Plastic and Reconstructive Surgery of the Head and Neck Proceedings of the Fifth International Symposium FACIAL PI 4STTC SURGERY

American Academy of Facial Plastic and Reconstructive Surgery

Edited

by

Fred J. Stucker, M.D., F.A.C.S.

Professor and Chairman, Department of Otolaryngology, Head and Neck Surgery Louisiana State University School of Medicine Shreveport, Louisiana

B. C. DECKER

PHILADELPHIA · HAMILTON

CONTENTS

9.

PART ONE

Aesthetic Nasal Surgery 1.

David H. Slavit Vito C Quatela Tom D. Wang

The Septocolumellar Complex, 3 Edward H. Farrior Richard T. Farrior

2.

Steroids and Rhinoplasty: A Double-Blind

10.

Study, 7 Dieter F. Hoffmann Ted A. Cook Vito C. Quatela Tom D. Wang Peter J. Brownrigg Robert E. Brummett

3. 4.

11.

Thomas C. McLure

12.

The Cover G i r l ' s Nose, 11

Projection and Reinforcement o f the Lobule w i t h Supratip N a r r o w i n g , 67

Nolan P. Kane

S. James Baum

Aesthetic Reconstruction o f the Platyrrhine

13.

External Rhinoplasty as a Natural Extension o f Anthony J. Yonkers Frederic P. Ogren C. Scott Howe David G. Schall

Revision Rhinoplasty Using the Open-Structure Rhinoplasty Technique, 27 Dean M. Toriumi Calvin M. Johnson Jr.

14.

Gender Identity i n Rhinoplasty, 75 Krzysztof Conrad

15.

Rhinoplasty Surgery i n a Residency T r a i n i n g Program, 79 Joedy L. Daristotle Richard C. Haydon III

PART T W O

Blepharoplasty 16.

A Staggered Skin-Muscle Flap to Optimize

Functional and Cosmetic Aspects o f Nasal T i p

Support i n L o w e r L i d Blepharoplasty, 85

Deformities, 33

Michael G. Stampar H. George Brennan

Wolfgang Stoll

8.

A n Analysis o f the Cosmetic Acceptability o f the External Rhinoplasty Scar, 7 1 Gary S. Churchill Devinder S. Mangat

the M i l l a r d Forked Flap, 23

7.

Rethinking the Nasal T i p : Reshaping Versus Excision o f Nasal T i p Cartilage, 55

Thomas Romo III Craig A. Foster Gwen S. Korovin

6.

Assessment and Management o f the Difficult Primary Rhinoplasty, 45 Sigmund L. Sattenspiel

Nose, 15

5.

Aesthetic Refinement i n Significant Nasal Augmentation, 4 1

The Challenge o f the Nasal D o r s u m , 37 Frank F. Rubin

17.

Asian Blepharoplasty, 89 Don Liu

xvii

xviii

Contents

18.

A Technique for Blepharoplasty Without Incis­

33.

ing or ' P u n c t u r i n g ' ' the Orbital Septum, 91 Emil Bisdccia Dwight A. Scarborough

19.

Lower L i d Blepharoplasty: A Precise Method o f Determining the Amount o f Skin and Muscle Removal, 95 Ronald A. Fragen Andrew J. Fragen

Face-Lifting in the Nineties: Selecting the Appropriate Technique, 165

k

E. Gaylon McCollough

PART FOUR

Liposuction, Fat Transplant, and Tissue Expansion 34.

Autotransplantation o f Fat in the Rabbit Ear: Factors to Enhance Graft Survival, 175

20.

Jeffrey M. Bartynski Mitchell S. Marion Tom D. Wang

Useful Variations in Blepharoplasty, 97 Gregory S. Keller

21.

Rule o f Supratarsal Fixation in Upper L i d Blepharoplasty, 99

35.

Emil Bisaccia Dwight A. Scarborough

Isaac I. Matta

22.

Blepharoplasty i n the Elderly Patient w i t h

36.

conjunctival and Lateral Strip Technique, 105 23. 24.

Liposuction o f the Very Young Face, 185 Wafik A. Hanna Ronald L DeVore

Senile Lower Eyelid Changes: Combined Trans­ Ira D. Papel

Facial Liposuction—An Office Technique, 181

37.

