Functional and cosmetic reconstruction of the facial lower third associated with placement of the transmandibular implant system

PURPOSE

Conventional preprosthetic procedures have typically focused on improvement of denture base stability and retention and have ignore patients' concerns about facial appearance and articulation difficulties. Soft tissue procedures have been developed, combined with insertion of the transmandibular implant (TMI) system through a submental incision, for functional and cosmetic reconstruction of the lower face to improve speech and facial esthetics, and prevent gingival hyperplasia along the lateral posts of the implant.

PATIENTS

The surgical procedure was evaluated in 146 patients with slight, moderate, severe, and extreme mandibular atrophy classified according to the proportion of muscle origin loss on the edentulous mandible. Preoperative, 3-month, and 1-year postoperative full-face and profile photographs were taken. Patients also were questioned about their satisfaction with their facial appearance and speech at these intervals. Gingival hyperplasia along the TMI posts was scored as present or absent.

RESULTS

Satisfaction with the soft tissue reconstruction in 146 patients treated according to this protocol was high, with almost every patient describing the positive comments they had received from their friends and relatives. Postoperatively, none of the patients requested a temporary denture to use during the 12-week incorporation period, although this was a common cosmetic and speech concern preoperatively. Gingival hyperplasia secondary to muscle pull was controlled satisfactorily.

CONCLUSIONS

With the described technique for placement of the TMI system, not only is masticatory function improved, but also the lower third soft tissues of the face are functionally and cosmetically reconstructed to the satisfaction of the patients.

Microdialysis of adipose tissue during surgery: effect of local alpha- and beta-adrenoceptor blockade on blood flow and lipolysis

The adrenergic regulation of adipose tissue lipolysis and blood flow was investigated in nonobese patients (10 men and 23 women) undergoing cholecystectomy. Two microdialysis probes were inserted into the scadipose tissue and microdialyzed in the absence or presence of 10(-4) mol/L of either nonselective beta-adrenoceptor blocker propranolol or nonselective alpha-adrenoceptor blocker phentolamine. The catecholamines increased rapidly after intubation and subsequent surgery and extubation (P = 0.0001; F = 11-13). In the middle of surgery, the elevations of the noradrenaline and adrenaline levels were almost 3 times the basal value. At the end of surgery, they dropped in parallel, but increased again, only to reach their absolute maximum in connection with extubation (10- and 3-fold elevation, respectively). Plasma glycerol and free fatty acids started to increase about 30 min after plasma catecholamines. These increases in catecholamines were paralleled by an increase in the dialysate glycerol level (lipolysis index). Propranolol inhibited by two thirds (P = 0.003) and phentolamine further stimulated by 25% (P = 0.04) the increase in glycerol in the tissue dialysate induced by the operation. There was a transient decrease in tissue blood flow (ethanol escape from the microdialysis probe; P < 0.001) at the beginning of the surgical procedure. This was not affected by propranolol or phentolamine. In conclusion, during anesthesia and surgical trauma, endogenous catecholamines modulate adipose tissue lipolysis via alpha- and beta-adrenoceptors. However, the vasoconstriction induced by these procedures seems to be independent of the adrenergic system.

The management of unilateral vocal cord palsy by augmentation using autologous fat

Augmentation of the vocal cord with Teflon paste has been one of the mainstays of treatment of a unilateral vocal cord palsy. Recently the licence for Teflon in the UK has been withdrawn, creating the need for an alternative. Over the last 2 years we have been using autologous fat harvested from the abdominal wall for this purpose. Fat is more difficult to work with than Teflon and we have developed a modified injection gun in order to facilitate the injection of the fat. The technique has been used in 14 patients with improvement of the voice in eight.

[Liposuction using a rotary cannula. Technical note]

The liposuction with a rotary cannula combines suction under traditional depression with rotation of the cannula mounted on a hand-piece, connected to a motor. This rotation, which can be has high as 400 r.p.m., allows 360 degrees treatment of lipodystrophy in a single procedure. Safety is ensured by an adjustable couple limiter, which prevents any risk of accidental movements when the cannula meets resistance. The authors conducted a study on 2 cases, which demonstrated a definite advantage of this technique in marked to severe lipodystrophy (1.5 to 7 litres of suction) and in high-density zones which are difficult to treat (epigastrium, knees, dorsal folds). This technique does not provide any decisive advantages in cases of minor lipodystrophy, which could justify its routine use in this context.

