Description of columellar defects and its tridimensional remedial techniques

Columella is an important facial component and provides support and projection to the tip of the nose. Columella defects may cause significant aesthetic and functional deformities. We present our case-load of 2007: 61 patients operated in that year had been carried out and concluded. Surgical techniques for the correction of columellar defects were classified as "open tip" and "closed tip". Then, depending on the defect, it was possible to intervene on different structures. Of the 61 patients who underwent corrective surgery, only 6 (<10%) maintained or presented again, after a temporary improvement, with the columellar defect at the end of the follow-up. For all the other patients, the final outcome was more than satisfactory. A very good aesthetic result was obtained with no functional complications. In fact, nose functionality is supported by medial crura, laid one upon the other, providing considerable resistance to the columella.

Augmentation rhinoplasty with autologous grafts

The authors present their experience with nasal reconstructive surgery using autologous grafts. Currently, grafts are classified into four categories: skin grafts, cartilage grafts, bone grafts, and composite grafts (Table 1). A sample of 132 patients with nasal defects requiring reconstruction was selected. Two cases, presenting nasal valve collapse and deformities after aesthetic nasal surgery, were analyzed in detail. Overall, satisfying aesthetic results (balanced tip projection, dorsum fullness, widening of internal nasal valve angle, minor scar retraction) were achieved for both patient and surgeon in 79% of the cases.

Alternative techniques in reconstructive surgery: bone-anchored extraoral implants for burn cases

BACKGROUND

The authors present their experience with the use of extraoral implants for reconstruction of the ear area after burns. The first step of the protocol includes positioning of implants in the mastoid process. The second step, after 3 to 4 months, is to realize the auricle prosthesis and apply it. Extraoral, bone-integrated implants offer low surgical risks and few postsurgical complications, leading to optimal aesthetic results, mainly in the ear area. Compared with traditional surgery techniques, the aesthetic results are better, with less surgery, possibly only two surgery sessions. Adhesive prostheses can be placed without the usual local irritation, and a more correct positioning can be obtained.

METHODS

For this study, two female patients, treated from December 2001 to January 2005, were selected to receive auricle epitheses. In the authors' experience, 79% of case reporting describes the creation of this epithesis type. The patient age has a range of 26 years. The two study patients initially had the same diagnosis: burns of the auricle-temporal region.

RESULTS

In all cases, a good aesthetic result was obtained.

CONCLUSION

The authors believe that bone-anchored implants for the treatment of auricle burns is a valid and brilliant technique that complements traditional reconstructive procedures. The advantages are the low incidence of long-term complications and the possibility of obtaining excellent aesthetic lasting results even for very complicated cases that would not have been solved in the past.

Asymptomatic lacrimal flow abnormalities in patients with septal deviations and turbinate hypertrophy

BACKGROUND

This study aimed to investigate the lacrimal flow in patients affected by septal deviations and turbinate hypertrophy and to evaluate changes after rhinoseptoplasty with dacryocystography (DCT) and computed tomographic dacryocystography (CT-DCT).

METHODS

The study prospectively recruited patients having septal deviations with or without turbinate hypertrophy who underwent surgical evaluation for correction of their respiratory symptoms and were not referred for epiphora. Patients were excluded if they had undergone surgery for cranial vault defects or had experienced septal deviations after traumatic accidents. All patients were studied with DCT and CT-DCT preoperatively and postoperatively.

RESULTS

A total of 24 patients (10 men and 14 women) were recruited for the study. Of these patients, 11 (45.8%) had a reduced flow of the medium contrast due to a partial obstruction at the level of the internal ostium. All 11 patients had septal deviations and turbinate hypertrophy, whereas 8 patients had a unilateral obstruction (72.7%), and 3 patients had a bilateral obstruction (27.3%). All flows were corrected after surgery.

CONCLUSIONS

The safe and well-tolerated radiologic techniques performed in this study provided detailed imaging of the lacrimal outflow system. A high incidence of partial obstruction to the internal ostium was found in patients with septal deviations, turbinate hypertrophy, and no lacrimal symptoms, suggesting a frequent presymptomatic condition.

