Otoplasty: the experience of 100 consecutive patients

Although prominent ears are the most common congenital deformity in the head and neck region, only approximately 8 percent of patients who present for treatment of this deformity will have some family history of the abnormality. More than 200 techniques have been described for correction of this deformity, indicating that there is no single widely accepted procedure that has been adopted by most surgeons. The authors of this study present their choice of a procedure that combines the most beneficial features of three previously described techniques and that provides consistently satisfactory results.The surgical technique consists of scoring of the antihelical cartilage on its anterior surface in a subcutaneous position (as described by Stenstrom), suturing to recreate the fold of the antihelix (in the fashion of Mustarde), and concha-mastoid suturing applied to the back of the ear to decrease the concha-scaphoid angle (in the manner of Furnas). The last 100 consecutive patients operated on by the senior author (J.A.F.) over a 10-year period were evaluated. Follow-up data were analyzed using the Kaplan-Meier survival method. The postoperative analysis focused on the incidence of postoperative complications and the overall results of the technique.Most operations were performed bilaterally, on women, and with the patient under local anesthesia. There were few complications, and the incidence of complications was much lower than had been noted in previously reported series. All patients were very satisfied with the improvement in the appearance of their ears.The combined technique presented is safe, easy to perform, and has few complications, and its final outcome is reproducible and long-lasting. It can be considered a standard technique to be used for treating patients of any age and with any magnitude of defect.     

The crumpled-ear deformity.

The common characteristics of the crumpled-ear deformity, the steps for surgical correction, and the authors' experience are described in this article. Commonly, the ear has a folded-over appearance; a normal length and width when unfurled; and wrinkling of the skin and cartilage of the helical rim, scapha, antihelix, and concha. Principles of correction of this deformity include (1) superficial scoring of the concave segments of the cartilage to open the wrinkled segments, (2) creating the antihelical fold by a mattress-suture technique, (3) repositioning of the helical rim, and (4) repositioning of the prominent ear lobe, if present. A total of 12 crumpled ears were evaluated in six patients, three of whom underwent surgery during their teenage years. No complications have been observed. A new classification of an ear deformity has been proposed based on morphology that to the authors' knowledge has not been described in the literature. Identification of the common features of the deformity allows for precise correction using already well-defined techniques.     

Combined otoplasty technique: chondrocutaneous conchal resection as the cornerstone to correction of the prominent ear

The failure to correctly analyze the complex deformity that comprises the prominent ear is the most common cause of the undesired surgical result. Recognizing conchal hypertrophy as one of the leading causes of the prominent ear deformity has led to a versatile and reproducible otoplasty technique that is easily modified to the common side-to-side variation in deformity. From January of 1993 to August of 2000, chondrocutaneous conchal resection has been used as the cornerstone to a combined sequence of maneuvers in otoplasty. The operation was performed on 47 patients (40 bilateral cases and 7 unilateral), and the total number of ears operated on was 87. There were three complications requiring revision surgery, and follow-up periods ranged from 6 months to 7 years, with all patients achieving a satisfactory result. Detailed methods of chondrocutaneous conchal resection along with the sequence of the authors' combined otoplasty techniques are presented.     

A minimally invasive approach for correction of chin ptosis

Although ptosis of the tip of the chin is common and can be seen in persons of any age, it is frequently seen in older patients seeking facial rejuvenation. A variety of techniques have been described to correct ptosis of the chin. The authors describe a minimally invasive method that can be used correct chin ptosis. This technique uses a small intraoral incision to place a U-shaped Prolene suture that gathers the soft tissue of the chin and elevates it above the lower border of the mandibular symphysis. A retrospective review of 314 cases performed in conjunction with face lifts between January of 1994 and January of 2000 was performed to evaluate this technique. There were no significant complications, and long-term results have been very satisfactory and lasting.     

