Aesthetic Deformity Research Articles

Clinical and Radiographic Poland Syndrome Classification: A Proposal

Many chest wall deformities have a characteristic radiologic appearance that can be the basis for a definitive diagnosis. Consequently, imaging techniques have fundamental roles in the detection, location, and characterization of these disorders. The authors propose a clinical and radiographic Poland syndrome (CRPS) classification system and possible treatment algorithm for the thoracic manifestations of Poland syndrome (PS) in women, based on both clinical examinations and imaging studies. A retrospective study was conducted of 28 female patients evaluated over 17 years in the 28th Infirmary, Plastic and Reconstructive Surgery Division of the Hospital Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, Brazil. After clinical examination, all patients underwent radiographic examination with chest radiographs, conventional computed tomography scans, magnetic resonance imaging and, in some cases, additional imaging studies. All clinical and radiologic variables were compiled in a database and used in the classification system, which included three levels of disease severity. Based on the CRPS classification of the 28 female patients, 10 patients had first-degree PS, 14 patients had second-degree PS, and four patients had third-degree PS. Eighteen patients underwent surgical correction; a total of 39 surgical procedures were performed using the CRPS algorithm. Identification of the severity of PS using the proposed classification system provided an accurate study of each patient and enabled better planning for the surgical correction of functional and aesthetic deformities.

Frontal Sinus Fractures: Current Concepts

Frontal sinus injuries may range from isolated anterior table fractures resulting in a simple aesthetic deformity to complex fractures involving the frontal recess, orbits, skull base, and intracranial contents. The risk of long-term morbidity can be significant. Optimal treatment strategies for the management of frontal sinus fractures remain controversial. However, it is critical to have a thorough understanding of frontal sinus anatomy as well as the current treatment strategies used to manage these injuries. A thorough physical exam and thin-cut, multiplanar (axial, coronal, and sagittal) computed tomography scan should be performed in all patients suspected of having a frontal sinus fracture. The most appropriate treatment strategy can be determined by assessing five anatomic parameters including the: frontal recess, anterior table integrity, posterior table integrity, dural integrity, and presence of a cerebrospinal fluid leak. A well thought out management strategy and meticulous surgical techniques are critical to success. The primary surgical goal is to provide a safe sinus while minimizing patient morbidity. This article offers an anatomically based treatment algorithm for the management of frontal sinus fractures and highlights the key steps to surgical repair.

The Muscle-Sparing Latissimus Dorsi Flap for Breast Reconstruction

Sir: We read the article by Saint-Cyr et al. with interest and would like to congratulate the authors on a typically comprehensive and beautifully illustrated article.1 Although partial latissimus dorsi flaps have been used as free tissue transfer for small defects, for example, in lower limb trauma, the article represents an elegant example of lateral thinking for breast reconstruction. The reduction in seroma rate, one of the principal drawbacks of latissimus dorsi harvest, appears particularly impressive. Our institute has a particular interest in the reparative surgery for aesthetic deformity following breast-conserving therapy, so the described technique, by leaving the main thoracodorsal pedicle in situ, theoretically “burns no bridges” for future latissimus dorsi reconstruction if required. With this in mind, we would be interested in finding out whether the authors have any experience with harvest of the remaining, transverse pedicle–supplied latissimus dorsi? Also, with respect to the narrow muscle pedicle, we note the predominant use of the muscle-sparing latissimus dorsi in skin-sparing mastectomy and wonder about the skin paddle extremity vascularity and any limits on dimensions that this may impose if more donor skin is required. Finally, it is well-recognized that the use of adjuvant radiotherapy, planned or otherwise, can both severely compromise the aesthetic result2,3 and substantially increase the incidence of adverse capsular contracture,4,5 even when mammary prostheses are covered completely by muscle. With such implants being only partially covered—with pectoralis major superomedially—would the muscle-sparing latissimus dorsi risk elevated rates of adverse capsular contracture and implant exposure? M. G. Berry, F.R.C.S.(Plast.) A. Curnier, F.R.C.S.(Plast.) A. D. Fitoussi, M.D. B. Couturaud, M.D. R. J. Salmon, M.D., Ph.D.

