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PubMed2002

Trans-supraorbital approach to supratentorial aneurysms.

OBJECTIVE: The trans-supraorbital approach has the advantage of combining the keyhole principle with cranial base surgery. The anatomic fields that can be visualized with the use of this procedure have been demonstrated in cadavers, and the advantages and potential surgical applications of this procedure are described in this report. This article is the first to describe a group of intracranial supratentorial aneurysms. METHODS: We used the trans-supraorbital approach in 22 cases of supratentorial aneurysms. In this technique, an incision is made through the eyebrow, then a 3.5-cm craniotomy is performed with en bloc extension to the orbital arch, complemented by different drilling extensions of the orbital roof according to the surgical objective. We describe the anatomic details of the experimental work as well as the clinical results. RESULTS: The trans-supraorbital technique offers an unlimited wide exposure of neurovascular structures in this microsurgical corridor. The craniotomy extension allows greater exposure than the conventional keyhole supraorbital approach, which makes the technique safe for the patient and comfortable for the surgeon. All patient outcomes were successful; no serious complications from the surgical technique occurred. Our success was achieved through better microscopic illumination in the deep field and by gaining access to the complete supratentorial vascular territory with minimal cerebral retraction and an acceptable cosmetic result. CONCLUSION: The trans-supraorbital approach is effective for gaining access to and treating supratentorial aneurysms. Also, the microsurgical field is more convenient in microscope-assisted surgery because total reliance on the endoscope is not required, and minimal brain retraction is needed. This modification of the keyhole procedure also provides multiple surgical options in this microsurgical corridor, using the principles of minimal invasiveness in cranial base surgery.

Adult↗
PubMed2003

BOTOX: a review.

BOTOX cosmetic is proving to be an affordable alternative for thousands of people looking to enhance their appearance without the cost, risks and downtime associated with surgical procedures. Botulinum toxin is a neuromuscular blocking agent produced by Clostridium Botulinum, an anaerobic bacterium. When first discovered BOTOX was pinpointed as the cause of severe paralysis acquired through the ingestion of contaminated food. Paralysis related to BOTOX is caused by chemodenervation, which is a result of blockage of the presynaptic release of acetylcholine at the neuromuscular junction. The corrugator (medial eyebrows), crow's feet, forehead, platysmal neckbands, and the jowl are frequently targeted areas for BOTOX injections. There are no current guidelines for physical limitations following the administration of BOTOX. Side effects associated with BOTOX infections appear to be either local, due to the paralysis of adjacent muscles, or mild flu-like symptoms lasting a few days in a small number of patients.

Botulinum Toxins, Type A↗
PubMed1989

The Tessier number 9 cleft.

The clinical, radiologic, and operative examination of two patients with the Tessier number 9 cleft has allowed the first complete description of this, the rarest of the rare craniofacial clefts. Soft-tissue disruption extends from the lateral third of the upper eyelid through a distorted lateral end of the eyebrow to the temporal scalp, with an associated hairline indicator. The skeletal disturbance similarly radiates superolaterally from the superolateral orbital rim across the greater wing of the splenoid to the upper squamous temporal. The three-dimensional extent of the bony disruption is associated with distortion of the cranial base and calvaria above.

Abnormalities, Multiple↗
PubMed1990

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.

Basal Cell Carcinoma↗
PubMed1994

Endoscopic techniques in coronal brow lifting.

Laboratory investigations in fresh cadaver heads demonstrated the feasibility of endoscopic techniques applicable to aesthetic surgery of the face, including the cheeks, the forehead, the orbit, the nose, and the nasal septum. Clinical experience with coronal brow lifting in 32 patients using endoscopic techniques is also presented. The elimination of the ear-to-ear coronal incision is an obvious advantage. The endoscopic approach accomplishes division and weakening of the corrugators, procerus, and frontalis muscles, as well as moderate elevation of the eyebrows. Excess skin is accommodated by dissecting the scalp posteriorly toward the occiput.

Adult↗
PubMed1995

Microsurgical forehead reconstruction: an aesthetic approach.