Ventral hernia repair with simultaneous panniculectomy

The repair of a ventral hernia in an obese patient presents an interesting clinical challenge. We retrospectively reviewed the charts of 55 patients who, over a 12-year period from 1983 to 1995, concomitantly underwent both ventral herniorrhaphy and panniculectomy or abdominoplasty. In six of 55 patients, the hernia was recurrent. Forty-six patients had primary abdominal wall hernias or diastasis recti. Nineteen of 55 patients had weight greater than 200 lbs. This last subset of patients had a significantly higher incidence of complications, such as seroma, cellulitis, and persistent wound drainage. In our 55 patients, we experienced only two hernia recurrences (3.6%) during an average patient follow-up of 53 weeks. From this experience, we believe that simultaneous ventral hernia repair and panniculectomy is a safe and efficacious approach to these two problems so commonly found in the obese patient. Patients with a preoperative weight greater than 200 lbs can be expected to have a greater risk of wound complications. In all cases, the wounds eventually healed with no long-term sequelae.

[Computerized tomography and magnetic resonance tomography studies before and after para-tibial fasciotomy]

Paratibial fasciotomy has been employed since 1981 to treat patients with chronic venous insufficiency (CVI) and therapy-resistant leg ulcers with severe lipodermatosclerosis. The characteristic morphological changes in CVI were evaluated shown before and after paratibial fasciotomy using computerized tomography (CT) and magnet resonance tomography (MRT). 10 patients (6 female, 4 male) were examined by CT and MRT pre- and postoperatively. Preoperatively there is a clear thickening of the dermis and subcutaneous field. In addition, the area around the achilles tendon is thickened, the fasciae are enlarged and the muscles of the lower leg show an increase of fatty tissue. A decrease of the cutaneous and subcutaneous thickening is seen postoperatively. The fasciotomy split is visible in most patients.

Use of fibrin glue in lower blepharoplasties

This prospective study investigates the long-term appearance of the scar following closure of lower blepharoplasty incisions with the fibrin adhesive Tissucol compared with the usual subciliary suturing. Eighteen eyelids closed with fibrin adhesive were compared with 12 eyelids where a 5-0 running suture was used for closure and to 10 eyelids that did not undergo surgery. The measurement team consisted of a panel, blind to patients and technique, that scored the scar morphology on a scale of 1-4. The Dunn test showed no difference between the group treated with the tissue adhesive and the group with conventional subciliary closure. There was a difference between the Tissucol treated group and the control group (P < 0.01). The surgical technique and the advantages in lower lid incision closure are discussed.

Subcutaneous approach for elevation of the malar fat pad through a prehairline incision

In summary, vertical suspension of the malar fat pad has been a safe procedure that results in the creation of a more youthful cheek and a lessening of the prominence of the nasolabial folds. No complications were encountered in this series with the suture suspension of the malar fat pad.

Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis

The pedicled buccal fat pad has been widely used for the repair of oral defects. A new application of this flap in the treatment of patients suffering from trismus caused by oral submucous fibrosis is reported. The patients underwent incision of the fibrotic bands and coverage of the buccal defect with a pedicled buccal fat pad flap. The surgical technique is described, and the results suggest that this is a logical, convenient, and reliable technique for the treatment of oral submucous fibrosis.

Partial subfascial abdominoplasty

An efficient liposuction is one performed behind and above the abdominal superficial fascia. It is followed first by a dissection at the deep side of this fascia, and then after a change of plane, at the supra-umbilical level to reach the pre-muscular fascia plane. Dissection is then adjusted according to the amount of excess skin. As the amount of tissue that needs to be vascularized by the subdermal arterial network is reduced, and as no major lymphatic trunk is cut, the partial subfascial abdominoplasty respects the anatomy of the region better. In our experience (65 cases since March 1989) this quick and reliable technique totally avoids the most frequent risk of abdominoplasty: seroma.

Superficial liposuction

Over a period of 12 years, the authors have seen that skin retracts after the judicious treatment of deep and superficial layers of fat tissue, laying to rest what has been one of the biggest fears of this treatment of lipoaspiration, namely cutaneous flaccidity. The adequate and judicious approach to these two layers, along with the increasing use and help of lipo-injection, permits the lessening of irregularities such as undulations and/or depressions.

