Endoscopic facial surgery.

The emergence of endoscopically assisted cosmetic surgery has been very rapid. Public demand has burgeoned this trend resulting in the widespread use of these techniques prior to their proven efficacy. Fortunately, the results to date are favorable. The endoscopic brow and forehead lift appear to be as reliable as the open coronal approach while inflicting less incisional morbidity and decreased postoperative recovery time. This combination of decreased morbidity and post surgical discomfort have led to increased patient acceptance of browlifting. The soft-tissue orbital complex is composed of the eyebrow, upper and lower eyelids, and the malar prominence. When used in conjunction with blepharoplasties, the endoscopic browlift and midfacial suspension dramatically improve the appearance of the eye when compared to blepharoplasty alone. The applied surgical anatomy, indications, and operative technique used in endoscopic upper facial rejuvenation are detailed. Surgeons who are not utilizing the endoscopic techniques are encouraged to do so when repositioning the eyebrow and malar prominence would improve the aesthetic result.

Surgery of the nasal tip.

One of the most challenging aspects of cosmetic rhinoplasty is nasal tip refinement. In efforts to control tip rotation, projection and architecture, surgeons face constant tradeoffs between tip position and dorsal reduction. Open structure rhinoplasty allows direct visualization of bony-cartilaginous deformities, preservation of nasal structural integrity and precise nasal tip alteration. The open rhinoplasty technique involves, control of tip projection and rotation, reshaping of nasal tip cartilage, minimal resection of the nasal dorsum and lower lateral cartilage and preservation or reinforcement of major tip supports. The advantage of open structure rhinoplasty includes preservation of inherent nasal supporting elements and precise nasal reshaping which are essential for aesthetically pleasing and predictable postoperative results.

The significance of positive margins (known and unknown) at the conclusion of Mohs surgery in the orbital region.

The Mohs fresh tissue technique has provided a high rate of cure in cases of malignant tumors in the orbital region. However, in some patients, tumor may persist after Mohs surgery if margins are falsely negative or if the Mohs surgeon elects to terminate the procedure with known positive margins. We report six patients who had residual tumor present in the periorbital region after Mohs surgery. These patients have a serious prognosis associated with subsequent morbidity. Accurate communication between the Mohs surgeon and subsequent treating surgeons, combined with aggressive tumor management, may help to minimize morbidity and improve mortality.

Esthetic refinements in forehead flap nasal reconstruction.

OBJECTIVE: To identify refinements in forehead flap nasal reconstruction that consistently provide better esthetic and functional results. DESIGN: Case series of patients undergoing forehead flap nasal reconstruction from July 1, 1987, to May 31, 1994. SETTING: University hospital ambulatory surgery department. PATIENTS: Thirty-two patients with various nasal defects. INTERVENTIONS: Modifications of currently accepted techniques of paramedian forehead flap nasal reconstruction, namely, flap harvest and contouring, W-plasty closure of the superior forehead donor site, and creation of soft-tissue triangles. The principles of open-structure rhinoplasty are incorporated into cartilaginous reconstruction of the nasal tip and columella. The alar rim is reconstructed with cartilage grafts placed at the nasal rim. MAIN OUTCOME MEASURES: Esthetic and functional results of nasal reconstruction were subjectively graded by three otolaryngologists (V.C.Q., D.A.S., and M.F.R.) and the patients. RESULTS: Improved esthetic and functional nasal reconstruction. The most common nasal subunits reconstructed were as follows: ala, 27 patients (84%); side-wall, 22 patients (69%); dorsum, 18 patients (56%), and tip, 15 patients (47%). The esthetic results ranged from average to excellent (3 to 5 on a scale of 5), the functional results ranged from improved to much improved over preoperative breathing (4 to 5). Two patients required unplanned surgical revisions. Forty-seven percent of patients chose to undergo dermabrasion. Five patients required postoperative intradermal injection of triamcinolone acetonide (Kenalog). Three patients required preoperative tissue expansion. Flap or graft loss, infection, or hematoma did not occur. CONCLUSIONS: The predictability of the techniques in providing excellent results in patients undergoing nasal reconstruction decreases the need for revision procedures and helps the patient and the surgeon achieve the desired outcome.

Microtia repair.

Management of microtia can be one of the most rewarding yet humbling challenges faced by the reconstructive surgeon. The preferred method of total auricular reconstruction is with autologous cartilage and skin, based on modifications of the methods of Tanzer and Brent. Our goals in auricular reconstruction of microtia are: (1) a satisfied patient; (2) proper positioning; and (3) a pleasing size and contour. The reconstructive process in classic microtia reconstruction can be divided into four stages. The first stage is the creation and placement of the underlying framework derived from the autologous rib cartilage of the sixth to eighth ribs. The second stage is rotation of the lobule from the microtia remnant into position inferiorly on the helical rim. The third stage is elevation by creation of an auriculocephalic angle with a skin graft. The final stage is formation of the tragus from a composite graft from the opposite ear. Atypical microtia presents distinct challenges to the reconstructive surgeon. Complete framework insertion may not be necessary with the presence of some recognizable structure. Other circumstances arise that make each reconstruction unique, such as low-lying hairline or skin shortage. The extreme situations of skin shortage will benefit from the use of a temporoparietal fascia flap. However, adherence to the well-established principles of total auricular reconstruction will lead to satisfaction of the patient, the patient's family, and the surgeon.

