Vito C. Quatela

Temporal Branch of the Facial Nerve and Its Relationship to Fascial Layers

OBJECTIVES To eliminate the inconsistency in the nomenclature, to anatomically and definitively describe the topographic relationship of the temporal branch of the facial nerve to the fascial layers and the fat pads, and to create an effective algorithm to define the safest approaches and planes for surgical procedures in this area. METHODS The study was performed using 18 hemifacial cadaveric specimens. In 12 hemifacial specimens, the facial halves were coronally sectioned and dissected. In 6 hemifacial specimens, planar dissection was performed layer by layer. RESULTS The temporal branch of the facial nerve that traversed inside the deep layers of the temporoparietal fascia and the superficial musculoaponeurotic system coursed along the zygomatic arch as 1 (14.3%), 2 (57.1%), 3 (14.3%), and 4 (14.3%) twigs in the specimens. The temporoparietal fascia had no attachment to the zygomatic arch and continued caudally as the superficial musculoaponeurotic system. Adhesions were between the temporoparietal fascia and the superficial layer of the deep temporal fascia around the zygomatic arch. In most specimens, the superficial layer of the deep temporal fascia continued as the parotideomasseterica fascia, and a deep layer abutted the posterosuperior edge of the zygomatic arch. CONCLUSION An easy and safe surgical approach in this area is to elevate the superficial layer deep to the intermediate fat pad directly on the deep layer of the deep temporal fascia descending to the periosteum along the zygomatic arch.

Proptosis after retrobulbar corticosteroid injections

PURPOSE This report describes the clinical, radiographic, and histopathologic findings in patients with proptosis secondary to lipomatosis after retrobulbar corticosteroid injection. DESIGN Retrospective, noncomparative, interventional case series and review of the literature. METHODS Five patients who developed symptomatic unilateral proptosis after steroid injection were studied and the literature was reviewed. RESULTS No previous description was found in the literature. All five cases were studied with computed tomography, and two cases were confirmed with histopathology. No fibrosis or granulomatous inflammation was identified. CONCLUSIONS Orbital lipomatosis is a potential complication of retrobulbar steroid injections. Symptomatic relief can be provided by a transconjunctival approach to the lower lid fat compartment.

Guillain-Barré syndrome presenting as acute bilateral vocal cord paralysis.

Guillain-Barre syndrome is an acute inflammatory demyelinating neuropathy characterized by symmetric areflexic paralysis. Vocal cord paralysis has infrequently been reported as a component of this syndrome. A review of the literature identifies only three previously reported cases in which vocal cord paralysis was a major feature of the disorder. In none was it the primary presenting symptom. We report an unusual case of Guillain-Barre syndrome in which the patient manifested stridor and acute respiratory distress resulting from bilateral vocal cord paralysis. The diagnosis of Guillain-Barre syndrome became apparent only after progression of the disease, hospitalization, and further evaluation. A case is presented followed by a review of the Guillain-Barre syndrome.

Bilobed Flap Reconstruction of the Temporal Forehead

The temporal forehead is a particularly challenging area for reconstruction. Temporal forehead skin lies in a broad flat plane that varies in thickness. The eyebrow, scalp hairline, and lateral canthus comprise its aesthetic boundaries and limit the available tissue for repair of defects. Characteristically, skin tumors of the temporal forehead have extensive subclinical spread and their removal leaves large defects. The goal of temporal forehead reconstruction is to recreate the aesthetic boundaries of the forehead and to regain symmetry with the contralateral side. The temporal forehead bilobed flap is a single-stage procedure that takes advantage of the best color match of adjacent tissue and often allows primary closure of the donor sites in relaxed skin tension lines with minimal distortion. Several cases are presented for illustration of the technique.

Management of the aging nose.

As a growing segment of our population, mature patients seeking rhinoplasty for both functional and aesthetic reasons will increasingly be encountered by the facial plastic surgeon. The aging process is characterized by a gradual derotation and deprojection of the nasal tip. This article provides an overview of versatile and proven techniques that may be applied to the majority of aging nose rhinoplasty cases and that have been found to yield predictable and lasting results.

