Biomedical subjects
Publications and source records attributed to B Guyuron.
Description and applications are presented for a technique of craniomaxillofacial-model surgery. The technique utilizes models created by and based on computer technology. This paper is based on the experience derived from 22 cases in which computer-generated models were used as the means of evaluation, presurgical planning and practice.
Appropriate deepening of the nasofrontal junction remains one of the most difficult parts of rhinoplasty. A guarded burr is introduced that provides a safe and effective means of deepening or creating a shallow nasofrontal groove. The burr has a special guard that prevents the cutting of soft tissue. The guarded burr is introduced in position through the routine elevation of the bridge soft tissue subperiosteally. The safety latch is used for orientation. With gentle movement along the line connecting the canthi, the desired amount of bone can be removed from the nasofrontal junction with little time consumed. It is important to avoid continuous friction, since this might result in significant heat production and thereby thermal injury to the soft tissue and fluid collection.
In certain patient categories single-jaw surgery will not result in the optimal outcome that can be achieved through bimaxillary surgery. These include patients with asymmetrical facial deformities (usually mid and lower face), long face deformity with vertical maxillary excess and significant mandibular retrognathism, and bimaxillary protrusion or retrusion. To correct such deformities a well-planned and orchestrated orthodontic preparation followed by bimaxillary orthognathic surgery is necessary. An interim occlusal splint will guide the surgeon in moving the maxilla, and the final splint will position the mandible. Precise attention to detail throughout the operative course is essential to an optimal outcome. Rigid fixation will minimize the need for traditional intermaxillary wiring.
This randomized study was conducted to evaluate the role of nasal packing following septorhinoplasty. Fifty septorhinoplasty patients were selected (on a random basis) to either receive or not receive nasal packing. Twenty-three of 25 patients with nasal packing and 22 of 25 patients without nasal packing were available for follow-up. This study suggests that patients with nasal packing are less likely to develop recurrent septal deviation and synechia and more likely to have improvement in the nasal airway. Only one of the patients with nasal packing found the removal of the packing the most uncomfortable part of the surgery. The most impressive and statistically significant finding, however, was the significant difference between the two groups in terms of airway improvement, which was 96 percent in the nasal packing group and 64 percent in the group without nasal packing. There was also a higher incidence of recurrent or residual septal deviation in the group without nasal packing (41 percent), while the group with nasal packing had only (13 percent) recurrent or residual deviation.
An anterior hairline incision with subcutaneous (superficial to the frontalis muscle) dissection is recommended for certain categories of rhytidectomy patients. Patient selection is a very important preoperative procedure. The technique and results are described and illustrated. Advantages and disadvantages are discussed.
A modified temple incision is discussed. The incision has been used on 286 patients. The incision starts cephalad in the temple hair, continues caudally parallel to the ear axis along the caudal border of the sideburn, turns cephalad close to the helix, and then continues along the anterior border of the ear. The advantages of the incision are numerous. First, it virtually eliminates any possibility for injury to the temporal branches of the facial nerve and preserves the temporal vessels. Second, the temple and sideburn skin flap is not elevated so the chance of hair loss is minimal. Third, the incision significantly increases the distribution length of the excised area; this minimizes any possibility of "dog ear" formation. Midface and upperface rhytidectomies are more effective because the skin is pulled a shorter distance. The drawbacks of the incision are the possibility of a visible scar in the most caudal portion of the sideburns and added surgical time because of the need for meticulous incision repair.
This retrospective study was undertaken to investigate the soft-tissue response rate to the skeletal and soft-tissue alterations following a rhinoplasty. Ninety-eight patients, 80 females and 18 males, with a mean follow-up of 13 months, were included in this study. The tracings of the outline of preoperative cephaloxerograms and life-size photographs were superimposed on the postoperative ones, and the differences were measured and confirmed with measurements of intraoperative resected segments. The soft-tissue response to skeletal alterations was measured in seven different zones. Zone 1 (nasion) and zone 7 (nasal spine area) had the lowest mean response rate of approximately 25 percent. Zone 2 (proximal bridge) and zone 3 (midbridge) had a 60 percent response rate. Zone 4 (supratip area) had a 43 percent response, zone 5 had a 41 percent response, and zone 6 had a 40 percent response rate. There were statistically significant differences among the response rates of thick, medium, and thin noses. Age was an important factor in zones 1, 4, 5, 6, and 7. The patient's sex did not influence the soft-tissue response rate to skeletal alterations. The soft-tissue response in relation to the alar base narrowing was about 52 percent. This study reveals a predictable soft-tissue response to skeletal alterations on all zones except zone 7 (nasal spine area).
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Bilateral facial reconstruction using an omental free-flap transfer for soft-tissue augmentation was performed on a 23-year-old man who had undergone previous surgical resection of an embryonal-cell rhabdomyosarcoma followed by radiation and chemotherapy. Eight weeks following surgery, the patient presented with pain and edema from a foreign-body reaction documented by electron microscopy. This was successfully managed with a course of steroid administration. The patient has remained symptom-free for 5 years.