S. Randolph Waldman

Multiple Procedures and Use o f the Liposuction Technique for Facial Contouring and Sculpture, 189

Epicanthoplasty in the Asian Eyelid, 113

Wafik A. Hanna Philip K. Robb

Lower Lids—Surgery or Peel?, 109

John A. McCurdy Jr.

38.

Tissue Expanders for Reconstruction W i t h i n Irradiated Head and Neck Tissues, 195 Michael H. Fritsch Randal W. Swenson

PART THREE

Aging Face Surgery 25.

A n Update on Quadrangular Rhytidoplasty, 119

39. 40.

William H. Friedman Steven J. Pearlman

26.

Deep Temporal Face-Lift: Technique and Jacques Faivre

Defining the Cervical Angle Using an Alloplastic Sling, 135

41.

Avoidance o f Temporal Bunching in

Complications o f Tissue Expander Use, 215 Frank W. Shagets William R. Panje

Pierre F. Giammanco

28.

Immediate Versus Chronic Tissue Expansion, 211 Brian K. Machida Maisie Liu-Shindo Gordon H. Sasaki Dale H. Rice Para Chandrasoma

Indications, 123 27.

Skin Expanders, 201 Joseph Agris

42.

Complications o f Soft Tissue Expansion, Ί19 Joseph Agris

Cheek/Neck Rhytidectomy, 139 Gregory S. Keller

29.

F i b r i n Glue i n Plastic Surgery: A New Method for the Treatment o f the A g i n g Face, 141 Werner L. Mang

30.

43.

Otoplasty: Natural, Safe, and Easy, 225 Thomas C McLure

44.

Correction and Reconstruction o f the

Aesthetic A u r i c u l a r Contour i n

Malformed A u r i c l e , 229

Rhytidoplasty, 149

Claus D. Walter

Sigmund L. Sattenspiel

32.

Procedures of the Auricle, Lip, and Chin

A g i n g Face Surgery, 145 Ivo Pitanguy

31.

PART FIVE

45.

Finesse i n Forehead L i f t i n g , 159

Reproducing a Near-Normal Pinna Anatomy, 233

Keith J. Wahl

Hilko Weerda

Contents 46.

The Surgical Treatment o f First- and SecondDegree Auricular Dysplasias, 237

58.

48.

Mark D. McKenney Walter E. Berman

The Surgical Treatment o f Third-Degree Auricular Dysplasia ( T h i r d Degree M i c r o t i a

59.

Augmentation Rhinoplasty Using Laminated

and Anotia), 239

Allograft Dura (Tutoplast), 307

Hilko Weerda

Η. George Brennan Marcelo Hochman

Cosmetic Surgery o f T h i n and W r i n k l e d Lips, 243

60.

Jacques Faivre

49.

Demineralized Bone Grafts for Nasal Reconstruction Versus Irradiated Cartilage, 301

Hilko Weerda

47.

xix

Submalar Augmentation: A n Alternative Method for Facial Rejuvenation, 313 William J. Binder

Lips and the Cosmetic Surgeon, 251 S. Randolph Waldman

50.

Mentoplasty Using Rolled Polyamide

Mesh:

Review o f 237 Cases, 257 Chin W. Swong Fred J. Stucker

51.

Surgical Considerations i n the Correction o f

PART SEVEN

Miscellaneous Facial Plastic Surgical Topics 61.

Chin Ptosis, 261

Michael S. Godin K. Thomas Robbins C Daniel Sooy

Howard W. Smith Monte S. Keen

62.

Implants and Augmentation

63.

A Porous Implant System (Porecon) for Facial Reconstruction and Augmentation, 267

The Use o f Medpor i n Cosmetic and Recon­ structive Surgery: Experimental and Clinical Evidence, 271 Henry B. Bikhazi Randy Van Antwerp

54.

64.

56.

65.

Mersilene Mesh i n Nasal and Facial Augmentation, 275

Augmentation Rhinoplasty Using Mersilene Mesh, 285 Devinder S. Mangat Gary S. Churchill

66.

Customized Tissue Clay: A N e w Surgical Material and Technique for Facial Reconstruction, 289

67.