Suction lipectomy of the neck

Suction lipectomy of the neck has been advocated in other reports. However, because of skin laxity, a simultaneous face/neck lift has been performed usually. In this series of 49 patients, ages 18 to 73, removal of submandibular fat was performed by suction lipectomy. A simultaneous face/neck lift was not done. In addition, no skin was excised. On the contrary, the apparent excess skin was found to be required for contouring. Approximately one-third of the patients had a simultaneous chin implant. Others had different aesthetic surgical procedures performed during the same operation. The removal of neck fat by suction has proven to be more efficacious than excisional methods of lipectomy. The risks of operation have been found comparable to suction lipectomy performed in other anatomic locations.     

Congenital upper auricular detachment

A rare case of unilateral congenital ear deformity has been presented. The deformity is characterized by detachment and posterior rotation of the right upper auricle in an otherwise grossly normal auricle. We believe that this deformity may be related to defective mesenchymal fusion or accretion between the auricular hillocks of the hyoid and mandibular arches. Satisfactory correction was achieved by auricular repositioning with two triangular flaps.     

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.     

Reconstruction using a three-dimensional orbitozygomatic skeletal model of titanium mesh plate and soft-tissue free flap transfer following total maxillectomy

The surgical strategy for maxillary reconstruction after maxillectomy has yet to be standardized. The authors developed a technique using a three-dimensional orbitozygomatic skeletal model of a titanium mesh for skeletal reconstruction after maxillectomy. From May of 1996 to September of 2000, 18 patients underwent reconstruction using the titanium mesh model in conjunction with a soft-tissue free flap following total maxillectomy for a maxillary malignancy. The soft-tissue free flap was conventional and consisted of two skin paddles to the maxillary defect. One skin paddle became the lateral nasal wall and the other was used to close the palatal defect. After modeling, the titanium mesh plate was implanted between the orbital contents and the upper edge of the free flap to lie over the front of the flap. The model was fixed to the residual zygoma laterally and to the nasal or frontal bone medially. The palatal skin paddle was anchored by three or four dermal stitches to the bottom edge of the titanium mesh to create a concave neopalate that allowed the patient to wear a denture. Thirteen of 18 patients who underwent implantation had good facial appearance and oral function. This procedure prevented lagophthalmos, facial deformity, and sagging of the palatal skin paddle caused by gravitational force. Five patients (27.8 percent) developed exposure or infection of the implant and lost the benefit of having the prosthesis. However, treatment did not require total removal of the implant. Maintaining adequate tissue volume during soft-tissue transfer on either side of the mesh plate may minimize the complication rate. Titanium mesh implantation for skeletal reconstruction after maxillectomy avoids the need for bone grafting and may be especially beneficial in fragile or aged patients.     

牵张成骨联合正颌正畸技术治疗颞下颌关节强直的效果分析

目的：探讨联合采用牵张成骨以及正颌正畸技术治疗颞下颌关节强直的效果。方法：选取我院收治的50 例颞下颌关节强直 继发小下颌畸形患者,根据不同的手术方式将其分为观察组以及对照组,对照组仅采取正颌正畸治疗,观察组一期通过关节成形 术解除关节强直,完成正畸治疗后,二期采用牵张成骨以及颏成形术矫治小下颌畸形伴随OSAHS,术后进行8-35 月的随访,评价 治疗效果。结果：观察组的牵张距离、颏前移距离以及术后张口度均明显大于对照组,且最大张口度均大于20 mm,平均最大张口 度由术前的3.2 mm增加至术后的36.7 mm,P<0.05,观察组术后能够恢复正常咬合关系和咀嚼功能,两组患者术后的平均睡眠紊 乱指数（AH1）、LAST、后气道间隙（PAS）以及SNB 角度比较有统计学差异,P<0.05,观察组术后患者的OSAHS 症状均得到显著 的改善,未出现OSAHS复发情况。结论：牵张成骨联合正颌正畸技术治疗颞下颌关节强直可以获得满意的效果,可以很好的矫治 牙额面畸形,且能够有效改善伴发的OSAHS 症状。     

