Barry M. Zide

The spectrum of calvarial bone grafting: introduction of the vascularized calvarial bone flap.

Two techniques of calvarial bone grafting (split-thickness and single-table) are reviewed. A new vascularized bone flap based on the temporal vasculature is presented. The indications and relative advantages of each are discussed. The calvarial bone flap is emphasized and strongly recommended. Since the flap is vascularized and contains membranous bone, it is particularly suited for bone grafting in clinically unfavorable recipient sites, such as scarred or irradiated beds or the hypoplastic zygomatic-maxillary complex in the Treacher Collins syndrome.

Twenty-year experience with early surgery for craniosynostosis. I: Isolated craniofacial synostosis : results and unsolved problems

Early surgery for isolated craniosynostosis is designed to improve morphology, to prevent functional disturbances, and equally important, to enhance the psychosocial development of the child. As the first of a two-part series, 104 patients with isolated craniofacial synostosis were retrospectively analyzed. Diagnoses included bilateral coronal (10), unilateral coronal (57), metopic (29), and sagittal synostosis (8). All patients underwent primary fronto-orbital advancement-calvarial vault remodeling procedures at less than 18 months of age (mean 8.1 months). Thirteen percent of patients (14) required a secondary cranial vault operation (mean age 22.6 months) to address residual deficits in craniofacial form. Perioperative complications were minimal (5.0 percent), and there was no mortality. Average length of postoperative follow-up was 46.0 months. By the classification of Whitaker et al., which assesses surgical results, 87.5 percent of patients were considered to have at least satisfactory craniofacial form (category I–II) at latest evaluation. Overall rates of hydrocephalus, shunt placement, and seizures (3.8, 1.0, and 2.9 percent, respectively) were low. Among the isolated craniosynostoses, unilateral coronal synostosis/plagiocephaly poses the most complex problems, including vertical orbital dystopia, nasal tip deviation, and residual craniofacial asymmetry; there is also a wide spectrum of findings and growth patterns in this subgroup.

Twenty-year experience with early surgery for craniosynostosis : II. The craniofacial synostosis syndromes and pansynostosis-Results and Unsolved Problems

As the second of a two-part series, 76 patients with pansynostosis and craniofacial synostosis syndromes were retrospectively analyzed. Diagnoses included pansynostosis (7), craniofrontonasal dysplasia (8), and Apert (24), Crouzon (15), and Pfeiffer (15) syndromes. All patients underwent primary fronto-orbital advancement-calvarial vault remodeling procedures at less than 18 months of age (mean 6.1 months). Twenty-eight patients (36.8 percent) required a secondary cranial vault operation (mean age 28.4 months). Additionally, a major tertiary procedure was necessary in 5 patients to deal with persistent unacceptable craniofacial form. To address the associated finding of midface hypoplasia, 64.8 percent (n = 35) of patients underwent Le Fort III midface advancement or had that procedure recommended for them. The remainder were awaiting appropriate age for this reconstruction. The more extensive pathologic involvement of the pansynostosis and craniofacial syndrome group is illustrated. As compared with the isolated craniofacial synostosis group previously reported, the incidence of major secondary procedures (36.8 versus 13.5 percent), perioperative complications (11.3 versus 5.0 percent), follow-up complications (44.7 versus 7.7 percent), hydrocephalus (42.1 versus 3.9 percent), shunt placement (22.4 versus 1.0 percent), and seizures (11.8 versus 2.9 percent) was significantly increased. Complex problems including those of increased intracranial pressure, airway obstruction, and recurrent turricephaly or cranial vault maldevelopment are repeatedly encountered. In addition, that early fronto-orbital advancement-cranial vault remodeling failed to promote midface development and hypoplasia of this region is almost a consistent finding in the craniofacial syndromic group. The average length of postoperative follow-up was 6 years. According to the classification of Whitaker et al., which assesses surgical results, 73.7 percent of patients were considered to have at least satisfactory craniofacial form (category I–II) at latest evaluation. An algorithmic approach to the treatment of all patients with craniosynostosis is presented utilizing early surgical intervention as the key element.

The mentalis muscle: an essential component of chin and lower lip position.

The soft-tissue chin may become ptotic following surgery in this area. The mentalis muscles which are responsible for proper central lip motion and chin point position may be affected. The mentalis muscle origin may require resuspension at a proper level. This reattachment may be performed by means of an intraoral approach. Non-absorbable sutures are used to hold the soft-tissue chin upwards. The exact method involves placing drill holes through the alveolar bone, into which sutures are passed. These sutures are then placed through the lower mentalis muscles and tightened. Chin and lip position may be corrected in certain cases. Ancillary procedures are required to correct vestibular scarring and submental scars.