The Impact of Reconstructive Procedures Following Bariatric Surgery on Patient Well-being and Quality of Life

Massive weight loss following bariatric surgery may lead to an excess of lax, overstretched skin, causing physical discomfort which may affect the patient's quality of life. Whereas the functional and aesthetic deformity is an expected result of massive weight loss, the role of the plastic surgeon in the multidisciplinary approach of the morbidly obese is still unclear. The purpose of the current study is to evaluate the results of reconstructive surgery following weight loss surgery, focusing on the impact on the physical and psycho-social well-being and quality of life of the patients. Out of a group of 465 patients, 61 patients underwent reconstructive surgery following weight loss surgery. In 43 respondents, the quality of life after reconstructive surgery was measured by the Obesity Psychological State Questionnaire. Patient satisfaction was evaluated. Reconstructive surgery resulted in a significant improvement in quality of life in patients at a mean interval of 42 months between weight loss and reconstructive surgery. The most frequent procedures were abdominoplasty and breast reconstruction. The relative high complication rate of 27.9% was of no influence on quality of life and the majority of the patients (67%) were satisfied with reconstructive surgery. This study shows that reconstructive surgery following weight loss after bariatric surgery results in a significant improvement in overall quality of life. Reconstructive surgery should be incorporated in the multidisciplinary care programme following weight loss surgery in the morbidly obese patient.

Comparison of three-dimensional microplate versus miniplate fixation on the stability of zygomatic complex fractures

The zygomaticomaxillary complex plays a key role in the structure, function, and aesthetic appearance of the facial skeleton. It provides normal cheek contour and separates the orbital contents from the temporal fossa and the maxillary sinus. The prominent convex shape of the zygoma makes it vulnerable to traumatic injury. Even minimally displaced zygomaticomaxillary complex (ZMC) fractures can result in functional and aesthetic deformities. Successful repair of ZMC fractures requires an accurate diagnosis, appropriate surgical exposure, and precise reduction to reconstitute the complex three-dimensional (3D) anatomy.

Endoscopic Repair of Anterior Table Frontal Sinus Fractures

Frontal sinus fractures account for 5 to 15% of all maxillofacial injuries. The majority of these fractures are the result of high-velocity injuries such as motor vehicle accidents, assaults, and sporting events. The treatment algorithm for complex frontal sinus fractures is controversial due to the associated risks of brain injury, meningitis, cerebrospinal fluid fistula, and mucocele formation. However, mild to moderately displaced anterior table fractures carry a relatively low risk of long-term morbidity and are generally treated as aesthetic deformities. Unfortunately, the coronal approach for repair of these injuries is associated with significant sequelae including a large scar, alopecia, paresthesias, and, uncommonly, facial nerve injury. These sequelae may result in a greater cosmetic deformity than does the initial injury. Consequently, an endoscopic approach to these injuries has recently been described. The advantages of endoscopic surgery include limited incisions, reduced soft tissue dissection, reduced risk of alopecia, minimal risk of postoperative paresthesias, reduced hospital stay, and improved patient selection. Disadvantages include a moderate learning curve, narrow field of view, lack of depth perception, and the fact that the surgeon cannot operate bimanually without an assistant.

Oncoplasty for lateral breast cancers.

Abstract Abstract #5158 Introduction: 65% of breast cancers develop in the lateral pole, particularly superiorly. Following conservative treatment, , tumourectomy may produce a typical deformity of superolateral nipple-areolar complex (NAC) deviation. This unaesthetic deformity, is exaggerated by the post-operative irradiation mandated by contemporary breast conserving therapy. Primary utilisation of the oncoplastic technique, 'lateral mammaplasty', allows both the avoidance of such deformities and wider excision margins.
 Patients and methods: The principle behind the technique is the combination of a wide, wedge-shaped tumourectomy combined with NAC repositioning on a de-epithelialised dermoglandular pedicle. Sentinel lymph node biopsy or formal axillary dissection may be performed simultaneously either via a separate or combined incision for inferior and superior lateral mammaplasties respectively. Aesthetic outcomes were assessed on a five-point scale with 1 being excellent and 5 poor.
 Results: eighty-six patients, with a mean age of 53 years (range 29 – 75) underwent lateral mammaplasty. Fifty-five (64%) were palpable and 73 (86%) had simultaneous axillary surgery. Mean tumour size pre- and post-operatively were 29.8 mm (8 – 81) and 33.6 mm (0 – 140) respectively. Mean excision weight was 150g (24 – 484). Eleven (12.8%) required revisional surgery due to involved or close margins and the aesthetic outcome was graded highly satisfying or satisfying in 68 (79%).
 Discussion: lateral mammaplasty has been found to be simple to perform with a short learning-curve. With clear excision margins in 87.8%, it is oncologically sound and compares favourably with simple tumourectomy. It should be considered when the tumour-to-breast volume ratio anticipates an aesthetic deformity. We have found it to be particularly satisfactory after neo-adjuvant chemotherapy for large volume tumours when a positive clinical response allows conservative surgery. It is also useful for revisional surgery in cases of involved or close margins following initial tumourectomy.
 Conclusion: lateral mammaplasty became routine in our institution as it allows, with the assistance of a simple oncoplastic procedure, highly satisfying aesthetic outcomes and the added security of wide excision margins. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5158.

