The Short Nose

The causes of the short nose deformity vary greatly, from congenital malformations to acquired deformities. Despite this degree of variation, key commonalities exist, namely, a shortened nasal length, overrotation of the nasal tip, and increased nostril show. This article is designed to help the reader identify precise causes of the short nose, outline associated anatomy, and discuss reliable surgical techniques to correct this deformity.

Lengthening the short nose

Lengthening the short nose is a challenging area of rhinoplasty. The short nose can be a naturally occurring aesthetic disproportion, or the result of a congenital abnormality or traumatic deformity. The surgical approach depends mostly on the quality of the lining, skeleton, overlying skin, and the amount of correction desired.

Common craniofacial anomalies: facial clefts and encephaloceles

The wide variety of craniofacial malformations makes classification difficult. A simple classification system allows an overview of the current understanding of the causes, assessments, and treatments of the most frequently encountered craniofacial anomalies. Facial clefts and encephaloceles are reviewed with respect to their diverse causes, pathogenesis, anatomical features, and treatments. Approaches to the surgical treatment of these conditions are reviewed.

Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.

Assessment of the effects on growth of porous hydroxyapatite granule cranioplasty in the immature guinea pig craniofacial skeleton

The immature guinea pig was used to study the effects on growth of porous granular hydroxyapatite used as an onlay cranioplasty and inlay cranioplasty to reconstruct full-thickness cranial defects in a growing craniofacial skeleton. Forty Hartley guinea pigs, 20 immature animals and 20 mature animals, were divided into four groups each containing five mature and five immature animals. The mature animals served as controls. Group I underwent elevation and replacement of the parietal periosteum. Group II underwent placement of hydroxyapatite between periosteum and parietal bone. Group III underwent elevation and replacement of autogenous bone flap after the formation of a 1 x 1-cm craniectomy defect in the parietal skull. Group IV underwent elevation of a 1 x 1-cm parietal craniectomy and reconstruction of the defect with hydroxyapatite granules placed between the dura and periosteum. Immature animals were killed at maturity at 3.5 months and mature animals were killed 2.5 months postoperatively. Macroscopic examination of the operative field, transverse and longitudinal cephalometric measurements, and histological sections encompassing the operative sites were compared. Macroscopically, all reconstructed operative sites were fully incorporated into the cranium. Histological staining of the sectioned operative site revealed no hydroxyapatite migration through the cranial bone or dura. No inflammatory or foreign body reaction was evident in the subcutaneous tissue, periosteum, or dura. No statistically significant cephalometric intergroup or intragroup differences were found at the conclusion of the study. The results of this study indicate that a granular porous form of hydroxyapatite may be used as an onlay or inlay cranioplasty in the immature guinea pig craniofacial skeleton without evidence of dural inflammation, granule migration, or growth restriction or retardation.

Common craniofacial anomalies: conditions of craniofacial atrophy/hypoplasia and neoplasia

The spectrum of craniofacial malformations includes conditions of congenital and acquired etiology. The conditions of craniofacial atrophy and hypoplasia may arise primarily or secondary to previous therapeutic interventions. The conditions of progressive hemifacial atrophy (Romberg disease) and radiation-induced hypoplasia will be reviewed on the basis of their etiology, pathogenesis, anatomy, and treatment. Approaches to the surgical management of these conditions will be discussed. The craniofacial neoplastic conditions of fibrous dysplasia, neurofibromatosis, and craniofacial tumors will also be reviewed and discussed.

Common craniofacial anomalies: the facial dysostoses

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the etiology and pathogenesis of facial dysostosis syndromes. 2. Recognize and classify common facial dysostoses. 3. Understand the different management plans for the reconstruction of facial dysostoses. The wide spectrum of craniofacial malformations makes classification difficult. A simple classification system allows an overview of the current understanding of the etiology, assessment, and treatment of the most frequently encountered craniofacial anomalies. Facial dysostoses are reviewed on the basis of their diverse etiology, pathogenesis, anatomy, and treatment. Conditions discussed include craniofacial microsomia, Goldenhar syndrome, Treacher Collins syndrome, Nager syndrome, Binder syndrome, and Pierre Robin sequence. Approaches to the surgical management of these conditions are reviewed.

