Robert T. Adelson

The secondary correction of post-traumatic craniofacial deformities

Objective To analyze the aesthetic and functional outcomes in a large series of patients who underwent secondary correction of post-traumatic craniofacial deformities (PTCD) and to highlight the underlying principles and formulate treatment guidelines. Methods A single surgeons retrospective case series of 57 patients who underwent correction of PTCD. Outcome Measures Evaluation by multiple surgeons who assessed aesthetic results and functional parameters after secondary correction of PTCD. Results A good to excellent aesthetic outcome was achieved in the majority of patients. Traumatic telecanthus, enophthalmos, and occlusal deformity were the deformities most refractory to secondary correction. Aesthetic results were adversely affected by the severity and number of pre-existing abnormalities and by the presence of established deformities (beyond 6 to 12 months). Conclusions The basic principles of treatment include an initial major osseous reconstructive surgery to restore an anatomically correct craniofacial architecture followed by selective ancillary procedures to address soft tissue deficits and functional deformities. Soft tissue deformity is the major deterrent to achieving an ideal outcome.

Temporalis muscle flap for reconstruction of skull base defects.

The temporalis muscle flap (TMF) is a valuable reconstructive technique utilized in a variety of challenging defects. However, its use for repair of skull base defects is less commonly reported.

Objective assessment of the accuracy of computer-simulated imaging in rhinoplasty.

OBJECTIVE The objective of the study was to evaluate the accuracy by which computer-simulated rhinoplasty images reflect surgical results in 6-month postoperative photographs. METHODS We performed a retrospective, objective evaluation of 5 features of the facial profile in the computer-simulated images and in the 6-month postoperative photographs of 36 rhinoplasty patients. Data recorded for the nasolabial angle, nasofrontal angle, columella tip angle, columella/infratip lobule ratio, and an established method of assessing tip projection were subjected to statistical analysis by 2-tailed t test and analysis of variance testing. RESULTS Simulated and actual measurements of columella tip angle were found to be significantly different (P = .021). The set of measurements taken from computer-simulated images at the nasolabial angle (P = .301), nasofrontal angle (P = .471), columellar/infratip lobule ratio (P = .402), and tip projection ratio (P = .547) were not statistically different from the respective measurements recorded from the 6-month follow-up images. CONCLUSIONS No significant difference was found between the measurements recorded from computer-simulated images and those recorded from 6-month postoperative photographs in 4 of the 5 features of the facial profile studied. The accuracy and predictive value of computer-simulated images is demonstrated and quantified for the first time.

Isolated congenital absence of the left lower lateral cartilage.

Introduction: Congenital defects of the nasal cartilaginous skeleton are rare, yet clinically relevant, entities that are important to recognize prior to operative repair Methods: A 47 year old woman was referred to our institution for lifelong leftsided nasal airway obstruction. On physical examination, a complete absence of the left lower lateral cartilage was suspected. Hypothesis: Complete congenital absence of the lower lateral cartilage Results: External approach rhinoplasty confirmed the above hypothesis, and reconstruction was performed with autologous septal cartilage. Conclusions: Careful history and physical examination is important in preoperative planning of nasal surgery. External rhinoplasty approach Isolated complete absence of left lower lateral cartilage identified (Figure 2a) Septal cartilage harvested Septal extension graft replaced the left medial crura Lateral crural strut graft replaced the left lateral crura Shield graft to orient and help reconstitute the tip Left domal onlay graft to emphasize left tip highlight Patient pleased with functional and aesthetic outcome Surgical Approach and Results 1. Losee JE, Kirschner RE, Whitaker LA, et al. Congenital nasal anomalies: a classification scheme. Plast Reconstr Surg 2004;113:676-689. 2. Bilkay U, Tokat C, Ozek C. Reconstruction of congenital absent columella. J Craniofac Surg 2004;15(1): 60-63. 3. Mavili ME, Akyurek M. Congenital isolated absence of the nasal columella: reconstruction with an internal nasal vestibular skin flap and bilateral labial mucosa flaps. Plast Reconstr Surg 2000;106(2):393 -399. 4. Yilmaz MD, Altunas A. Congenital vomeral bone defect. Am J Otolaryngol 2005;26(1):64-66. 5. Klinger M. Caviggioli, Klinger F, et al. Isolated congenital absence of the nasal bones and aesthetic surgical correction: managing and case report. Aesth Plast Surg 2005;29(4):246-249. References 47 year old otherwise healthy Latin American female Lifelong left sided nasal airway obstruction No prior facial trauma or surgery Exam showed mild septal deviation, profound nostril asymmetry, and the absence of any palpable cartilage within left side of the nasal tip (Figure 1) Case Presentation Figure 2a. Complete absence of lower lateral cartilage on the left. Figure 2b. Surgical repair with septal extension, lateral crural strut, and domal onlay grafts. Isolated, non-syndromic cases of absent nasal structures is exceedingly rare. No previous reports exist of isolated absence of a lower lateral cartilage. May occur after fusion of mesenchymal components by 10th week of gestation from vascular accident or pressure phenomenon. Despite its rarity, this anomaly reinforces the importance of careful pre-rhinoplasty analysis and familiarity with principles of open structure rhinoplasty. Conclusions Introduction History and physical examination are crucial to appropriate pre-operative planning of functional and cosmetic rhinoplasty Externally, special attention is paid to the characteristics of the skin-soft tissue envelope, the nasal bones, middle nasal vault, and the lower lateral cartilages. Internally, examination of the septum, the internal and external nasal valves, nasal sidewalls, inferior turbinates and the nasal mucosa. Congenital anomalies of the nose can be responsible for nasal airway obstruction and are present in 1/20,000 to 1/40,000 births Figure 1. Asymmetry of external nose noted with basal and frontal views.