Irradiated Homologous Cartilage i n Augmentation Rhinoplasty, 297 Richard A.K. Chaffoo Richard L. Goode

Low-Energy H e l i u m Neon Laser and Tissue Healing: Effects on Human Fibroblast Collagen Production and Rat Sciatic Nerve Morphology, 339 Carl B. Myers Arien D. Meyers Donald W. Goin Richard A. Clark

Zygoma: A Rosetta Stone, 345 Walter R. Sabiston

Michael Evan Sachs Thomas Romo III

57.

Role o f the Expert Witness in Malpractice Litigation, 335 Meron J. Levitats

Jeffrey J. Colton G. Jan Beekhuis

55.

M i n i m i z i n g Blood Loss D u r i n g Outpatient General Anesthesia Through a Safe M i x o f Vasoconstrictor and Hypotensive Technique— Labetalol is the K e y , 331 Anthony S. Krausen Frederick Carpenter

Alexander Berghaus

53.

Facial Paralysis F o l l o w i n g Local Dental Anesthesia, 329 Richard A. Gallo Charles P. Kimmelman

PART SIX

52.

AIDS-Related Complications o f Soft Tissue Repair, 323

Inverted Continuous Single- or DoubleInterlocking Subcuticular Suture (Inverted Zipper), 349 Charles H. Hutchins Paul T. Davis

68.

Double- and Triple-Interlocking Suture Techniques, 353 Charles H. Hutchins Paul T. Davis

xx

Contents 81.

PART EIGHT

Functional and Reconstructive Surgery of the Nose

Laser Turbinectomy Associated w i t h Septorhinoplasty, 415 Fred J. Stucker

69.

A System o f Total Nose Reconstruction, 359

82.

Septorhinoplasty, 419

Edward J. Bowen-Jones Arvin M. Lalbahadur Ian C. McGibbon Anil Madaree

70.

Modification o f the Nasal Skeleton, 363

83.

L o w e r Lateral Techniques i n Open-Approach

PART NINE

Maxillofacial Surgery

Albert L. Roper II

Progress o f Rhinoplasty i n India, 373

84.

V.P. Sood

73.

The " S w i n g i n g D o o r " Technique for

85.

Moshe Goldshur H.Z. Joachims Steve Becker Michael Nash Robert Einhorn Yosef Krespi

86.

Effect o f Intranasal Splints i n Preventing

87.

88.

The Transfixion Incision, 387

The Partial-Transfixion Incision i n

89.

Monte S. Keen Juan Moscoso

The Cartilaginous Columellar Strut for Reconstructive Rhinoplasty: The ' B o w i e K n i f e " Strut Revisited, 397

90.

A l a r Valvular Collapse, 405 Ritchie A.L. Younger

91.

Suite, 409 Combined Medical and Surgical Therapy o f the Allergic Nose, 413 Richard J. Trevino

Computerized Three-Dimensional Facial Analysis, 457 Dean M. Toriumi George Maupin Wayne F. Larrabee Jr.

Rhinoplasty and Laser Turbinectomy: Considerations for the In-Office Surgical Stuart G. Selkin

Degloving Approach for Infraorbital R i m Exposure, 453 Larry J. Shemen Pamela Lipkin Cecil Grimes

Robert M. Sweet

80.

Extended Role o f Internal Plate Fixation i n M a x i l l a r y Fractures, 449 Victor V. Strelzow

1

79.

Facial Burns: Treatment o f the Sequelae, 445 Berndt Mayer Ivo Pitanguy

Rhinoplasty, 393

78.

Traumatology o f the Midface: Miniplate Osteosynthesis, 443 Werner L Mang Werner Schwab Flotian Wendl

Herbert Kean

77.

Reversible Visual Loss i n Orbital Trauma, 439 Gerald S. Gussack Saunders Hupp

John A. Fornadley Gregg S. Parker Thomas A. Tami

76.

External Septorhinoplasty and Nasal Trauma, 431 J. Oliver Donegan

Complications o f Septal Surgery, 383

75.

Banked Fascia Lata and the Repair o f Orbital Floor Fractures, 427 Edward H. Bedrossian Jr.

Septorhinoplasty, 379

74.

Simultaneous Rhinoplasty and Orthognathic Surgery, 423 Peter D. Waite

Rhinoplasty, 369 72.

Oakley Smith Peter Adamson Guy Tropper Philip Cole Becky L. McGraw

A x i a l Frontonasal Flap: Flap Extension and Jung I. Park Mark Gordon Ronald B. Minkin Mitchell L. Bressack

71.