Experience with anatomic breast implants

Anatomic implants provide useful alternatives to breast augmentation for the discerning surgeon, particularly in breasts with tight skin envelopes or deficient lower poles.

Porous hydroxyapatite granules for alloplastic enhancement of the facial region

Hydroxyapatite is a biocompatible alloplast with the same chemical composition as bone. It is readily incorporated into host bone, does not undergo appreciable resorption, does not incite a clinically significant foreign body reaction, and resists infection. This article describes forms of hydroxyapatite, procedures for use, and clinical examples.

Total soft-tissue reconstruction of the middle and lower face with multiple simultaneous free flaps in a pediatric patient

A 2-year-old boy sustained a massive facial soft-tissue wound secondary to a dog attack. Essentially all the soft tissues of the face were absent, including innervation and intraoral lining. We describe the reconstruction of this defect with five simultaneous free tissue transfers. To our knowledge, this is the first report of five simultaneous free flaps in any patient.

An algorithm for abdominal wall reconstruction

Acquired abdominal wall defects result from trauma, previous surgery, infection, and tumor resection. The correction of complex defects is a challenge to both plastic and reconstructive and general surgeons. The anatomy of the abdominal wall, as well as considerations in patient assessment and surgical planning, are discussed. A simple classification of abdominal wall defects based on size, depth, and location is provided. Publications regarding the various abdominal reconstruction techniques are reviewed and summarized to familiarize the reader with the treatment options for each particular defect. Finally, an algorithm is presented to guide the surgeon in selecting the optimal reconstructive technique.

Pericranial flap correction of superior sulcus depression in the anophthalmic orbit

Distortion of the supratarsal sulcus of the upper eyelid after orbital trauma is a well-recognized and troublesome problem. This is particularly true of the anophthalmic orbit. The authors present two patients in whom this deformity has been addressed using a pedicled pericranial flap. They found this technique provides abundant, well-vascularized tissue that is manipulated easily to conform to the demands of the defect. In addition, the vascularity of the tissue provides predictability of the result when compared with other described techniques such as fat and dermis-fat grafts.

Subperiosteal rejuvenation of the midface and periorbital area: a simplified approach

A simplified approach to subperiosteal midface rejuvenation is presented. The technique was developed through experience with 60 subperiosteal face lifts over an 8-year period. Because it does not involve a lower eyelid incision, there is no risk of ectropion, yet the midfacial structures and orbicularis oculi muscle can be elevated easily and precisely. The procedure can be performed alone but is more commonly performed in conjunction with brow lift and traditional SMAS dissection of the lower face and neck. The benefits of this subperiosteal approach to the midface are powerful elevation of the midfacial structures, improvement of the nasolabial folds, enhancement of the cheek prominences, smoothing of the nasojugal folds, and tightening of the orbicularis oculi. The procedure is performed through small incisions in the temple and gingival sulcus. The operation is technically straightforward and poses little risk to neurovascular structures. Concerns over prolonged swelling have not materialized. There have been no instances of lower lid or canthal abnormalities.

Surgical outcomes using bioabsorbable plating systems in pediatric craniofacial surgery

The purpose of this study was to evaluate the surgical outcomes of the 1.5-mm LactoSorb plating system (Walter Lorenz Surgical, Inc., Jacksonville, FL, U.S.A.) used to stabilize the osteotomized calvarial bone in pediatric patients who have undergone craniofacial surgery. The records of 33 consecutive pediatric patients who underwent craniofacial surgery from January 1997 through December 1997 were reviewed. There were 18 male and 15 female patients, and the age ranged from 4 months to 12 years. Patients were followed-up at 1 week, 1 month, 3 months, 6 months, and 12 months after surgery. For those patients reviewed, the following information is included: age, sex, diagnosis, surgical procedures, number and size of LactoSorb plates and screws used in each patient, operative difficulty of the screws and the heat pack, and postoperative complications, including wound healing, palpability, and infection. The LactoSorb plating system was used to stabilize the osteotomized calvarial bones in 33 patients who were diagnosed with: 1) craniosynostosis, 2) hydrocephalus, 3) fibrous dysplasia, or 4) cranial deformation. Orbital rim advancement and anterior cranial vault reshaping were performed in 17 patients. Posterior cranial vault reshaping, orbital rim advancement, and anterior cranial vault reshaping were performed in eight patients. Posterior cranial vault reshaping only was performed in seven patients. Excision of fibrous dysplasia from temporal bone was performed in one patient. One patient had a postoperative wound infection, and LactoSorb plates were palpable postoperatively in four patients. The LactoSorb plating system provided adequate rigidity for stabilizing the osteotomized calvarial bone during surgery and maintained adequate rigidity after surgery during the bone healing period before absorption. This plating system showed satisfactory results in pediatric craniofacial surgery patients.