The Spectrum of Isolated Congenital Nasal Deformities Resembling the Cleft Lip Nasal Morphology

OBJECTIVE To define the intrinsic (hypoplasia) and extrinsic (deformational) contributions to congenital nasal deformities and the potential of a carrier state for orofacial clefting. METHODS Retrospective case series. RESULTS The factors affecting 4 congenital nasal deformities are postulated after contrasting the patients characteristics. CONCLUSIONS The spectrum of congenital nasal deformities includes those that resemble the cleft lip nasal deformity, but careful inspection is needed for proper classification. Classifying congenital nasal deformities can be difficult in part due to the highly variable normal range. The most minor form of the typical unilateral cleft lip nasal deformity is the microform cleft. The potential of an isolated cleft lip nasal deformity without obvious cleft lip has been previously suggested to represent a carrier state for orofacial clefting. Definitive genetic studies and continued anthropometric documentation in relatives of patients with orofacial clefts are needed if we are to uncover previously unidentified associations, and a potential carrier state.

Split Myomucosal Advancement Flap for Reconstruction of a Lower Lip Defect

A healthy 82-year-old Caucasian woman presented with an infiltrative basal cell carcinoma of the left lower lip vermillion. Definitive removal of the malignancy required two stages of Mohs micrographic surgery, and the resultant lower lip defect measured 2.8 × 1.1 cm and involved the vermillion–cutaneous border of the left lower lip, including wet and dry lip mucosa, skin, subcutaneous fat, a’nd a portion of the underlying orbicularis oris muscle (Figure 1). Sensation of the surrounding tissue was intact, and facial nerve motion was normal. Given the patient’s age, dentition, and defect size and the risks of microstomia, oral incompetence, and impaired sensation after repair, how would you reconstruct this defect?

Laryngeal Involvement in Progressive Nodular Histiocytosis: A Case Report

Progressive nodular histiocytosis (PNH) belongs to an exceedingly rare family of benign proliferative skin disorders known as non-Langerhans cell histiocytoses (NLCHs). Since initial description as progressive nodular histiocytoma by Taunton et al 1 in 1978, there have been only a handful of case reports describing this rare entity. In the past, there has been a great deal of confusion in classifying the various histiocytoses owing to the rarity in which they were encountered as well as to the tremendous overlap, both clinically and histologically, observed between these diseases. 2 The lesions encountered in this family of diseases are generally benign; however, in the case reported herein, the involvement of the larynx led to partial airway obstruction, a clinical occurrence previously undescribed (to our knowledge).

Computer Simulated Imaging in Rhinoplasty

Computers have moved from curiosity to commonplace within the practice of facial plastic surgery. The ability to record, archive, manipulate, and recall digital images allows surgeons to more readily demonstrate relevant cases to future patients, critically review one’s own results, and improve communication with patients seeking aesthetic and functional nasal surgery. This chapter reviews the relevant body of literature regarding computer simulated imaging (CSI) as it pertains to rhinoplasty. Studies of the role of CSI in preoperative counseling are utilized to demonstrate the power of this technique as well as to provide guidelines for ethical and legal application of this technology. The accuracy of CSI is explored in detail to allow the practicing rhinoplasty surgeon have greater knowledge in determining how to incorporate CSI into their own practice. Recommendations for incorporating CSI in rhinoplasty evaluation, education, and preoperative planning are based upon both peer-reviewed literature and the author’s use of CSI and are further delineated in case studies.

Prevention of Head and Neck Keloid with 5% Imiquimod Cream

Objective: Retrospectively review the charts of patients from the University of Florida Facial Plastic Surgery Clinic over the past 4 years in order to evaluate the efficacy of keloid prevention after surgery with application of 5% imiquimod cream topically to excised areas. Method: Retrospective chart review. Classification of keloid subsite in the head and neck, and recurrence rates as documented in electronic encounters will be analyzed. Patients that have not followed up for greater than 3 months will receive a phone call for follow up. Results: The main result measured will be recurrence rates of head and neck keloid that have undergone surgical excision of these lesions followed by application of 5% imiquimod cream for 6 weeks. This will be obtained from retrospective review of clinic charts from the University of Florida patient database in addition to phone calls to previously treated patients that have not been seen in clinic for greater than 3 months. Conclusion: Pending results and analysis, we hypothesize that application of 5% imiquimod cream following surgical excision of head and neck keloid leads to lower recurrence rates than what is quoted in the literature.

Analysis of Flap Tension in Surgical Rejuvenation of the Midface: A Cadaver Study

Objective. To determine the flap tension present for 2 different surgical approaches for midface lifts and whether a gingivobuccal incision for release of the midface periosteum will diminish the resultant load on the midface flap. Study Design. Cadaver study. Setting. Anatomy laboratory at the University of Florida. Subjects and Methods. Twelve fresh-frozen cadaver heads are subjected to a transblepharoplasty (TB) approach on one side of the cadaver head while a transtemporal (TT) approach is performed on the contralateral side. The tension (grams) generated by moving the midface flap a distance of 1.03 cm is recorded by a digital load cell. A gingivobuccal incision is made on each side to allow transoral periosteal release (TOPR) of the midface flap, and the experiment is repeated. Three trials are performed for each operation, and the average load is calculated. A paired t test is applied. Results. The tension resulting from the TT approach (172 g) was not found to be significantly different from that of the TB approach (179 g; P = .75). Significant differences in the resultant tension were not appreciated when comparing standard techniques to TT with TOPR (141.5 g; P = .27) or for TB with TOPR (164.1 g; P = .45). Discussion. An experimental method is described for determining flap tension in facial rejuvenation surgery. No significant difference is found between flap tensions generated in the TB and TT approaches to the midface.