Douglas K. Ousterhout

Placement of the umbilicus in an abdominoplasty.

The location of the umbilicus was measured in 100 randomly selected non-obese subjects. It was found that a line drawn from the highest level of the crest of one ilium to the same point on the other side will transect the umbilicus in 96 percent of the subjects. This relationship can be of use during an abdominoplasty, when determining the location for the umbilicus.

Autogeneic skull bone grafts to reconstruct large or complex skull defects in children and adolescents

Autogeneic split or free skull bone grafts harvested at the time of operation were used to repair large or complex skull defects in 19 children; in 2 children, autogeneic fresh rib grafts were also used. Follow-up examinations for periods of 1 and 7 years showed that the use of autogeneic grafts is superior to the use of materials such as acrylic or metals for cranioplasty in children.

Feminization of the forehead: contour changing to improve female aesthetics

Anthropologists have identified those characteristics which enable them to differentiate the male from the female skull. Some women have masculine skeletal characteristics which, if changed, would improve their facial appearance. Changing the skeletal configuration through bony contouring of the craniofacial skeleton for aesthetic purposes is a natural spinoff of craniomaxillofacial surgery. Techniques for sculpturing the masculine characteristics present in the foreheads of some females are discussed. The deformity has been divided into three subdivisions. Group 1 patients can be treated through bony contouring alone; group 2 patients require bony contouring in conjunction with a methyl methacrylate cranioplasty; and group 3 are those patients with a more severe deformity requiring osteotomies. The technique, results, complications, and patient acceptance are discussed.

Craniosynostosis and Hydrocephalus

Ten cases of craniosynostosis associated with hydrocephalus were found in a retrospective review of 250 cases of children with craniosynostosis. Four children had Pfeiffers syndrome, 3 had Crouzons syndrome, 2 had kleeblattschädel with multiple anomalies and therefore could not be classified into a definite syndrome, and 1 had isolated sagittal synostosis. Of these 10 children, 5 had kleeblattschädel, two with Crouzons syndrome, one with Pfeiffers syndrome, and 2 with multiple anomalies. In all patients, hydrocephalus was controlled by a shunting procedure. Possible causes of hydrocephalus in association with craniosynostosis are discussed.

The role of the lateral canthal tendon in lower eyelid laxity.

Measurements of lower eyelid length were completed to determine if the length of the lower eyelid increased with advancing age. The results support the that the lower eyelid indeed does not get longer with aging. In two groups of 100 patients each, at either end of the adult age spectrum, there were no statistical differences in the lengths of the lower eyelids. Our data support the concept that the lateral canthal tendon stretches with advancing age and allows the lateral canthus to drift medially, thus allowing for shortening of the horizontal palpebral fissure and contributing to the marked laxity of the lower eyelids often seen in older individuals. More attention should be paid to this etiologic factor in the surgical correction of lower eyelid laxity.

Combined suction-assisted lipectomy, surgical lipectomy, and surgical abdominoplasty.

Although combined suction-assisted lipectomy (SAL) and surgical abdominoplasties have been described, the surgical excisions have in general been small and limited to the lower portion of the lower abdomen (i.e., just above the pubis). For the obese patient this is an insufficient lipectomy. SAL alone is unsatisfactory because the marked skin excess will not shrink sufficiently to allow a desired final result. Surgical abdominoplasty alone is also insufficient in the obese patient because the thickness of the abdominal panniculus is not reduced and, additionally, secondary to tissue tension with wound closure, some necrosis of skin above the pubis is not unusual. In this article results are described from a small consecutive series of obese patients treated with a combined extensive SAL, surgical lipectomy, and surgical abdominoplasty. The sequence of fat removal is different than that which has been previously described. In all of the patients the results were pleasing, and there were only two relatively minor complications.