Cartilage grafts for head and neck augmentation and reconstruction. Autografts and homografts.

This article reviews cartilage grafting in the head and neck, emphasizing its use in facial surgery. The harvesting and preparation of cartilage grafts are reviewed, and both autografts and homografts are discussed. The implementation of cartilage grafts in the nose, ear, eyelid, orbit, and larynx also is presented.

Effects of cyanoacrylate tissue adhesives on cartilage graft viability.

Cartilage graft fixation using cyanoacrylate tissue adhesives has aided in the accuracy and stability of these grafts in facial reconstructive procedures. To objectively determine how these adhesives affect cartilage viability, freshly harvested cartilage from septoplasty procedures was bonded in vitro with one of four cyanoacrylate adhesives: Histoacryl, Bucrylate, Krazy Glue, or Eastman 910 monomer. Viable chondrocytes will incorporate the sulfur-35 (35S) isotope in the synthesis of chondroitin sulfate, and is therefore a reliable test of cartilage viability. The bonded cartilage specimens were stored from 3 days to 4 weeks at 4 degrees C and then were incubated with the 35S isotope. Autoradiographs were made and the sections were counterstained. Throughout the study period, there was no statistical difference in the viability of Histoacryl-bonded specimens as compared to the controls. Specimens bonded with Bucrylate, Krazy Glue, and Eastman 910 monomer statistically demonstrated markedly less viability compared to those bonded with Histoacryl at the P = .01 level of significance. Further, the cartilage separated from these latter adhesives at the longer study times, most likely secondary to cartilage devitalization. Histoacryl optimizes graft viability as compared to these other available cyanoacrylate tissue adhesives in vitro.

Eye banking: techniques for eye preservation in selected neoplasms encroaching on the globe.

Removal of the globe and associated structures has been advocated for tumors invading the periorbital bone and periosteum, orbital fat, or extraocular muscles. In some patients with cancerous tumors encroaching on the globe, however, it may be possible to remove the tumor and save the eye. Tenon's fascia is a firm fibrous sheath surrounding the entire globe except the cornea. If the neoplasm spreads along fascial planes rather than through them, and if this layer remains free of tumor involvement, preservation of the globe can be considered. Oculoplastic reconstructive techniques may limit exposure and diplopia, allowing the eye to be "banked" in vivo, and saved as a spare for the future. Six patients with malignant tumors encroaching on the globe have had definitive surgical extirpation with preservation of the eye. Three patients have had the globe uncovered successfully. Five of six patients remain disease-free, with followup from 6 months to 6 years. No globes have been removed. These techniques appear to be therapeutically sound, preserve function and appearance, and improve patient morale. The indications and limitations of this approach to certain cases of periorbital cancer are discussed.

Skin excision revision rhinoplasty.

A technique of skin excision revision rhinoplasty is described for application in patients undergoing rhinoplasty. This group of patients includes those with soft-tissue polly beak deformities and a variety of other difficult post-rhinoplasty deformities. Horizontal nasal dorsal skin excision affects tip elevation and eliminates supratip fullness, while vertical midline nasal dorsal skin excision enhances tip definition, decreases dorsal height, and eliminates supratip fullness. We describe several patients who underwent either horizontal or vertical nasal dorsal skin excision for a variety of cosmetic deformities following conventional closed and open rhinoplasty. The techniques presented herein are meant to be added to the list of techniques available to the revision rhinoplasty surgeon rather than to replace existing techniques.

Calvarial bone graft harvest. Techniques, considerations, and morbidity.

The importance of calvarial bone grafting in craniomaxillofacial trauma and facial reconstructive surgery is now widely recognized. Numerous harvesting techniques have evolved to optimize the desired thickness, size, shape, and curvature for a particular reconstructive need. At the same time, donor site selection and morbidity must be considered. This report includes a discussion of several currently utilized calvarial bone graft harvesting techniques, with emphasis on minimizing complications and morbidity. Choice of optimal harvesting technique and donor site for specific reconstructive situations will likewise be discussed. Finally, the specific morbidity in our multi-institutional calvarial bone graft harvest series of 121 patients and over 350 grafts will be reviewed.

The human auricular chondrocyte. Responses to growth factors.

