Perceived functional impact of abnormal facial appearance

Functional facial deformities are usually described as those that impair respiration, eating, hearing, or speech. Yet facial scars and cutaneous deformities have a significant negative effect on social functionality that has been poorly documented in the scientific literature. Insurance companies are declining payments for reconstructive surgical procedures for facial deformities caused by congenital disabilities and after cancer or trauma operations that do not affect mechanical facial activity. The purpose of this study was to establish a large, sample-based evaluation of the perceived social functioning, interpersonal characteristics, and employability indices for a range of facial appearances (normal and abnormal). Adult volunteer evaluators (n = 210) provided their subjective perceptions based on facial physical appearance, and an analysis of the consequences of facial deformity on parameters of preferential treatment was performed. A two-group comparative research design rated the differences among 10 examples of digitally altered facial photographs of actual patients among various age and ethnic groups with "normal" and "abnormal" congenital deformities or posttrauma scars. Photographs of adult patients with observable congenital and posttraumatic deformities (abnormal) were digitally retouched to eliminate the stigmatic defects (normal). The normal and abnormal photographs of identical patients were evaluated by the large sample study group on nine parameters of social functioning, such as honesty, employability, attractiveness, and effectiveness, using a visual analogue rating scale. Patients with abnormal facial characteristics were rated as significantly less honest (p = 0.007), less employable (p = 0.001), less trustworthy (p = 0.01), less optimistic (p = 0.001), less effective (p = 0.02), less capable (p = 0.002), less intelligent (p = 0.03), less popular (p = 0.001), and less attractive (p = 0.001) than were the same patients with normal facial appearances. Facial deformity caused by trauma, congenital disabilities, and postsurgical sequelae present with significant adverse functional consequences. Facial deformities have a significant negative effect on perceptions of social functionality, including employability, honesty, and trustworthiness. Adverse perceptions of patients with facial deformities occur regardless of sex, educational level, and age of evaluator.     

Facial skeletal reconstruction using porous polyethylene implants

A retrospective review of clinical outcomes was performed to determine the clinical utility and morbidity associated with the use of porous polyethylene facial implants. Three hundred seventy implants were placed in 162 consecutive patients, in 178 operations performed in 11 years. The number of patients, the number of implants used, and the average follow-up period were categorized according to the cause of the deformity. The resultant distribution was as follows: acquired (tumor-related), 17 patients, 39 implants, and 30 months; congenital, eight patients, 31 implants, and 92 months; aesthetic, 39 patients, 97 implants, and 24 months; secondary posttraumatic, 48 patients, 139 implants, and 37 months; and acute trauma (internal orbit reconstruction), 50 patients, 64 implants, and 9 months. The distribution of implants according to location was as follows: frontal, 21; temporal, 30; internal orbit, 145; infraorbital rim, 28; malar, 58; paranasal, 29; nasal, 13; mandible, 24; and chin, 22. The combined average follow-up period per patient was 27 months (range, immediate postoperative period to 11 years). All implants were placed in the subperiosteal plane, and the majority were fixed with titanium screws. Antibiotics were administered perioperatively. No implants were extruded or migrated, formed clinically apparent capsules, or caused symptoms attributable to bioincompatibility. The overall reoperation rate was 10 percent (n = 16), which included operations to remove implants because of acute infections (2 percent, n = 3) or a late infection (1 percent, n = 1), to remove implants causing displeasing contours (2 percent, n = 3), and to improve contours (6 percent, n = 9). Porous polyethylene implants have biomaterial properties favorable for facial skeletal augmentation. Screw application of the implants to the skeleton allows precise predictable contouring, thus limiting the need for revisional surgical procedures.     

The use of hydroxyapatite cement in secondary craniofacial reconstruction.

