Multivectored suture suspension: a minimally invasive technique for reanimation of the paralyzed face.

BACKGROUND: Despite advanced techniques for reanimation of the lower face, many patients opt for static suspension procedures, which are less invasive and have a relatively short recovery period. However, even static suspension procedures require general anesthesia, overnight hospital stay, and significant soft tissue manipulation. We present a minimally invasive technique, the multivectored suture suspension, which addresses these drawbacks. OBJECTIVES: To study the technical feasibility and efficacy of the multivectored suture suspension technique in the paralyzed face. DESIGN: The study was carried out prospectively in 12 patients with House-Brackmann grade 6 facial paralysis. Nine patients presented within 6 months of tumor resection and 3 patients presented more than 1 year after surgery. MAIN OUTCOME MEASURES: The parameters evaluated were (1). restoration of nasal breathing; (2). improvement of drooling; (3). restoration of normal speech; (4). cosmetic results; and (5). total surgical time. RESULTS: With an average follow-up of 14 months, patient evaluation of the outcome parameters was as follows: (1). 10 patients (83%) reported significant and 2 (17%) reported moderate restoration of nasal breathing; (2). 10 patients (83%) reported significant improvement and 2 (17%) reported modest drooling improvement; (3). 8 patients (66%) reported significant improvement and 4 (34%) reported modest improvement of speech; (4). 9 patients (75%) reported complete satisfaction and 3 (25%) reported moderate satisfaction with cosmesis. The average surgical time was 46 minutes. Three revisions were required for suture failure. CONCLUSIONS: The multivectored suture suspension technique is a minimally invasive, reversible method of lower facial reanimation that provides improved cosmesis with restoration of nasal breathing. It can be performed under local anesthesia in an outpatient setting, thereby reducing morbidity and cost.

Eosinophilic angiocentric fibrosis in a patient with nasal obstruction.

Eosinophilic angiocentric fibrosis (EAF) is a rare clinicopathologic entity that usually affects the upper respiratory tract. We describe the case of a 45-year-old man with nasal obstruction caused by EAF. His lesion featured the distinct radiologic and histopathologic characteristics of EAF, which include an onionskin and whorled fibrosis that surrounds the blood vessels and an inflammatory infiltrate that is predominated by eosinophils. The etiology of EAF remains unknown. Given our increasing knowledge of this rare entity, reports of EAF may appear more frequently in the future.

The application of sentinel node radiolocalization to solid tumors of the head and neck: a 10-year experience.

OBJECTIVES/HYPOTHESIS: The goals of the research study were to develop an easily mastered, accurate, minimally invasive technique of sentinel node radiolocalization with biopsy (SNRLB) in the feline model; to compare it with blue-dye mapping techniques; and to test the applicability of sentinel node radiolocalization biopsy in three head and neck tumor types: N0 malignant melanoma, N0 Merkel cell carcinoma, and N0 squamous cell carcinoma. STUDY DESIGN: Prospective consecutive series studies were performed in the feline model and in three head and neck tumor types: N0 malignant melanoma (43 patients), N0 Merkel cell carcinoma (8 patients), and N0 squamous cell carcinoma (20 patients). METHODS: The technique of sentinel node radiolocalization with biopsy was analyzed in eight felines and compared with blue-dye mapping. Patterns of sentinel node gamma emissions were recorded. Localization success rates were determined for blue dye and sentinel node with radiolocalization biopsy. In the human studies, all patients had sentinel node radiolocalization biopsy performed in a similar manner. On the morning of surgery, each patient had sentinel node radiolocalization biopsy of the sentinel lymph node performed using an intradermal or peritumoral injection of technetium Tc 99m sulfur colloid. Sentinel nodes were localized on the skin surface using a handheld gamma detector. Gamma count measurements were obtained for the following: 1) the "hot" spot/node in vivo before incision, 2) the hot spot/node in vivo during dissection, 3) the hot spot/node ex vivo, 4) the lymphatic bed after hot spot/node removal, and 5) the background in the operating room. The first draining lymph node(s) was identified, and biopsy of the node was performed. The radioactive sentinel lymph node(s) was submitted separately for routine histopathological evaluation. Preoperative lymphoscintigrams were performed in patients with melanoma and patients with Merkel cell carcinoma. In patients with head and neck squamous cell carcinoma, the relationship between the sentinel node and the remaining lymphatic basin was studied and all patients received complete neck dissections. The accuracy of sentinel node radiolocalization with biopsy, the micrometastatic rate, the false-negative rate, and long-term recurrence rates were reported for each of the head and neck tumor types. In the melanoma study, the success of sentinel node localization was compared for sentinel node radiolocalization biopsy, blue-dye mapping, and lymphoscintigraphy. In the Merkel cell carcinoma study, localization rates were evaluated for sentinel node radiolocalization biopsy and lymphoscintigraphy. In the head and neck squamous cell carcinoma study, the localization rate of sentinel node radiolocalization biopsy and the predictive value of the sentinel node relative to the remaining lymphatic bed were determined. All results were analyzed statistically. RESULTS: Across the different head and neck tumor types studied, sentinel node radiolocalization biopsy had a success rate approaching 95%. Sentinel node radiolocalization biopsy was more successful than blue-dye mapping or lymphoscintigraphy at identifying the sentinel node, although all three techniques were complementary. There was no instance of a sentinel node-negative patient developing regional lymphatic recurrence. In the head and neck squamous cell carcinoma study, there was no instance in which the sentinel node was negative and the remaining lymphadenectomy specimen was positive. CONCLUSION: In head and neck tumors that spread via the lymphatics, it appears that sentinel node radiolocalization biopsy can be performed with a high success rate. This technique has a low false-negative rate and can be performed through a small incision. In head and neck squamous cell carcinoma, the histological appearance of the sentinel node does appear to reflect the regional nodal status of the patient.