Autosomal dominant craniometaphyseal dysplasia is caused by mutations in the transmembrane protein ANK

Craniometaphyseal dysplasia (CMD) is a rare skeletal disorder characterized by progressive thickening and increased mineral density of craniofacial bones and abnormally developed metaphyses in long bones. Linkage studies mapped the locus for the autosomal dominant form of CMD to an approximately 5-cM interval on chromosome 5p, which is defined by recombinations between loci D5S810 and D5S1954. Mutational analysis of positional candidate genes was performed, and we describe herein three different mutations, in five different families and in isolated cases, in ANK, a multipass transmembrane protein involved in the transport of intracellular pyrophosphate into extracellular matrix. The mutations are two in-frame deletions and one in-frame insertion caused by a splicing defect. All mutations cluster within seven amino acids in one of the six possible cytosolic domains of ANK. These results suggest that the mutated protein has a dominant negative effect on the function of ANK, since reduced levels of pyrophosphate in bone matrix are known to increase mineralization.     

Extent of Spine Deformity Predicts Lung Growth and Function in Rabbit Model of Early Onset Scoliosis

Early onset deformity of the spine and chest wall (initiated <8 years of age) is associated with increased morbidity at adulthood relative to adolescent onset deformity of comparable severity. Presumably, inhibition of thoracic growth during late stage alveolarization leads to an irreversible loss of pulmonary growth and thoracic function; however the natural history of this disease from onset to adulthood has not been well characterized. In this study we establish a rabbit model of early onset scoliosis to establish the extent that thoracic deformity affects structural and functional respiratory development. Using a surgical right unilateral rib-tethering procedure, rib fusion with early onset scoliosis was induced in 10 young New Zealand white rabbits (3 weeks old). Progression of spine deformity, functional residual capacity, total lung capacity, and lung mass was tracked through longitudinal breath-hold computed tomography imaging up to skeletal maturity (28 weeks old). Additionally at maturity forced vital capacity and regional specific volume were calculated as functional measurements and histo-morphometry performed with the radial alveolar count as a measure of acinar complexity. Data from tethered rib rabbits were compared to age matched healthy control rabbits (N = 8). Results show unilateral rib-tethering created a progressive spinal deformity ranging from 30° to 120° curvature, the severity of which was strongly associated with pulmonary growth and functional outcomes. At maturity rabbits with deformity greater than the median (55°) had decreased body weight (89%), right (59%) and left (86%) lung mass, right (74%) and left (69%) radial alveolar count, right lung volume at total lung capacity (60%), and forced vital capacity (75%). Early treatment of spinal deformity in children may prevent pulmonary complications in adulthood and these results provide a basis for the prediction of pulmonary development from thoracic structure. This model may also have future use as a platform to evaluate treatment effectiveness.     

Surgical reconstruction of the contracted orbit

Anophthalmic patients and patients afflicted with retinoblastoma incur severe deformity of the orbit. Treatment of the severely contracted orbit is very difficult, and patient satisfaction is often poor. Since 1988, we have performed temporalis muscle transfer and surgical expansion of the contracted bony orbit in 26 patients. Satisfactory results were obtained. Gradual expansion of the orbit was performed in case of congenital anophthalmic patients. The treatment should be established in multiplicity, among many methods available for contracted eye sockets, according to the degree of orbital deformity and the amount of residual conjunctiva. In case of severe deformity, volume expansion surgery and temporalis muscle transfer are necessary. If augmentation is required in the periorbital region, rib bone onlay graft must be performed. We were able to shorten the operative time by modifying the three-wall orbital expansion technique of Tessier and Wolfe to a more simplified method. Our observations show that our procedures achieved symmetry in both eyes in all patients, and there have been no remarkable complications.     

