Jason K. Potter

Treatment of mandibular angle fractures with a malleable noncompression miniplate

PURPOSE This study evaluated the results in patients treated for fractures of the mandibular angle with a single, thin, malleable miniplate designed for use in the midface. PATIENTS AND METHODS Forty-six patients with 51 fractures of the mandibular angle were treated by open reduction and internal fixation using one noncompression, thin, malleable miniplate and 1.3-mm self-threading screws placed through a transoral incision. No patient was placed into postsurgical maxillomandibular fixation. They were prospectively studied for complications. RESULTS Seven patients (15.2%) experienced complications. All were considered minor and did not require hospitalization. Three had asymptomatic fracture of the bone plate, but at the time of diagnosis the fracture had already healed and it required no treatment. Two patients had fracture of the bone plate with continued fracture mobility requiring maxillomandibular fixation. Three minor infections occurred requiring intraoral incision and drainage. CONCLUSIONS The use of this small bone plate for fractures of the angle of the mandible provided adequate fixation in most cases but was associated with an unacceptable incidence of plate fracture. However, the results also indicate that the fixation requirements for angle fractures is less than previously thought.

Liquid injectable silicone: Is there a role as a cosmetic soft-tissue filler?

For many years, surgical procedures have been the mainstay to produce rejuvenation in the aging face, but the last decade has seen a tremendous increase in the number of nonsurgical procedures aimed at reducing or eliminating facial wrinkles. According to a recent survey conducted by the American Society of Plastic Surgeons, the number of injection procedures has increased 68 percent within the practices of our members, with botulinum toxin type A (Botox) and collagen being the two most commonly injected substances. Since Botox was approved by the U.S. Food and Drug Administration for cosmetic purposes, its use has increased 83 percent from 2001 to 2002. The use of fat injections has likewise increased 312 percent, and the use of collagen, 136 percent from 1992 to 2002.1 Although these products are able to reduce or eliminate facial wrinkles and contour deformities, their effects are temporary and continued treatment is required to maintain results. Patient demand and pressure are driving companies to develop a permanent alternative in the injectable softtissue filler market. Liquid silicone has a long and notorious history as an injectable material for augmentation of soft-tissue contours. Early attempts to augment the female breast with liquid silicone injections had untoward consequences that frequently led to mastectomy.2 Augmentation of surface contours of many areas of the body and face with liquid silicone has been reported in the literature,3,4 along with the complications from these procedures.5–7 The complications that often occurred following injection of liquid silicone triggered the Food and Drug Administration to intervene by banning the sale of liquid silicone for medical use in the late 1960s. Several events have generated renewed interest in the use of liquid injectable silicone for facial rejuvenation, including absence of data linking silicone with systemic disease; Food and Drug Administration approval of silicone oil for use in the prevention and management of retinal detachment; the introduction of the microdroplet technique for liquid silicone injection; and public pressure for a long-lasting filler material. Silicone refers to a group of polymers based on the element silicon. These polymers vary in form from liquid to gel or solid. Silicone is classified and regulated as a medical device. This means that silicone does not achieve its primary intended purpose by chemical action or through its metabolism. Polydimethylsiloxanes are the typical commercially available material. The viscosity of the various liquids is determined by the degree of polymerization. Dimethylsiloxanes will remain in liquid form indefinitely.8 Medical-grade silicone refers to material that is pure in quality, sterile, and of constant viscosity. Viscosity is measured in centistokes (cs). Currently, the only Food and Drug Administration–approved liquid injectable silicone devices available, Silikon 1000 (Alcon Laboratories, Inc., Fort Worth, Texas)9 and Adatosil 5000 (Bausch and Lomb Surgical, Claremont, Calif.),10 have viscosities of 1000 cs and 5000 cs, respectively. By comparison, the viscosity of wa-

A review of psychological outcomes and suicide in aesthetic breast augmentation

Summary: Aesthetic surgery is an essential component of plastic surgery and has become increasingly popular in American society. In 2002, 1.8 million surgical cosmetic procedures were performed in the United States, representing a 294 percent increase from 1992. The 1992 U.S. Food and Drug Administration moratorium on silicone breast implants arose in response to numerous reports of connective tissue disease associated with silicone gel breast augmentation and has led to a decade-long battle over the safety of silicone breast implants that continues today. Numerous scientific and epidemiologic studies of the past decade have established that there is no association between silicone breast prostheses and systemic disease. Recently, a new front has opened in the conflict regarding the safety of breast augmentation: the psychological impact of breast augmentation. Quality studies assessing the psychological characteristics of breast augmentation patients and the psychological impact of breast augmentation surgery are few and most studies are flawed in their methods. Recent reports have provided corroborating evidence to support the psychological benefits of cosmetic surgery and breast augmentation. New reports citing an increased risk for suicide among women with breast implants have brought renewed concerns but are unable to demonstrate a cause-and-effect relationship between breast implants and suicide. The present challenge is to determine whether the increased risk reported in epidemiologic studies is falsely associated with breast implants or whether it represents underlying risk factors or psychopathology in women undergoing breast augmentation that puts them at increased risk for suicide. The purpose of this article is to review the literature regarding the psychological impact of breast augmentation and assesses current scientific findings, with emphasis on the validity of suicide risk in breast augmentation patients.