Fever after craniofacial surgery in the infant under 24 months of age

A retrospective review was undertaken of 126 consecutive craniofacial procedures involving a transcranial component, performed at the Children's Medical Center at Dallas, between 1990 and 1994. Standard postoperative axillary temperature measurements were recorded until discharge. Age at surgery of less than 24 months correlated very strongly with a postoperative temperature of greater than 38 degrees C (r = -0.92). The incidence of postoperative fever was high in all age groups, yet there was still a significant difference between the group younger than 2 years and the group in which surgery was performed after the age of 2 years across all postoperative temperature ranges, from >38 degrees C to >39.5 degrees C (p < 0.001, chi-square test). The white blood cell count was elevated above the age-related normal in 67 percent of febrile patients. There was no correlation between type or duration of surgical procedure, length of intensive care or hospital stay, or the need for blood transfusion and the development of a significant postoperative fever. There were minor infectious complications in four patients (3 percent), only one of which was a wound problem related to the surgery. All infectious complications were easily identifiable clinically. There was no mortality or serious infections. The development of postoperative fever, and an elevated white blood cell count, is to be expected in pediatric patients undergoing craniofacial procedures. The routine laboratory investigation of postoperative fever in pediatric craniofacial patients under 2 years of age without procedures involving transgression of the paranasal sinuses is not warranted unless there are associated clinical indicators.

Risk factors for complications in pediatric tissue expansion

Tissue expansion in children has been associated with complication rates of 20 to 40 percent. A critical analysis of 6 years' (1988-1993) experience with 180 expanders placed in 82 consecutive children was performed to identify those factors which predispose to complications. Major and minor complications each occurred in 9 percent of patients. The factors associated with a statistically significant increase in complications were burns and soft-tissue loss, patient age under 7 years, use of internal expander ports, and a history of two or more prior expansions. In addition, complications were significantly more likely to occur within the first 90 days than during any subsequent expansion. Factors that did not influence complication rate included patient gender, wound drainage upon expander insertion or removal, intraoperative use of antibiotic irrigation, number of expanders placed, use of customized expanders, and operating surgeon.

The importance of the dura in craniofacial surgery

The hypothesis of this study is that craniofacial procedures that rely on devascularization of cranial bone are successful largely because of the unique environment that the dura offers. This hypothesis was tested by sequentially labeling animals with tetracycline and studying the healing of cranial bone grafts when replaced immediately and when subjected to room air exposure for 90 minutes and contrasting healing in mature and immature animals. Bilateral parietal bone flaps were harvested from guinea pigs. On one side, the bone was replaced as a control, and on the other side, the dura was resected prior to replacing the bone flap. The animals were divided into four groups of five animals each. The first and second groups were immature animals (3 to 4 weeks of age), and the third and fourth groups were mature animals (4 to 6 months of age). In the first and third groups, the bone flaps were replaced immediately, and in the second and fourth groups, the bone flaps were exposed to room air for 90 minutes, since this has been shown to destroy surface osteocytes and simulates extreme exposure conditions that could occur in clinical situations. Sequential marking with tetracycline was performed to study the mineralization rate and overall matrix formation. Significantly decreased mineralization rates occurred in bone flaps not in contract with dura. In those bone flaps exposed to room air for 90 minutes, healing occurred only on the side where dura was present. The clinical implications of the importance of the dura in craniofacial procedures are discussed.