Endoscopy for regional lipectomy

With the advances in endoscopic surgery, reconstructive surgeons search for applications in the field of soft tissue contouring. The improvements in endoscopic surgery in other fields are based on surgery within well-contained spaces that allow insufflation. However, minimally invasive surgery in the soft tissue planes has been limited by the relative inability to control separation of the tissue planes to allow a working space for instrumentation. This animal model shows the ability to open up and elevate any soft tissue space by means of external traction elevation and exact separation of tissue layers to allow endoscopic surgery without the need for insufflation. With the use of endoscopic equipment, the removal of fat from any area of the body becomes a much more precise art because of visualization and illumination and the ability to gain immediate hemostasis while exact contouring through removal of layers of fat can be achieved.

Consistent hepatic metastasis of human colorectal cancer in severe combined immunodeficient mice

A major stumbling block in the study of human colorectal cancer metastasis has been the lack of an effective in vivo model producing liver metastasis on a consistent basis. In this study surgical specimens of colorectal carcinoma were implanted in scid mice and studied for engraftment, growth, and the capacity to produce hepatic metastases. Human colorectal cancers would engraft and propagate in the subcutis and intraperitoneally. Sporadic metastasis to the liver occurred in 3 of 54 (6%) animals with cancer implanted subcutaneously. Liver metastasis occurred in 24 of 25 (96%) mice with cancer implanted in the gonad fat pad. Tumor growth to extremely large volumes subcutaneously did not enhance metastatic potential, and neither did longer term growth in the subcutaneous space. Tumor placed in the gonad fat required no special manipulation and in most cases a single piece of solid tumor was implanted. In situ hybridization confirmed the persistence of the human tissue in these metastasizing tumors. Our model will allow for the study of the processes involved in metastasis of solid tumors, characterization of differences between the primary tumor and the metastatic one, and evaluation of possible therapeutic modalities.

Importance of soft tissue integrity on biomechanical studies of the patella after TKA

This study evaluated the effects of soft tissue integrity on patellar tracking and patellofemoral joint force after total knee arthroplasty. The results indicate that partial dissection of the soft tissue integrity in the in vitro biomechanical studies of the patellofemoral joint can alter patellar tracking and joint force significantly, leading to improper conclusions.

[Development and clinical anatomy of the rectal adventitia. significance for radical operation of rectal carcinoma]

The development, topography and clinical anatomy of the adventitia recti were studied in 300- to 600-microns-thick sections through the pelves of human fetuses and newborn children and 5-mm sections through the pelves of adults. The adventitia recti constitutes a continuous compartment bordered laterally by the fascia recti. In the adult the adventitia recti consists mainly of adipose tissue. The extent of the adventitia recti differs in different parts of the rectal wall. The branches of the vasa rectalia superiora and the visceral lymph nodes of the rectum are situated within the adventitia recti. Our findings suggest that it is necessary to remove the adipose tissue of the adventitia recti and the adjoining lymph nodes individually during resection of the rectum in order to minimize the risk of tumor recurrence.

The role of orbital fat preservation in facial aesthetic surgery. A new concept

Preservation of lower orbital fat in facial rejuvenation is a new concept for preventing the "operated" appearance that may follow fat removal in conventional blepharoplasty. By creating a narrower, more shallow orbit, the surgeon can create a truly youthful eyelid-cheek complex. Orbital fat advanced over the complete inferior orbital rim hides the bony framework that becomes apparent with normal aging. This technique is used routinely in isolated blepharoplasty and with composite rhytidectomy. It accompanies repositioning of the orbicularis oculi muscle, cheek fat, and facial platysma muscle. It is a procedure that can correct postoperative problems caused by excess orbital fat removal, lower eyelid retraction, and contour problems resulting from malar augmentation. The orbital fat is one of the many deep "pieces" of the human face that must be preserved and repositioned for optimal facial rejuvenation.

Concept of triangular, trapezoidal, and rectangular debulking of eyelid tissues: application in Asian blepharoplasty

There has been continued refinement and understanding in the concepts of Asian blepharoplasty. Among Asians, aesthetic upper eyelid surgery to convert a creaseless upper eyelid (popularly referred to as "single eyelid") to one with a crease ("double eyelid") is the most frequently performed cosmetic surgery in Asia and among Asians living in the Western hemisphere. I have discussed my understanding of the concept of this surgery, utilizing a tarsal height-based external incision method plus assymmetrical debulking of the preaponeurotic tissues, including some fat, septum orbitale, pretarsal and preseptal orbicularis oculi muscles, and preseptal skin.

An intermeniscal fibrous band in a recreational runner

An intermeniscal fibrous band was found to produce anterior knee pain in a recreational runner. Arthroscopic resection of the band eliminated the symptoms of pain with running. A literature review found no prior reports of this entity. The differential of plica syndrome and Hoffa's disease was reviewed.

