Johannes Franz Hönig

Severe granulomatous allergic tissue reaction after hyaluronic acid injection in the treatment of facial lines and its surgical correction.

Hyaluronic acid is considered to be nonimmunogenic. Frequently, it is used for the correction of facial lines. It is believed that hyaluronic acid injection fillers are safe and have no occurrence of serious adverse reactions or allergic reactions. Nevertheless, recent publications have documented the rate of intermittent swelling and severe granulomatous allergic reactions that evolved into abscesses. A clinical case of a 54-year-old patient is presented. After injection of hyaluronic acid in the treatment of nasolabial folds elsewhere, she developed palpable painful erythematous nodules evolving into abscesses several month after injection. Surgical treatment and correction of these lesions after hyaluronic acid injection of the nasolabial folds and the histological findings of these erythematous nodules are described. Histological and clinical examination documented intermittent swelling and severe granulomatous allergic reactions that may render the use of hyaluronic acid unacceptable. Patients should be informed of the potential complications when treating facial lines with hyaluronic acid gel.

Cellular, Histomorphologic, and Clinical Characteristics of a New Octyl-2-Cyanoacrylate Skin Adhesive

Short-chained cyanoacrylates have been used for many years for topical skin closure. Toxic effects in cell culture of a new long-chained octyl-2-cyanoacrylate tissue adhesive are compared with those of short-chained ethyl-2- and butyl-2-cyanoacrylates. Two cellular tests were used: the agar overlay test and the MTT test. An in vitro test using copper plates coated with the three types of cyanoacrylates serves for evaluating the stability of polymerized skin adhesives. Bilateral neck skin incisions in Goettingen miniature pigs were glued on one side with Dermabond. On the other side, conventional sutures were applied. After the pigs were killed, the resulting skin samples were tested for the tensile strength of their wound stability. Samples of pig dermis were exemplarily and histomorphologically characterized. A clinical examination after submandibular lymph node dissection should examine the application in humans. Cell culture tests were used to show the toxic effects of the three cyanoacrylates. In a copper test, octyl-2-cyanoacrylate was more stabile than ethyl- and butyl-cyanoacrylates. Breaking strength was 30% lower 28 days after operation with the new product than with sutures. In electron microscopy, octyl-2-cyanoacrylate showed no disadvantages with regard to tissue regeneration and no histotoxicity. For plastic surgery, this new topical skin adhesive is a real alternative with attractive results, as compared with conventional suture.

Facelift approach with a hybrid SMAS rotation advancement flap in parotidectomy for prevention of scars and contour deficiency affecting the neck and sweat secretion of the cheek.

Tumors of the parotid gland are generally be removed by the standard external bayonet-shaped incision approach without reconstruction of the parotid bed. The disadvantage of this approach is frequently an obvious scar affecting the neck and a conspicuous hallow contour around the angle of the mandible in addition to a sweat secretion of the cheek (Frey syndrome).To overcome these disadvantages, especially the facial depressed deformity subsequent to parotid surgery, during the last several years, the author has concentrated on facelift incision used in combination with a hybrid SMAS rotation advancement flap.Twelve patients (7 male; 5 female) ranging in age from 32 to 73 years (mean age, 57.8 years) fulfilled the selection criterion of having a clinically benign discrete parotid lump with a benign preoperative fine-needle cytology result. Parotidectomy was performed using the modified facelift incision in conjunction with the rotation advancement hybrid SMAS flap. All patients were followed up every 3 months during the first year. During follow-up, the patients were specifically asked about their satisfaction with their postoperative appearance and whether they would consent to the operation again.The vascularized hybrid vicryl mesh/SMAS rotation advancement flap is clinically simple to perform and provides satisfactory cosmetic and functional results in patients undergoing conservative parotidectomy and prevents the gustatory sweating. There are no drawbacks to the use of the modified facelift incision to remove tumors of the parotid gland.

Classification system and treatment of zygomatic arch fractures in the clinical setting.

A new classification system and algorithm of zygomatic arch fractures is described that provides the surgeon with a useful starting point from which to organize a valid treatment plan and management of zygomatic arch fractures. Hönig Merten (HM) class I is defined as an isolated tripod fracture, HM class II as an isolated stick fracture of the arch, and HM class III is a combined fracture of the malar bone and the zygomatic arch.Although reduction of the class I and II is usually closed, open reduction is mandatory in class III zygomatic arch fractures.

Facial bone distraction osteogenesis for correction of malocclusion: a more than 70-year-old concept in craniofacial surgery.

Bone distraction has been used increasingly since McCarthy and associates showed in their clinical investigation new osseous formation in the elongated area while performing mandibular distraction in 1992. However, at the craniofacial skeletal level, the initial description of the classic technique of distraction osteogenesis should be credited to German craniofacial surgeons Rosenthal (for bone lengthening of the mandible in a microgenia patient around 1927) and Wassmund (for the clinical advancement of a maxilla in a patient with hypoplasia of the upper jaw in 1926). Both procedures are described, and their original schedules and cases are presented.