Periocular malignant fibrous histiocytoma.

We present a case of periocular cutaneous malignant fibrohistiocytoma that invaded the orbit. Complete excision is recommended for atypical fibrohistiocytic tumors around the eye. Examination of specimen margins by frozen section should be undertaken with caution. It is recommended that frozen section evaluation be performed by a pathologist familiar with spindle cell neoplasm to ensure complete removal of this tumor.

Lower eyelid aesthetics after endoscopic forehead midface-lift.

OBJECTIVE To assess and quantitate the immediate effect of endoscopic forehead midface-lift on infraorbital hollowing and lower eyelid skin excision. METHODS Twenty-five patients who underwent an endoscopic forehead midface-lift with a lower eyelid blepharoplasty or lower eyelid blepharoplasty without a midface-lift between January 1, 2005, and May 15, 2005, were included in the study. Preoperative and immediate postoperative measurements of the vertical height of the lower eyelid were taken in all patients. The change in the vertical height of the lower eyelid after endoscopic forehead midface-lift with blepharoplasty was compared with the change in lower eyelid height after either transconjunctival or lower eyelid skin pinch blepharoplasty or skin muscle flap blepharoplasty alone. The amount of lower eyelid skin excised after endoscopic forehead midface-lift with blepharoplasty was compared with both transconjunctival or lower eyelid skin pinch blepharoplasty and skin muscle flap blepharoplasty when a midface-lift was not performed. RESULTS The average change in the vertical height of the lower eyelid after the endoscopic forehead midface-lift was 5 mm. Lower eyelid blepharoplasty alone, whether transconjunctival with skin pinch or skin muscle flap, did not affect the vertical height of the lower eyelid. The change in the vertical height of the lower eyelid with midface surgery over blepharoplasty alone was statistically significant (P < .001). The average amount of lower eyelid skin excised after endoscopic forehead midface-lift and lower eyelid skin pinch was 7.0 mm compared with 5.5 mm for both the transconjunctival lower eyelid skin pinch and the skin muscle flap techniques. The difference in skin excision when a midface-lift was performed compared with blepharoplasty alone was statistically significant (P = .008). CONCLUSIONS The endoscopic forehead midface-lift can reduce the vertical height of the lower eyelid by an average of 5 mm and allows more skin excision over blepharoplasty alone. The endoscopic forehead midface-lift is a powerful tool for decreasing the vertical height of the lower eyelid, lessening infraorbital hollowing, and improving dermatochalasis.

Skin Excision Revision Rhinoplasty

A technique of skin excision revision rhinoplasty is described for application in patients undergoing rhinoplasty. This group of patients includes those with soft-tissue polly beak deformities and a variety of other difficult post-rhinoplasty deformities. Horizontal nasal dorsal skin excision affects tip elevation and eliminates supratip fullness, while vertical midline nasal dorsal skin excision enhances tip definition, decreases dorsal height, and eliminates supratip fullness. We describe several patients who underwent either horizontal or vertical nasal dorsal skin excision for a variety of cosmetic deformities following conventional closed and open rhinoplasty. The techniques presented herein are meant to be added to the list of techniques available to the revision rhinoplasty surgeon rather than to replace existing techniques.

Midface Lift: Panel Discussion

UNLABELLED What is the most efficient dissection plane to perform midface lift? What is the best incision/approach (preauricular, transtemporal, transoral)? Why? What specific technique do you use? Why? What is the best method/substance for adding volume to midface lifting? In approaching the midface, how do you see the relationship of blepharoplasty versus fillers versus midface lifting? ANALYSIS How has your procedure or approach evolved over the past 5 years? What have you learned, first-person experience, in doing this procedure?

Endoscopic-assisted facelifting.

Over the past two decades the use of endoscopes for facial rejuvenation gained wide popularity due to its reliable and reproducible results and limitation of the morbidity related to the open approaches. A thorough knowledge of the anatomy is of paramount importance to safely release all the fascial attachments while avoiding injuries to the facial nerve. The authors find the endoscopic forehead midface lift to be a reliable and safe procedure for facial rejuvenation.