Infraorbital rim augmentation

In patients with recessive infraorbital rims, alloplastic augmentation of the infraorbital rims makes the eyes appear less prominent and improves appearance. Ten patients (seven women and three men) with an average age of 30 years (range, 23 to 45 years) underwent augmentation of the infraorbital rim with alloplastic implants over a 9-year period. With an average follow-up of 3 years (range, 6 months to 6 years), reconstructions have remained stable and satisfactory, with no incidence of infection, infraorbital nerve damage, or palpebral fissure distortion. One patient underwent additional surgery to correct contour irregularities, and one patient requested implant removal 1 month after surgery.     

Improving aesthetic outcomes after alloplastic chin augmentation

A novel approach to increase chin projection with alloplastic material is presented. Key aspects of the technique include the consideration of anthropometric normal values in preoperative assessment and planning, a submental approach with wide subperiosteal exposure of the area to be augmented, the use of two-piece porous polyethylene implants for augmentation, and screw fixation of the implant to the mandible. Screw fixation improves the predictability and precision of reconstruction by preventing implant displacement, by obliterating gaps between the implant and the facial skeleton, and by facilitating final implant contouring. In a series of 46 patients (24 primary and 22 secondary) operated on over a 6-year period, this approach allowed anatomically correct, stable chin contours to be created. Iatrogenic problems with macrogenia, mentalis dysfunction, and soft-tissue distortion resulting from implant migration and capsular contracture have been avoided. There have been no infections. Two patients who had had multiple previous chin operations requested revisional surgery to refine contour.     

The ptotic (witch's) chin deformity: an excisional approach.

Ptosis of the chin pad is common and can be seen in patients of all ages. It may be associated with too little or (at times) too much anterior chin projection. Often there is an associated deep submental skin crease present. Frequently, the primary concern of the patient is the appearance or exaggeration of chin ptosis in smiling ("dynamic" ptosis). This report describes a flexible approach to the correction of developmental (and some iatrogenic) ptotic chin deformities. The key element in the approach is the direct excision of sagging or excess chin fat, muscle, and skin. No attempt is made to reposition or lift ptosis-prone soft tissues. If a deep submental skin crease is present, it too is excised. If the chin needs added anterior projection, it is accomplished with a stable alloplastic chin implant. The approach is uniquely suited to correct anterior overprojection caused by an excess of soft tissue at the front of the chin and has been successful in correcting the "dynamic" ptosis that appears with smiling.     

Cranial reconstruction with computer-generated hard-tissue replacement patient-matched implants: indications, surgical technique, and long-term follow-up

The aim of this clinical study was to evaluate the effectiveness and safety of using computer-generated alloplastic (hard-tissue replacement) implants for the reconstruction of large defects of the upper craniofacial region. Fourteen patients who had large (> 150 cm2) preexisting defects of the cranium or cranio-orbital region underwent surgical reconstruction. Preoperatively, a three-dimensional computed tomographic scan was obtained from which an anatomic model was fabricated. The defect in the model was then used to create an alloplastic (hard tissue-replacement polymer) implant for reconstruction and surgical placement. At the time of surgery, the implant was secured into position with either metal or resorbable fixation. In cases where the frontal sinus was in proximity to the implant, the frontal sinus was either cranialized and covered with a pericranial flap or obliterated with hydroxyapatite cement. In cases that had been previously irradiated or infected, wide bony debridement and coverage with a vascularized muscle was initially performed, followed by implant reconstruction 6 months later. All implants fit easily into the bone defects, and only four (29 percent) required some minor adjustments to complete the fit. All patients healed uneventfully. With a minimum of 1 year follow-up (average, 3 years) in all cases, excellent contours have been maintained and all patients have remained infection-free. In large cranial defects, custom implants fabricated from porous, hydrophilic hard-tissue replacement polymer provide an exacting anatomic fit and a solid stable reconstruction. This method of reconstruction in these defects is rapid and exact, and significantly reduces operative time. Critical attention must be paid, however, to management of the frontal sinus and preexisting bone infection and the quality of the overlying soft-tissue cover.     

