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Background: The aim of this study was to evaluate freeze-dried cortical allograft bone for nasal dorsal augmentation. The 42-month report on 18 patients was published in 2009 in Plastic and Reconstructive Surgery with 89 percent success at level II evidence, and this article is the 10-year comprehensive review of 62 patients., Methods: All grafts met standards recommended by the American Association of Tissue Banks, the U.S. Food and Drug Administration, and the Centers for Disease Control and Prevention. Objective evaluation of the persistence of graft volume was obtained by cephalometric radiography, cone beam volumetric computed tomography, and computed tomography at up to 10 years. Vascularization and incorporation of new bone elements within the grafts were demonstrated by fluorine-18 sodium fluoride positron emission tomography at up to 10 years. Subjective estimation of graft volume persisting up to 10 years was obtained by patient response to a query conducted by an independent surveyor., Results: The authors report objective proof of persistence of volume alone or combined with proof of neovascularization in 16 of 19 allografts. The authors report the patient's subjective opinion of volume persistence in 37 of 43 grafts. The dorsal augmentation was assessed overall to be successful in 85 percent of 62 patients evaluated between 1 and 10 years, with a mean of 4.7 years., Conclusions: Freeze-dried allograft bone is a safe and equal alternative for dorsal augmentation without donor-site morbidity. Further studies are needed to (1) confirm these findings for young patients needing long-term reconstruction, and (2) partially demineralize allograft bone to allow carving with a scalpel., Clinical Question/level of Evidence: Therapeutic, IV.

There is usually some relapse in position of the alar cartilage after primary repair of unilateral cleft lip. Therefore, preoperative or postoperative external splinting has been recommended to supplement either closed or open suspension of the alar cartilage. The authors present a method using a resorbable internal nostril splint to shield the positioned alar cartilage from deformational forces caused by scar, and thus avoiding the problems associated with external splinting. An internal nasal splint was placed in 15 infants during repair of unilateral complete cleft lip and nasal deformity. The nasal morphology was compared with that of 15 control patients who had the same nasolabial procedure without internal splinting. Average follow-up time was 20.4 months (range, 4 to 30 months). Photogrammetric analysis showed that asymmetry of the alar contours averaged 8.6 percent in the splinted patients, as compared with 23 percent for controls (p <0.01). Thus, alar asymmetry was decreased two-thirds in the splinted group. An internal resorbable nasal splint is an adjunct to open alar suspension in primary repair of the unilateral cleft lip nasal deformity. An internal nasal splint protects the corrected alar cartilage longer than an external splint and eliminates drawbacks, such as necrosis, cutaneous depression of the nostril sill, and patient noncompliance. This strategy of temporary internal support of healing cartilage has other applications.

Residual air within saline breast implants can cause patient discomfort due to the mechanical and auditory effects of sloshing. Small amounts of air have no clinical significance, but if larger quantities are present and audible, the patient is reassured that the implant shell is gas-permeable and that the air will dissipate/diffuse. This study examined the time necessary for air dissipation in saline breast implants.Twelve McGhan style #68 saline breast implants were divided into two groups: group A, which included six implants with a size of 240 cc, and group B, which included six implants with a size of 270 cc. The implants were filled with room-temperature, intravenous, normal saline to their designated volumes, plus 30 cc of overfill. All air was evacuated, and each implant was inoculated with 5 cc of air. The implants were then submerged in a single tank of normal saline at 37 degrees C, at a depth of 20.4 cm to replicate capillary pressure. Intragroup analysis showed the air bubble was absent in group A at an average of 35.3 days (variance = 4.13) and in group B at an average of 38.0 days (variance = 0). If audible intraluminal air is present in the clinical setting, the patient can be reassured that the problem will resolve in approximately 30 days or less.