Arthritis of the temporomandibular joint and resulting deficient mandibular growth are seen in as many as 25 percent of patients with juvenile rheumatoid arthritis. The magnitude of joint involvement and resulting growth deficiency varies significantly. These patients typically develop a "birdface" deformity with retruding mandible, alteration of the cervicofacial angle, and class II occlusion with limitation of the bite opening. A multidisciplinary approach, including the surgeon, a dentist, an orthodontist, and a rheumatologist, is necessary to ensure a safe and successful surgical outcome. The side effects of pharmacologic agents used to control the disease on coagulation, healing, and bone density should be considered seriously.
Results using our modification of the Putterman procedure are reported in 43 eyelids. The procedure is very effective in cases of minimal to moderate eyelid ptosis (3 mm or less) and in the presence of normal levator function. The patients, following a thorough clinical evaluation, are tested using 2.5% phenylephrine eyedrop solution, which acts as an extremely useful prognostic indicator. Depending on the degree of ptosis and the response to phenylephrine, 6 to 9 mm of combined Müller's muscle and conjunctiva is resected using a specially designed clamp under local or attended local anesthesia (no tarsal plate is resected). The incision is repaired using a running 6-0 Prolene horizontal mattress technique, and the ends are brought up through the skin and tied over the tarsal plate. In the treatment of 43 eyelids, with the exception of one slight overcorrection, there were no complications encountered with this simple procedure. Excellent results can be expected in properly selected patients, and recovery time is minimal. Our success in the last 4 years with this modified procedure allows us to strongly recommend it for the correction of mild to moderate ptosis when there is an acceptable response to phenylephrine.
The procedure of split-skull cranioplasty was first investigated at the turn of the century. The present authors first reported their technique of split-skull cranioplasty in 1983, and describe here their experience with this procedure in the management of extensive and difficult cranial defects. Twenty-nine patients (11 females and 18 males) are reviewed. Ten patients had histories of infection before reconstruction surgery. Eleven patients received radiation therapy at the grafted areas. The postoperative follow-up period ranged from 6 months to 4 1/2 years. There was no evidence of bone resorption during that time, and minor complications occurred in only two of the patients. This procedure offered several advantages: 1) the bone graft, an autogenous material, can be used in previously infected areas; 2) the reconstruction contour is smooth and natural; 3) there was no morbidity or scarring at the donor site; 4) surgery time is much shorter than with split-rib cranioplasty. The primary disadvantage of split-skull cranioplasty is the decreased thickness of the skull at the donor site.
Currently, 50 cases of craniocarpotarsal dysplasia, or whistling face syndrome (WFS), have been reported, with more than 60 anatomical anomalies involving the head, hands, and feet, in addition to the face. In spite of the fact that there is much information concerning the surgical correction of many of these deformities, such as the surgical program for the hands outlined by Call and Strickland in 1981, there is little information concerning the surgical correction of facial deformities. In view of this, we present here a case report of a patient with WFS and our surgical approach to the facial deformities involved. Since January 24, 1983, when this 7-year-old girl first came into our care, she has successfully undergone a total forehead reshaping, correction of congenital upper eyelid ptosis, and a bilateral commissuroplasty. Follow-up for more than three years has shown stable surgical results.
I describe a simple technique of full-scale life-size photography using marker/stickers and a ruler at the side of the face as an index for magnification. I also report a technique of soft-tissue cephalometric analysis that consists of some new proportion and some old angles and measurements. This technique will enable the plastic surgeon, even if not artistically inclined, to draw an aesthetically pleasing and very proportionate profile outline of the nose and measure the proportions of the front view on the majority of patients. The difference between the patient's nasal outline and the planned nasal definition is then measured and expressed in quarters of millimeters to give the surgeon a very precise numeric guide for surgery. This will help the plastic surgeon define the aesthetic goals very accurately and also might be helpful in detecting other facial disharmonies that might be influential in the outcome of the rhinoplasty. Using this technique of analysis, along with the prediction guidelines extrapolated from my study on soft-tissue response to surgical alteration, one can develop a fairly predictable approach to rhinoplasty.
A patient with basal cell naevus syndrome (Gorlin-Goltz Syndrome) is presented. Of note in the case was the extensive symmetrical tumour invasion of both external auditory canals requiring bilateral radical resection. The patient expired 14 months later, at which time the autopsy revealed widespread metastases to the pleura, diaphragm, pericardium, epicardium and myocardium. Although lung metastases have been reported in this syndrome, no cases have been reported of metastases to these sites.
An unusual case of frontal bossing due to excess subcutaneous fibroadipose tissue in a 38-year-old woman with Möbius syndrome is presented. A relatively simple transcoronal resection of soft tissue resulted in successful elimination of this type of frontal bossing.
A simplified technique of harvesting of the ear cartilage graft is described which (1) uses a postauricular incision to minimize the visible scars, (2) removes the whole floor of the conchal fossa to avoid the irregularities, and (3) uses a tie-over dressing to eliminate the need for a head dressing. This technique has been used on 88 patients with one visible and tender medial irregularity, and three minor palpable, but invisible irregularities.
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