Plástica periodontal para excisão cirúrgica estética de granuloma piogênico

The pyogenic granuloma is a benign lesion, which shows preference for the upper, anterior and buccal gingiva. The treatment consists of surgical excision, however, it may produce esthetic deformities. Patient V.G.V., 43 years old, revealed a recurrent lesion in the facial gingiva of element 21. Excisional biopsy and coverage of the exposed area by means of zetaplasty and rotated flap designs were performed. Postoperative results showed appropriate esthetic gingiva and no recurrence of the lesion. It was concluded that the employed technique may serve as a treatment option to gingival lesions in esthetics areas.

Overresection of the Lower Lateral Cartilages: A Common Conceptual Mistake with Functional and Aesthetic Consequences

Overresection of the lower lateral cartilages to narrow the tip in individuals with thick skin is a common mistake with functional and aesthetic consequences. The most frequent deformities are external valve dysfunction, alar retraction, alar pinch, tip asymmetry, lack of tip definition, and parrot beak deformity resulting from drooping of the tip. In 82 patients who underwent revision surgery from 1998 to 2007 the lower lateral cartilages were missing. To restore function of the external nasal valve and correct aesthetic deformities it is essential to rebuild the anatomical structure. Tip deformities were analyzed pre- and postoperatively based on clinical evaluation and standardized photographs. Patient satisfaction was evaluated subjectively. Improvement of the poorly defined tip, the underprojected tip, the overrotated tip, and alar pinch was accomplished in all patients (100%). The function of the external nasal valve was restored in all patients (100%). The postoperative results showed a clear improvement in tip asymmetry (95.0%), tip deviation (76.5%), alar retraction (87.0%), and tip ptosis (85.7%). The average follow-up period was 13.8 months. Forty-eight patients (59.8%) rated the result as "excellent," 27 (32.9%) as "very good," 5 (6.1%) as "good," 1 as "not satisfied" (1.2%). Overresection of the lower lateral cartilages to narrow the tip in individuals with thick skin is frequently followed by dysfunction of the external nasal valve and aesthetic deformities. We completely rebuild the structure of the nasal tip. Only an anatomically correct configuration correlates with ideal aesthetics and physiologic function.

Use of a porcine dermal collagen graft (Permacol) in parotid surgery

Our aim was to present the results of the use of porcine dermal collagen graft (Permacol) in the prevention of Frey’s syndrome and face-contouring aesthetic deformities after operations on the parotid. We treated 19 patients with parotid tumours. After resection, a Permacol sheet was applied to the perimeter of the tissue deficit so that it was fully covered, and was sutured firmly. This technique produced satisfactory aesthetic results with good facial contouring in all patients. It also protected the exposed parotid nerve plexus, and none of the patients developed Frey’s syndrome. Permacol produced good results in both postoperative facial contouring and prevention of Frey’s syndrome.

Simultaneous Functional Endoscopic Sinus Surgery and Esthetic Rhinoplasty in Orthognathic Patients

Patients treated for dentofacial deformities may be predisposed to aggravated sinonasal disease postoperatively, particularly if concurrent rhinoplasty is performed. The authors present their experience with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and functional endoscopic sinus surgery (FESS). Thirteen patients were treated with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and FESS from January 2002 to December 2005. An operative algorithm for patients with dentofacial deformities requiring rhinoplasty was developed. The surgical procedure was performed under general anesthesia with nasotracheal intubation and maxillary/mandibular osteotomies first. Nasotracheal intubation was then converted to orotracheal intubation and FESS was performed. The third step was correction of the esthetic deformities of the nose through an open approach. In all cases, it was possible to successfully complete the combined operation. Median operation time was: 2 hours and 18 minutes for orthognathic bimaxillary surgery, 54 minutes for rhinoplastic surgery; and 23 minutes for FESS. All the patients had good esthetic and functional results and were free from symptoms consistent with previous rhinosinusitis. The combination of orthognathic surgery, rhinoplasty, and FESS in selected cases is safe and effective.