Sixty-one patients underwent secondary craniofacial reconstruction for contour defects using hydroxyapatite cement over a 3-year period (20-month mean follow-up). There were 56 children, aged 2.2 to 18 years (mean, 10.7 years), 21 boys and 35 girls. This is the first series of pediatric patients in whom the use of hydroxyapatite cement has been reported. There were five adults aged 21 to 46 years (mean, 32 years), 3 men and 2 women. Thirty-one patients underwent reconstruction for secondary orbitocranial defects after surgery for synostosis, 7 after surgery for hypertelorism, 10 for posttraumatic skull defects, and 13 for a variety of other facial skeletal defects. There were seven complications (11 percent), ranging from a retained drain to postoperative seromas, all of which required reoperation without loss of the contour correction. All of the complications occurred in the first 18 months of our study. There has been excellent retention of implant volume with no recurrence of contour defects to date. We have not found any visible evidence of interference with craniofacial growth over the study period. We conclude that hydroxyapatite cement is a versatile and safe biomaterial when used for the correction of secondary craniofacial contour defects in children and adults. The coupling of antibiotics with this biomaterial may have applications in the treatment of osteomyelitis.     

The fate of plates and screws after facial fracture reconstruction.

Rigid plate and screw fixation is the mainstay of treatment for complex fractures of the facial skeleton. Complications of plate and screw fixation include prominence, infection, exposure, and migration. Five hundred and seven patients undergoing plate and screw fixation for facial fractures (1112 fractures) from 1983 to 1988 were followed for complications. Sixty-one patients (12 percent) required hardware removal. The location on the facial skeleton influenced symptoms and the rate of hardware removal. Infection and exposure may be decreased with antiseptic irrigations, avoiding mucosal damage, attention to proper mucosal closure, and correct placement of plates. Prominence may be decreased by the use of microplates in the supraorbital, frontal, and naso-orbital-ethmoid locations.     

Costello syndrome in two siblings and minor manifestations in their mother. Further evidence for autosomal dominant inheritance?

We report on two siblings: the index patient, a 9 months old boy and his 2.5 years old sister, both presenting the main clinical signs and symptoms of Costello syndrome (CS): severe mental and motor retardation, feeding difficulties, failure to thrive in the first months of life, coarse facial appearance, skin hyperlaxity and skeletal deformities. Their mother presented with mild to moderate mental retardation, short stature, facial fullness and wart-like lesions on her face. The present observation confirms previous data on the apparent autosomal dominant pattern of inheritance in Costello syndrome with variable expression.     

A rational approach to nasal reconstruction in leprosy

Destruction of the nasal septum and nasal bones by Mycobacterium leprae and subsequent infection is still seen regularly in leprosy endemic areas. The social stigma associated with this deformity is significant. Many different procedures have been developed to reconstruct the nose. Patients operated on at Anandaban Hospital and the Green Pastures Hospital and Rehabilitation Center between 1986 and 2001 were reviewed. There were 48 patients with an average age of 47 years. Five deformities were mild, 22 were moderate, 13 were severe, and eight were not graded. Bone grafting with nasolabial skin flaps was performed in 14 cases, bone grafting alone was performed in 10 cases, flaps alone were performed in seven cases, and cartilage grafting was performed in 10 cases. In three patients, a prosthesis was inserted, and in three patients a gull-wing forehead flap was performed. Overall, excellent or good cosmetic results were obtained in 83 percent of cases. Grafting with conchal cartilage was associated with the best cosmetic results and had minimal complications. Bone grafting with or without nasolabial flaps was associated with a 50 percent complication rate of infection or graft resorption. In mild to moderate deformities, cartilage grafting is recommended; for more severe deformities, bone grafting with bony fixation and skin flaps is recommended. Perioperative antibiotics must be used, and these procedures should be performed by an experienced surgeon. In very severe cases with skin deficiency, reconstruction with a forehead flap gives good results.     

Some topical problems in the use of spiral computed tomography in the treatment of patients with posttraumatic deformities of the middle and upper third of the facial skull

The paper presents a procedure for examining patients with posttraumatic deformities of the middle and upper third of the facial skull on a spiral computed tomograph and the schemes for estimating the size of enophthalmos, which permit elimination of eyeball recession.     

Complications of controlled tissue expansion in the pediatric burn patient

All patients at the Burn Institute reconstructed with tissue expanders between June of 1984 and June of 1987 were included in this review. There were 122 expanders used in 77 patients. Complications were defined as "absolute" (23 of 122 expanders, 20 percent) if they resulted in loss of expanders or additional surgery or none of preoperative plan was satisfied or "relative" (14 of 122 expanders, 11 percent) if they included spotty alopecia or alopecia greater than 50 percent or the operative plan only partially satisfied, reflecting poor judgment. The most common absolute complication was prosthetic exposure secondary to wound dehiscence occurring in the scalp area. Complications relative to specific anatomic areas were neck and face, 2 of 20 (10 percent); lower extremity, 1 of 4 (25 percent); trunk, 0 of 6 (0 percent); and scalp, 20 of 92 (22 percent). We feel that this high complication rate in the use of tissue expanders may be unique to the pediatric burn patient. Knowledge of indications for use and potential complications is essential to add this entity to the armamentarium of the burn reconstructive surgeon.     

