Correction of secondary cleft lip deformities

Learning Objectives: After studying this article, the practitioner should be able to (1) describe the common secondary deformities of the cleft lip, (2) determine the appropriate timing for surgical intervention to correct the deformities, and (3) determine the best method of addressing each of the individual secondary deformities of the cleft lip. Secondary deformities are common in children born with a cleft lip and palate. Patients with cleft lip deformity will undergo multiple surgical procedures early in life, so it is imperative to prioritize treatment of their secondary deformities and minimize the number of interventions needed. Of the many approaches used to correct these problems, surprisingly few work well consistently. As with all plastic surgery, the timing and procedure should be predicated on the severity of the deformity.     

Distraction osteogenesis: a new surgical technique for use with the multiplanar mandibular distractor

If distraction osteogenesis is to reach its full potential and achieve the level of accuracy that is possible with orthognathic surgery, its outcomes need to be as predictable. To this end, the authors developed a planning process for distraction osteogenesis similar to that used in orthognathic surgery. However, the success of the planning process depends on the authors' ability to execute the plan at the time of surgery. As a result, the authors needed to develop a surgical technique that would enable them to precisely install the distractor as indicated in the presurgical plan. The surgical technique presented in this article was developed for this purpose. The authors used this technique in seven patients (four boys and three girls; age range, 4 to 10 years). Four patients presented with unilateral deformities, and three patients presented with bilateral deformities. The follow-up period in this group of patients ranged from 12 to 33 months. The purpose of the technique is to replicate the position of the distractor on the mandible as determined by the presurgical plan. To this purpose, a custom drill guide and a surgical template have been developed. Both of these are used following the principles of triangulation to establish the pin position and orientation of the distractor. In the authors' hands, the use of this surgical technique has resulted in outcomes close to those predicted by the planning process.     

The surgical management of fibrous dysplasia of bone

The surgical management of Polyostotic Fibrous Dysplasia (FD) of bone is technically demanding. The most effective methods to manage the associated bone deformity remain unclear. The marked variation in the degree and pattern of bone involvement has made it difficult to acquire data to guide the surgeon's approach to these patients. In light of the paucity of data, but need for guidance, recognized experts in the management of these patients came together at the National Institutes of Health in Bethesda, Maryland as part of an International meeting to address issues related to fibrous dysplasia of bone to discuss and refine their recommendations regarding the surgical indications and preferred methods for the management of these challenging patients. The specific challenges, recommended approaches, and "lessons learned" are presented in hopes that surgeons faced with typical deformities can be guided in the surgical reconstruction of both children and adults with FD.     

A technique of brachioplasty

Various techniques for the management of upper extremity contour deformities have been suggested since aesthetic brachioplasty was first described. Such deformities are commonplace with aging, after normal weight loss, and especially after massive weight loss such as is seen following bariatric surgery. Despite the multiplicity of procedures described for the correction of these deformities, there are still problems associated with current brachioplasty techniques, including incorrectly placed incisions, widened hypertrophic scars, and postoperative contour deformities. In addition, postoperative skin laxity and ptosis in the axillary region are frequently encountered in the more extreme deformities. The authors present their technique for upper extremity brachioplasty. This technique is suitable for patients with severe brachial ptosis and skin laxity, with relatively little lipomatous tissue, which may extend from the olecranon to the chest wall. The described surgical approach provides excellent overall extremity contour with favorable scars while simultaneously addressing axillary contour deformities.     

Correction of type II breast deformities following conservative cancer surgery.

Breast deformities following conservative cancer surgery are seen with increasing frequency and often represent difficult reconstructive problems. Type II deformities are characterized by localized tissue insufficiency, which can be due to skin insufficiency (type IIa), subcutaneous tissue insufficiency (type IIb), or both (type IIab). Correction of a locally damaged breast is a surgical challenge that can result in a fully restored breast if selection of the surgical procedure is properly carried out. A series of 37 patients who underwent correction of type II deformities from 1980 to 1989 was reviewed. Results obtained with different surgical procedures, including simple submuscular placement of traditional or expandable implants, breast reshaping, transposition of a latissimus dorsi muscle or musculocutaneous flap, TRAM flap, and reverse abdominoplasty, were evaluated. Aesthetic outcome was judged to be good or excellent in 78 percent of patients. Guidelines for selection of the most appropriate surgical procedure according to the defect's etiology, morphology, and location and to the breast's size and shape are presented.     

Blepharo-canthal deformities in patients following craniofacial surgery

Functional problems and deformities of the eyes have become a major concern in the surgical treatment of ortital hypertelorism and craniofacial dysostosis, as experience with skeletal relocation for these disorders has been gained. Comprehensive preoperative and postoperative study and measurements of the bony orbits, the globes, the lids, the canthi, and the nose are necessary for the evaluation of present techniques and the design of alternative procedures. Some of the deformities of the blepharo-canthal complex are part of the congenital malformation. Other distortions, seen only postoperatively, are secondary to specific surgical maneuvers. Awareness of these primary and secondary factors has led to better soft tissue reconstruction at the time of the bony orbital translocations or the craniofacial disjunction. We describe the techniques which we have found especially useful in avoiding and correcting these postoperative blepharocanthal deformities.     