Alloplastic nasal and perialar augmentation

Our favorable experience with use of porous hydroxyapatite granules to augment the craniofacial skeleton (more than 200 patients during an 8-year period) has led us to use this method to augment the nasal skeleton in selected cases. Extensive experience has been achieved in augmenting the perialar, maxilla, and glabellar area with very favorable results. A much more limited experience has been gained in augmenting the nasal dorsum, and this method must be considered investigatory at present.

Surgical intervention for the complications of meningococcal-induced purpura fulminans

Purpura fulminans is an infrequent but sometimes catastrophic illness that usually complicates a viral, rickettsial or bacterial infection. This communication presents a retrospective review of 152 patients with meningococcemia hospitalized at Children's Medical Center of Dallas from January, 1983, through December, 1993. Eighteen (11.9%) of the 152 patients developed purpura fulminans. Thirteen (72%) of the 18 patients with purpura fulminans needed one or more surgeries including skin grafts, local debridement, microvascular flaps or amputations. Five patients (28%) died.

Abdominal-wall reconstruction with expanded musculofascial tissue in a posttraumatic defect

An anatomic basis for expansion of the abdominal wall is presented and clinically demonstrated in an adult man with a posttraumatic defect. The patient demonstrates an intact, functional abdominal wall 4 years after the procedure. The procedure provides autogenous, innervated, well-vascularized, contractile tissue for repair of abdominal-wall hernias. Large tissue expanders are placed between the external oblique and internal oblique muscles. A small incision in the posterior rectus sheath is made in order to gain access to the potential space between these muscles. The incision in the posterior rectus sheath is kept small to minimize risk of denervation of the rectus abdominis muscle. Tissue expansion is carried out over several weeks. After removal of the expanders, abundant musculofascial tissue is available for reconstruction of the abdominal wall. The abdominal wall is then reconstructed with innervated, functioning tissue.

The role of the dura in cranial bone regeneration in the immature animal

In an animal model, the effect of transferring mature pericranial tissues to immature animals with cranial bone defects was tested. Isogeneic guinea pigs of different ages were used: "infants" (3-4 weeks) and "adults" (> 18 months). Bilateral parietal cranial defects were made in infant guinea pigs and the guinea pigs were divided into three groups. In group 1 (n = 6), the infant periosteum was resected and replaced as an autograft on one side (control), and adult periosteum was transplanted as an isograft on the other (experiment). In group 2 (n = 5), dura was used as the variable. In group 3 (n = 5), combined dura and periosteum were the variables. After 8 weeks, there was complete or near complete bone regeneration in all animals in which infant dura was present. There was minimal to no bone regeneration in defects in which adult dura was present. Unlike dura, periosteum had little influence on the capacity of the bone to regenerate.

Rhinoplasty: a practical guide for surgical planning

A method for determining the aesthetically proportioned nasal length, tip projection, and radix projection in any given face is described. The proportioned nasal length is two-thirds (0.67) the midfacial height and exactly equal to chin vertical. Tip projection is two-thirds (0.67) the surgically planned or ideal nasal length. Radix projection, measured from the junction of the nasal bones with the orbit, is one-third (0.33) the ideal nasal length. The preferred clinical reference for measuring radix projection is the plane of the corneal surface; the radix projects 0.28 times the ideal nasal length from this surface (range: 9-14 mm). These-dimensional relationships were confirmed from direct clinical measurements taken from 87 models and subsequently applied in 126 consecutive rhinoplasties. The significance of this dimensional approach to rhinoplasty lies in the fact that planned nasal dimensions are based on facial measurements that allow the nose to vary in size directly with the face. Furthermore, it removes the dorsum as the primary focus in dimensional assessment. Rather, the dorsal prominence may be consistently described relative to a plane connecting the "ideal" radix and tip.

Augmentation of the craniofacial skeleton with porous hydroxyapatite granules

Augmentation of the craniofacial skeleton with porous hydroxyapatite granules (Interpore 200) has been performed in 52 sites on 43 patients. Follow-up extends to 5 years, and 26 patients have been followed for greater than 1 year with excellent results. The procedure has been used for reconstruction of congenital and posttraumatic deformities and for purely aesthetic purposes. Areas that have benefited from hydroxyapatite augmentation include the skull, zygomaticomaxillary region, lateral mandible, perialar region, periorbital area, and temporal region. There have been no cases of infection, and only two patients have required minor revisions. Resorption has not occurred.