The Role o f Partial Turbinectomy in Aesthetic

92.

Mandibular Reconstruction Following Resection for Benign Tumors, 463 George P. Katsantonis Festus Krebs Frank Simo

Contents 93.

Heterologous Demineralized Bone M a t r i x i n Mandibular Defect Repair, 467

105.

Arnold L. Goodman John S. Rubin Hubert Eddy Roy A. Myers Charles Suter

PART TEN

94.

106.

John S. May James N. Thompson Jai H. Ryu

Oral Function F o l l o w i n g Cancer Surgery, 473

Surgical Management o f T h y r o i d Carcinoma w i t h Laryngotracheal Invasion, 479

107.

Craniofacial Resection: A Tailored Approach, 487

Francois Disant Alain Morgon

108.

Vinod K. Anand Ossama Al-Mefty

97.

Experiences w i t h Masseter Crossover Flap i n Oral-Oropharyngeal Reconstruction, 491

109.

99.

Microsurgical Flaps, 541

110.

Local Flaps, 545 Brian L. Matthews Jeffery B. Hiltbrand Barry Leshin James N. Thompson

Total Upper L i p Reconstruction, 501 Rammohan Tiwari

101.

102.

111.

Nose, 549 John W. Pate Jr. John C. Wilkinson

112.

Lateral R h i n o t o m y , 5 1 1

Cervico-Occipital Flap: A N e w , Reliable Tech­ nique for Resurfacing Defects o f the Neck, 515 Rammohan Tiwari

The Perichondrial-Cutaneous Skin Graft: A Laboratory and Clinical Review, 557 Fred J. Stucker William A. Portuese

William W. Montgomery Mack L. Cheney

103.

Z-Advancement Rotation Flap Reconstruction o f Full-Thickness Cutaneous Defects o f the

Transzygomatic and Transpalatal Excision o f Juvenile Nasopharyngeal Angiofibroma w i t h Intracranial Extension: Rationale, 505 Stephen ). Haines Arndt j. Duvall III

Reconstruction o f Midfacial Defects F o l l o w i n g M o h s ' Surgery: Innovations i n the Use o f

Functional Approaches to Skull Base Surgery, 497 Samuel C. Levine Lawrence J. Marentette

100.

Carcinomas o f the Face: Local Flaps and Free Werner L. Mang Ulrich Steinau Werner Schwab

Large Hemangioma at the Base o f the Tongue: A Therapeutic Approach, 493 Chalee Kanchanarak

Myocutaneous Postauricular Flap as a OneStage Procedure for Management o f Carcinoma o f the Ear, 535 Sidney S. Feuerstein

Rammohan Tiwari

98.

Superficial Temporal Fascia Flap i n Cervicofacial Plastic Surgery, 531

Michael Friedman

96.

Effects o f L i p i d Angiogenic Factor on Local Skin H a p s , 529

Ian A. McGregor

95.

Hyperbaric Oxygen Therapy and the Survival of Surgical Flaps Raised i n Irradiated Skin, 525

Gregory Τ. Mesna Lawrence J. Marentette

Head and Neck Surgery: Resection and Reconstruction

xxi

PART TWELVE

Rehabilitation of Seventh Nerve Paralysis 113.

Expanded P T F E Patch for Suspension i n Facial Paralysis, 561 John M. Dobrowski Kedar K. Adour Raymond L. Hilsinger Jr.

PART ELEVEN

Grafts and Flaps in Facial Reconstruction 104.

Controlled Local Hypothermia and Survival o f Myocutaneous Flaps i n the Pig M o d e l , 521 George S. Coding |r. Charles W. Cummings Donald A. Bright

114.

Facial Reanimation by Cranial Nerve Substitu­ tion W i t h o u t Tongue or Shoulder Paralysis, 565 William R. Panje Thomas J. Dobleman

xxii

Contents

115.

Dual Simultaneous System-2: A New

125.

Chemical Peel (Chemabrasion o f the Face), 613

Technique for Facial Reanimation in Total Emil P. Liebman

Proximal Facial Nerve Paralysis, 569 Michael Evan Sachs

116.

