Mutaz B. Habal

Prevention of postoperative facial edema with steroids after facial surgery

A one-bolus (dose) of 1 g of methylprednisolone was administered intravenously to patients undergoing facial surgery or craniofacial surgery, before the termination of the operative procedure. The degree of facial edema noted was reduced, and when it occurred, it was mild and of shorter duration. These observations were made on the experimental design first, and later in the clinical setting. No adverse effects were noted, and patients given this treatment required less pain medication in the immediate postoperative period. The mechanism of action of the steroids is multifactorial, related to decrease in the accumulation of fluid at the capillary level, and reduction of flow at the venoarterial sphincters. The use of steroids is safe when used with caution in selected patients, and by experienced surgeons.A one-bolus (dose) of 1 g of methylprednisolone was administered intravenously to patients undergoing facial surgery or craniofacial surgery, before the termination of the operative procedure. The degree of facial edema noted was reduced, and when it occurred, it was mild and of shorter duration. These observations were made on the experimental design first, and later in the clinical setting. No adverse effects were noted, and patients given this treatment required less pain medication in the immediate postoperative period. The mechanism of action of the steroids is multifactorial, related to decrease in the accumulation of fluid at the capillary level, and reduction of flow at the venoarterial sphincters. The use of steroids is safe when used with caution in selected patients, and by experienced surgeons.

Diced cartilage grafts wrapped in alloderm for dorsal nasal augmentation

Dorsal nasal augmentation is commonly performed for various aesthetic deficiencies and/or reconstructive defects such as the saddle nose deformity. However, the optimal technique for volume augmentation has yet to be identified. The senior author (F.P.) has since developed a new modified technique using wrapped diced cartilage within an AlloDerm. This novel construct provides the plastic surgeon a smooth, convenient, pliable option with similar operative times as compared with other popular techniques. In summary, this technique has been proven to be successful in achieving attractive, safe, and acceptable outcomes in nasal dorsal configuration and overall patient satisfaction.

Aesthetics of feminizing the male face by craniofacial contouring of the facial bones

The “forceful” and macho look of a prototypical man may not be unduly appealing to others whom he meets. This “forceful” look might not even appeal to the individual himself. In order to soften this appearance, a series of operative procedures has been devised for use on the craniofacial skeleton. These surgical steps can be done in a single operation or as a series of multiple operative procedures. Moreover, the needs of some patients may require that only special segments of these procedures be performed. This article presents these operative procedures and describes the feasibility with which they can be performed. Complications and unfavorable outcomes, when they occur, are usually related to unrealistic expectations on the part of the patient. The surgical steps routinely performed are those that contour the forehead, orbits, malar eminence, cheeks, chin, angle of the mandible, and larynx. Three categories of patients are described: the female with a male face; the male with a “forceful look”; and the patient requesting a gender identity change. The psychosocial, psychological, and behavioral problems leading to the decision for surgery will be the basis of final patient selection.The “forceful” and macho look of a prototypical man may not be unduly appealing to others whom he meets. This “forceful” look might not even appeal to the individual himself. In order to soften this appearance, a series of operative procedures has been devised for use on the craniofacial skeleton. These surgical steps can be done in a single operation or as a series of multiple operative procedures. Moreover, the needs of some patients may require that only special segments of these procedures be performed. This article presents these operative procedures and describes the feasibility with which they can be performed. Complications and unfavorable outcomes, when they occur, are usually related to unrealistic expectations on the part of the patient. The surgical steps routinely performed are those that contour the forehead, orbits, malar eminence, cheeks, chin, angle of the mandible, and larynx. Three categories of patients are described: the female with a male face; the male with a “forceful look”; and the patient requesting a gender identity change. The psychosocial, psychological, and behavioral problems leading to the decision for surgery will be the basis of final patient selection.

Postnatal Palatoplasty, Implications For Normal Speech Articulation—A Preliminary Report

During the last ten years patients born with cleft palates had their palates closed between three and eight months of age. The primary objective has been to have the clefts closed soon to minimize faulty habits of speech articulation and intraoral, oropharyngeal and laryngeal compensatory movements for speech. Over one hundred ninety patients with a variety of cleft types were treated. Of these patients, twenty-two were randomly selected for complete and comprehensive evaluation one to eight years after the corrective procedure. Oro-nasal balance of articulatory resonance was noted. There was not any need for secondary palatal procedures in any of the patients, and no deleterious effects on facial growth were found. Normal articulation development was observed in all the patients treated by this methodology as measured by a standardized test and developmental norms.

