John L. Frodel

Salvage of partial facial soft tissue avulsions with medicinal leeches

BACKGROUND: Medicinal leeches have been demonstrated to be extremely useful and safe in the salvage of venous outflow compromised tissue, particularly in digit replants and various forms of flaps. OBJECTIVE: To demonstrate the utility of medicinal leeches in the salvage of venous outflow-compromised traumatic soft tissue avulsions in key facial structures. METHODS: A retrospective review of 4 cases involving the external ear, nose, lip, and scalp in which apparent venous outflow compromise was present. Medicinal leeches were applied acutely in each of these 4 cases, salvaging each of the partially avulsed soft tissue segments. RESULTS: Complete or near complete salvage of each soft tissue segment after using medicinal leeches. CONCLUSIONS: Although it is unusual for a partial soft tissue avulsion of the face to require medicinal leech therapy, situations may occur in which there is adequate arterial inflow but inadequate venous outflow. In such cases, medicinal leeches may play a very important role in salvaging the soft tissue segment. This is particularly important in vital structures such as the ear, nose, lip, and eyelid in which acute or secondary reconstruction is complex. EBM rating: C.

Dealing with the difficult trauma and reconstructive surgery patient.

Many of the issues that exist for cosmetic surgery patients exist for noncosmetic patients in areas such as reconstructive surgery and trauma. Although cosmetic and noncosmetic patients usually are considered separate in terms of elective versus nonelective, there are other issues in dealing with reconstructive surgery patients versus those undergoing cosmetic surgery. This article reviews a variety of issues specific to noncosmetic reconstructive surgical patients and discusses issues unique to pediatric patients, craniomaxillofacial trauma patients, patients who have skin cancer defects, scar revision patients, and major reconstruction after cancer resections and craniomaxillofacial trauma.

Revision of severe nasal trauma.

Facial trauma commonly includes injury to the nose and perinasal area. In this review, we will focus on the sequelae of severe nasal trauma and provide examples of correction of the severely deviated nose, the severely collapsed nose, and revision of a traumatic deformity after prior rhinoplasty. We will then discuss coexistent deformities of perinasal regions in addition to functional and posttraumatic nasal correction, including posttraumatic periorbital deformities.

Reconstruction of Periparotid Defects Using Temporoparietal Fascia Flap with Layered Acellular Human Dermal Allograft

Excision of lesions in the periparotid area can leave a sizable concavity of the preauricular area with skeletonization of the mandible. To achieve the bulk necessary to fill this defect, we propose using a composite graft. Acellular human dermal allograft provides the thickness of the graft, and the temporoparietal fascia flap provides blood supply to the dermal graft. Our hypothesis is that vascularization of the graft will promote greater ingrowth of native tissue and prevent breakdown and absorption of the graft. Four representative patients are described.

Facial Defect Reconstruction with Scalp Skin Grafts

Abstract The objective of this study is to demonstrate the benefits of scalp‐based split‐thickness skin grafts as a reconstructive modality for facial skin defects, noting advantages relative to traditional harvest sites. The study is presented as a case series with chart review set in a tertiary referral center. We reviewed the charts of patients with facial skin defects whose reconstruction required more skin than could be harvested with standard full‐thickness skin grafting techniques and, accordingly, included a split‐thickness skin graft from the adjacent scalp. Preoperative and postoperative photographs, along with operative and postoperative records, were used to evaluate final cosmetic results and complications. We reviewed 15 patients, with ages ranging from 6 to 90 years. Common indications were skin cancer resection, avulsive skin trauma, and ear reconstruction. While patients generally had good cosmetic outcomes, with excellent color matching relative to traditional distant donor sites, a major advantage of the scalp donor site was low donor‐site morbidity. Scalp donor sites were commonly reepithelialized at 7 to 10 days postoperatively and had low reported pain scores. There were no major complications. Reconstruction of facial skin defects that require skin coverage with split‐thickness skin grafts can optimally be harvested from adjacent scalp skin, providing adequate cosmesis but, perhaps most importantly, much lower donor‐site morbidity than with traditional nonhair‐bearing donor sites.

Management of Posttraumatic Pseudotelecanthus.

Injuries to the nose and perinasal region are common. Though the nasal fractures are commonly recognized and properly addressed, injuries to adjacent structures such as the orbit, medial canthus, and midface skeleton can be missed or misdiagnosed leading to improper primary treatment and subsequent secondary deformities. In this discussion, we focus on secondary deformities of the medial canthal region injuries that result from inadequate primary repair of the displaced medial canthal tendon apparatus in naso-orbital-ethmoid fractures. Emphasis is placed on the difference in complexity of the secondary pseudotelecanthus deformity relative to primary fracture treatment. Case examples are used to discuss the complexity of the correction of such deformities.

Calvarial bone grafting techniques as an adjunct to rhinoplasty

Principles and techniques for augmentation rhinoxad plasty arc well established. However, the use of calvarial bone for nasal dorsal augmentation has only recently bexad come accepted as a standard technique in rhinoplasty. Not only is the use of this material often useful in reconxad structive situations such as in the treatment of the sequelxad ae secondary to severe nasoethmoid injuries, but calvarial bone is also occasionally indicated in rhinoplasty when significant augmentation is necessary. While options also include other autogenous materials such as conchal cartilage, homologous materials such as irradiated cartixad lage and demineralized bone, and alloplastic materials such as Silastic, Proplast, and mersiline mesh, the rhinoxad plastic surgeon should be familiar with at least one techxad nique of harvesting calvarial bone . Accordingly, a simxad plified approach to harvesting outer cortex calvarial bone will be presented. PROCEDURE The surgeon should select a site in the parietal region greater than 2 em from the midline in order to avoid potential penetration of the sagittal sinus. The orientaxad tion of the proposed graft should be anteroposteriorly, as this allows for a graft with the flattest profile (Fig 1). An incision is made through the scalp and underlying periosteum directly overlying the proposed graft. Minixad mal or no hair is shaved. The scalp is retracted and perixad osteum elevated in a standard fashion . At this point, it is important to determine the proper length and width of the graft that will be used for the augmentation rhinoxad plasty. The proposed graft size is then outlined on the calvarium. Using a drill or osteotome, a wide groove is created in the outer cortex around the graft site. When the diploic space is reached, noted by slight increase in bleeding bone, the proper depth has been attained. Several techxad niques can then be used to elevate the graft. The first