q21.3-24.12 and myosin heavy-chain 9, non-muscle (MYH9) in 22q12.2-12.3 were selected as candidate genes. Association analyses from these genes yielded marginally significant P-values for SNPs in SDC2 and GDF6 (0.01

Rhinoplasty in the Hispanic patient.

In the United States, rhinoplasty has traditionally been performed in Caucasian patients. Ethnic rhinoplasty is often thought of as a procedure done to reshape the nose of a black or Asian patient. Little attention has been paid to rhinoplasty in Hispanic patients. There has been a large increase in the Hispanic population of the United States, and plastic surgeons will see a concomitant rise in requests for rhinoplasty among this population. In an effort to increase our understanding of Hispanic rhinoplasty, a retrospective review of a senior surgeon's experience was performed. A retrospective chart review was done examining the senior author's (S.S.) rhinoplasty practice over the past 10 years. Hispanic patients presenting for aesthetic and corrective rhinoplasty (cleft patients were excluded) were analyzed. The Hispanic nose was divided into three archetypes. Type I is characterized by a high radix and prominent vault; these noses should be corrected by dorsal reduction and resection of caudal septum. Type II is characterized by a dependent tip with inadequate projection; dorsal augmentation with diced cartilage and tip support with cartilage grafts are important. Osteotomies should generally be avoided in this group. Type III noses are characterized by a broad nasal base with thick skin and a wide tip; rhinoplasty in this group requires correction of the dorsum-base disproportion using several techniques including columellar struts, tip grafts, and dorsal augmentation. Hispanics are projected to become the largest minority population within the next 10 years, and rhinoplasty in this population will become more frequent over time. It behooves plastic surgeons to become familiar with the different archetypes of Hispanic noses and appropriate corrective techniques for each.