Cleft lip: unilateral primary deformities

The understanding and management of all aspects of unilateral cleft lip deformities continue to evolve. Just as we are entering the era of exciting advances in the understanding of the pathogenesis of craniofacial disorders, expansion of our understanding of the dynamic relationships of the structural and soft-tissue components of cleft deformities has assisted surgeons in achieving progressively improved and consistent outcomes for these patients. The anatomic and physiologic complexity of unilateral cleft lip deformities has been recognized for centuries, and generations of researchers have cumulatively contributed to our current understanding. This article examines the history, classification, anatomy, and controversies in the surgical management of unilateral cleft lip deformities, allowing surgeons to formulate a reasoned, longitudinal management plan for their patients on the basis of the available current data.     

Cleft lip, cleft palate, and velopharyngeal insufficiency

This article provides an introduction to the anatomical and clinical features of the primary deformities associated with unilateral cleft lip-cleft palate, bilateral cleft lip-cleft palate, and cleft palate. The diagnosis and management of secondary velopharyngeal insufficiency are discussed. The accompanying videos demonstrate the features of the cleft lip nasal deformities and reliable surgical techniques for unilateral cleft lip repair, bilateral cleft lip repair, and radical intravelar veloplasty.     

A fresh look at the open rhinoplasty technique

Use of the open rhinoplasty technique (ORT) in certain nasal and septal deformities has proven to be an invaluable asset in the rhinoplasty armamentarium of the authors. Primarily owing to the markedly increased exposure with this technique, more accurate assessment of the deformities is possible and additional or improved surgical maneuvers become available, particularly in the tip. Sculpting the entire cartilaginous and/or bony vault, as well as correcting difficult septal malalignments, can be carried out under better direct vision with greater precision, accuracy, and predictability. This has led to improved and more consistent final results. Previous criticisms of unsightly columellar scars have been virtually eliminated through the use of improved surgical techniques and simple magnification. Overall, open rhinoplasty technique can provide many distinct advantages in certain nasal deformities with no real disadvantages over conventional closed techniques.     

How trematodes cause limb deformities in amphibians

We used trematode cyst infestation to induce limb deformities in two species of frogs of the genus Rana and compared them to deformities induced by surgical limb bud rotations. The specific deformities produced by both treatments closely resemble those of wild-caught deformed amphibians and are consistent with a known developmental response to disruption of the spatial organization of cells in developing limb buds. Histological analysis showed that trematode cysts cause massive disruption and abnormal cellular growth involving the limb buds of infected individuals. Our results indicate that trematode cyst infestation causes deformities in frogs by perturbation of the positional relationships of cells in developing limb buds. The crippling effects of cyst-infection on frogs may reflect complex co-evolutionary interactions among trematodes, frogs, and other hosts in the trematode's life cycle.     

The role of primary bone grafting in complex craniomaxillofacial trauma

The role of craniofacial surgical techniques and immediate bone grafting in the management of complex craniofacial trauma has been reviewed. Four hundred and one patients with complex facial injuries have been treated. Two hundred and forty-one primary bone and cartilage grafts have been performed in 66 patients. Complex facial injuries should be managed by direct exposure, reduction, and fixation of all fractures utilizing interfragmentary wiring. Very comminuted or absent bone is replaced by immediate bone grafting, producing a stable skeleton without the need for external fixation devices. Associated mandibular fractures are managed with rigid internal fixation utilizing A-O technique. Results of immediate bone grafting have been excellent, and complications are rare. All deformities should be corrected, whenever possible, during the initial operation. This one-stage reconstruction of even the most complex facial injuries will prevent severe postoperative traumatic deformity and disability that may be extremely difficult or impossible to correct secondarily.     

Dental Informatics to Characterize Patients with Dentofacial Deformities

Relevant statistical modeling and analysis of dental data can improve diagnostic and treatment procedures. The purpose of this study is to demonstrate the use of various data mining algorithms to characterize patients with dentofacial deformities. A total of 72 patients with skeletal malocclusions who had completed orthodontic and orthognathic surgical treatments were examined. Each patient was characterized by 22 measurements related to dentofacial deformities. Clustering analysis and visualization grouped the patients into three different patterns of dentofacial deformities. A feature selection approach based on a false discovery rate was used to identify a subset of 22 measurements important in categorizing these three clusters. Finally, classification was performed to evaluate the quality of the measurements selected by the feature selection approach. The results showed that feature selection improved classification accuracy while simultaneously determining which measurements were relevant.     

Inflammation as a potential risk factor for spinal deformities in farmed Atlantic salmon (Salmo salar L.)

Inflammation is an overall protective response and can be defined as a cellular and non specific immune response to irritation, injury, or infection leading to the local accumulation of leukocytes and fluid. In intensive farming conditions, fish are usually transported, sorted, vaccinated and subjected to stressful handling procedures which may potentially lead to local inflammation and affect the integrity of the spine. The present mini‐review aims to introduce the reader in the field of spinal deformities in salmon, propose inflammation as a risk factor for spinal deformities and emphasize the need for conducting further research in the area having an integrated and multidisciplinary perspective.     