The purposes of this study were (1) to document outcome after primary fronto-orbital advancement for the four major eponymous craniosynostotic syndromes (Apert, Crouzon, Pfeiffer, and Saethre-Chotzen) and (2) to identify factors that might influence need for primary and secondary fronto-orbital advancement or foreheadplasty. Also tested was the hypothesis that coincident sagittal synostosis could modulate brachycephaly and affect whether a primary or secondary frontal operation was necessary. Data were collected on age and indications for initial operation, type of primary and secondary frontal procedures, and concomitant sagittal synostosis. Patients initially managed by subcranial Le Fort III were included in the study group but excluded from analysis of fronto-orbital advancement. Patients treated by monobloc advancement or Le Fort III osteotomies with frontal grafting or Anderl modification were assessed as having had primary fronto-orbital advancement. Minimum time to follow-up was 5 years. A total of 126 patients met inclusion criteria. Lateral photographs were examined to assess preoperative and postoperative sagittal position of supraorbital rims-to-globes. Frontal re-advancement was indicated if the corneal apex was anterior to the supraorbital rim. Foreheadplasty was indicated for unacceptable frontal contour and normal supraorbital rim-to-globe relationship. Primary correction for frontal retrusion was not required in 4 percent of Apert (1 of 25), 16 percent of Crouzon (7 of 44), 6 percent of Pfeiffer (2 of 31), and 19 percent of Saethre-Chotzen (5 of 26) patients. Of those infants who had a primary fronto-orbital advancement, reoperation for either supraorbital retrusion or frontal deformity was necessary in all 16 Apert patients and in 5 of 19 Crouzon (26 percent), 10 of 26 Pfeiffer (38 percent), and 13 of 20 Saethre-Chotzen (65 percent) patients (p < 0.001). Age at initial fronto-orbital advancement did not influence reoperative rate. No correlation was found between concomitant sagittal synostosis and necessity for primary or secondary frontal correction (p = 0.22). In summary, phenotypic diagnosis was determinant for outcome as defined by need for secondary fronto-orbital advancement, foreheadplasty, or both. Apert patients had the highest incidence of reoperation for frontal retrusion or forehead contour. Crouzon and Saethre-Chotzen patients were most likely to express a minor phenotype and not require fronto-orbital correction. Coincident sagittal synostosis did not influence frontal projection, as reflected in need for either primary or secondary frontal advancement.

Static suspension remains an option for certain patients with facial paralysis. Endoscopically assisted facial suspension obviates the need for a counter-incision at the oral commissure to distally inset the fascia lata graft as described in the standard technique. The endoscopic technique is simple, allows secure placement of perioral fascial strips, and can be performed as an outpatient.

A cadaver and clinical study was performed to determine the value of transantral endoscopy in diagnosis and treatment of orbital floor fractures. Six fresh cadaver heads were dissected using a 30 degree, 4-mm endoscope through a 1 cm2 antrotomy. In the cadaver, the orbital floor and the course of the infraorbital nerve were easily identified. The infraorbital nerve serves as a reference point for evaluation of fracture size; three zones of the floor are described that are oriented relative to the infraorbital nerve. In the clinical study, nine patients with orbital floor fracture initially underwent endoscopy at the time of fracture repair: three patients had comminuted zygomatico-orbital fractures, five had monofragmented tetrapod fractures, and one had an isolated orbital blowout fracture. Endoscopic dissection of the orbital fractures revealed seven fractures with an area > 2 cm2 and two fractures with an area of < 2 cm2. The isolated orbital floor blowout fracture had entrapped periorbital tissue, which was completely reduced endoscopically. A separate patient with a < 2 cm2 displaced fracture also had stable endoscopic reduction. In the remaining seven patients, the endoscopic technique assisted with the floor reconstruction by identifying the precise fracture configuration as well as identifying the stable posterior ledge of the orbital floor fracture. There have been no complications in any of our patients to date. We conclude: (1) Transantral orbital floor exploration allows precise determination of orbital floor fracture size, location, and the presence of entrapped periorbita. The information obtained through endoscopic techniques may be used to select patients who would not benefit from lid approaches to the orbital floor and may possibly eliminate nontherapeutic exploration. (2) Transantral endoscopic orbital floor exploration assists the reduction of complex orbital floor fractures and allows precise identification of the posterior shelf for implant placement. (3) Transantral endoscopic techniques can completely reduce entrapped periorbital tissue caught in a trapdoor type of fracture.