Satisfactory forehead reconstruction can be accomplished by microsurgical free tissue transfer. Basic principles of forehead resurfacing include: (1) replacement with similar quality soft tissue as a well-defined complete aesthetic unit, (2) establishment of the hairline 5-6 cm above the eyebrows, and (3) use of adjunctive procedures to enhance the aesthetic result. We have found the radial forearm flap and the groin flap to be excellent flaps for achieving this goal.

Adult↗
PubMed1995

Corrugator supercilii muscle resection through blepharoplasty incision.

Corrugator supercilii muscle resection through an upper blepharoplasty incision, with or without concomitant blepharoplasty, is suitable for patients who have significant corrugator hyperactivity and deep frown lines without eyebrow or forehead ptosis. This procedure is also appropriate for patients who decline a forehead rhytidectomy. After infiltration of local anesthesia with intravenous sedation, skin and fat are excised when a concurrent blepharoplasty is planned. The plane between the orbicularis oculi muscle and the orbital septum is dissected until the corrugator supercilii muscle is exposed. This muscle is identified immediately cephalad to the medial half of the superior orbital rim. The muscle is resected carefully to prevent injury to the supratrochlear nerve medially and the supraorbital nerve laterally. The resultant depression is eliminated with fat removed during the blepharoplasty, or fat or dermis from other sites should the aesthetic plan not include eyelid surgery. Eight patients, seven females and one male, underwent this procedure. The follow-up period ranged from 11 to 19 months, with a mean of 14.5 months. Patients' ages ranged from 25 to 66 years, with a mean of 51.3 years. A scale of 1 to 5, with 5 being excellent, was used to rate postoperative appearance, producing a mean of 4.25. The advantages of fewer skin incisions, less tissue mobilization, and a direct approach to the origin of the problem make this procedure a valuable adjunct to the cosmetic surgery armamentarium.

Adult↗
PubMed1995

Anatomy of the forehead muscles: the basis for the videoendoscopic approach in forehead rhytidoplasty.

The musculoaponeurotic system that performs mime for the upper third of the face is composed of the subcutaneous fascia and the occipitofrontalis, corrugator supercilii, and procerus muscles. Perfect understanding of the activity of these muscles provides for correction of horizontal furrows on the forehead, horizontal lines on the root of the nose, and glabellar frown lines. An anatomic gap in the deep layer of the subcutaneous fascia provides for the wide mobility of the scalp and forehead. A natural eyebrow lift is achieved by interrupting the restrictive forces of the corrugator supercilii and procerus muscles against the upward action of the occipitofrontalis muscle. The forehead rhytidoplasty through the endoscopic approach can achieve these results with small incisions and without skin resection.

Adult↗
PubMed1995

Retroauricular hairline flap transfer to the face.

For facial skin defects including the hair-bearing area of preauricle-sideburn, lateral forehead-temporal hairline, and upper eyelid-eyebrow region, the transfer of a hairline flap that incorporates a skin flap is one option available for creating a natural hairline. An island or free retroauricular hairline flap (retroauricular skin flap including retroauricular hairline) based on the superficial temporal vessels or posterior auricular vessels was used to reconstruct facial skin defects including hair-bearing areas in seven patients. All flaps "took" perfectly, and aesthetically satisfactory results were achieved with minimal donor-site morbidity. However, flap vessels must be selected with great care during the surgical procedure because of the anatomic variation found among patients in the positions of the superficial temporal and posterior auricular vessels.

Adult↗
PubMed1996

Autogenous soft-tissue procedures and osseointegrated alloplastic reconstruction: their role in the treatment of complex craniofacial defects.

Between 1990 and 1994, twenty-seven patients with extraoral craniofacial defects were treated at the Craniofacial Osseointegration and Maxillofacial Prosthetic Rehabilitation Unit in Edmonton. Fourteen patients required management by a combination of alloplastic and autogenous techniques to optimize their reconstructive result. Autogenous soft-tissue procedures were performed almost twice as often in patients whose deformity was the result of trauma. Autogenous soft-tissue procedures included soft-tissue expansion, static facial slings, free and pedicled vascularized bone grafts, eyebrow reconstruction, brow lifts, and scar revisions. These reconstructive procedures are illustrated in three cases.

Adult↗
PubMed1997

Fibrin glue fixation in forehead endoscopy: evaluation of our experience with 206 cases.