The role of the plastic surgeon in the management of surgical infection.

At our Medical Center, our reconstructive service has actively sought referrals of acute and chronic infections by declaring an interest in undertaking the integrated management and reconstruction of these cases. The practices of the two senior surgeons were reviewed for three academic years (1992 to 1995). Cases of surgical infection were analyzed as to site, ablative procedures, and reconstructive procedures. In total, 139 patients with 147 infections were identified. Sites of infection included head and neck (9.5 percent), trunk and pelvis (39.5 percent), upper extremity (22 percent), and lower extremity (29 percent). One-hundred thirty-one ablative procedures were done on this group, as were 126 reconstructive procedures, including 17 fasciocutaneous flaps, 26 pedicled muscle flaps, and 28 microsurgical flaps. With a mean follow-up of 14 months, 92 percent of these patients had resolution of infection. The 8 percent failure group included recurrences, amputation, and death. This series demonstrates that a plastic surgery service can attract a diverse population of surgical infections and manage them successfully with ablation and a wide variety of reconstructive procedures. The coordination of ablation and reconstruction may be optimally performed by the plastic surgeon.     

Clinical and X-ray assessment of different modes for correcting orbital bottom defects in posttraumatic deformities of the middle one-third of the facial skeleton

The paper describes the evolution and consequences of different modes of eliminating orbital bottom defects and deformities that develop in posttraumatic deformities due to bone fractures of the facial mid-skeleton. Spiral computed tomography of this portion of the facial skeleton has demonstrated that the optimum results of restoration of the orbital bottom and those of elimination of eyeball displacement give the use of osteoplasty with a split parietal bone graft.     

Chin disfigurement following removal of alloplastic chin implants

Insertion and subsequent removal of alloplastic chin implants is not an innocuous procedure, as commonly believed. Ten women, aged 23 to 62 years of age (mean 45 years) are reported in whom severe soft-tissue deformities were observed 6 months to 6 years (mean 32 months) after removal of their implants. Resulting deformities consisted of chin ptosis and bizarre soft-tissue pogonial bunching and dimpling in repose or on animation in 9 of the 10 patients (90 percent). Asymmetrical motion of the lower lip was noted by 5 of the 10 patients. Two patients complained of pain and tenderness over the soft-tissue pogonion. The "bizarre" soft-tissue chin deformities, once established, are virtually uncorrectable. Presently, we recommend serious consideration be given to performing an immediate osseous genioplasty in patients requiring removal of alloplastic chin implants to prevent the evolution of such abnormalities.     

The expanded transposition flap: shifting paradigms based on experience gained from two decades of pediatric tissue expansion

The authors present their experience with the design of expanded skin flaps gained over the past two decades in a large series of 995 expanded flap reconstructions performed in 626 operations in 430 patients. The indications for tissue expansion were giant congenital pigmented nevi (72.7 percent), scar contractures (11.2 percent), and a remainder for a variety of congenital and acquired deformities. Surgical strategies were reviewed retrospectively to determine the location in the body where the tissue expansion was performed, the number of procedures required to accomplish the reconstructive goal, and the design of the expanded flap that was used to reconstruct the involved area. Specific points that were noticed included contour deformities (such as webbing, dog-ears, or decreased limb circumference) following flap reconstruction, anatomic distortions (such as distortion of the eyebrow or the distance from the brow to hairline) following reconstruction, final position of the scars in relation to anatomic landmarks, borders of aesthetic units, and relaxed skin tension lines, and the potential for later scar contracture. Careful examination of reconstruction by region of involvement demonstrated significant advantages in the use of expanded transposition flaps over pure advancement. These advantages and the modifications in the design of expanded flaps for each body region are discussed in a series of representative cases. They emphasize the ability of transposition flaps to dissipate tension away from the flap apex and distribute it more proximally, thus redirecting the tension lines so there is less likelihood of anatomic distortion in the reconstructed area. Also, flaps designed in this manner allow improved contour by avoiding webbing, tenting across concavities, and bunching of skin laterally. The authors conclude that restricting the expanded flap design to advancement alone to minimize potential scarring severely limits the reconstructive capabilities of the added tissue and distracts from the surgeon's ability to accomplish the initial reconstructive goal. The cost of additional incisions is worthwhile to achieve better final contour of the reconstructed part, lesser risk of anatomic distortion, better position of the scars, and lowered risk of scar contracture.     

