H. Steve Byrd

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.

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.

Using the autospreader flap in primary rhinoplasty.

Background: When performing dorsal reduction in primary rhinoplasty, one must pay close attention to the height of the upper lateral cartilages. They are in part responsible for the dorsal aesthetic lines and often require a lower profile. Methods: The technique the authors describe uses the transverse portion of the upper lateral cartilages rotated medially to function as a local spreader flap while reducing the profile of the dorsum and preserving the aesthetic lines. This is a surgical technique that adjusts the height of the upper lateral cartilages in a precise and safe manner while preserving the function of the internal valve. Results: The authors present two patients seen at 1 and 3 years after undergoing the autospreader flap technique. In the experience of the senior author (H.S.B.) with this procedure over the past decade, preoperative surgical goals were achieved reliably. Conclusions: The authors review the anatomical indications in which they found this technique to be simple, reproducible, and effective in shaping the dorsal midvault while preserving the function of the internal valve. Autospreader flap rotation should be considered when dorsal reduction is required.

Primary correction of the unilateral cleft nasal deformity

&NA; An 18‐year experience with the management of the unilateral cleft nasal deformity in 1200 patients is presented. A primary cleft nasal correction was performed at the time of lip repair in infancy; a secondary rhinoplasty was done in adolescence after nasal growth was complete. The technical details of the authors’ primary cleft nasal correction are described. Exposure was obtained through the incisions of the rotation‐advancement design. The cartilaginous framework was widely undermined from the skin envelope. The nasal lining was released from the piriform aperture, and a new maxillary platform was created on the cleft side by rotating a “muscular roll” underneath the cleft nasal ala. The alar web was then managed by using a mattress suture running from the web cartilage to the facial musculature. In 60 percent of cases, these maneuvers were sufficient to produce symmetrical dome projection and nostril symmetry. In the other 40 percent, characterized by more severe hypoplasia of the cleft lower lateral cartilage, an inverted U infracartilaginous incision and an alar dome supporting suture (Tajima) to the contralateral upper cartilage were used. Residual dorsal hooding of the lower lateral cartilage was most effectively managed with this suture. This primary approach to the cleft nasal deformity permits more balanced growth and development of the ala and domal complex. Some of the psychological trauma of the early school years may be avoided. Also, because of the early repositioning of the cleft nasal cartilages, the deformity addressed at the time of the adult rhinoplasty is less severe and more amenable to an optimal final result. (Plast. Reconstr. Surg. 106: 1276, 2000.)

Septal extension grafts revisited: 6-year experience in controlling nasal tip projection and shape.

Previously, we introduced septal extension grafts as an alternative to columellar strut grafts to predictably control nasal tip projection and shape.1 These grafts were particularly useful in “high-risk” patients characterized by a weak midvault, alar retraction, or a “pollybeak” deformity. Our initial study of 20 patients showed that a structural extension from the septum served to reliably control the tip complex. The grafts were described in three forms: paired spreader grafts, paired batten grafts extending diagonally across the caudal and dorsal septal L-strut, and direct extension grafts. The paired spreader grafts are placed in a position between the upper lateral cartilages and the caudal septum to widen the internal nasal valve. The batten grafts are placed below the junction of the septum and upper lateral cartilages and thus do not affect the width of the midvault or the internal nasal valve. The direct extension graft was used in cases with limited cartilage availability. The graft was directly affixed to the anterior septal angle and the caudal septum at three points. In all cases, the caudal end of the graft was positioned beneath the domes of the lower lateral cartilages and provided a stable platform for tip complex suturing and maintenance of tip projection. Our experience since has continued to show remarkable stability and reliability in controlling tip complex shape and projection. However, we have made several observations that are important to consider when using septal extension grafts. These points are demonstrated in the following three cases. First, paired spreader extension grafts can cause considerable widening of the supratip/ midvault area, especially in patients with short nasal bones. The solution to this potential problem is either to trim the graft dorsally or to suture the graft posterior to the septal angle to reduce its prominence and its lateral displacement of the upper lateral cartilages. The patient in Figure 2, with short nasal bones and thin skin, has excessive widening of the midvault extending caudally into the supratip area after use of paired spreader septal extension grafts (Figs. 1 and 2). Second, excessive length of the septal extension grafts can cause visibility at the caudalmost edge. This manifests as an abnormal columellar/lobular relationship (hanging columella) caused by caudal displacement at the junction of the medial and middle crura. The patient in Figure 4 illustrates this potential problem. This can easily be avoided by confirming on lateral intraoperative view that the infratip lobule has not been excessively displaced caudally (Figs. 3 and 4). Third, using the principles of strong fixation of the tip complex to a stable, septal-based graft, we have identified the native caudal septum as a substitute for the extension graft. This is possible in patients with long noses who desire cephalad tip rotation. It is usually necessary to trim the caudal septum in these cases. As an alternative to traditional uniform trim-

Fifty years of the Millard rotation-advancement: looking back and moving forward.

Summary: Of all the methods for repair of the unilateral cleft lip, none has gained as much popularity as the rotation-advancement. Millard’s original principle of 50 years ago continues to guide surgeons in closure of the cleft lip. Unlike earlier procedures, the brilliance of the rotation-advancement is that it permits individual manipulation and modifications while maintaining Millard’s original surgical and anatomical goals. Millard and many other surgeons have made modifications to adjust the procedure to each specific patient, to address some of its faults, and to gain new advantages. In this article, the authors review the techniques of Drs. Ralph Millard, Steve Byrd, Court Cutting, John Mulliken, and Samuel Stal. The variations from Millard’s original technique are highlighted, including a discussion of the benefits of each modification.

Definitive repair of the unilateral cleft lip nasal deformity.

Summary: The majority of patients with a unilateral cleft nasal deformity still benefit from additional nasal surgery in their teenage years, despite having undergone a primary nasal repair. However, the secondary nasal deformity of these patients stands in sharp contrast to those of children who have not benefited from primary repair. The authors’ algorithm for the definitive correction of these secondary deformities considers the differences in these two patient groups and defines their indications for rib cartilage grafts and their method of using septal and ear cartilage in the repair. Balancing the muscle forces on the septum and alar cartilage is emphasized in both the primary and secondary repair. Both cartilage malposition and hypoplasia of the lower lateral cartilage complex have been identified as factors contributing to the deformity.

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.

Bilateral cleft lip and nasal repair.

Summary: The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.

Idiopathic Midline Granuloma—current Classification and Management Controversies

Midline granuloma is a mutilating process produced by a number of diseases that progressively destroy the nose, paranasal sinuses, and palate. Infectious, neoplastic, and idiopathic forms of this disease have been described. The specific diagnoses must be ascertained, as the treatment is different depending on the etiology of the disease. Radiation therapy is the treatment of choice for idiopathic midline destructive disease, while cytoxan is appropriate for Wegeners granulomatosis, polymorphic reticulosis, and primary nasal lymphomas. When the diagnosis is uncertain, the least-toxic therapy should be used. If the treatment is failing, an alternate therapy should be tried. This article reviews the history of idiopathic midline granuloma, describes the current classification of the disease, and discusses controversial issues demonstrated by two patient presentations.