The first human auricular (elastic cartilage) chondrocyte cell culture model is presented. These chondrocytes, harvested from fresh human cadaver auricular cartilage, are easily grown in culture. They produce type II collagen and abundant alkaline phosphatase. Like growth plate chondrocytes, human auricular chondrocytes respond mitogenically to both transforming growth factor-beta and basic fibroblast growth factor by increasing proliferation twofold. The growth factors exert a synergistic effect on thymidine uptake in this model, with maximal stimulation occurring at the dose combination of basic fibroblast growth factor, 10 ng/mL, and transforming growth factor-beta, 3 ng/mL. Human nasal septal (hyaline cartilage) chondrocytes do not increase proliferation in response to these two growth factors. Human auricular chondrocytes also increase matrix production in response to transforming growth factor-beta, as indicated by increased proteoglycan production and increased collagen synthesis. The increased matrix production combined with increased proliferative rate elicited with transforming growth factor-beta and basic fibroblast growth factor indicates that human elastic cartilage chondrocytes harvested from the external ear are better suited for in vitro cartilage implant growth than human hyaline cartilage chondrocytes. Further biochemical and molecular biological characterization of the human auricular chondrocyte cell culture model is currently under way. Additional work is also under way to generate multilayer culture growth on absorbable frameworks, in the pursuit of the long-term goal of in vitro production of autogenous cartilage implants.

Bilobed flap reconstruction of the temporal forehead.

The temporal forehead is a particularly challenging area for reconstruction. Temporal forehead skin lies in a broad flat plane that varies in thickness. The eyebrow, scalp hairline, and lateral canthus comprise its aesthetic boundaries and limit the available tissue for repair of defects. Characteristically, skin tumors of the temporal forehead have extensive subclinical spread and their removal leaves large defects. The goal of temporal forehead reconstruction is to recreate the aesthetic boundaries of the forehead and to regain symmetry with the contralateral side. The temporal forehead bilobed flap is a single-stage procedure that takes advantage of the best color match of adjacent tissue and often allows primary closure of the donor sites in relaxed skin tension lines with minimal distortion. Several cases are presented for illustration of the technique.

Steroids and rhinoplasty. A double-blind study.

Many facial plastic surgeons use perioperative steroids to reduce postoperative edema and morbidity. This use of steroids is based more on theory and anecdotal experience than on controlled studies. We studied 49 patients undergoing rhinoplasty in a randomized, double-blind fashion to evaluate the effects of perioperative and postoperative steroid use. We found significantly less postoperative eyelid and paranasal edema in those patients receiving steroids. In addition, trends toward less ecchymosis, less intranasal edema, and less discomfort in the patients receiving steroids were noted.

Significant premaxillary augmentation.

Substantial premaxillary augmentation is necessary as an adjunctive treatment in most cleft rhinoplasties and in those patients exhibiting an acute nasolabial angle due to retrusion of the premaxila. We describe our technique of evaluation and treatment of this condition using a custom-carved piece of material made from a woven combination of Teflon and organic fibers (Proplast). Detailed technical illustrations as well as patient results are demonstrated. We have found this technique in our hands to be a simple, safe, and effective means of correction of significant premaxillary retrusion.

The versatile midforehead browlift.

Ptosis of the brow is a significant and often unrecognized portion of aging of the upper face. It contributes to both cosmetic and functional aging. Correction is often mandatory prior to blepharoplasty in that functional problems may be worsened without elevating the brow. Direct and coronal browlifts are the most common approach to the problem. Midforehead browlifts have been reserved for men with receding hairlines. We have, for the past three years, performed midforehead browlifts on all our patients needing ptotic brow correction. Our review of 72 patients treated in this way, including 52 women, shows excellent and long-lasting cosmetic and functional improvement. There have been few complications, and the resultant incisional scars have been very well accepted. Therefore, we feel that the midforehead browlift, performed as we describe, is the ideal surgical correction for the ptotic brow.

Periocular malignant fibrous histiocytoma.

We present a case of periocular cutaneous malignant fibrohistiocytoma that invaded the orbit. Complete excision is recommended for atypical fibrohistiocytic tumors around the eye. Examination of specimen margins by frozen section should be undertaken with caution. It is recommended that frozen section evaluation be performed by a pathologist familiar with spindle cell neoplasm to ensure complete removal of this tumor.

Modified tracheoesophageal diversion for chronic aspiration.

Breakdown of the normal protective function of the larynx, either through primary laryngologic or neurologic causes, leads to chronic aspiration, recurrent pneumonitis and possibly death. In this paper we discuss the existing surgical treatments for chronic aspiration. Tracheal separation and trecheoesophageal diversion are discussed, as are the difficulties of using these procedures in patients with pre-existing tracheostomies. A modification of tracheoesophageal diversion is presented whereby this procedure can now be utilized in those patients with pre-existing tracheostomies. The modified tracheoesophageal diversion is performed in five patients successfully. Since most patients have already had tracheotomies in an attempt to control aspiration, we feel that our technique of modified tracheoesophageal diversion enables this group of patients to benefit from this procedure as well.