Chin augmentation with nasal osteocartilaginous graft

The use of the nasal hump removed during rhinoplasty was described by Aufricht in 1934 and 1958. In the past 10 years, the author has been using a similar technique but with significant variations. Before beginning the rhinoplasty surgery, the author dissects, through a submental incision, a subperiosteal mental pocket. Then, the osteocartilaginous nasal hump is removed; once the mucoperiosteum/mucoperichondrium is meticulously dissected, the nasal hump is tailored to achieve a mental form and the removed alar cartilage, nasal spine, or septal cartilage is used to fill or supplement the concavities of the hump. This report includes a total of 36 cases, 10 of which were controlled after 3 to 8 years of implantation by tridimensional computed tomography, from which the author observed an osteointegration with the mandibular bone and no reabsorption of the grafts or alteration of the structure of this bone. The patients revealed a high degree of satisfaction, and during the clinical examination, the author could not observe or palpate any distortion of the shape or projection of the chin. None of the grafts needed review or removal. This simple, fast procedure is a very good alternative for patients with some form of microgenia or when patients and surgeons are not likely to use alloplastic implants.     

Capsule injection for the prevention of contracture

From 1990 through 1999, 164 patients with prior augmentation mammaplasty underwent implant removal by the author, and 128 of the patients had the implants replaced. Of that group, 86 were noted on preoperative examination to have capsule contracture of grade III or IV. Patients with preoperative capsule contracture were offered the option of a postoperative injection of triamcinolone intended to prevent recurrent contracture. Patients who elected to have replacement with gel-filled implants were excluded. A total of 48 patients underwent injection of triamcinolone 4 to 6 weeks after surgery. Of the remaining 38 patients, 12 were not offered injection because they selected gel-filled implants and 26 declined injection. Follow-up ranged from 8 months to 10 years (mean, 46 months), and no patient was followed up for less than 8 months. Of the 48 patients who received injections, two developed recurrent contracture, one at 3 years and one at 4.5 years. Of the 26 patients who declined injection, eight had recurrent contracture (three bilateral) within 12 months. These data suggest that in this high-risk group of patients, a postoperative injection of triamcinolone can reduce the risk of recurrent contracture.     

Reconstruction of late craniofacial deformities after irradiation of the head and face during childhood

Little is known about the results of surgical management of late craniofacial abnormalities arising after irradiation of the head and face for treatment of childhood cancers. The clinical records of 10 children (4 males and 6 females) who received 4500 to 6500 rads (mean 5160 rads) of craniofacial radiation between birth and 8 years of age (mean 5 years) and who subsequently had reconstructive surgery were reviewed. Six of the 10 patients received orbital radiation, 3 received maxillary-midfacial radiation, and 1 patient underwent radiation to the frontal bone. Histologic tumor types included retinoblastoma (4), rhabdomyosarcoma (3), Ewing's sarcoma (2), and neurofibrosarcoma (1). In addition to radiation, 7 of the 10 patients underwent surgical resection or debulking of their tumors and 6 received adjuvant chemotherapy. All patients presented from 4 to 20 years after treatment (mean 10 years) with varying, but severe degrees of soft-tissue and bony hypoplasia of the irradiated territories. Onlay bone grafting with soft-tissue reconstruction by a combination of local pedicle flaps and dermal-fat grafts was initially performed in 9 patients, and an occipitoparietal bone-flap switch procedure was done in 1 patient. Late follow-up ranged from 11 months to 7.5 years (mean 34 months). A total of 8 secondary procedures were necessary in 4 of the 10 patients (40 percent). Of these 4 patients, major revisions were performed in 3 and minor adjustments in 1. In addition, 2 patients in whom secondary procedures had not been done would benefit from further reconstruction. Therapy for cancer of the head and face during childhood has profound and ongoing effects on the growth of soft tissue and bone.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Our experience with Wisebands: a new skin and soft-tissue stretch device

Complex wounds that involve skin and soft-tissue defects that are unsuitable for primary closure by conventional suturing are common in the field of surgery. Among the many surgical options available to overcome these problems are various mechanical devices that have recently been proposed for delayed primary closure of such wounds. The authors present their experience with a new complex wound closure device, Wisebands, a device uniquely designed for skin and soft-tissue stretching. During the last 2 years, the authors have treated 20 patients with 22 skin and soft-tissue wounds for which primary closure was not feasible. The Wisebands devices were applied to the wounds, stretching the skin and underlying soft tissue, gradually closing the defects until the edges were sufficiently approximated for primary closure. Successful wound closure was achieved in 18 patients (90 percent). The Wisebands devices were removed in two patients (10 percent) because of major wound complications. In two other patients (10 percent), minor wound complications had occurred that did not necessitate removal of the device. At a mean follow-up of 1 year (range, 10 months to 2 years), stable scarring with no functional or significant aesthetic deficit was achieved. The authors conclude that the Wisebands device facilitates closure of complex skin and soft-tissue wounds, with low morbidity and complication rates, and can provide the surgeon with another important tool for closing complex wounds. Nevertheless, appropriate patient selection, intraoperative judgment, and close postoperative care are essential to ensure closure and avoid undue complications.     