Analysis and treatment of hemifacial microsomia

Our experience over the past 25 years leads us to conclude that hemifacial microsomia is a progressive skeletal and soft-tissue deformity with the earliest skeletal manifestations in the mandible. We find that not only does the mandibular asymmetry become worse with time, but as the contralateral side grows, the deformed mandible also increases ipsilateral secondary deformation of the maxilla, nose, and orbit. We also find that there is virtually no "catch up" growth on the affected side of the face and that these patients always become more deformed with age. The psychological problems also increase with time and progression of the facial deformity. Based on our experience with correction of end-stage deformities, we now treat these patients at the earliest possible age, as determined by the patient's skeletal classification. We treat the mandible first in the hope that this repositioning in a more physiologic position will unlock the growth potential of the adjacent structures, minimize secondary deformity, and improve function and appearance to the greater benefit of the skeletal and psychological growth of the patient.     

Use of fast-setting hydroxyapatite cement for secondary craniofacial contouring

Patients who have previously had surgical correction of major craniofacial deformities will often have residual contour deformities they wish to have improved at a later date. The development of hydroxyapatite cement has simplified these procedures. The setting time is reduced to 5 to 8 minutes by mixing the cement with a phosphate-based solution, increasing the tensile strength, and maintaining the same biocompatibility and osseoconductivity. This study includes 48 patients who presented with a variety of residual contour irregularities secondary to a craniofacial congenital anomaly or a posttraumatic defect. All but one of the patients with congenital craniofacial conditions had their initial surgical correction performed by the senior author (Magee) and had regular follow-up visits. Variable amounts of hydroxyapatite cement were used according to the size of the defect to be corrected. Five patients had a postoperative complication: two infections, one seroma, one persistent swelling, and one drain retention. Patients were followed from 6 months to 3 years (mean, 1 year 5 months). Good results were achieved in 38 patients, acceptable results with minor asymmetries were seen in seven patients, and three other patients required a second intervention to obtain a better contour. Cranioplasty with fast-setting hydroxyapatite cement is a simple and reliable procedure, with a low complication rate. Attention to simple technical and operative principles can provide excellent results.     

Thoracodorsal vessels as recipient vessels for the free TRAM flap in delayed breast reconstruction.

The internal mammary vessels have been recommended as the first choice recipient vessels for delayed breast reconstruction with the free TRAM flap. This approach has avoided surgery in the previously operated axilla, has required a shorter pedicle length, and has allowed for more medial placement of the TRAM tissue. Frequency of nonusable axillary vessels has been reported at 11 percent, with a 6 percent incidence of flap loss in the delayed reconstructive setting. We reviewed our experience with the thoracodorsal vessels as recipient vessels in delayed free TRAM breast reconstruction to assess more accurately the adequacy of these potential recipient vessels. All patients undergoing delayed TRAM reconstruction were reviewed. Forty-seven of 300 consecutive TRAM procedures were for planned delayed free reconstruction. In seven of the patients (15 percent), the thoracodorsal vessels were found to be inadequate for free reconstruction. A supercharged pedicled TRAM was used for reconstruction in each of these seven patients. Average operating room time was 7 hours. Mean follow-up time was 38 months. Nineteen percent of all patients developed at least one complication. Twelve percent of free TRAM patients developed a complication, whereas 57 percent of supercharged patients developed a postoperative complication. The difference in complication rates was statistically significant. The thoracodorsal vessels have provided an adequate recipient vessel in 85 percent of delayed free TRAM reconstructions, comparable to previous reports. Pedicling and supercharging the flap, in those situations in which the thoracodorsal vessels were inadequate, were associated with an increased incidence of postoperative complications. This suggests that in the delayed reconstructive setting, higher-risk patients benefit from free reconstruction over supercharged reconstructions. A second recipient vessel should be used when the thoracodorsal vessels are inadequate for planned free TRAM reconstruction. In these circumstances, we would recommend the use of the internal mammary vessels followed by the thoracoacromial vessels as reliable alternative recipient sites for delayed free TRAM reconstruction.     