Presurgical finite element simulation of scoliosis correction

For surgical correction of scoliotic spinal deformity, internal fixation systems apply lateral and distractive corrective forces. In order to gain maximal correction, a finite-element analysis of the spinal deformity correction technique has been carried out preoperatively, after first employing the spinal deformity correction finite-element model to determine the in vivo spinal stiffness. The presurgical analysis also gives us an appreciation of how the parameters of deformity, stiffness and corrective forces jointly contribute to the value of the correction index. The paper presents the methodology and clinical application. It also summarizes the results for ten patients, whereby the efficacy of presurgical analysis is assessed by comparing the corrective index values by presurgical simulation with the surgical results for equivalent levels of corrective forces.     

Functional morphology of the human chin

The protruding chin is an attribute that defines modern Homo sapiens to the exclusion of all other primates, including fossil hominids. The functional significance of the chin has been contemplated for most of the 20th century, but as yet no compelling functional argument for its evolution has withstood careful scrutiny. Consequently, the human chin is often cited as an example of a nonadaptive trait. Past attempts to explain the chin in a functional or mechanical context have failed, largely as a result of an incomplete understanding of in vivo masticatory biomechanics. When the morphology of the chin is considered in light of experimental data on mastication, its evolution can be interpreted as a consequence of recent changes in mandibular proportions that have altered the relative importance of different masticatory stresses. Hypotheses proposing that chin morphology is the result of sexual selection or spatial constraints may be untestable. As with arguments that posit no functional role for the chin, the credibility of these hypotheses has depended, to a large degree, on the refutation of previous biomechanical explanations.     

Double-Z rhombic technique for reconstruction of facial wounds

The double-Z rhombic technique of repair of excisional defects is characterized by borrowing the required tissue from two nonadjacent opposite sides of the defect. Most other flaps borrow the required tissue from a single adjacent region or all adjacent directions. The "sharing" of tissue from two opposite regions minimizes tension in that direction, while not borrowing from the remaining regions prevents the distortion of anatomic landmarks located along that direction. The orientation of the final scar and direction of tissue tension can be controlled by rotating the rhombic defect about its central axis. This study was undertaken to assess the utility of the double-Z rhombic technique in terms of cosmesis and avoidance of displacement of mobile anatomic landmarks such as eyelids, eyebrows, nasal alae, and lips. Excisional defects resulting from removal of skin neoplasms in 30 patients in whom primary closure or reconstruction with direct tissue advancement was not feasible and displacement of facial landmarks was undesirable were reconstructed using the double-Z rhombic technique. No considerable asymmetry or facial anatomic landmark deformity was observed in any of the 30 patients. Our results are presented along with representative illustrations.     

Ear reduction with or without setback otoplasty

Ear reduction has been performed occasionally for aesthetic considerations. This series is comprised of 8 patients representing 7 bilateral reductions and 1 unilateral reduction for a total of 15 ears. Historically, surgery for macrotia consisted of resections of full-thickness wedges from the periphery of the ear. The surgical defect was repaired by directly approximating the wound edges. Additional removal of triangular or crescent-shaped segments from adjacent sides of the wound prevented the cupping of the reconstructed ear. Secondary deformities were not uncommon consequences. The most distressing were cruciform scars that defaced the lateral surface of the ear. These were frequently exacerbated by the uneven coaptation of the underlying cartilages. The current technique places the incisions at strategic locations where the scars that form are less conspicuous. The initial steps are essentially identical with the lateral transhelical approach to otoplasty for protruding ears. In some patients, both procedures have been combined during the same operative session.     

Positioning Accuracy in Otosurgery Measured with Optical Tracking

Objectives

To assess positioning accuracy in otosurgery and to test the impact of the two-handed instrument holding technique and the instrument support technique on surgical precision. To test an otologic training model with optical tracking.

Study Design

In total, 14 ENT surgeons in the same department with different levels of surgical experience performed static and dynamic tasks with otologic microinstruments under simulated otosurgical conditions.

Methods

Tip motion of the microinstrument was registered in three dimensions by optical tracking during 10 different tasks simulating surgical steps such as prosthesis crimping and dissection of the middle ear using formalin-fixed temporal bone. Instrument marker trajectories were compared within groups of experienced and less experienced surgeons performing uncompensated or compensated exercises.