Aesthetic considerations in the reconstruction of the anophthalmic orbit

Twenty-four patients with severe anophthalmic orbit syndrome were treated with a combination of techniques utilizing autogenous tissue. Autogenous corticocancellous bone grafts were used in the orbit as a volume filler. The temporalis muscle and a fasciae flap with a pericranial flap were used as a curtain to cover the bone grafts and to give a softening effect. The prosthesis used was a regular eye shell. With this method it can be smaller, thinner, and lighter to produce less deformation of the lower lid, particularly when used for a long period of time. In children who have this deformity compounded by small orbits after oncologic treatment, three-wall orbital enlargement is done to achieve a larger orbit, so as to match the normal unaffected socket and produce symmetry.Twenty-four patients with severe anophthalmic orbit syndrome were treated with a combination of techniques utilizing autogenous tissue. Autogenous corticocancellous bone grafts were used in the orbit as a volume filler. The temporalis muscle and a fasciae flap with a pericranial flap were used as a curtain to cover the bone grafts and to give a softening effect. The prosthesis used was a regular eye shell. With this method it can be smaller, thinner, and lighter to produce less deformation of the lower lid, particularly when used for a long period of time. In children who have this deformity compounded by small orbits after oncologic treatment, three-wall orbital enlargement is done to achieve a larger orbit, so as to match the normal unaffected socket and produce symmetry.

Large Congenital Melanocytic Nevus: Light and Electron Microscopic Findings

The family of a 10-month-old black girl with a large periocular congenital melanocytic nevus (CMN) was given markedly differing advice from experienced physicians regarding how the lesion should be managed. The nevus was eventually removed surgically because of concern about the risk of malignant transformation and because of its cosmetic appearance. Histologically, the lesion was a dermal nevus, but extended deeply into subcutaneous tissue and had neuroid features. The ultrastructural characteristics of melanocytes varied according to the depth at which they resided, but cells did not differ basically from melanocytes found in smaller acquired nevi. Given the limited understanding of the biologic basis for malignant transformation, large size remains the most important risk factor in CMN.

Controlled bone regeneration: The ultimate process in bone repair

The main goal of bone healing, besides the healing of the bone, is ensuring that the dynamic system of repair is under biologic control. To do so, the soft tissue has to be kept isolated to avoid any herniation into the bony defect, that would produce and interfere with the bone interface or collapse the original defect resulting in a relapse.

Surgical Management of “Pus-Pot” Perineum

Ten cases of disabling pus-pot perineum secondary to hidradenitis suppurativa, urethral stricture disease, condyloma acuminatum and anoperineal fistula were treated by wide excision of involved tissues. In 7 men the testicles were transposed to thigh pouches, and in 3 the entire penile skin was excised and replaced with a skin graft.

Deformational plagiocephaly: a look into the future.

P lagiocephaly, originally described as asymmetric distortion (flattening of one side) of the skull, can occur anteriorly or posteriorly and can result from positional forces or premature fusion of the coronal or lambdoid suture. Whereas the majority of anterior plagiocephaly cases are caused by coronal synostosis, the vast majority of posterior cases result from positional or Bdeformational[ forces.1 Deformational forces can result from intrauterine constraint, fetal malposition, multiple fetuses, oligohydramnios, or cephalohematoma. More commonly, however, deformational forces occur postnatally due to a supine sleeping position with or without superimposed torticollis. In 1992, the American Academy of Pediatrics recommended that all infants be placed on their back to sleep to decrease the risk of sudden infant death syndrome, defined as sudden death of an infant younger than 1 year that remains unexplained after complete autopsy and death scene investigation as noted by the National Institute of Child Health 1990. That also need not be confused with cardiopulmonary events that are more common and can be alleviated easily with proper stimulation. Following this recommendation, the incidence of the positional etiology began to sharply rise from 1 in 300 (O’Broin et al) to as high as 48%, depending on the criteria. The other cause of posterior plagiocephaly, lambdoid craniosynostosis, however, has remained the lowest of all single-suture craniosynostoses and occurs in only 3 in 100,000 live births.

Breast Augmentation and the implant mania

Recent enthusiasm about the new breast implants was quelled in discussion on the new controversies in breast enlargement. The so-called f u z z y implant is now being used with enthusiasm. After the problems with the older nonsticky silicone implant were recognized, f u z z y and s t i cky implants (polyurethane-covered) were introduced. The new implant introduced more variables and a new set of complications with no solutions on the horizon. Since we found it difficult to formulate traditionally accepted standards, we introduced a new problem in an effort to solve an old one. The concept behind the new implant is not recent but its use is now widespread-a plastic surgery vogue. For the plastic surgeon already practicing in the trenches or on the bench, as well as for the one just starting out, it is difficult to find good hard data to support fully either of the two models. We still present and discuss data based on the appearance of the result of surgery and on the feel to the examiners hands. We should look at comparable results for an assessment. However , we do not really know what to measure; hence, our dependence on appearance and feel becomes obvious. We want to be scientists, but we are artists at heart who are barely literate in science. As plastic surgeons we are far removed from the science of biomaterials; we take what we can get and what is presented to us as safe and effective. To solve the breast implant problem, we need not only scientists who play with numbers, but those