Devastating Methicillin Resistant Staphylococcus Aureus Wound Infection following Abdominoplasty in a Prior Bariatric Surgery Patient

A 46-year-old female smoker presented 12 months after laparoscopic adjustable gastric banding, with massive weight loss and skin excess of the abdomen and flanks. She underwent abdominoplasty with muscle plication and flanks liposuction, but on the 14th postoperative day this was complicated by a methicillin-resistant Staph. aureus wound infection. Multiple surgical debridements and high doses of intravenous antibiotics were necessary for cure and to avoid further septic complications. Complete wound closure was achieved after 3 months of therapy. Concomitant risk factors for wound infection (obesity, smoking, flap construction) contributed to a rare but potentially fatal wound complication following abdominoplasty. We alert the surgeon to such postoperative infections and the necessity for a non-conservative approach.

Reconstruction of the nasal dorsum with autologous rib cartilage

The authors present their experience with the correction of deformities of the nasal saddleback using rib cartilage grafts. They present a review of international literature on this topic, analyzing 33 patients selected from 452 cases of rhinoplasties performed between January 1990 and December 2004 at the Department of Plastic and Reconstructive Surgery of the University of Rome "Tor Vergata." Nasal saddleback is one of the most complicated defects to correct surgically. It can be a consequence of nasoethmoid-orbital fractures and is in this case associated with other evident signs like telecanthus, teleorbitism, or orbital dystopia. It can be also a consequence of surgical procedures in the nasal area where a loss of bone or septal cartilaginous support has occurred. They compare the techniques employed in the reconstruction and describe the advantage of the use of cartilage from the 11th rib and evaluate the results of an engineering analysis of tension forces on the rib cartilage. Of the total number of patients treated, good cosmetic results were obtained in 84% of the cases and excellent functional results in almost all of the cases (94%).

Traumas of the middle skull base with TMJ involvement. Case report

The authors report their experience with temporomandibular joint (TMJ) traumas involving breakage of the roof of the glenoid cavity, an infrequent event that occurs in those cases in which, as a result of the condylar neck not fracturing, the traumatic energy is transmitted to the middle skull base. As the literature contains no valid series for establishing standardized protocols for the treatment of these fractures, we propose our own orthopedic-functional approach. The patient observed by us had suffered a cranio-facial trauma and presented the classical symptoms and signs of TMJ traumas and complete bilateral Bell paralysis. He was subjected to a CAT scan and then to 2-stage treatment consisting of functional rest with liquid diet followed by physiotherapy. An almost total recovery in TMJ function was observed after 1 month. At 1-year follow-up the facial paralysis had resolved completely. On the basis of our experience, breakages of the glenoid cavity can be compared, in terms of treatment procedure, to intracapsular fractures of the TMJ with surgery confined to cases of ankylosis sequelae. To avoid the onset of ankylosis careful control of clinical, functional and radiological follow-up is required.

A new free flap model in the rat: the pectoralis major muscle

We have designed a rat pectoralis muscle free flap transplant at the level of the pubis. The first choice of arterial pedicle was the thoraco-acromial artery at the level of its branching from the axillary artery. The venous pedicle was the thoraco-acrominal vein. This first technique was attempted on six rats with several failures due to the small diameter of the axillary artery. For this reason, we were obliged to use the axillary vessels. This new technique was performed in 10 rats with positive results in nine cases. The new transplantation of the pectoralis major muscle flap with nerve may be attempted.

Sublingual ranula: report of a submandibular clinical case

Ranula is a raised mucocele on the oral floor. When the mucocele extends and passes the sublingual space and invades the submandibular space it may be called ''plunging ranula''. Its etiology is not completely known. Our clinical case is a clear example: a 10-year old formation, not painful, developed during several years and originally of small dimension located in the sublingual region. The purpose of this study is to underline that the surgical treatment of choice, in these clinical situations, is the drainage of the cavity and marsupialization rather than a radical removal.

The use of osseointegrated epistheses in severe face burn sequelae

Four cases are presented of severe face burn sequelae with mutilation of one or both pinnae, treated using osseointegrated epistheses. In the light of over 10 years' use of this technique, applied in other forms of anatomical deficits in the head such as congenital malformations, demolition owing to extensive neoplasias, and serious traumatic sequelae, it is recommended that burn patients should be carefully considered from both the psychological and the technical point of view. It is suggested that such patients should be analysed by a specific team consisting of a plastic surgeon, a psychologist, and a prosthetist who assess their expectations, analyse their actual reactions, and above all judge their degree of acceptance of an episthesis. A description is provided of the advantages of the technique, which is mainly indicated when the mutilated area presents a deficit of tissues capable of being reconstructed using traditional surgical techniques.

