Ron Hazani

Correction of Posttraumatic Enophthalmos

Management of posttraumatic enophthalmos can present as a challenge to the reconstructive surgeon, particularly in cases of late presentation. This article reviews the pertinent anatomy of the orbit, diagnostic modalities, indications for surgery, and surgical approaches as they relate to the treatment of posttraumatic enophthalmos. Internal orbital reconstruction has evolved to an elegant procedure incorporating various biologic or alloplastic implants, including anatomical pre-bent implants. Successful repair of late enophthalmos has been demonstrated in multiple recent studies and is likely related to the precision with which orbital anatomy can be restored.

Anatomical Landmarks to Avoid Injury to the Great Auricular Nerve During Rhytidectomy

BACKGROUND An estimated 116 086 facelifts were performed in 2011. Regardless of the technique employed, facial flap elevation carries with it anatomical pitfalls of which any surgeon performing these procedures should be aware. Injury to the great auricular nerve (GAN) is the most common of these injuries, occurring at a rate of 6% to 7%. OBJECTIVES We report our findings on the location of the GAN on the basis of anatomical landmarks to aid surgeons with planning their surgical approach for safe elevation of rhytidectomy skin flaps in the lateral neck region. METHODS Sixteen fresh cadaveric heads were dissected under loupe magnification. All specimens were dissected in a 45-degree (facelift) position in which a mid-sternocleidomastoid (SCM) incision was used for exposure. Measurements from the bony mastoid process, bony external auditory canal, external jugular vein, and anterior border of the SCM to the GAN were taken in each cadaver. RESULTS The GAN follows a consistent course over the mid-body of the SCM before bifurcating into anterior and posterior branches and terminal arborization. Regardless of the length of the SCM, the GAN at its most superficial location was found to be consistently at a ratio of one-third the distance from either the mastoid process or the external auditory canal to the clavicular origin of the SCM. CONCLUSIONS Knowledge of the anatomy, course, and location of the GAN along the surface of SCM muscle based on anatomic landmarks and distance ratios can facilitate a safer dissection in the lateral neck during rhytidectomy procedures.

Reconstructing a natural looking umbilicus: a new technique.

An attractive umbilicus is an essential component of the abdominal wall. It defines the midline abdominal sulcus and adds to a shapely abdominal curvature. Certain procedures place the umbilicus at risk thus providing a need for a neoumbilicus.Three-hundred and twenty cases of abdominoplasties, panniculetomies, and TRAM flaps for breast reconstruction were reviewed. Five patients underwent an umbilical reconstruction after loss of the native umbilicus. A crescent-shaped incision was used to create an inferiorly based skin flap. The flap was inset to the abdominal fascia. A small full-thickness skin graft was used to form the superior hood.All patients attained an esthetically pleasing umbilicus with minimal scarring. No contracture, flap necrosis, or graft loss were noted.We present a novel, simple, and reliable technique of umbilical restoration. It circumvents the need for external scars and allows for achieving a naturally appearing umbilicus.

Bony Anatomic Landmarks to Avoid Injury to the Marginal Mandibular Nerve

BACKGROUND Marginal mandibular nerve injuries are more likely to be symptomatic than other facial nerve injuries following facelift procedures. The marginal mandibular nerve courses over the facial artery in the region of the mandible. The nerve is most susceptible to injury in this location because it lies superficial to the anterior facial artery. OBJECTIVES The authors describe the location of the marginal mandibular nerve based on superficial anatomic landmarks as it crosses the facial artery above the mandibular border, in order to help surgeons avoid injury to this nerve during facelift procedures. METHODS Eighteen cadaveric facial halves were dissected with the aid of loupe magnification. The distance from the facial artery to the palpable masseteric tuberosity at the angle of the mandible was measured. The distance from the masseteric tuberosity to the mental midline was also measured to determine a ratio of the facial nerve from the masseteric tuberosity to the mental midline. RESULTS The facial artery was found to be an average of 3.05 ± 0.13 cm anterior to the masseteric tuberosity along the mandible. The marginal mandibular nerve crossed the facial artery along the mandibular border approximately 3 cm anterior to the masseteric tuberosity. The distance from the masseteric tuberosity to the mental midline averaged 11.3 ± 0.54 cm. Therefore, the marginal mandibular nerve courses superficial to the facial artery at approximately one-fourth of the distance from the masseteric tuberosity to the mental midline. CONCLUSIONS Knowledge of the masseteric tuberosity and mental midline landmarks of the facial artery can provide a reliable and safe approach to surgery of the lower face.