On the surgical treatment of facial paralysis in the early nineteenth century

The treatment of facial paralysis is generally considered to have been nonsurgical until the end of the nineteenth century. However, the authors discovered recently that already in the 1840s the celebrated German facial reconstructive surgeons Dieffenbach and von Langenbeck applied the technique of subcutaneous myotomy to healthy facial muscles to reestablish balance in the chronically paralyzed faces of their patients. They performed their operations at a time when anesthesia, asepsis, antisepsis, and antibiotics had not yet been introduced into surgery. It is concluded that Dieffenbach and von Langenbeck were the first, in recorded history, to develop a surgical way to treat irreversible facial paralysis. As their principles are still being used in surgical practice, they cannot be regarded as antiquated, which illustrates the difficulties that reconstructive surgeons still experience in the treatment of irreversible facial paralysis.     

Possibilities of the x-ray diagnosis of posttraumatic fat embolism

The paper is concerned with some data, obtained during a study of case histories and x-ray findings of 12 (0.1%) of 9260 patients treated over the last 10 years in a traumatology department at a regional hospital for various traumas. Posttraumatic oil embolism was diagnosed in these 12 patients during their life. Of them 2 patients were women, and 10 men aged 20 to 74, and 7 patients were under 30. Five patients died. Open fracture was registered in 4 patients, closed fracture--in 7 patients, and contusion of the soft tissues--in one. Two cases were presented as an example. A conclusion was made of a possibility of the effective diagnosis and treatment of this severe posttraumatic complication at a provincial hospital.     

Tau syndrome (thrombocytopenia and absent ulnar) with mental retardation and facial dysmorphy.

A girl with pancytopenia (hemoglobin 9 g. 2,000 PMN. 75,000 platelets) was examined at 23 years of age. She had microcephaly, facial dysmorphy, skeletal deformities (kypho-scoliosis, club feet, club hands) and mental retardation. Puberty was normal, Roentgenograms showed bilateral agenesia of the distal part of the ulna with dislocation of the head of the radius. No other skeletal parts were absent. The condition is probably due to an autosomal recessive gene, the parents being second cousins.     

Patterns of maxillofacial injuries in powered watercraft collisions

Because of the widespread popularity of water sports, plastic and reconstructive surgeons can expect to manage an increasing number of injuries associated with these activities, particularly those related to powered watercraft vehicles. Although seat belts for motorists and helmets for motorcyclists may be efficacious, such devices currently do not serve a similar role in powered watercraft sports. In this study, a retrospective chart review of 194 consecutive patients who presented to the University of Miami/Jackson Memorial Hospital (Level I trauma center) as a result of powered watercraft collisions is presented. The purpose of this investigation was to assess the incidence, cause, demographics, and available management options for head and neck injuries secondary to powered watercraft. Identified were 194 patients who presented because of watersports-related injuries during the period January 1, 1991, through December 31, 1996. From this group, 81 patients (41.8 percent) sustained injuries directly attributable to powered watercraft collisions, including 41 personal watercraft collisions (50.6 percent), 39 boat collisions (48.1 percent), and 1 airboat collision (1.2 percent). The patient population, as expected, tended to be young and male with an average age of 29 years (range, 8 to 64 years old). Interestingly, 41 of the patients (50.6 percent) who presented to this trauma center as a result of powered watercraft collisions also sustained associated head and neck trauma. Of 74 injuries 24 were facial fractures (32.4 percent), 18 were facial lacerations (24.3 percent), 14 were closed head injuries (18.9 percent), 8 were skull fractures (10.8 percent), 4 were scalp lacerations (5.4 percent), 4 were C-spine fractures (5.4 percent), 1 was an ear laceration (1.4 percent), and 1 was a fatality (1.4 percent). Le Fort fractures were the most commonly identified facial fracture in this series. The number of these injuries seen in hospital emergency rooms will most likely increase in the future as the popularity of water-related recreational activities becomes even more widespread. Based on these findings, it is strongly recommended that future efforts be directed toward the prevention of these injuries through patient education and the eventual development of efficacious and safe protective equipment.