Temporalis fascia grafts for facial and nasal contour augmentation

AlloDerm for dorsal nasal irregularities

After nasal surgery, thinning of the nasal skin, bony irregularities, or adhesions of dorsal skin to underlying bone can all occur. These problems can be solved by using either alloplastic materials or various autogenous tissues. In this study, AlloDerm, a dermal replacement derived from cadaveric skin, has been used to cover the osseocartilaginous framework of the nose in an attempt to achieve a smooth contour and a natural feel in secondary rhinoplasties. Fifteen patients were treated and observed for a minimum of 24 months. Clinically palpable or visible bony irregularities were successfully covered, and adhesions of dorsal skin to nasal bones were diminished. Prolonged but not socially unacceptable dorsal nasal swelling, which resolved during the first 4 months, seemed to be the only problem related to its use. With this limited experience, AlloDerm was found to be useful in secondary nasal surgery to cover osseocartilaginous irregularities, to eliminate the adhesions between nasal bones and overlying skin, and to create a smooth nasal dorsum.

Maxillary reconstruction: functional and aesthetic considerations

Maxillary reconstruction is a challenging endeavor in functional and aesthetic restoration. Given its central location in the midface and its contributions to the key midfacial elements--the orbits, the zygomaticomaxillary complex, the nasal unit, and the stomatognathic complex--the maxilla functions as the keystone of the midface and unifies these elements into a functional and aesthetic unit. Maxillary defects are inherently complex because they generally involve more than one midfacial component. In addition, most maxillary defects are composite in nature, and they often require skin coverage, bony support, and mucosal lining for reconstruction. In the reconstruction of maxillary defects secondary to trauma, ablative tumor surgery, or congenital deformities, the following goals must be met: (1) obliteration of the defect; (2) restoration of essential functions of the midface, such as mastication and speech; (3) provision for adequate structural support to each of the midfacial units; and (4) aesthetic reconstruction of the external features. This review will discuss the pertinent anatomic considerations, the historical approaches to maxillary reconstruction, and the merits of the techniques in use today, with an emphasis on state-of-the-art reconstruction and dental rehabilitation of extensive maxillary defects.

New use for the temporalis superficialis fascia in the facial contour: lip sculpture

Since 1989, the author has been using autologous grafts of the temporalis superficialis fascia, with a total of 303 areas grafted. The grafts are readily acquired; they do not present any problem to the donor area and they eliminate peribucal wrinkles in particular, contribute to the filling in and increase of the turgidity of the lips by hardening them, and produce the projection of the cutaneous vermillion line. The fascia are interposed between the skin and the muscles by dominating the action in the skin and having an exceptional integration of a definitive character with no absorption. We visualize the placement of the pieces of fascia with the assistance of a Reverdin needle, as there are no incisions, but rather just small holes. Its use is also applied to the fading of the naso-labial furrow and the glabellar wrinkles. The same material is used in correcting rhinoplasty sequelae and the increase of volume in the congenital or acquired sunken-in face. The contribution with the definitive use of grafted fascia offers refinement in the filling in the facial contour at the centripetal sunken-in areas of the face, as an ancillary procedure in the musculo-cutaneous facelift stretching.

Galea and subgalea graft for lip augmentation revision

In this paper we will review the results obtained during the last 2 years with the aponeurotic galea and subgalea for vermillion lip augmentation. The survey was carried out on 42 patients who displayed either an absence of or reduction in the vermillion of one or both lips or a senile lip. In all cases the surgical procedure introduced aponeurotic galea and subgalea in the space found between the orbicular lip muscle and the vestibular mucus, just behind the vermillion. All the operations were performed under local anaesthetic. The size of the aponeurotic galea fragment removed varied in length between 10 and 12 cms. and in width between 1 and 2 cms., using the following parameters for its dimensions: the previous volume of the lips, and the distance between the two buccal commissures when in the "smile position."

SMAS autografts for the nasal dorsum

Many patients of rhytidectomy age have had previous rhinoplasty or nasal injury and have dorsal irregularities or saddle-nose deformities. SMAS tissue ordinarily discarded at rhytidectomy may be used for nasal dorsal augmentation and padding. Six patients undergoing rhytidectomy who also had prior nasal surgery or deformity were selected. Two of the patients had saddle deformities, and four had palpable and visible bony or cartilaginous irregularities. In all patients, substantial improvement was noted. In the saddle deformities, significant long-term results were achieved, with graft longevity as great as 24 months. The technique should be considered in rhytidectomy patients with concomitant nasal dorsal deformities.

Reconstruction of the temporomandibular joint using a temporalis graft with or without simultaneous orthognathic surgery

PURPOSE

This article reports the outcome of free temporalis fascia and muscle graft (TFG) reconstruction of the temporomandibular joint (TMJ) with and without simultaneous orthognathic surgery (SOS).

