Faculty Bibliography

GOALS/PURPOSE:Rhinoplasty is the most common procedure seen in the teenage population. Many of these patients have facial imbalance both recognized and unrecognized by the individual and family. Most often it involves chin or midface deficiency. When the discussion involves the possibility of additional surgery, such as an alloplastic chin implant or a surgical osteotomy, the conversation halts because the patient and family seek a simpler solution.Autologous fat transfer is a useful adjunct to achieve facial balance in chin and cheek in the teen population. More recently, we have been using this technique to correct facial disharmony in rhinoplasty patients. METHODS/TECHNIQUE:Fat grafting was performed at the time of rhinoplasty in 22 patients (age, 15-19 years). Presurgical planning involved cephalometric and computer-enhanced photographic analysis of the face. Midface retrusion and underprojected mentum were treated. Deficient sites were treated with small aliquots of fat, which were injected into the supraperiosteal plane. The average amounts of fat grafting injected per region were 2 to 3 mL for the malar region and 8 to 10 mL for the chin and geniomandibular borders. RESULTS/COMPLICATIONS:Twenty-two patients underwent augmentation of soft tissue and skeletal deficiencies. Analysis of postoperative results showed excellent outcomes with enhancement of facial profile and proportions. The mean follow-up was 3 years. The majority of patients reported high degree of satisfaction. No complications were observed. CONCLUSIONS:The combination of rhinoplasty and autologous fat grafting offers very satisfactory esthetic outcomes and improvement of facial balance with minimal added time, cost, and risk.

In 1985 this cleft team, dissatisfied with the treatment and results from cleft lip and palate repair, began a longitudinal long-term study using dynamic maxillary orthopedics and periosteoplasty as was originally described by Drs Millard and Latham. All cases were carefully documented through adolescence, including clinical assessments, orthodontic, radiographic, and cephalometric analyses. In 1998, in this journal, we published our data on 35 complete unilateral and 10 complete bilateral cleft patients. At that time facial growth was following normal cephalometric patterns. Crossbites were dental and treated with orthodontics. There was radiologic evidence of bone within the alveolus with elimination of the oronasal fistula, and facial aesthetics revealed soft faded scars and balanced noses.That publication was a preliminary study with the intent to provide long-term results when full facial growth was achieved. This article reports on 25 patients from the initial cohort (20 unilateral and 5 bilateral) that we were able to closely follow up for 25 years, with the same clinical team, making it the longest study of its kind.At this stage, data revealed continued growth of the midface both vertically and horizontally. Secondary alveolar cleft bone grafting when required was in small aliquots placed into well-healed tissue, and orthodontic movement of teeth was through a consolidated alveolus. Orthognathic procedures were performed in 2 of 5 bilateral and 0 of 20 unilateral cases.We concluded that in this cohort, dynamic maxillary orthopedics and periosteoplasty, despite controversy in the literature, did not negatively impact facial growth and provided the benefit of early structural normalization and social integration by consolidation of the maxilla, closure of the oronasal fistula, tension free closure of the lip, and by balancing the nose.

Children often cannot adequately express their feelings about physical issues that may be affecting them emotionally. Nonverbal communication with art has been a time-tested tool in understanding and interpreting the feelings of children under stress. For 27 years, the author has used art as a helpful index of anxiety and self-esteem in children undergoing plastic surgery for congenital, traumatic, and aesthetic problems. A child psychiatrist and an art therapist evaluated 200 drawings. The evaluations corroborated the need to "listen" to our patients no matter what their size.

Radionuclide bone single photon emission computed tomography (SPECT) scintigraphy is an excellent method for the assessment of the vascular patency and bone viability. The scintigraphic findings are important in the management of microvascularized bone grafts used in the reconstruction of bone defects. These living bone grafts are necessary when the blood supply at the host site has been compromised as a result of radiation therapy or when the bone defect is greater than 6 cm. Bone scintigraphy is unique because the uptake of radiopharmaceutical is dependent both on an adequate delivery system and a living network of osteocytes. SPECT scintigraphy provides improved imaging characteristics and structural detail of the grafted bone. Eleven patients with microvascularized bone grafts to the mandible demonstrated marked bone reaction of the entire bone graft in the postoperative period. The accumulation of radiolabelled 99mTc methylene diphosphonate (MDP) correlated extremely well with postoperative findings and clinical response. SPECT bone scintigraphy was a safe, simple and effective method for the assessment of both patency of anastomosed blood vessels and the metabolic viability of the microvascularized bone graft.