Mandibular augmentation

Porous polyethylene implants are available that are designed to augment the mandibular ramus and body. They can be used to increase the bigonial distance in patients with normal mandibular anatomy who desire an increase in lower facial width. When used in combination with extended chin implants, they can camouflage the skeletal contour inadequacies associated with class II mandibular deficiency. The implants are placed through intraoral incisions and fixed with titanium screws. In a clinical experience with 11 patients over 6 years, this technique has proven to be safe and effective.     

Maxillary advancement for mandibular prognathism: indications and rationale

The surgical correction of mandibular prognathism has traditionally involved posterior repositioning of the mandibular body. This treatment approach corrects the skeletal disproportion at the expense of reducing facial skeletal volume and can unpredictably result in inadequately supported soft tissues with loss of skeletal definition. In an effort to avoid these sequelae of mandibular reduction, 18 patients diagnosed as having mandibular prognathism were treated with maxillary advancement surgery at the Le Fort I level. Mean patient SNB angle was 85.2 degrees, as compared with a normal 79 +/- 3 degrees. Maxillae were documented to be in normal position relative to both cranial base and Frankfort horizontal. The mean maxillary advancement was 6.9 mm, with a range of 4.5 to 8.8 mm. All patients required genioplasty to reduce vertical chin height and/or to laterally shift the chin. At the time of follow-up (mean 16.2 months), all patients retained cephalometric data suggestive of enlarged mandibles and excessive anterior facial divergence. However, maxillomandibular harmony and facial convexity had been restored without sacrificing skeletal volume. Treatment results demonstrated these faces to be skeletally well proportioned despite lower face protrusion that was beyond "normal." Postoperative appearances were characterized by a well-supported soft-tissue envelope and a highlighted skeletal foundation, creating angular, well-defined lower faces. These findings support the credibility of maxillary advancement as the procedure of choice in selected individuals with mandibular prognathism. Indications and an aesthetic rationale for this surgical approach are presented.     

Maxillary reconstruction with a fibula osteoseptocutaneous free flap and simultaneous insertion of osseointegrated dental implants

The fibula osteoseptocutaneous flap is a good option for reconstruction of three-dimensional composite maxillary defects. This flap provides both bone and soft-tissue reconstruction and allows osseointegrated dental implantation, either simultaneously or in a second-stage procedure. Simultaneous placement of osseointegrated dental implants reduces operative sessions and allows faster oral rehabilitation for properly selected patients. The defects may result from trauma or resection of benign tumors or low-grade malignancies. Between August of 1999 and July of 2001, three patients underwent maxillary reconstruction with the fibula osteoseptocutaneous flap and simultaneous osseointegrated dental implants. The cause of the defect was trauma in two cases and resection of an adenoid cystic carcinoma in the other. The mean length of the fibula used for bony reconstruction was 4.7 cm. One osteotomy was performed in one case and no osteotomy was necessary in the other two. Skin islands of 8 x 2.5 cm and 16 x 3.5 cm were used for two patients. For the other patient, a double skin island was used for both nasal (6 x 4 cm) and oral (6 x 5 cm) reconstructions. Two osseointegrated implants were inserted into the fibular bone for each patient. Six months after the first-stage procedure, palatal rotation flaps or mucosa grafts were used to cover the exposed implant necks and prepare the implants for prostheses. One month after the second-stage procedure, prostheses were placed. An implant-supported prosthesis was used for one patient and implant/tissue-supported prostheses were used for the others. At a mean follow-up time of 30 months (range, 16 to 38 months), all patients were able to use the dental prosthesis for chewing (beginning 6 weeks after the final procedure) and all patients were satisfied with the cosmetic results.     

Facial infiltrating lipomatosis.