Identifying a Safe Zone for Midface Augmentation Using Anatomic Landmarks for the Infraorbital Foramen

BACKGROUND Midface augmentation is commonly used to improve the appearance of concave faces and to achieve balance in the facial contour. It can also be an adjunct to orthognathic or reconstructive surgery. However, an inherent risk of midface augmentation is injury to the infraorbital nerve where it exits the infraorbital foramen (IOF). This can result in significant morbidity, including loss of sensation to the midface, nasal sidewall, upper lip, and lower eyelid. OBJECTIVES The authors identify a safe zone of dissection in the midface for subperiosteal placement of infraorbital, paranasal, malar, and submalar implants, which avoids injury to the infraorbital nerve. METHODS Given the popularity of transconjuctival and intraoral access to the midface skeleton, the authors identified relevant bony and dental landmarks from radiographic images and measured distances between the IOF and these landmarks. Forty-four computed tomography scans of adult hemifaces were used to accurately locate the IOF in relation to the anatomic landmarks. RESULTS Most often, the IOFs location correlated with the second premolar on a vertical axis. The average distance between the IOF and the infraorbital rim, piriform aperture, tip of the second premolar cusps, and lateral orbital rim was approximately 8.61, 17.43, 41.81, and 25.93 mm (respectively) in men and 8.25, 15.69, 37.33, and 24.21 mm (respectively) in women. CONCLUSIONS A safe zone of dissection for midface augmentation has been identified, which differs from previous findings. Awareness of this zone may help clinicians locate the IOF and avoid injury to the nerve.

Correction of gynecomastia in body builders and patients with good physique.

Background: Temporary gynecomastia in the form of breast buds is a common finding in young male subjects. In adults, permanent gynecomastia is an aesthetic impairment that may result in interest in surgical correction. Gynecomastia in body builders creates an even greater distress for patients seeking surgical treatment because of the demands of professional competition. The authors present their experience with gynecomastia in body builders as the largest study of such a group in the literature. Methods: Between the years 1980 and 2013, 1574 body builders were treated surgically for gynecomastia. Of those, 1073 were followed up for a period of 1 to 5 years. Ages ranged from 18 to 51 years. Subtotal excision in the form of subcutaneous mastectomy with removal of at least 95 percent of the glandular tissue was used in virtually all cases. In cases where body fat was extremely low, liposuction was performed in fewer than 2 percent of the cases. Results: Aesthetically pleasing results were achieved in 98 percent of the cases based on the authors’ patient satisfaction survey. The overall rate of hematomas was 9 percent in the first 15 years of the series and 3 percent in the final 15 years. There were no infections, contour deformities, or recurrences. Conclusions: This study demonstrates the importance of direct excision of the glandular tissue over any other surgical technique when correcting gynecomastia deformities in body builders. The novice surgeon is advised to proceed with cases that are less challenging, primarily with patients that require excision of small to medium glandular tissue. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Bilateral breast reconstruction: the simultaneous use of autogenous tissue and identical twin isograft.

Not all patients seeking autogenous breast reconstruction have sufficient donor tissue for a bilateral reconstruction. Identical twin isotransplantation, as a model system for allotransplantation without immunologic barriers, broadens the definition of “spare parts” surgery. In this case, we demonstrate the simultaneous transplantation of both autogenous and syngeneic deep inferior epigastric perforator flaps for bilateral breast reconstruction. As our understanding of immunology evolves, allotransplantation may further increase our reconstructive options for other postmastectomy patients.

Extended mesh repair with external oblique muscle reinforcement for abdominal wall contour abnormalities following TRAM flap.