Abnormalities of canines eruption

The aim of this article is to present the personal experience on the treatment of 2 groups of patients presenting the same problem: the recovery of teeth 13 and 23 in the dental arch. The 1(st) group consists of adult patients aged approximately 20-28 years with a retained position of the permanent canines and permanence of the respective deciduous teeth in the dental arch. In the 2(nd) group, the loss of the deciduous teeth had not been followed by the physiological eruption of the permanent teeth. The authors' aim is to demonstrate that similar orthodontic treatments can represent valid solutions for the treatment of pathologies with different etiopathogenesis.

Reconstruction of partially amputated external ear with costal cartilage graft: case report

Many causes are responsible for secondary anomalies of the outer ear, such as: car accidents, sport- or work-related accidents, assaults, bites from animals or humans, benign or malignant tumours, burns and the effects of surgical interventions of the ear (plastic surgery on the ear or attempts at correction of primary malformations of the ear). The anatomical complexity of the ear makes its reconstruction particularly complicated with post-operative results that are often disappointing. The Authors describe their experience in the reconstruction of a partially amputated outer ear following a dog bite. The therapeutic protocol required various surgical stages. Initially, a cutaneous expander was applied at the level of the mastoid in order to ensure a sufficient quantity of local skin. The second stage was to remove cartilage from the ribs, followed by construction of a cartilaginous model of the ear and its insertion into the subcutaneous mastoid region after removal of the cutaneous expander and any residual ear cartilage. The last stage was to separate the neo-formed outer ear from the mastoid skin with the insertion of a cartilage graft to the posterior region of the reconstructed ear. This graft was covered by the occipital fascia rotated at 180 degrees and by a skin graft removed from the pubis. The postoperative result was satisfactory with recuperation of a good aesthetic appearance of the ear. Aim of the present report is to describe the surgical technique employed in the reconstruction of secondary anomalies of the ear and to highlight errors committed during this procedure. These considerations have allowed us to stress some fundamental elements in the reconstruction of the ear. In particular, the watershed was the awareness that we had to create a cartilaginous model that respected, as far as possible, the anatomy of the outer ear with all its ridges, trenches and cavities. This as well as ensuring a sufficient quantity of local skin in order to cover the cartilaginous graft and, therefore, reduce the risk of exposing the cartilage and subsequent infection, to guarantee an optimal end result.

[Skull base fractures with TMJ involvement: literary review and case report]

The authors report their experience in the treatment of middle skull base fractures with TMJ involvement of ten patients affected by fractures of the glenoid cavity and of the petrous part of the temporal bone, with TMJ disfunction and facial nerve palsy. The treatment has been based on functional rest, a liquid diet for 5 days and than a functional physiotherapy aimed at rehabilitation of the TMJ. The efficacy of treatment has been showed after 2 months by restoring the dental occlusion and the TMJ's function in nine out of ten cases. Three out of four patients (75%) at the same control showed a full resolution of the facial nerve palsy. At an eighth month's follow-up all the cases had a complete resolution of the symptoms. Finally no significant studies have been reported in literature to set standardized protocols for the treatment of glenoid cavity fractures. According to the experience of authors the fractures of the medium cranial base involving the glenoid cavity should be treated as the current trends of intracapsular TMJ fractures. The orthopedic-functional treatment turns out particularly efficacious when there isn't a reduction of mandibular vertical heights.

Post surgical modification of facial divergency in 40 patients with mandibular prognathism

With a Le Fort type I and sagittal-bilateral surgery in a single time is usually impossible to solve problems of divergency and maxillary-mandibular prognathism in patients with tooth-skeletric III class. According to the Authors, in these patients, to plan an efficient surgical correction treatment, is suitable to analyse, before surgery, not only all data of maxillary-mandibular protrusion but also those of facial divergency.

Cephalometric study of posterior airway space in patients affected by Class II occlusion and treated with orthognathic surgery

The posterior airway space (PAS) is delimited by hard and soft tissues with anomalies that may produce alterations in volume. In patients with severe hypoplasia of the middle and lower third of the face, a decrease in volume of the PAS is present, producing a polysyndromic condition that ranges from snoring to obstructive sleep apnea syndrome (OSAS). The aim of this report is to define PAS variations via a cephalometric study in patients affected by class II occlusion and treated with orthognathic surgery. The authors studied 44 patients affected by class II occlusion who underwent surgery to correct the maxillomandibular malformation. The patient cohort was classified according to the type of surgery performed: Le Fort I osteotomy with or without a sagittal split osteotomy. To evaluate PAS variation, cephalometric analyses were performed by pre- and postoperative lateral teleradiography. This study showed an increase in PAS volume, especially at the hypopharynx and the lower part of the oropharynx, when the sagittal split osteotomy was performed and/or the maxilla was moved anteriorly and/or superiorly. A decrease of PAS can be seen in downward and/or backward maxillary movements. In conclusion, cephalometric studies of hard and soft tissues (such as tongue, pharynx, soft palate, etc.) should be performed in all patients affected by maxillomandibular malformation. This approach may provide data for the diagnosis of respiratory pathologies that vary from snoring to OSAS.