MATERIALS AND METHODS

Twenty-nine patients (45 joints) were evaluated retrospectively. Group 1 consisted of 17 patients (16 women 1 man) and 30 joints. Fifteen (88%) patients had sagittal split ramus osteotomies (SSRO); 8 (53%) of these patients also had Le Fort I osteotomies, and 2 patients (12%) had only Le Fort I osteotomies with TFG. Group 2 consisted of 12 patients (15 joints) who received only TFG and no SOS.

RESULTS

Group 1 had 9 patients (53%) with an incisal opening greater than 35 mm, 11 joints (37%) with greater than 6 mm lateral excursive movement, and 11 patients (65%) were asymptomatic postoperatively. Average follow-up was 57.4 months (range, 23 to 69 months). Group 2 had eight patients (67%) with an incisal opening greater than 35 mm, six joints (40%) with greater than 6 mm lateral excursive movement, and seven patients (58%) were asymptomatic postoperatively. Average follow-up was 55.1 months (range, 48 to 64 months).

CONCLUSION

TFG with and without SOS produced similar treatment outcomes in comparing groups 1 and 2. No significant differences were observed for the number of patients with an incisal opening > 35 mm (P = .703), lateral excursion > 6 mm (P = 1.00), and successful elimination of pain (P = 1.00), even though group 2 had a significantly greater number of patients (P < 0.01) that were operated on unilaterally. Combining treatment outcomes for both groups, the number of previous joint surgeries significantly affected success (P < .01). The presence of osteoarthritic changes did-not significantly affect treatment outcome (P = .187).

The role of free pericranium grafts in augmentation rhinoplasty

Various tissues and materials have been used in augmentation rhinoplasty. This paper presents a retrospective analysis of 14 patients, 8 female and 6 male, in whom free pericranium grafts were used in order to restore postsurgery or posttraumatic nasal defects. There were no complications from either the donor or the recipient site. The early and medium term results were satisfactory. It is concluded that free pericranium, compared with other autografts, is a good alternative due to its several advantages and hardly any disadvantages. In selected cases it can even be the material of choice.

Extended vascularized temporalis muscle-fascia flap

The use of an extended vascularized temporalis muscle flap is described. The deep layer of the temporalis fascia is partially everted over the temporalis muscle preserving its vascularity. A composite flap comprising temporalis muscle and its fascia attached along its superior border, is rotated for reconstruction of postoperative defects in the middle cranial fossa floor and mastoidectomy cavities. The versatility of this flap is discussed.

The volume limitation of the galeal temporalis flap in facial augmentation

Galeal temporalis flaps based on the superficial temporal vessels have been used for facial augmentation and can be extended to the contralateral side beyond the midline in order to achieve maximum volume. In five patients, the volumes of extended galeal flaps were measured intraoperatively using a water displacement method. The calculated volume varied between 28 and 38 cm3. Experience with this flap showed satisfactory results with no complications; therefore, it is concluded that the extended galeal temporalis flap may be a first choice in the correction of facial soft tissue deficits less than 40 cm3. Clinical cases are presented.

Expanding contractures of the tunica albuginea due to Peyronie's disease with temporalis fascia free grafts

We describe a procedure to expand contractures of the tunica albuginea by multiple full thickness relaxing incisions followed by inlay of tailored temporalis fascia free grafts. This technique is performed without resection of the tunica albuginea, although in the case of calcified plaques the calcifications themselves are removed, preserving the overlying tunica. Between September 1988 and February 1990, 12 patients have undergone this procedure, all of whom have greater than 3 months of followup and have experienced spontaneous erections within the first week postoperatively. Of the patients 11 resumed intercourse within 8 weeks of surgery and 1 required 12 weeks. No patient had sensory loss postoperatively and there has been no donor site morbidity. Correction of curvature was accomplished in all patients and there have been no recurrences within a maximal followup of 22 months. Within the limitations of such a small study we believe that there is evidence supporting this approach in potent patients with severe acquired penile curvature.

Surgical repair of defects in the rabbit temporomandibular joint disc: a comparison of various techniques

A study was designed to evaluate the effects of different types of repair (suture vs. graft), donor graft tissues (dermis vs. fascia), and methods of graft fixation (sutured vs. laser-assisted) on excisional defects of the rabbit TMJ disc made anterior to the retrodiscal tissue. Groups created to compare the different variables were assessed at 30 and 90 days postoperatively by macroscopic and histologic methods, microangiography, and mechanical strength testing. Without repair, all excisional defects of the disc failed to heal. Suturing of the reapproximated margins did not appear to promote healing or provide much strength beyond the properties of the suture material. Dermal grafts, fixed by suturing, induced healing by becoming incorporated into the disc, restoring discal continuity, and approximating normal disc strength. The use of laser-assisted tissue welding for dermal graft fixation was found to be inadequate and was subsequently abandoned. Fascial grafts could be fixed into position by both suture and laser-assistance, but consistently failed to exhibit successful transplantation and promote healing at the disc site.