How to Block and Tackle the Face

Regional blocking techniques as noted in dentistry, anesthesia, and anatomy texts may result in inconsistent and imperfect analgesia when needed for facial aesthetic surgery. The advent of laser facial surgery and more complicated aesthetic facial procedures has thus increased the demand for anesthesia support. Surgeons should know a fail-safe method of nerve blocks. Fresh cadaver dissections are used to demonstrate a series of eight regional nerve-blocking routes. This sequence of bilateral blocks will routinely provide profound full facial anesthesia. Certain groupings of blocks are effective for perioral or periorbital laser surgery.

Early surgery for craniofacial synostosis : an 8-year experience

A prospective review is presented of 50 patients with one of the craniofacial synostosis syndromes who underwent early interventive craniofacial surgical correction (average age 7.6 months at time of surgery). The study has demonstrated the efficacy and safety of the techniques when employed in the infant. Satisfactory cranio-orbital form was achieved in the majority of the patients, although 10 patients required secondary surgery because of sutural refusion or the development of turricephaly or calvarial contour irregularities. Despite earlier hopes, this surgery did not result in the development of satisfactory occlusal relationships and midfacial form in the craniofacial dysostosis group (Crouzons, Aperts, etc.). Based on this clinical experience, a surgical treatment plan is presented for the newborn with craniofacial synostosis.

The medial canthus revisited--an anatomical basis for canthopexy.

Cadaver anatomical studies have demonstrated a superior component to the medial canthal tendon. The anatomical basis for the angular and dystopic deformities following nasoethmoidal trauma or surgical dissection is discussed. Based on these studies a more refined technique for medial canthopexy is presented. The three cardinal tenets of medial canthopexy are also emphasized.

Chin surgery: I. Augmentation--the allures and the alerts.

The correction of sagittal deformities of the chin presents a seemingly simple surgical challenge. However, several authors have reported negative sequelae from such chin surgery, During the past 11 years, the senior author (B.M.Z.) has evaluated more than 100 such cases of adverse results after chin augmentation. Many surgeons, it seems, use chin implants unnecessarily and, thus, get into trouble. Because alloplastic chin augmentation is deceptively easy, it tends to be overused in certain situations. Either the surgeons evaluation is too narrowly focused or his/her abilities to perform other types of surgery (e.g., osseous genioplasty) are limited. Herein, the authors present a diagnostic evaluation protocol, QUAC (Quick Analysis of the Chin), to assist in avoiding simple mistakes in alloplastic chin augmentation. This protocol will alert the surgeon to situations that, if unrecognized, will cause problems and create an unhappy patient. This article will specifically focus on (1) lower lip analysis; (2) the effect of the labiomental fold; (3) chin pad evaluation, both static and dynamic; (4) the anatomy of the cleft chin; (5) special situations; and (6) how to troubleshoot three common problems. The accompanying article, Chin Surgery II, will present a new operation that treats a chin problem that was previously difficult to correct.

Large arteriovenous malformations of the face: aesthetic results with recurrence control.

Large facial arteriovenous malformations are problematic for patients because of grotesque disfigurement, risk of rapid enlargement, and life-threatening rupture. Successful treatment of these relentless complex lesions is one of the most difficult challenges facing plastic surgeons. From a series of 300 large facial arteriovenous malformations, 85 patients were treated with embolization and excision; six of these cases (representing six separate anatomic regions: labial, auricular, eyelid, cheek, chin, and occipitoparietal) were selected for review. The purpose of this article was to look critically at the management of these six facial arteriovenous malformations, including patient presentation, angiographic procedures, surgical planning and technique, and postoperative long-term follow-up care. Lessons learned from the six representative cases provide clues for the management of large facial arteriovenous malformations and demonstrate the possibilities of recurrence and their occasionally relentless behavior. The cases show that long-term control of these lesions with acceptable aesthetic results can be achieved. The mainstay of treatment includes the following: (1) selective intra-arterial embolization with fine catheters and direct lesional embolization; (2) judicious resection and reconstruction with local or expanded tissue flaps; and (3) careful follow-up with serial examinations, duplex, and arteriography.

Dog‐Ears: A Review

Background. The closure of any circular or asymmetric wound results in puckering or excess of tissue known as dog‐ears. Objective. Facility in managing dog‐ears is an invaluable tool in cutaneous surgery due to its common presentation. Methods. Methods for correcting dog‐ears are extensively detailed in both the plastic and dermatologic surgery literature. This review provides a practical outline of nine methods of dog‐ear correction along with pertinent schematic and clinical illustration. Results. A comprehensive approach to dog‐ears requires knowledge of tissue dynamics, adherence to proper surgical technique, and strategies for the management of dog‐ears. Conclusions. A thorough understanding of dog‐ear formation and correction allows the surgeon to choose the most appropriate management for dog‐ears in any clinical setting.