Congenital torticollis in association with craniosynostosis

The incidence of congenital torticollis in association with plagiocephaly is 1 in 300 newborns, with the torticollis resulting from pathologically sustained contraction of the sternocleidomastoid. Such conditions as facial asymmetries, craniovertebral anomalies, cervical hemivertebra, and mono- or polydysostoses may also be associated with torticollis diagnosed during the neonatal period. With particular reference to synostotic (coronal and/or lambdoidal) plagiocephaly, a clear distinction is made in this paper between posterior neurocranial flattening secondary to the sustained rotation of the skull resulting from torticollis and that seen in synostotic plagiocephaly. The rarity of torticollis with sustained contraction of the sternocleidomastoid muscle relative to the frequency of occipital-parietal flattening in newborn kept in the supine position has not been discussed in the literature and is therefore of clinical importance. In light of the fact that the prognosis and, consequently, the treatment plan vary directly with the presence or absence of synostoses, clinical evaluation also includes cephalometrics, plain skull X-rays, and CT imaging. If the torticollis is associated with neurocranial deformity but synostosis is absent, cervical traction and physiotherapy resolve the symptoms. When, however, the clinical picture is complicated by synostotic plagiocephaly, corrective surgery is necessary, though cervical traction and physiotherapy are essential to provide early and complete cure of the torticollis.

New approach to the surgical treatment of severe exophthalmos in Graves disease

In the last few years, various surgical techniques to correct orbital decompression in patients with Graves ophthalmopathy have been proposed. In those patients in whom a high degree of exophthalmos is mainly the result of the hypertrophied endorbital muscles with respect to endorbital fat hypertrophy, lipectomy is insufficient to obtain an acceptable increase of endorbital volume. The authors propose a method that provides for the monobloc bilateral quadrantotomy by extracranial access. Despite traditional methods of decompression, the advantage of this technique is better advancement of the orbital margins. The bicoronal and endoral incisions guarantee no facial scars. Compared with the craniotomy, the extracranial access is also less stressful for the patient.

Prenatal diagnosis: evolution in craniofacial surgery

Prenatal diagnosis of craniomaxillofacial malformations permits early surgery, before 6 months of life and possibly, in the near future, in utero, thereby obtaining the best aesthetic and functional results. Increased knowledge of embryology has largely improved the diagnosis of craniomaxillofacial anomalies, their classification, and therapeutic protocols. We analyzed nine pregnancies (one twin) in which cleft lip and palate (CLP)--isolated or associated with, for example, holoprosencephaly, hypertelorism, and micrognathia--was diagnosed by ultrasonography. Only one fetus of these pregnancies was later operated on in our unit. This patient, with 7 years follow-up, represents our clinical case. For these cases, early diagnosis of CLP allowed informed parental choice regarding the continuation or termination of the affected pregnancy and planning of surgical procedures to correct the malformation. This is demonstrated by the presented clinical case involving an infant operated on within 6 months with success.

Surgical planning and correction of medial craniofacial cleft

In the framework of malformations that concerns the craniofacial area, the orbit is often involved because it represents the border structure between the neurocranium and the splanchnocranium. In these malformations it is very easy to find hypertelorism. Tessier classified clefts rising from the anterior skullbase and involving the maxilla and the alveolar process, as medial or 0 = 14 clefts. We report on a 2-year-old patient, treated with cranial decompression at an early age, suffering from this kind of malformation. To correct it, the surgical technique of facial bipartition was used. This technique, used for the first time by Tessier and then modified by Stricker and colleagues, allows the simultaneous correction of the orbits and maxilla. It is very important to make a correct diagnosis, to plan for surgery carefully for patients suffering from this kind of pathology, and to prescribe the most effective therapy. A computerized analysis system, based on the study of teleradiographic images and on three-dimensional computed tomography, to quantify the extent of the malformation and to define surgical planning was developed.