Methods of rigid fixation

Rigid fixation has been an exciting and major advance in maxillofacial surgery. Further studies will elucidate how much strength is necessary to achieve the proper amount of fixation necessary in each region of the facial skeleton. This information coupled with improvements in design will allow production of the lowest-profile implants possible for each area of the craniofacial skeleton. An exciting future possibility is construction of rigid fixation systems made of resorbable plates and screws. Research is in progress to find methods of constructing a system that incorporates the proper rate of resorption, the necessary strength, and precisely constructed plates and screws.

The coracobrachialis muscle flap for coverage of exposed axillary vessels: a salvage procedure

The coracobrachialis muscle has been suggested for possible use in coverage in infraclavicular defects, specifically in postmastectomy reconstructive patients. This case report demonstrates the successful clinical use of this flap for coverage of exposed axillary vessels in the infraclavicular area. Anatomy and techniques of dissection are reviewed as well as potential disadvantages.

Abdominal wall expansion in congenital defects

A method for expanding the skin, fascia, muscle, and peritoneal layers of the abdominal wall is described, and clinical application is demonstrated in two children with cloacal exstrophy and congenital absence of the lower half of the abdominal wall. This technique provides an innervated composite reconstruction of defects in excess of 50 percent of the abdominal surface and is recommended in large secondary defects where peritonealization has been achieved and in congenital defects that do not lend themselves to standard methods of closure. Cadaver dissection confirms that tissue expanders may be placed with preservation of innervation and blood supply to the abdominal wall.

Multimodality treatment of locally advanced breast carcinoma

Forty patients with 41 locally advanced breast lesions at stages IIIA and IIIB and the inflammatory stage were treated with combined-modality therapy from July 1980 to August 1985. Treatment included induction chemotherapy consisting of three cycles of fluorouracil, doxorubicin hydrochloride, and cyclophosphamide, followed by mastectomy in those patients whose lesions were operable (n = 28), and resumption of chemotherapy. Nine patients received postoperative radiation therapy. The mean follow-up was 34 months. Greater than 50% reduction in tumor size was achieved in 72% of patients after three cycles of chemotherapy. Overall, local control was achieved in 85% of patients with 59% survival and 53% disease-free survival, while 10% of patients developed local recurrences. Excluding lymphedema of the upper extremity (n = 2) and inflammatory carcinomas (n = 4), local control was achieved in 96% of patients, with 75% survival and 68% disease-free survival, while 4% of patients developed local recurrences. The rate of disease-free survival was 71% in patients with partial response to chemotherapy, contrasted with 43% in patients who did not respond or only minimally responded to chemotherapy. Actuarial five-year survival, based on life-table analysis, was calculated to be 46% for the group overall, 58% for the group excluding lymphedema of the upper extremity and inflammatory carcinoma, and 56% for the 28 patients undergoing mastectomy.

Successful use of the Denver peritoneovenous shunt in patients with nephrogenic ascites

Tense ascites in patients who require hemodialysis for renal failure (nephrogenic ascites) is a rare but ominous complication. Its appearance is often followed by a rapid physical deterioration. Nonsurgical attempts to control the ascites are often unsuccessful. Four patients with refractory ascites were treated with Denver peritoneovenous shunts (DPVS). These patients suffered from ventilatory failure, anorexia with malnutrition, and hypotension during hemodialysis. Patients were followed for as long as 18 months after DPVS, and all experienced clinical resolution of the ascites. Ventilatory failure, malnutrition, and hypotension either improved or resolved after shunting. Shunt-related morbidity occurred in all patients and consisted of mechanical complications in four patients and bacteremia in one patient. These problems were resolved by either revision or removal of the DPVS. No deaths were directly related to shunting. Peritoneovenous shunting successfully treats nephrogenic ascites and reverses the morbid sequelae usually associated with this syndrome.