Aesthetic management of the nasal component of naso-orbital ethmoid fractures.

Learning Objectives: After studying this article, the participant should be able to: 1. Discuss the critical anatomic structures of the nose that are affected in naso-orbital ethmoid fractures. 2. Discuss the advantages of early, complete nasal reconstruction of these fractures. 3. Apply a clinical algorithm to such nasal reconstruction. 4. List the techniques used in aesthetic reconstruction of the nose in naso-orbital ethmoid fractures. Background: Fractures of the naso-orbital ethmoid complex pose challenging management issues. Although basic treatment principles have been well described, the aesthetic management of the nasal component has not been adequately addressed in the literature. Methods: When secondary nasal deformities occur, they are difficult to correct. Optimal primary correction of the nasal deformity is accomplished using the following four principles: (1) rigid fixation of the nasal pyramid and restoration of nasal height and length; (2) restoration of tip projection; (3) septal reduction/reconstruction; and (4) lateral nasal wall augmentation. Results: Successful management of naso-orbital ethmoid fractures is a complex and challenging task. Both the bony and soft-tissue components must be addressed and the extent of the injury must be adequately diagnosed to avoid omission of critical steps in the reconstruction. Inadequate treatment of naso-orbital ethmoid fractures can produce a severe cosmetic deformity that is very difficult to correct secondarily. Conclusion: The authors discuss the nasal component of naso-orbital ethmoid complex injuries and detail the key principles in their algorithm for aesthetic nasal reconstruction.

Biomaterials for Reconstruction of the Internal Orbit

Orbital floor injuries, alone or combination with other facial fractures, are one of the most commonly encountered midface fractures. Techniques for orbital reconstruction have migrated away from autogenous bone grafts to well-tolerated alloplasts, such as titanium and Medpor. Material for reconstructing the orbit can then be selected based on requirements of the defect matched to the mechanical properties of the material. Material selection is largely and ultimately dependent upon surgeon preference.

Proximal peroneal perforator in dual-skin paddle configuration of fibula free flap for composite oral reconstruction.

Background: Composite defects of the oral cavity are often the result of trauma or advanced-stage tumor extirpation. The resultant deformity frequently requires a three-dimensional reconstruction of bone and soft-tissue. The fibula free flap is the preferred method of reconstruction, with various modifications focused on providing supplemental soft-tissue coverage. The objective of this study was to ascertain both anatomic and clinical data regarding the proximal peroneal perforator and its contribution to the evolution of the fibula free flap. Methods: Ten cadaver lower extremities were dissected to isolate the most proximal perforator supplying skin over the proximal lateral lower leg. Data were recorded regarding perforator presence, location, and course. Furthermore, review of clinical cases in which the proximal perforator was used in fibula free flap design was performed for operative data collection. Results: Cadaveric dissections revealed the proximal perforator to be present in 90 percent of specimens. Most commonly, the perforator, originating from the peroneal artery, traveled a short intramuscular course through the soleus muscle prior to supplying the overlying skin. In all clinical cases, the perforator was easily located with Doppler prior to incision, and there were no cases of flap failure or skin paddle loss. Flap inset was found to be optimal in all cases, with no tethering or undue tension. Conclusions: The proximal peroneal perforator was found to be anatomically reliable and clinically useful in composite oral cavity reconstruction following tumor removal. The gained separation between skin paddles allows for greater versatility in flap design and inset. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Correction of the Crooked Nose

Correction of the deviated nose is one of the most difficult tasks in rhinoplasty surgery and should be approached in a systematic manner to ensure a satisfied patient and surgeon. Correction of the deviated nose is unique in that the patients complaints frequently include aesthetic and functional characteristics. Equal importance should be given to the preoperative, intraoperative, and postoperative aspects of the patients treatment to ensure a favorable outcome.

Preparation of the Neck for Microvascular Reconstruction of the Head and Neck

Reconstruction of congenital, developmental, or acquired head and neck defects remains a significant challenge for the oral and maxillofacial surgeon. Microvascular free tissue transfer has several advantages over nonvascularized bone grafts and pedicled soft tissue flaps that currently make it the modality of choice for the reconstruction of extirpative defects of the head and neck. Preoperative planning must include detailed attention to the technical aspects of the microvascular procedure. This includes a thorough understanding of the vascular anatomy of the patients neck; vascular anatomy of the various flaps including pedicle lengths; and a knowledge of how to facilitate microvascular surgery in the neck and to manage complicating factors in the difficult neck.