The endoscopic approach has totally replaced the bicoronal approach for the treatment of forehead aging in our practice since November of 1993. The fixation in proper position is obtained with fibrin glue. Results of a series of 206 procedures performed in 196 patients are presented. Eyebrow positioning and muscle weakening were rated on a scale of 1 to 4. The evaluation has been made at a minimal follow-up time of 6 months. The comparison of the results between the first series of 28 patients during the first 6 months of our experience and the second series of 69 patients during the following period showed a significant increase in the number of excellent results (from 47 to 78 percent). Altogether, the satisfactory results (rated excellent or good) increased from 71 to 86 percent. Fibrin glue provides a stable fixation with the possibility of displacement in several directions, including transversal expansion. Complications have been minimal. Secondary procedures and association with other facial operations have been analyzed.

Aged↗
PubMed1997

Browpexy: lateral orbicularis muscle fixation as an adjunct to upper blepharoplasty.

Lateral ptosis of the eyebrow is a major part of the complex changes that patients are seeking to improve with an upper blepharoplasty. Two hundred and eight patients have undergone a browpexy procedure at the time of blepharoplasty. This operative maneuver, which is performed through the blepharoplasty incision, prevents the brow from dropping below the superior orbital rim and creates a defined tarsal sulcus to produce a sculptured upper eyelid.

Adult↗
PubMed1998

Blepharoptosis repair by selective use of superiorly based muscle flaps.

Thirty-three patients with severe blepharoptosis were treated by the superiorly based orbicularis oculi muscles, interdigitated orbicularis oculi-frontalis muscle flaps, or frontalis muscle flaps. The superiorly based muscle flaps are modifications of direct transplantation of the frontalis muscle to the tarsal plate on the basis of anatomic study that the frontalis muscle and its fascia are connected with the orbicularis oculi muscle at the eyebrow region. The selection of muscle flaps is based on the extent of levator function of patients. When eyelid excursion is moderate (3 to 5 mm), the orbicularis oculi muscle flap technique was effective. For patients with weak eyelid excursion (2 to 4 mm), the interdigitated orbicularis oculi-frontalis muscle flap was the procedure of choice. For patients with minimal eyelid excursion (less than 2 mm), frontalis muscle flap technique is indicated. The majority of patients recorded as satisfactory results according to the criteria of Souther and Jordan after an average follow-up period of 18.5 months. Even though four patients showed undercorrection, there has been no complete failure or laxity of the advanced flaps in our series. The orbicularis oculi muscle technique or the interdigitated orbicularis oculi-frontalis muscle flap technique offers several advantages over the conventional frontalis muscle flap technique, such as being a simple technique with a good operative field, single incision on supratarsal fold, no depression on the forehead, no risk of neurovascular injury, and relatively easy technique with less complication. The frontalis muscle flap technique is better in patients with less than 2-mm eyelid excursion to avoid recurrence even if the superiorly based frontalis muscle flap technique has some inherent shortcomings.

Adolescent↗
PubMed1998

Subperiosteal face lift: a 200-case, 4-year review.

The subperiosteal face lift is a procedure designed to rejuvenate the upper and middle thirds of the face. Herein is reviewed a 4-year series of 200 consecutive patients who have undergone a subperiosteal face lift with a special emphasis on handling of the zygomatic arch. The main operative indication was significant ptosis of the midface soft tissue. Dissection of the maxilla, zygoma, periorbital areas, and the anterior arch was carried out through either a gingivo-buccal sulcus incision (39 cases) or a subciliary incision (161 cases). Dissection of the posterior arch was carried out in a plane superficial to the innominate fascia. A back-cut was made in the superficial musculoaponeurotic system and subcutaneous tissue down to midtragus, and a subperiosteal tunnel was entered by piercing through the posterior arch periosteum. By using a Cottle elevator (sweeping superiorly and inferiorly), the arch dissection was completed in a posterior to anterior direction. All patients underwent a concurrent brow lift (190 endoscopically and 10 by means of coronal incision). The forehead incision was used to dissect the lateral orbital rims. Twelve patients (6 percent) had undergone a previous rhytidectomy. All but four patients were women and ranged in age from 34 to 76 years (mean, 54+/-11). Mean follow-up period was 27 months (1 to 41 months). The postoperative complication rate was 5 percent and included transient frontal branch weakness (n = 2), resolved at 41 and 71 days postoperatively; hematoma (n = 2); transient infraorbital nerve paresthesia (n = 1); asymmetrical smile (n = 3); and facial tics (n = 2). Two patients (1 percent) required a secondary surgery on their brows or midface. An upper blepharoplasty was needed in 26 patients (13 percent). The overall aesthetic results were excellent, with good elevation of the eyebrows, lateral canthus, and the midface soft tissues. In conclusion, the subperiosteal face lift is a procedure designed to rejuvenate the upper and middle thirds of the face. Approaching the arch posteriorly and in a systematic fashion simplifies the procedure and reduces the risk of facial nerve injury.