Results

Experienced surgeons have significantly better positioning accuracy than novice ear surgeons in terms of mean displacement values of marker trajectories. The instrument support and the two-handed instrument holding techniques significantly reduce surgeons’ tremor. The laboratory set-up presented in this study provides precise feedback for otosurgeons about their surgical skills and proved to be a useful device for otosurgical training.

Conclusions

Simple tremor compensation techniques may offer trainees the potential to improve their positioning accuracy to the level of more experienced surgeons. Training in an experimental otologic environment with optical tracking may aid acquisition of technical skills in middle ear surgery and potentially shorten the learning curve. Thus, simulated exercises of surgical steps should be integrated into the training of otosurgeons.     

The dorsalis pedis free flap: technique of elevation, foot closure, and flap application

The dorsalis pedis free flap is an excellent reconstructive tool for thin remote mucosal defects, for heel and hand defects where innervation is critical, and as an osteocutaneous flap with unique application to mandibular and floor of mouth reconstruction. The major criticism with this flap is related to its uncertain vascularity and the donor defect. We have found in our series of 45 cases that the vascular anatomy is exceedingly reliable. Problems with the donor defects are all related to technique. With care in flap elevation and foot closure, which we describe in detail, an acceptable donor site with minimal complications can be achieved. The clinical applications of this flap are illustrated by three case reports. Our experience with the donor site has not been problem-free. However, we do believe that with meticulous technique primary healing will occur without functional disability and with minimal cosmetic deformity.     

A simple method for in vivo measurement of implant rod three-dimensional geometry during scoliosis surgery

Scoliosis is defined as a spinal pathology characterized as a three-dimensional deformity of the spine combined with vertebral rotation. Treatment for severe scoliosis is achieved when the scoliotic spine is surgically corrected and fixed using implanted rods and screws. Several studies performed biomechanical modeling and corrective forces measurements of scoliosis correction. These studies were able to predict the clinical outcome and measured the corrective forces acting on screws, however, they were not able to measure the intraoperative three-dimensional geometry of the spinal rod. In effect, the results of biomechanical modeling might not be so realistic and the corrective forces during the surgical correction procedure were intra-operatively difficult to measure. Projective geometry has been shown to be successful in the reconstruction of a three-dimensional structure using a series of images obtained from different views. In this study, we propose a new method to measure the three-dimensional geometry of an implant rod using two cameras. The reconstruction method requires only a few parameters, the included angle θ between the two cameras, the actual length of the rod in mm, and the location of points for curve fitting. The implant rod utilized in spine surgery was used to evaluate the accuracy of the current method. The three-dimensional geometry of the rod was measured from the image obtained by a scanner and compared to the proposed method using two cameras. The mean error in the reconstruction measurements ranged from 0.32 to 0.45 mm. The method presented here demonstrated the possibility of intra-operatively measuring the three-dimensional geometry of spinal rod. The proposed method could be used in surgical procedures to better understand the biomechanics of scoliosis correction through real-time measurement of three-dimensional implant rod geometry in vivo.     

Breast reconstruction following lumpectomy and irradiation

The traditional approach to breast cancer has been the surgical mastectomy. The cosmetic deformity resulting from this procedure has led to the development of our current methods of breast reconstruction. The inherent attraction of lumpectomy and radiotherapy has been its equation with improved cosmesis. This procedure may be an effective alternative to surgery from the cancer perspective and does produce, in the majority of patients, an acceptable cosmetic result. However, this paper demonstrates that it may produce a result that is less optimal than mastectomy with postoperative breast reconstruction. The etiology of the increased deformity can either be the localized lumpectomy with marked internal derangement of breast volume or the radiation therapy itself. In addition, those who develop a combination require a solution to both. We describe three patients who illustrate these problems and believe that a greater awareness of these potential complications should be available to aid patients in choosing their cancer treatment.