The Use o f Gold Weight Implants in the Oculoplastic Rehabilitation o f Facial Paralysis, 573

PART FOURTEEN

Congenital Deformities 126.

Joseph R. Spiegel Robert Thayer Sataloff Mary J. Hawkshaw

117.

Management o f the Paralyzed Eyelid, 577

Eugenio A. Aguilar III Robert A. Jahrsdoerfter

127.

Facial Paralysis and the Eye: Strategies for Preservation o f Function and Cosmesis o f the

Francois Disant Alain Morgon

128.

Eyelids, 583 Carl A. Patow John J. Conley PART THIRTEEN

Noncutaneous Head and Neck Melanomas, 589 Samuel R. Fisher David J. Hoyt Jonathan J. Dutton

120.

129.

James H. Pennington Jr. Richard T. Farrior

130.

131.

Bacitracin: A Unique Sensitizer Used w i t h Increasing Frequency After Skin Surgery, 599

123.

M u l t i p l e - M a r g i n Frozen Section in Surgery for

132.

Facial Skin Malignancies, 603

M u l t i p l e Congenital Defects: Decisions and Dilemmas, 653

George G. Kitchens

John E. demons

Treatment o f Recurrent Large and Multiple Keloids, 607 Fred J. Stucker Chin W. Swong

124.

Congenital Nasal D e r m o i d Cyst: Management U t i l i z i n g the External Rhinoplasty Approach, 649 Raymond J. Konior Russell W.H. Kridel

Bruce E. Katz

122.

The M a x i l l a r y Influence in the Attainment o f Perfection in Lip-Nose Correction o f Cleft L i p and Palate, 643 Sheila Rohatgi Sabyasachi Kar

Cosmetic Surgery Practice, 595 121.

M a x i l l a r y and M a n d i b u l a r Osteotomies in the Cleft Palate Patient, 637

Management o f Superficial Skin Lesions in a S. Randolph Waldman

Surgical Correction o f the Nasal T i p o f the Unilateral Cleft L i p Nose: A Combined A p proach, 629 Mark V. Connelly

Cutaneous Procedures 119.

Ear Reconstruction w i t h R i b Cartilage Graft in C h i l d r e n , 625

William R. Panje Gary Y. Shaw

118.

The Role o f the Plastic Surgeon i n M i c r o t i a Repair, 621

Metastases f r o m Solar-Induced Squamous Cell Carcinomas o f the Skin, 611 Frank C. Koranda

133.

Pediatric Craniofacial Surgery, 655 Lawrence J. Marentette Stephen J. Haines

CHAPTER 5 2

A Porous Implant System (Porecon) for Facial Reconstruction and Augmentation ALEXANDER BERGHAUS, M.D.

Bone, cartilage, o r synthetic materials may be used for facial reconstruction and augmentation. I should like to point out the possibilities offered by a modern synthetic material and discuss our results w i t h implants o f porous polyethylene (Porecon; Effner G m b H , B e r l i n , Federal Republic o f Germany).

MATERIALS AND METHODS Polyethylene is altogether one o f the simplest synthetic compositions. I t is a more o r less branched, long-chained hydrocarbon. T h e material I use has no additives. Rubin already achieved good long-term results w i t h nonporous, compact polyethylene decades ago i n the U n i t e d States. I n Pbrecon, however, the scanning electron microscope reveals at 2,600-fold magnification the fine ramification o f an interconnecting open-pore system w i t h a pore size o f ap­ proximately 150 μπι. These pores permit the ingrowth of con­ nective tissue that is also supplied by capillary vessels. This finding has been repeatedly confirmed experimentally. Ingrowth o f bone has likewise been observed on i m p l a n ­ tation o f the material i n an osseous bed. The g r o w t h o f bone into the pores o f a synthetic material can by no means be taken for granted but represents a particular advantage o f porous polyethylene. I n contrast to polyethylene, Proplast implants f r o m the same series o f animal experiments d i d not display ingrowth of either connective tissue or bone. This is ascribed to the fact that the pore connections o f Proplast do not have an adequately large diameter. W i t h polyethylene, the shape of the implant also remains constant postoperatively, w h i c h was demonstrated experimen­ tally using the edge o f an implanted cube. Proplast, o n the other hand, was fragmented i n the implant bed by the host tissue; parts o f the synthetic material appeared i n medullary spaces. Further studies have shown that there is apparently much less danger o f infection w i t h porous polyethylene than 2