Adult↗
PubMed1998

Plastic surgery of the face in Byzantium in the fourth century.

Oribasius was an eminent Byzantine physician who lived in the fourth century. His greatest contribution to medical history was his anthology of all important medical works of his time, entitled Synagogue Medicae. This complete medical encyclopedia of his era consisted of more than 70 volumes. A significant part of this work has been lost. What remains, however, allows us to glimpse the surprising richness and knowledge of ancient medicine. Chapters 25 and 26 of the original 42nd book of Oribasius are of specific interest to the plastic surgeon, because they deal with reconstruction of facial defects. Reconstructive procedures for defects in the eyebrows, forehead, cheeks, nose, and ears are described. Advancement flaps are suggested for the reconstruction, and recommendations are made about debridement, flap design, and thickness of flaps. It becomes obvious from these texts that Greek, Roman, and Byzantine surgeons had the knowledge and experience to perform several reconstructive procedures of the face and nose. This knowledge was passed to the Arabs and then to Western Europe in the 15th century and became part of the foundation for modern plastic surgery.

Byzantium↗
PubMed1989

Osteoplastic pterional craniotomy.

We describe a new method for small frontotemporal craniotomies. Adequate exposure is obtained. Sparing of the trunk of the frontotemporal branch of the facial nerve as it passes near the eyebrow preserves forehead mimetic function, and maintenance of the blood supply to the bone flap helps to prevent resorption.

Carotid Artery Diseases↗
PubMed2004

Trichofolliculoma with incidental focal acantholytic dyskeratosis.

Incidental focal acantholytic dyskeratosis has been described in a variety of cutaneous lesions, including benign and malignant epithelial lesions, fibrohistiocytic lesions, inflammatory lesions, and melanocytic lesions. It has also been observed in follicular lesions such as comedones and ruptured follicles. We report the case of a 47-year-old man with a firm, flesh-colored 2-mm pruritic papule in the sun-exposed area above the left eyebrow. An excisional biopsy was performed, the tissue was processed, and the hematoxylin and eosin slides were evaluated. Microscopic examination showed a dilated cystic cavity filled with keratinous debris and scattered fragments of hair. Smaller secondary follicular structures branched from the primary cyst's walls into the adjacent dermis. Hyperkeratosis, acantholysis, dyskeratosis, and suprabasilar clefts were also focally present. Correlation of the lesion's clinical morphology and microscopic features established a diagnosis of trichofolliculoma with incidental focal acantholytic dyskeratosis. Hence, trichofolliculoma can be added to the list of follicular lesions in which focal acantholytic dyskeratosis may be observed as an incidental microscopic change.

Acantholysis↗
PubMed2001

Humoral immunodeficiency with facial dysmorphology and limb anomalies: a new syndrome.

We report a 6 year old girl with an isolated humoral immune deficiency and a unique combination of dysmorphic features. Physical findings include microcephaly, micrognathia, sickle shaped eyebrows, hypoplastic alae nasi, thenar hypoplasia, partial 4-5 syndactyly of toes, recessed great toes, anterior anus, and hypoplastic labia minora. Radiographic findings include triphalangeal thumbs and hypoplastic first metatarsals. She has postnatal growth retardation and her development is substantially slower than her twin's. Her clinical course has been complicated by recurrent sinopulmonary infections and pneumococcal bacteraemia. Laboratory evaluation revealed hypogammaglobulinaemia, absent B cells, and a 46,XX karyotype. A review of the literature and the London Dysmorphology Database did not produce any recognizable syndromes that match her constellation of findings. She may represent a unique syndrome of unknown etiology.

Abnormalities, Multiple↗