Surgical treatment of severe dysthyroid ophthalmopathy--long-term results

Conservative therapy in cases of severe dysthyroid ophthalmopathy (DO) has not given satisfactory results. Since 1986, 51 patients (99 orbits) with marked DO have been treated by surgical decompression of the orbits. The procedure begins within the upper eyelid. The excision of the excessive skin and subcutaneous tissue is performed and eyelid fat is removed. In order to obtain the correction of the upper eyelid retraction, the levator aponeurosis is divided by 2-3 transverse incisions in its central part and Muller's muscle is sectioned at the level of its tarsal insertion. Through an incision in the lower eyelid, the posterior part of the orbital floor, the lateral orbit wall, as well as the periorbital and intraorbital fat are removed. Through an incision made over the medial margin of the orbit, the ethmoidal part of the medial orbital wall and the retrobulbar fat are removed. The periorbital periosteum should be incised at several sites. After operation all patients showed a significant reduction of exophthalmos (5-11 mm, 7.16 mm on average), significant reduction of intraocular pressure, marked improvement in ocular muscle function, as well as considerable reduction or disappearance of subjective symptoms. There was an improvement in vision in 68% patients who had impaired vision before the operation. There were no cases of subsequent impairment of vision or ocular motility. Mild relapse was recorded in three cases only and only one patient required unilateral reoperation. Strabismus surgery had to be performed in five patients due to unsatisfactory correction of double vision. It can be concluded that this method of orbital decompression gives very good functional and aesthetical long-term results.

Endoscopy and biopsy of the orbit

Flexible endoscopes produce high-quality images, are small in size, and can deliver microsurgical instruments or laser probes. Early attempts at orbital endoscopy were limited by the relatively large size and poor visualization of rigid endoscopes. We performed endoscopic orbital exploration using the Olympus HYF flexible endoscope in four live dog orbits. We achieved excellent visualization of orbital structures including the globe, blood vessels, extraocular muscles, intermuscular septa, optic nerve, and fat. Visualization, hemostasis, and dissection were aided by the use of hyaluronic acid infused through the endoscope. We biopsied fat and extraocular muscle without complication using Olympus endoscopic cup biopsy forceps (confirmed by histopathologic examination). Our experience indicates that orbital endoscopy aided by viscoelastic hydrodissection may permit a less invasive approach to optic nerve sheath fenestration, tumor biopsy and treatment, and the removal of foreign bodies.

[Myringoplasty using a fat graft]

A technique for closing small tympanic perforations with a fat graft taken from the ear lobe is described. Our results and those of other authors are summarized and the advantages of the technique are detailed.

[Hoffa disease: diagnosis and arthroscopic treatment]

The diagnosis of Hoffa disease (syndrome of impigement of the infrapatellar fat pad) was established in 20 patients with anterior knee pain by clinical physical examination, magnetic resonance imaging and arthroscopic findings. Arthroscopic partial or total resections of the infrapatellar fat pad were performed after arthroscopic examination. According to the Larson's rating score for knee function, 18 cases had a satisfactory result at an average follow-up of 36 months. The results of follow-up also suggested there was no significant difference between the partial and total resections of the fat pad.

The soft-tissue shaving procedure for removal of adipose tissue. A new, less traumatic approach than liposuction

OBJECTIVE

To introduce the soft-tissue shaving cannula, a new, precise alternative to conventional liposuction that embodies an entirely different method of soft-tissue extraction and that appears to be less traumatic and more precise than methods currently used in liposuction.

DESIGN

Nonrandomized, nonblinded comparison of the soft-tissue shaver and conventional liposuction devices in fresh cadavers, followed by clinical use of the liposhaver in selected patients undergoing cosmetic facial liposuction.

INTERVENTIONS

Conventional liposuction devices and the soft-tissue shaving cannulas in fresh cadavers (< 8 hours old). A submental lipectomy and a melolabial fold liposhaving were performed in a clinical setting.

OUTCOME MEASURES

Subjective evaluation by the operating surgeons.

RESULTS

The fat was cleanly shaved and the contour result was even, without dimpling or asymmetry.

CONCLUSIONS

Our early experiences suggest that this new liposhaving technique may offer a precise, less traumatic alternative to conventional liposuction. Fat can be shaved in an open fashion under direct vision. It does not rely on a vacuum seal. The soft-tissue shaving cannula shaves fat one layer at a time. The depth of each layer removed, the depth of soft-tissue injury, and the optimal settings and sizes for various procedures remain to be reported.