Surgical removal of intra- and extraoral cavernous lymphangiomas using intraoperative-assisted intralesional fibrin glue injections.

&NA; Benign lymphangiomas are encountered frequently in the head and neck region. They may be well circumscribed or diffusely invasive, involving subcutaneous tissue and underlying muscle, and consist of dilated, thin‐wall sinuses. Surgical therapy with excision as wide as possible, while taking care to avoid rupturing the lesion, is the treatment of choice. To simplify complete excision, the authors introduce an intraoperative technique—intralesional injection of fibrin glue. Using this technique over period of 10 years in 27 patients (age range, 7‐24 years) they removed successfully intra‐ and extraoral lymphangiomas. There have been no recurrences. This technique helps avoid rupture of the epithelium and bleeding, and makes it easier to remove lymphangiomas surgically and as completely as possible. This technique reduces recurrence remarkably and ensures successful surgical excision.

Mandibula Distraction Osteogenesis for Lengthening the Mandibula to Correct a Malocclusion : A More Than 70-Year-Old German Concept in Craniofacial Surgery

Bone distraction is still on the rise again since McCarthy et al. presented in their clinical investigation new osseous formation in the elongated area while performing the distraction of the mandible in 1992. But at the level of craniofacial skeleton, the initial description to the technique of distraction osteogenesis should be credited to the German craniofacial surgeons Rosenthal for the bone lengthening of the mandible in a microgen patient in 1927. The procedure is described and the original schedules and case are presented.

A de novo discharging sinus of the fronto-orbital suture : a rare presentation of a dermoid cyst

Dermoid cysts are developmental anomalies, resulting primarily from trapped germinal epithelium. In the neck and head region, the most common location is the fronto-orbital upper outer quadrant of the orbit. Because only a few cases of dermoid cysts with discharging sinus of the fronto-orbital area have been reported in the literature, the authors present an unusual case of a frontozygomatic suture dermoid cyst, presenting as a sinus, in an 56-year-old man. The histologic report confirmed that the cystic lesion was a dermoid cyst with a tract. Diagnosis and management are discussed.

Avoidance of implicit hazards: the realignment of maxillary and mandibular arches in comminuted and facial fractures.

The authors introduce an attempt to elevate the problem of proper realignment of the maxillary and mandibular arches to achieve an exact transversal width of the lower third of the face with an index of the sum of the maxillary and mandibular central incisors, together with a new Artex-Callotte System (Karl Storz GmbH, Tuttlingen, Germany). This allows individual and anatomically correct restoration of the dental arches. This is especially helpful if either a large number of teeth or portions of dental alveolar processes have been lost in comminuted panfacial fractures. In addition, a sequential, step-management concept of comminuted panfacial fractures is described and illustrated. The goals of treatment with this method are to reestablish the midfacial height and projection and the occlusion, and reestablish the integrity of the nose, the orbit, and the transversal dimension of the lower jaw. This simple method is not yet well appreciated.

Video endoscopic-assisted brow lift: comparison of the eyebrow position after Endotine tissue fixation versus suture fixation.

To improve brow ptosis and forehead rhytids, minimal invasive surgery has successfully been applied more recently. Clinical studies have revealed that inadequate fixation for anchoring a transposed released soft tissue will result in a loss of suspension of the lateral eyebrow. Therefore, we evaluated the results of eyebrow position in a series of endoscopic-assisted eyebrow lift cases by comparing broad base of fixation with an Endotine device versus conventional single-point tissue fixation with suture loop fixation of the soft forehead tissue. Between 2003 and 2005, 47 patients (12 males and 35 females, age 38.5 ± 6.2 years)) underwent eyebrow lift and a forehead plasty. In one group, which consists of 25 patients (6 males and 19 females, age 36.5 ± 5.1 years), soft tissue fixation of the elevated forehead was performed conventionally with one suture loop on each side that passed through the galea-periosteum and anchored to the cranial bone (bone tunnels). In the other group of 22 patients (4 males and 18 females, age 39.3 ± 6.4 years), the elevated forehead was anchored to Endotine 3.5 version. Despite the fact that 6 months after surgery, drooping of the lateral brow position was observed, with a mean of 2.3 ± 0.8 mm, in the overall cases 12 months after surgery, differences in the position of medial third of the eyebrow were noted between these groups. In the Endotine group, the medial third of the eyebrow portion stayed more stable at its transposed position and was in mean 1.5 ± 0.6 mm higher compared with the suture soft-fixed group. The results confirmed that Endotine enhances soft tissue suspension by allowing better distribution of tension over multiple points over time and thereby supports re-adherence strength of the transpose medial flap forehead to the frontal bone. For minimizing a relapse of the elevated lateral eyebrow portion after adequate dissection and tissue release, suspension of the lateral soft forehead tissue is paramount. It should be located between the temporoparietalis fascia and the deep temporal fascia, with extensive tension after resection of temporal fascia window additionally supported by reabsorbable threads or gore tex sutures.