Management of soft-tissue trauma to the face

The management of acute soft-tissue trauma can be very challenging for the facial plastic surgeon. The goals of management of facial trauma are the preservation of form and function. These goals are particularly important in facial soft-tissue trauma, where injuries can cause not only esthetic deformities but also can affect neural function, normal mastication, visual fields, and salivary outflow. This article outlines the evaluation and treatment of acute soft-tissue facial trauma. The key components include allowing for the stabilization of the patient, complete examination of the injury and face, thorough wound irrigation and debridement of necrotic tissue, preservation of all viable tissue, tension-free closure, and realignment of important facial esthetic structures. Special consideration must be given to injuries of functional structures such as the facial nerve, ductal systems or organs, and ensuring appropriated management of these structures.

Erfolgreiche Korrektur einer adhärenten Narbe im Bereich des Handrückens mit Matriderm®

Adherent scars on the hand often lead to a major functional impairment and an aesthetic deformity. The rate of recurrence after scar correction is usually very high. A 57-year-old woman with an adherent scar on the back of her hand and major functional impairment was successfully treated with Matriderm. Using Matriderm as an additional layer between the atrophic skin and the tendons adherency of the scar could be prevented. One year after surgery the patient is free of pain. There is normal mobility between the skin and the underlying tissue. Complete wrist flexion and extension could be achieved. To the best of our knowledge this is the first case reported of using Matriderm for the correction of a scar that was caused by the paravasal injection of cytostatic drugs.

Gap junction intercellular communication: A review of a potential platform to modulate craniofacial tissue engineering

Defects in craniofacial tissues, resulting from trauma, congenital abnormalities, oncologic resection or progressive deforming diseases, may result in aesthetic deformity, pain and reduced function. Restoring the structure, function and aesthetics of craniofacial tissues represents a substantial clinical problem in need of new solutions. More biologically-interactive biomaterials could potentially improve the treatment of craniofacial defects, and an understanding of developmental processes may help identify strategies and materials that can be used in tissue engineering. One such strategy that can potentially advance tissue engineering is cell-cell communication. Gap junction intercellular communication is the most direct way of achieving such signaling. Gap junction communication through connexin-mediated junctions, in particular connexin 43 (Cx43), plays a major role bone development. Given the important role of Cx43 in controlling development and differentiation, especially in bone cells, controlling the expression of Cx43 may provide control over cell-to-cell communication and may help overcome some of the challenges in craniofacial tissue engineering. Following a review of gap junctions in bone cells, the ability to enhance cell-cell communication and osteogenic differentiation via control of gap junctions is discussed, as is the potential utility of this approach in craniofacial tissue engineering.

Multidisciplinary management of spinal lipoma

Spinal lipomas (congenital lipomyelomeningoceles) can cause significant aesthetic deformity of the lower spine in addition to recognised neurological problems. Surgical management consists of untethering the cord in symptomatic cases, and debulking of the lipomatous component to improve the spinal contour. However, management remains controversial. Between May 1998 and November 2002, 23 cases of lumbosacral spinal lipoma were operated on by neurosurgeons at our hospital. Of these, eight (34%) patients were subsequently referred to plastic surgery for aesthetic revision, which was performed by a combined team of plastic surgeons and neurosurgeons. In addition, three new patients had their primary surgery as a planned procedure performed by the same combined team. The purpose of this paper is to present the method and results of combined plastic surgery and neurosurgery technique in these 11 cases of spinal lipoma. Follow up ranged between 12 months and 4 years (mean 20 months). One patient had wound break down and three patients developed seroma. Two patients had cerebrospinal fluid (CSF) leakage which required re-exploration and prolonged hospitalisation. The aesthetic results were very satisfactory in 10 out of the 11 patients. The frequency of secondary referral for aesthetic revision, together with the incidence of CSF leak, underlines the importance of managing spinal lipomas in a multidisciplinary team involving neurosurgeons and plastic surgeons. This series demonstrates that aesthetic results are encouraging but decreasing the CSF leakage rate remains a challenge. Further follow up will determine the role of early combined surgery in the management of spinal lipoma.

Kostenanalyse der konservativen versus operativen Therapie der Makromastie

Macromastia causes back and neck pain, scaphodynia, intertrigo of the inframammary crease up to dysaesthesia. Typical complaints of patients with macromastia are physical burden, psychological irritation and aesthetic deformity, often resulting in social isolation. Despite the demonstrable success of reduction mammaplasty to eliminate not only the symptoms of macromastia but the cause of the ailment, conservative therapy is still favoured by insurance companies and bearing of costs for surgical therapy therefore is rejected. Expenses of conservative treatment as well as costs related to appeal and lawsuits against insurance decisions exceed the case-based lump sum of reduction mammaplasty manifold. Conservative treatments do not eliminate the causes of the illness. Therefore the rejection of a medically indicated reduction mammaplasty has to be regarded as unfavourable and economically inefficient.