w i t h silicone. Other advantages are the easy workability o f the synthetic material w i t h a scalpel and scissors and the u n problematic sterilization w i t h , for instance, ethylene oxide. Resorption o f porous polyethylene has never been unequivo­ cally demonstrated. I have not observed any resorption of this material i n either animal experiments o r clinical practice. The good w o r k a b i l i t y o f the material has led to the de­ velopment of manifold implants for diverse defects of the skull and the soft parts o f the face. Thus there are implants o f the calotte, forehead, cheek, c h i n , and auricle (Fig. 52-1). In the area o f the nose, however, caution is indicated; i n m y o p i n i o n , the t i p o f the nose is not suited for the i m ­ plantation o f synthetic materials i n view o f its exposure to too many micromovements. Porecon implants can, however, be used at the bony bridge o f the nose. Irrespective o f the implant bed, such an implant must always be covered by an adequate amount o f healthy s k i n . The coronal incision is particularly appropriate for exposure i n the correction o f frontal defects. I t requires no suturing over the implant, w h i c h is favorable for the ingrowth and heal­ ing as w e l l as for the cosmetic results. A smooth surface can be achieved more readily w i t h a synthetic implant than w i t h costal cartilage o r bone (Figs. 52-2A and B ) . Our patients have shown no signs o f resorption even af­ ter a postoperative follow-up o f 5 years. I n 1982, we inserted a Porecon frame into the skin cover­ ing the auricle to replace necrotic cartilage i n a case o f p u r u ­ lent perichondritis. The result is still satisfactory and stable after 7 years. N o resorption has been observed. Delicate three-dimensional frames have been developed for the correction o f microtia. Implantation has been success­ fully performed w i t h the fan-flap technique, w h i c h involves encasing the synthetic frame i n fascia o f the temporal mus­ cle p r i o r to coverage w i t h a skin transplant (Figs. 52-3A and B ) . 3

267

268

Implants

and

Augmentation

Figure 52-2. Patient w i t h f r o n t a l d e f e c t after o p e r a t i o n o f a m u c o c e l e b e f o r e {A) a n d 4 years after s u r g i c a l c o r r e c t i o n w i t h P o r e c o n i m p l a n t (£). N o t e s m o o t h surface, w i t h n o r e s o r p t i o n .

PART SIX

CHAPTER 52

A Porous

Implant

System

We are presently working on a tracheal prosthesis com­ posed of porous polyethylene and silicone. The fact that we have clearly exceeded a 1-year survival time with this implant in repeated animal experiments opens up prospects of it soon being applied for tracheal replacement i n humans as well.

RESULTS We have so far applied 26 Porecon implants for facial reconstruction, primarily for correction o f microtia and fron­ tal defects. These implants have shown good to very good long-term results (maximal follow-up o f 7 years). A cheek implant had to be removed again because o f the implants' hypermobility.

(Porecon)

for

Facial

Reconstruction

Because porous polyethylene is easily workable, can be well sterilized, and does not promote infections, we regard it as an extremely interesting implant material for facial recon­ struction and augmentation. The good long-term results con­ f i r m this positive assessment.

REFERENCES 1.

R u b i n L R . Polyethylene as a bone and cartilage substitute: A 32 year retrospective. I n : R u b i n L R . e d . Biomaterials i n reconstructive sur­

2.

the patient.

1983.

Berghaus A , M u l c h G , H a n d r o c k Μ . Porous polyethylene and Proplast; T h e i r behaviour in a b o n y i m p l a n t bed. A r c h O t o r h i n o l a r y n g o l 1984;

W i t h synthetic implants, the risk o f possible rejection is offset by the advantage o f avoiding a second intervention i n

269

Porecon implants offer the further advantage o f not hav­ ing to expect resorption, w h i c h , at least w i t h conserved car­ tilage transplants, cannot be ruled out entirely.

gery. St. L o u i s : C V M o s b y ,

DISCUSSION

and Augmentation

240:115-123. 3.

Berghaus A . P o r e c o n — I m p l a n t R

and f a n f l a p : A concept f o r recon­

struction o f the auricle. Facial Plast Surg 1988; 5 : 4 5 1 - 4 5 7 .