Many patients undergoing reconstructive surgery after mastectomy opt for reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap. Among the morbidities related to TRAM flap reconstruction is the development of abdominal wall contour abnormalities, including bulges or hernias. Several repair techniques at the flap abdominal wall donor site have been described for use at the time of flap harvest in an attempt to reduce the risk of such abdominal wall complications. For patients that develop abdominal wall contour abnormalities, numerous reconstructive options have been reported, with mixed results.Ten patients were identified as having abdominal wall contour abnormalities after a TRAM flap and underwent an extended mesh repair with external oblique muscle reinforcement. The mesh was secured to the bony landmarks of the lower abdomen and the abdominal wall fascia.All patients achieved complete resolution of abdominal wall bulging. In the follow-up period, no recurrences, infections, or seromas were noted. One patient, who failed an earlier repair at the inferior abdominal wall, reported symptoms consistent with a scar neuroma. Symptoms were treated successfully with gabapentin and a nonsteroidal anti-inflammatory drug.We propose a novel and reliable method of lower abdominal wall reconstruction for patients with post-TRAM flap abdominal wall contour abnormalities. This technique incorporates the use of a large Marlex mesh reinforced with bilateral external oblique muscle flaps. We report a series of 10 patients who have achieved resolution of their symptoms and have regained a natural, flat-appearing abdominal wall contour.

The safe zone for placement of chin implants.

Background: Alloplastic chin augmentation requires the surgeon to predict the location of the mental foramen and the origin of the mentalis muscle to avoid the postoperative sequelae lower lip parasthesia, lower lip incompetence, or chin ptosis. The authors define a safe zone of dissection along the inferior border of the mandible for placement of alloplastic chin implants. Methods: Fourteen fresh cadaveric hemifaces were dissected with the aid of loupe magnification. Previously described anatomic landmarks were used to identify the origin of the mentalis muscle and the location of the mental foramen along the alveolar ridge of the mandible. Vertical distances were then measured from the mandibular border to the inferior aspect of the mentalis muscle origin and the lower edge of the mental foramen to construct the zone of safe dissection. Results: The mentalis was identified as a fan-shaped muscle originating from the alveolar process below the incisors roots and inserting into the chin just below the labiomental sulcus. The mental foramen was located most commonly below the roots of the first and second premolars or in the space between the roots. The mentalis origin and the mental foramen were 1.8 ± 0.3 cm and 1.5 ± 0.2 cm cephalad to the inferior edge of the mandible, respectively. These distances define the borders of a safe zone above the mandibular border. Conclusions: A safe zone of dissection for alloplastic chin augmentation is identified. This study is applicable to implant placement through a submental or an intraoral incision. This safe zone is also useful for reconstructive or orthognathic mandible procedures.

Caudal resection of the upper lateral cartilages and its measured effect on tip rotation.

BackgroundCommonly used maneuvers for upward tip rotation include cephalic trim of the lateral alar cartilages, caudal resection of the septum, and shortening of the upper lateral cartilages (ULCs). Few techniques for surgical manipulation of the ULCs are found in the literature, and none accurately describe the measured effect of the caudal resection on tip rotation. The purpose of this study is to predict the change in upward rotation of the nasal tip for a measured incremental resection of the ULCs. MethodsTen fresh cadaveric noses were dissected with the aid of loupe magnification via an open rhinoplasty approach. The ULCs were sectioned in 20% increments, and measurements of the nasolabial angle (NLA) were recorded with the use of a goniometer. True lateral photographs were obtained for the photographic analysis of the specimens. ResultsThe average length of the ULC was 16.8 ± 1.6 mm. Serial reduction of the ULC length by 4 sequential 20% increments resulted in a mean NLA change of 3.6, 2.7, 2.1, and 1.9 degrees, respectively. The average incremental change in NLA for the 4 resections was 2.6 degrees. ConclusionsCaudal resection of the ULC has a measurable effect on the upward rotation of the nasal tip. A 20% resection correlates with an average change in the NLA of 2.6 degrees. Because caudal resection of the ULC is a powerful tool in the armamentarium of the rhinoplasty surgeon that can cause narrowing of the internal nasal valve and hallowing of the lower nasal sidewalls, it should be used with caution in a selected group of patients when attempting to elevate the “droopy” tip.