Extracorporal septal reconstruction with polydioxanone foil

Conventional septoplasty cannot be the answer to all types of septal deviation. Indications of extracorporal septal reconstruction with polydioxanone (PDS) foil: (i) selected cases of very high septal deviations, (ii) post-traumatic and (iii) extremely pronounced congenital septal deviations and/or aesthetic deformities. Polydioxanone foil facilitates the incorporation of a newly implanted septal graft without significant postoperative complications and is absorbed within 25 weeks. The surgical technique is described in detail, and the early postoperative functional and aesthetic results (mean follow-up: 11 months) on 16 patients (mean age: 42 years) are reported. Overall, 88% of the patients responded positively to the question of whether they would choose to undergo the same procedure again, knowing the postoperative result. The procedure is easy to learn and has already proved to be an excellent combination of modern functional and aesthetic nasal surgery.

The Septospinal Ligament in Cleft Lip Nose Deformity: Study in Adult Unilateral Clefts

Septal deviation and alar cartilage deformities constitute an important component of both the aesthetic deformity and airway compromise in unilateral cleft lip nose deformity. The purpose of this study was to examine the retrocolumellar preseptal area in this deformity for evaluation of deforming forces in the adult population. Fifty-five patients aged 13 years or older presenting with unilateral cleft nasal deformity were included. The caudal border of the septum was accessed using an incision along the ipsilateral membranous septum. Perioperatively, the curved caudal septal edge was exposed and explored down to its attachment with the hypertrophied anterior nasal spine. The overlying tethering tissues were excised and submitted for histopathologic examination. The curved septal cartilage was straightened and the misplaced anterior nasal spine was excised. The remaining cleft nasal deformity was corrected depending on the specific presenting pathologic abnormality. A well-defined, tough, fibrous band was detected extending from the deviated curved surface of the septal cartilage to the anterior nasal spine that was filling up the retrocolumellar area. Histopathologic examination revealed fibrous tissue in all cases studied, consistent with diagnosis of a ligament. Postoperatively, the nasal tip complex cosmetic result was considered to be good or very good in 89.7 percent, satisfactory in 8.1 percent, and poor in 2.0 percent of patients. A well-defined ligament has been documented and demonstrated in adult patients with unilateral cleft lip nose deformity. The authors recommend that this septospinal ligament, previously unreported, should be excised in toto to achieve straightening of the septum, columellar centralization, and nasal sill symmetry in unilateral cleft lip nose deformity.

Abdominal lipectomy and mesh repair of midline periumbilical hernia after bariatric surgery: How to spare the umbilicus

Abdominal lipectomy is becoming an increasingly common surgical procedure in patients with esthetic deformities resulting from massive weight loss induced by bariatric surgery. Sometimes a midline incisional hernia coexists with the pendulus abdomen. Herein presented is a technique to perform a retromuscular mesh repair of the incisional hernia while sparing the umbilicus. The abdominal lipectomy with concomitant retro-muscular mesh repair of a midline incisional hernia is done sparing the vascular supply of the umbilicus on one side only. 5 consecutive women with pendulus abdomen resulting from bariatric surgery-induced massive weight loss and concomitant midline incisional hernia underwent abdominal lipectomy and incisional hernia mesh repair. Mean BMI was 28.6 kg/m2 (range 26-35), one patient was a smoker, and another had type 2 diabetes requiring oral hypoglycemic agents. Two patients had had a previous incisional hernia repair with intraperitoneal mesh. One patient had partial necrosis of the umbilicus and another experienced necrosis of only the epidermis that recovered fully. The umbilicus can be safely spared during abdominal lipectomy with concomitant midline incisional hernia mesh repair. Recurrent incisional hernia and common risk factors for wound healing such as diabetes and obesity increase the risk of umbilical necrosis.

Lower Lid Deformity Secondary to Autogenous Fat Transfer: A Cautionary Tale

Although autogenous fat grafting is performed with increasing frequency, its safety around the periorbital area remains ill defined. This article presents the case of a young woman whose tear troughs were treated using autogenous fat transfer (AFT), with resultant bilateral lower lid deformities. Secondary correction of this aesthetic deformity caused by AFT to the tear trough proved extremely difficult and resulted in a temporary lower lid ectropion. After resolution of her ectropion, the patient was very satisfied with her postoperative appearance. The authors recommend a judicious approach to the correction of this deformity with AFT until objective outcome studies on this technique become more widely available.