Facial infiltrating lipomatosis is a rare congenital disorder in which mature lipocytes invade adjacent tissue. The phenotypic features include soft-tissue and skeletal hypertrophy, premature dental eruption, and regional macrodontia. There is a high risk for regrowth after resection that is, perforce, subtotal. The etiology, natural history, optimal management, and relationship to other disorders of fatty overgrowth are unclear. In this study, the clinical features, radiographic findings, histopathology, and postoperative results were analyzed in 13 patients with facial infiltrating lipomatosis. The condition was diagnosed in infancy (eight male subjects, five female subjects) and characterized by enlargement of the cheek (n = 12) or chin (n = 1). Other findings included cutaneous capillary blush (n = 9), ipsilateral macroglossia (n = 8), and mucosal neuromas (n = 6). Most patients had early eruption of ipsilateral deciduous and permanent teeth (n = 12). Computed tomography and magnetic resonance imaging showed an infiltrated soft-tissue mass of fatty density (n = 13) and skeletal overgrowth (n = 9). Multiple resection was performed on six patients (mean number of operations per patient, 2.5; range, one to six operations); regrowth and/or worsening of the capillary stain occurred in all six patients. Because surgical removal of the mass is usually unsuccessful, specific management of this condition will require insight into its etiopathogenesis. Given the presence of mucosal neuromas and lipomatosis, this study included testing for the known mutations in three entities that are associated with these soft-tissue findings (Cowden syndrome, Bannayan-Riley-Ruvalcava syndrome, and multiple endocrine neoplasia type 2B). Results of DNA analyses for these germline mutations were negative. It is more likely that this disorder is caused by a somatic mutation involving a local increase in growth factor(s).     

Breast cancer after augmentation mammaplasty: treatment by skin-sparing mastectomy and immediate reconstruction

Breast conservation has been associated with poor cosmetic outcome when used to treat breast cancer in patients who have undergone prior augmentation mammaplasty. Radiation therapy of the augmented breast can increase breast fibrosis and capsular contraction. Skin-sparing mastectomy and immediate reconstruction are examined as an alternative treatment.Six patients with prior breast augmentation were treated for breast cancer by skin-sparing mastectomy and immediate reconstruction. One patient underwent a contralateral prophylactic skin-sparing mastectomy. Silicone gel implants had been placed in the submuscular location in five patients and in the subglandular position in one patient a mean of 10.2 years (range, 6 to 20 years) before breast cancer diagnosis. The mean patient age was 41.3 years (range, 33 to 56 years). Four independent judges reviewed postoperative photographs to grade the aesthetic results in comparison with the opposite native or reconstructed breast.The American Joint Committee on Cancer staging was stage 0 in one patient, stage I for four patients, and stage II for one patient. Five of the six patients presented with a palpable breast mass. Latissimus dorsi flap reconstruction was performed in four patients (bilaterally in one) and a transverse rectus abdominis muscle (TRAM) flap was used in two patients. Three patients were treated by skin-sparing mastectomy with preservation of the breast implant (two patients with latissimus flaps, and one patient with a TRAM flap). The tumor location necessitated the removal of implants in two patients (one patient with a latissimus flap and one with a TRAM. A saline implant was placed under the latissimus flap after gel implant removal. The patient who underwent bilateral skin-sparing mastectomies desired explantation and placement of saline implants. No remedial surgery was performed on the opposite breast to achieve symmetry. Complications occurred in two patients at the latissimus dorsi donor site (seroma in one patient, and seroma and infection in one). Five patients underwent complete nipple reconstructions. The mean duration of follow-up was 33.6 months (range, 15.5 to 70.3 months), and there were no recurrences of breast cancer. The aesthetic results were judged to be good to excellent in all cases.Skin-sparing mastectomy and immediate reconstruction can be used in patients with prior breast augmentation, with good to excellent cosmetic results. Depending on the tumor and implant location, the implant may be preserved without compromising local control.     

Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap

Reconstruction of composite defects of the mandible is a challenging problem. Although the use of an osteocutaneous free flap, alone or in combination with another soft-tissue free flap, is generally accepted to be optimal, the bony reconstruction is sometimes undervalued, especially when the cancer is advanced. In such situations, reconstruction is often performed with a reconstruction plate covered with a soft-tissue free flap. Between January of 1997 and July of 2000, 80 patients with composite or extensive composite oromandibular defects underwent treatment with a reconstruction plate and a soft-tissue free flap. All of the patients were male, and the ages of the patients at the time of treatment ranged from 32 to 78 years (mean, 51 years). Tumors were classified as stage IV in 56 patients (70 percent), whereas the remaining 24 patients (30 percent) had recurrent carcinomas. The titanium mandibular reconstruction system manufactured by Stryker (Freiburg, Germany) was used to bridge the mandibular defects. The soft-tissue free flaps used for wound and plate coverage were as follows: anterolateral thigh flap (n = 75), radial forearm flap (n = 3), transverse rectus abdominis myocutaneous flap (n = 1), and tensor fasciae latae flap (n = 1). Five patients with recurrent carcinomas and 10 with stage IV carcinomas (18.75 percent) died 2 to 6 months after the operation and were excluded from the study. The remaining 65 patients were monitored for an average follow-up period of 22 months (range, 6 to 40 months). During that period, one or more complications occurred for 45 patients (69.2 percent). Plate exposure was the most common complication and was observed for 30 patients (46.15 percent). Twenty of the 65 patients (30.8 percent) required secondary salvage reconstruction with a fibula osteoseptocutaneous flap. The decision to perform a secondary salvage procedure was based on the general health of the patient, the extent of local disease, and the severity of the complications. Patients underwent salvage operations after an average of 11.5 months (range, 6 to 26 months). The major reasons for the second operation were as follows: reconstruction plate exposure (n = 12), soft-tissue deficiency and mandibular contour deformation of the lateral face (n = 7), intraoral contracture and lack of a gingivobuccal sulcus (n = 6), trismus (n = 4), and osteoradionecrosis of the mandible (n = 2). The total flap survival rate was 90 percent (18 of 20 free flaps). In two cases, the skin paddles of the fibula osteoseptocutaneous flaps exhibited partial failure and were revised with pedicled pectoralis major and deltopectoral flaps. The reconstruction plate and free soft-tissue flap procedure for the reconstruction of composite defects of the oromandibular region has many late complications, which eventually necessitate reconstruction of the mandible with an osteocutaneous free flap.     

Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: an ideal treatment method for mandibular ameloblastoma

Thirteen patients with large ameloblastomas of the mandible underwent segmental mandibulectomy and immediate reconstruction, with simultaneous placement of osseointegrated implants. All patients received palatal mucosal grafts around the dental implants 6 to 10 months after surgical treatment and received implant-supported prostheses another 1 to 2 months later. There were five female and eight male patients, with a mean age of 32 years (range, 17 to 50 years). The mean length of the mandibular defect was 8.8 cm (range, 5 to 13 cm). All free fibula flap procedures were successful, with no reexplorations or partial flap losses. There was no clinical or radiographic evidence of failure during the osseointegration process for any implant. With functional occlusal loading, the marginal bone loss around the implants was less than 1.5 mm in a mean follow-up period of 40 months (range, 18 to 70 months). There were no recurrences during that time. The technique described allows improved access to the bone at the time of reconstruction, immediate assessment of alveolar ridge relationships, and accurate fixation of the implant-fibula construct. The advantages of this procedure include a reduced risk of recurrence with segmental resection, reliable mandibular reconstruction, and reduction of the number of surgical procedures, allowing full oral rehabilitation in a shorter time. It is concluded that segmental mandibulectomy and immediate vascularized fibula osteoseptocutaneous flap reconstruction, with simultaneous placement of osseointegrated implants, represent an ideal treatment method for large ameloblastomas of the mandible.     

Long-term results of MISTI gold breast implants: a retrospective study

MISTI Gold breast implants (Bioplasty, St. Paul, Minn.) filled with polyvinylpyrrolidone-hydrogel were developed as a promising alternative to silicone-filled implants. Some studies have reported on the positive effects of the implant, such as improved radiolucency and biocompatibility of the gel; however, there are also reports that such implants increased in volume and were subject to capsular contracture in the human body, resulting in demands for their removal. The purpose of this retrospective study was to analyze the long-term results of a series of patients with MISTI Gold breast implants. Between 1991 and 1993, the authors inserted 83 MISTI Gold implants in 61 patients with an average age of 46 years (range, 16 to 69). The authors were able to follow up 48 patients with 71 MISTI Gold implants. The average follow-up was 68 months (range, 10 to 108 months). The retrospective study found that 59 percent of all MISTI Gold implants were removed after an average period of 4.14 years. The main reason for implant removal was an increase in volume of 38 percent, followed by capsular contracture in 14 percent of all 71 MISTI Gold implants. The average increase in volume of all removed MISTI Gold implants was 43 percent. Capsular contracture was graded as Baker I and II in 63 percent and as Baker III and IV in 37 percent. In conclusion, the authors believe that MISTI Gold implants do not fulfill the criteria of safe breast implants, and they agree with the December of 2000 opinion of the Medical Devices Agency of the Department of Health in London that the hydrogel-filled breast implants should not be used until more information about the filler material and its metabolic fate is available.     

Permanent lip augmentation employing polytetrafluoroethylene grafts.