Aesthetic considerations in the elevation of the eyebrow.

In an increasingly diverse and multicultural society, it becomes increasing imperative to understand the aesthetics and proper analysis of the face, particularly as it applies to forehead lifting and elevation of the eyebrow. Most articles published to date have emphasized the surgical anatomy and/or surgical technique of forehead lifting and addressed the question of brow aesthetics in a uniform, generalized fashion. In addition, the emphasis on brow elevation as a means to brow/upper lid rejuvenation can further distract the surgeon from appreciating each person's unique brow aesthetics. This article examines current surgical concepts of brow/upper lid proportion and harmony and compares and contrasts them with cultural notions of the "pleasing brow" as represented by the makeup and fashion industries. There is great variation in what is considered to be a "beautiful brow," and the facial plastic surgeon must understand the nuanced elements of eyebrow configuration that contribute to the overall balance and harmony of the face.

The efficacy of resorbable plates in head and neck reconstruction.

OBJECTIVE/HYPOTHESIS: The advent of malleable macroporous resorbable plates has allowed the surgeon a greater range of reconstructive options and has decreased the morbidity of conventional plating procedures. Completely malleable after warming to 55 degrees C, resorbable plates can readily conform to most morphologic appearances of fractures or defects and provide rigid fixation when cooled. The plating systems used in head and neck reconstruction are described. STUDY DESIGN: Nine patients were selected for reconstruction using a resorbable plating system. The resorbable system was tested under a variety of clinical situations including frontal sinus fractures (three patients), midface fractures (two patients), mandibular defects (two patients), and laryngeal fractures (two patients). METHODS: Each case was evaluated for rigidity of fixation, and ease of plate contouring and application. Furthermore, the postoperative functional and cosmetic results and complications were contrasted between the resorbable plating systems and each surgeon's vast experience with traditional plating systems. RESULTS: The resorbable plating system was found to be as effective as traditional plating systems with respect to rigidity of fixation, functional results, and complications. In addition, the resorbable system was far easier to contour and, consequently, to apply, while producing higher cosmetic satisfaction after plate resorption than traditional plating. CONCLUSIONS: Based on our experience, resorbable plates appear to be safe, easy to contour and apply, as well as effective for a wide range of head and neck reconstructive applications. In addition, the shortcomings of permanently retained plates such as plate migration, bone growth restriction, and imaging artifact are avoided.

Current applications of platelet gels in facial plastic surgery.

The response of living tissue to injury is a central component in the planning of all surgical procedures. The wound-healing process is typically divided into three phases (inflammatory, proliferative, and remodeling) and is a complex process in which a multitude of cellular and humoral components interact to restore a wound defect. Platelets and their released cytokines and growth factors are pivotal in the modulation of this entire process. Although several techniques may be used to achieve hemostasis after initial injury, few initiate and actually accelerate tissue regeneration. Both platelet gel and fibrin glue are effective hemostatic agents. Platelet gels, unlike fibrin glue, have a high concentration of platelets that release the bioactive proteins and growth factors necessary to initiate and accelerate tissue repair and regeneration. In particular, two growth factors that play a major role in platelet gels are platelet-derived growth factor, a powerful chemoattractant, and transforming growth factor beta, which significantly increases and stimulates the deposition of extracellular matrix. In creating a platelet gel, autologous blood is centrifuged to produce a concentrate high in both platelets and plasma. This concentrate can be applied to wounds, providing hemostasis, adhesion, and enhanced wound healing. Recent techniques for the autologous concentrating process have been streamlined, and now platelet gels are clinically accessible to most physicians. Platelet gels have global applications in surgery and are especially useful for the soft tissue and bony reconstructions encountered in facial plastic and reconstructive surgery. In these applications, their use has been associated with a decrease in operative time, necessity for drains and pressure dressings, and incidence of complications. When applied to bony reconstruction it provides adhesion for the consolidation of cancellous bone and comminuted fracture segments.