[The interdisciplinary approach and early surgery in the trigonocephaly]

Craniofacial surgery aims to stop the pathological process due to the presence of one or more malformations affecting this part of the body, in order to prevent and reduce the secondary damage caused by wrong development of the stricken structures. However, in order to achieve this goal, it is necessary to abide by some criteria, like the interdisciplinary nature of therapeutic procedures and early surgery. Since craniofacial malformations affect some anatomical areas that need combined approaches for diagnosing, preventing and correcting the existing anomalies or the possible complications, it is extremely necessary to set a collaboration between different medical and surgical disciplines. Surgical "timing", lasting from 4 to 6 months, is the basis of early surgery, which aims to prevent the morphostructural alterations of the part, assuring again the physiological growth of the stricken tissues. For this reason, craniostenosis are the malformation syndromes that mainly fit this kind of therapeutic protocol. In this document the authors describe the application of the above cited principles for the resolution of the stenosis of the metopic suture in 9 patients (3 males and 6 females), admitted to the Department of Maxillofacial Surgery of the University of Rome "La Sapienza".

Study and planning of the surgical procedure for the orbital district in patients affected by craniofacial malformations

Orbital surgery is of critical importance within the framework of craniofacial surgery. The conical conformation of orbits requires analysis and surgical procedure planning methods involving all three dimensions. We present our protocol for the analysis and our three-dimensional surgical procedure plan to treat orbital malformations using teleradiography and two- and three-dimensional computed tomographic imaging. A number of clinical cases treated according to this approach are also presented.

[Bicoronal approach in the management of frontal sinus fractures]

The frontal sinus is located at the level of the junction between the naso-ethmoido-orbital region, the cranial vault and the skull base and plays a particularly important role in the biomechanics of the centro-facial region. It represents a locus minoris resistentiae placed between the fronto-orbital frame, whose resistance to trauma is good, and the thin posterior fronto-ethmoidal structures. Fractures of the frontal sinus more frequently involve the anterior wall of the frontal sinus and, occasionally, also the posterior wall and the base of the sinus. Where the fracture involves the anterior sinsu wall alone, surgical reduction is indicated to correct cosmetic defects arising from an altered bone profile, either via bicoronal access or by direct attack when there are skin lesions too. If the fracture extends to the posterior wall of the sinus without causing bone displacement or dural lesion, most authors agree that only the fractures of the anterior wall should be treated to avoid obliterating the sinus cavity. When the fracture of the posterior wall is comminuted with displacement of bone fragments, there are usually dural lesions too; in this event, once dural plasty has been performed, it is necessary to cranialize the frontal sinus by demolishing its posterior wall. Fractures of the skull base, associated with a high frequency of lesion or obstruction of the sinusal ostio and severe infective complication, require cranialization of the sinus that is also separated from the cranial cavity using a median-pedicled pericranial flap. To control the point of fracture, a rigid fixation system can be employed (microplates) or osteosynthesis with metal wires that restore the eurhythm of the frontal-orbital region and simultaneously guarantee good stability of the repositioned fragments.

[Simultaneous surgical correction of temporomandibular ankylosis and facial symmetry. Presentation of a case]

The authors stress the fact that the clinical course of a monolateral TMJ ankylosis tends to be more severe in young people. In this paper we analyze the diagnostic procedure for a tridimensional observation of any morphological and spatial alteration. The surgical procedure that permits the simultaneous correction of ankylosis and associated facial deformities is discussed.

[Surgical treatment of hemangioma of bones of the orbito-zygomatic region]

The incidence of intraosseous haemangiomas is very low. The mandible, the zygoma, the maxilla and the frontal bone are the most frequent areas of localization in the craniomaxillofacial region. Pain and swelling are the most important symptoms of these tumors when they are localized in the orbit or in zygoma. Surgery, without preoperative embolization is always the best treatment for intraosseous haemangiomas of the zygoma. The radical removal of the tumor frequently causes a plain aesthetical loss which has to be restored. Calvarial grafts are a good solution to the problem of reconstruction of bone loss. They are easy to prepare, near to the implant zone, and they don't need changes of the patient's position during the operation. The implants fixed by mini- and micro-fixation systems provide a good functional and aesthetical result. The authors, after a review of the literature about intraosseous haemangiomas of the cranio-maxillofacial region, report two cases of intraosseous haemangioma of the zygoma in which removal of the tumor and reconstruction with calvarial grafts has been performed.