There is a paucity of literature regarding aesthetic enhancement of the lips. This is due to the lack of reliable techniques employing autogenous tissue and the reluctance on the part of surgeons to use an alloplastic implant in this anatomic region, which is superficial, subject to trauma, and must conform to innumerable geometric shapes. The ideal lip augmentation procedure should provide for a predictable, permanent enlargement without visible scars or donor-site deformity, can be customized to the particular patient's anatomy, and can be reversed if so desired. A series of 21 alloplastic lip implants employing polytetrafluoroethylene with a mean follow-up of 14.33 months is presented. The overall complication rate was 9.52 percent. Permanent lip augmentation can be achieved with alloplastic sheet grafts of polytetrafluoroethylene in a safe and predictable fashion. Stiffness of the lips develops with progressive thickness of the grafts. Grafts exceeding 3 mm in thickness should be avoided.     

Facial autologous soft-tissue contouring by adjunction of tissue cocktail injection (micrograft and minigraft mixture of dermis, fascia, and fat)

Facial aging is both a physiologic and anatomic process characterized by changes in the skin and supporting tissues. The aging process produces an outer envelope that gradually expands while its contents gradually involute and the underlying structure weakens. This process results in an excess of skin that tends to create folds, grooves, and deepening furrows. Contour augmentation and filling depressions with autologous tissue or heterogeneous materials are widely used in face rejuvenation as an adjunctive procedure. There is unanimous agreement on the advantages of autogenous tissue grafts over alloplastic materials and heterogeneous transplants. It is also well known that the revascularization of a small graft (fat, dermis, and/or composite graft) is better than a large graft. For this reason, fat injections consisting of small particles have recently become popular. According to different authors, a graft take may vary from 30 to 50 percent. Nevertheless, it has been thoroughly documented that a graft consisting of dermis or fascia is superior to a fat graft in both the graft take rate and quality of the tissue. Strips of dermal graft have been used successfully for several years to fill lip contour and nasolabial folds. However, the main disadvantage of this technique is that utilization is restricted only to certain areas where there is a need for a small incision. To overcome this obstacle, the author developed a simple technique to obtain an injectable mass from a mixture of dermis, muscle strips, fat tissue, and fascia to use in body contouring (especially in the facial region) in large areas. The author describes the use of the technique in 450 patients. Follow-up in these patients from 6 months to 10 years showed that the application of the "tissue cocktail" procedure in select patients improved the author's results and created a marked increase in the number of satisfied patients with no complaints. The take and durability of this kind of graft were superior to the author's results using fat grafts. The tissue cocktail graft remained stable for several years, as effectively seen in the chin region. The sole complication from the procedure was some bruising, which was resolved in several days. No single infection or inclusion cyst was observed in this series.     

Analysis and results of treatment of established posttraumatic facial deformities.

The clinical records of 125 patients undergoing treatment for posttraumatic facial deformities (PTFD) from 1979 to 1990 were retrospectively reviewed. Patients with complex fractures had a combination of at least three of the major fracture categories [Le Fort I, II, III; naso-orbital-ethmoid (NOE); zygomatic; frontobasilar; and mandibular]. Twenty-five patients (20 percent) were found to have severe posttraumatic facial deformities resulting from a complex facial fracture pattern. Sixteen were males and nine were females, and their ages at the time of our first reconstructive procedure ranged from 22 to 64 years (mean 33 years). All patients presented to our clinic with severe posttraumatic facial deformities from 1 month to 26 years (mean 5 years) after original injury. The number of prior reconstructive attempts averaged two (range 0 to 9). Arbitrary severity scores assigned by us were mild in 4, moderate in 12, and severe in 9 patients. Once treatment was initiated in our clinic, the average number of operations was 3.76 until completion (range 1 to 15). Surgical treatment was aimed first at reestablishing proper skeletal, vertical, transverse, and sagittal proportions. Once skeletal foundations were reset, the more delicate naso-orbital-ethmoid and lateral canthal relations were addressed. Of the 25 patients, 13 (52 percent) suffered a complication at some point during their surgical management. In these 13 patients, 20 complications occurred in a total of 94 operations for an overall complication rate of 21 percent. Fifteen of the 20 complications were related to infection. Skeletal abnormalities in patients with posttraumatic facial deformities can generally be corrected with current craniomaxillofacial techniques. Ultimately, an excellent result in terms of skeletal reconstruction is compromised by the status of the surrounding soft tissue. More in-depth knowledge of the nature and magnitude of the initial and subsequent soft-tissue injury will contribute to our ability to treat these disfiguring posttraumatic sequelae.