Congenital Malformations: Preliminary Report of an Investigation of Reduction Deformities of the Limbs,Triggered by a Pilot Surveillance System

A brief account is given of a pilot study-surveillance system of congenital anomalies. The steps taken to investigate a suspected increase in the numbers of infants born with reduction deformities of the limbs are described. Information is presented concerning 35 infants with reduction deformities of the limbs and other deformities born in four provinces during 1969. The importance of accurate reporting of all congenital malformations on vital statistics documents and on hospital records is emphasized. It is concluded that: (1) The pilot study-surveillance system is capable of demonstrating changes in incidences of anomalies and of initiating follow-up studies within a reasonable length of time; and (2) The information collected on these 35 patients, while not sufficient to establish the etiology of the anomalies, does suggest that no currently recognized factor has been identified for the majority of these cases and that there is a great need for further detailed investiation of possible etiological factors.     

Metatarsophalangeal fusion for hallux valgus: indications and effect on the first metatarsal ray.

Arthrodesis of metatarsophalangeal joint was performed in 31 cases of severe hallux valgus. With the surgical technique used, which is described in detail, internal fixation and plaster cast immobilization were not necessary. Analysis of the results suggested that the operation is indicated for severe deformities in elderly patients, preferably women. The basic metatarsal deformity was corrected by the procedure.     

Finite element simulation of spinal deformities correction by in situ contouring technique

Biomechanical models have been proposed in order to simulate the surgical correction of spinal deformities. With these models, different surgical correction techniques have been examined: distraction and rod rotation. The purpose of this study was to simulate another surgical correction technique: the in situ contouring technique. In this way, a comprehensive three-dimensional Finite Element (FE) model with patient-specific geometry and patient-specific mechanical properties was used. The simulation of the surgery took into account elasto-plastic behavior of the rod and multiple moments loading and unloading representing the surgical maneuvers. The simulations of two clinical cases of hyperkyphosis and scoliosis were coherent with the surgeon's experience. Moreover, the results of simulation were compared to post-operative 3D measurements. The mean differences were under 5 degrees for vertebral rotations and 5 mm for spinal lines. These simulations open the way for future predictive tools for surgical planning.     

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.     

The zones of adherence: role in minimizing and preventing contour deformities in liposuction

True body sculpting demands a three-dimensional artistic understanding of the anatomic and surgical adipose layers of the central trunk when performing circumferential liposuction. This is essential in preventing complications from both ultrasound-assisted and suction-assisted lipoplasty. The authors describe five zones of adherence that should be avoided to prevent contour deformities in the central trunk area when performing circumferential liposuction. The anatomy of the subcutaneous tissue of these five anatomic zones is reviewed and correlated radiographically with magnetic resonance imaging studies. Aesthetic and technical considerations required to properly liposculpt the central trunk are demonstrated by case analysis of primary and secon-dary liposuction patients. These cases also delineate how to prevent and/or minimize deformities after liposuction.     

Finite element simulation of spinal deformities correction by in situ contouring technique

Biomechanical models have been proposed in order to simulate the surgical correction of spinal deformities. With these models, different surgical correction techniques have been examined: distraction and rod rotation. The purpose of this study was to simulate another surgical correction technique: the in situ contouring technique. In this way, a comprehensive three-dimensional Finite Element (FE) model with patient-specific geometry and patient-specific mechanical properties was used. The simulation of the surgery took into account elasto–plastic behavior of the rod and multiple moments loading and unloading representing the surgical maneuvers. The simulations of two clinical cases of hyperkyphosis and scoliosis were coherent with the surgeon's experience. Moreover, the results of simulation were compared to post-operative 3D measurements. The mean differences were under 5° for vertebral rotations and 5 mm for spinal lines. These simulations open the way for future predictive tools for surgical planning.     

A practical classification of septonasal deviation and an effective guide to septal surgery

The conventional designation of septal pathology is a deviated septum, and the common treatment of choice is submucous resection of the septum. These limited generic terms leave the surgery open to frequent failure and render the education of this topic suboptimal. During 1224 septal surgeries, we have observed six different categories of septal deviation requiring different surgical treatments. A study was conducted to investigate the frequency of different classes of septal deviation and to develop guidelines for a more successful surgical correction of each category. Ninety-three consecutive patients who underwent septoplasty were carefully evaluated for the type of septal deformity, age, gender, history of trauma, and previous septal surgery. The surgical technique was reviewed for each category of the septal deformity. Of the 93 patients, 71 were women and 22 were men. Ages ranged from 13 to 76, with an average age of 31.5. Most patients exhibited a "septal tilt" deformity (40 percent; 37 of 93) or a C-shape anteroposterior deviation (32 percent; 30 of 93). The other deformities were C-shape cephalocaudal (4 percent; 4 of 93), S-shape anteroposterior (9 percent; 8 of 93), S-shape cephalocaudal (1 percent; 1 of 93), or localized deviations or large spurs (14 percent; 13 of 93). Each of the six categories of septal deviation requires specific management. If a single procedure is selected for all of the septal deformities, disappointing results may ensue.