Clinical experience in cranial and facial reconstruction with demineralized bone

While autogenous bone is the preferred building material for skull and facial bone reconstruction, it has definite disadvantages that make the continued use of alloplastic materials inviting. Studies in the past few years have generated considerable publicity about demineralized bone as a possible substitute for autogenous bone. A clinical study using commercially available, demineralized bone in 25 patients with a follow-up period of 6 to 18 months was completed. Results indicated that where there was a functional need or the environment (tissue envelope) was satisfactory, the demineralized bone induced osteogenesis; otherwise, there was considerable resorption of the implant. This implies that, for filling bony defects or reconstructing posttraumatic deformities, the implant generally worked fairly well, while attempts to augment bony contours, especially large areas such as the forehead, were generally not satisfactory. Even where there was a functional need for bone, a significant degree of unpredictable resorption of the demineralized implant occurred.

Hydroxyapatite paste (BoneSource) used as an onlay implant for supraorbital and malar augmentation.

&NA; This study was designed to evaluate hydroxyapatite paste (BoneSource; Leibinger Corp., Dallas, TX) as an alloplastic implant for supraorbital and malar augmentation. Ten male Sprague‐Dawley rats had cylindrical onlay implants made of the hydroxyapatite cement placed above their left orbits on the supraorbital rim. Size‐ matched Medpor implants were placed similarly on the right side. To test the utility of this new material in the midface, hydroxyapatite paste and Medpor implants were also placed in the right malar regions of a different set of rats. The implants were left in situ for 6 months and examined for evidence of bone ingrowth, infection, migration, resorption, and detrimental effects on the surrounding tissue. All hydroxyapatite cement implants provided excellent soft tissue projection and demonstrated steadfast adherence to the adjacent bone. The surface of the hydroxyapatite implant in contact with the native bone demonstrated evidence of native bony ingrowth into approximately 12% of the implant. There was no evidence of implant migration or gross infection. There was no bony resorption below the hydroxyapatite paste, but four of the Medpor implants showed evidence of this in the underlying bone. Only one negative aspect to the use of hydroxyapatite cement paste as an onlay implant was identified. Two of the supraorbital and one of the malar hydroxyapatite implants had approximately 20 to 25% volume loss during the experimental period (P = 0.05). Overall, the vast majority of the implants retained their original form. We concluded that hydroxyapatite paste may possibly be used to effectively augment bone in the supraorbital and malar regions. Its biocompatibility, excellent bony adherence, and tendency to be replaced by natural bone may make it suitable for the aesthetic patient. The possible resorptive aspects of the material need to be evaluated further.

Maxillary hypoplasia secondary to midfacial trauma in childhood.

Three normal children who suffered midfacial trauma and developed midfacial retrusion that would require Le Fort III advancements for correction of the deformity are described. The common denominator in these three cases seems to be an injury to the medial facial structure including the nasal septum. It is concluded that midfacial fractures in childhood may be a cause of subsequent midfacial hypoplasia.

Sliding genioplasty, avoiding mental nerve injuries.

Mental nerve injuries have been inculcated in sliding genioplasty. An anatomical study was completed (and published) that demonstrated a surgical approach that would, it was hoped, prevent such nerve injuries. A prospective clinical study to test this hypothesis has now been completed. On the basis of the anatomical finding mentioned previously, fifty consecutive sliding genioplasties were compared with the immediate 50 consecutive sliding genioplasties preceding the anatomical finding. Sensation testing was based on multiple finger touches on both sides of the lower lip and chin in both groups. The anatomical finding was that in none of the mandibles studied did the inferior alveolar nerve canal dip more than 5.5 mm below the inferior border of the mental nerve canal. All the osteotomies in the prospective study were completed with at least 6 mm between the most proximal osteotomy and the inferior border of the mental nerve canal. In the retrospective cases, the distance between the canal and the osteotomy was generally not recorded. Surgery was completed on a broad spectrum of aesthetic and congenital-developmental deformities. In the 50 prospective cases, there were no permanent mental nerve injuries. There were three permanent injuries (one bilateral complete numbness, one unilateral complete numbness, and one unilateral partial numbness). Although keeping 6 mm or more between the inferior border of the mental nerve canal and the proximal osteotomy during sliding genioplasty does not absolutely rule out or prevent an injury to the inferior alveolar nerve within the bony canal, it seems that by not keeping the 6 mm the chances of a nerve injury would be greatly increased. It seems advisable to always keep 6 mm as a minimal distance because avoiding a nerve injury should be an obligatory goal of this surgery. If a greater distance can be kept without decreasing the aesthetic result, it should be considered.