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The House of Cards, by Jean-Siméon Chardin (1699-1779)Article.
Traditional approaches to repair naso-orbital-ethmoid (NOE) fractures require scalp or facial incisions to gain exposure. Other fractures may be present, however, that require additional incisions. Anthony Cultrara, MD, and associates discuss their experience using the midfacial degloving (MFD) approach to treat NOE and concomitant midfacial fractures. With MFD external facial incisions are avoided, and by extending the flap superiorly and laterally the NOE complex can be exposed. Multiple facial fractures were successfully reduced without any complications in 9 patients who underwent MFD and all were satisfied with their functional and cosmetic results. Although MFD may be technically difficult and a familiarity with the procedure is necessary, this study demonstrates that the role of the MFD approach to treat facial trauma has expanded to include patients with NOE and concomitant facial fractures.
Patients with thick nasal skin can be challenging for the rhinoplasty surgeon, as the bulky skin envelope may mask alterations of the nasal framework, especially at the tip. There are several techniques aimed at thinning the skin–soft tissue envelope, more specifically the fibromuscular layer under the dermis, which can be hazardous if performed overzealously or improperly. Richard E. Davis, MD, and Ivan Wayne, MD, describe their technique of carefully debulking the fibromuscular layer of the nasal tip area to improve nasal tip definition. The added benefit of this procedure is that material is then available as an augmentation graft or for camouflage of nasal defects. Although this technique only applies to patients whose skin flaps are at least 5 mm in thickness, case reports demonstrate its effectiveness in improving the nasal tip contour and in providing stable augmentation over time.
Jeffrey A. Hall, MD, and associates describe a modification of the Skoog dorsal hump reduction to preserve the aesthetic contour of the nose and maintain function of the internal nasal valve. Removal of a segment of the bony-cartilaginous dorsum is performed via an open rhinoplasty approach. After the dorsum is adjusted to the desired level, it is placed back into position and stabilized by sutures to the upper lateral cartilages, thereby functioning as an onlay spreader graft. The procedure is ideal for patients with short nasal bones, a primarily cartilaginous dorsal hump, thin dorsal skin, and minimal deviation of the nasal dorsum. It is effective in reducing dorsal height, correcting any subsequent open roof deformity, preserving the middle nasal vault and internal valve, and keeping the natural contour of the nasal dorsum.
Injury to the facial nerve is an important cause of morbidity after trauma or surgery. bcl2 is an antiapoptotic gene that has been shown to protect facial motor neurons from cell death after peripheral injury. Sam P. Most, MD, first studied a wild-type mouse as a model for examination of facial nerve recovery after peripheral cut or crush injury. This model was prospectively compared with transgenically mutated mice that demonstrated overexpression of the bcl2 gene. His results show that transgenic bcl2 mice demonstrated more rapid and complete recovery in certain aspects of facial nerve function after injury than was statistically significant when compared with wild-type mice. This study indicates that manipulation of genes in the apoptotic pathway can prevent long-term dysfunction of nerves after injury, which may lead to improved functional rehabilitation of patients who sustain facial nerve trauma.
This issue's Highlights was written by Carlo P. Honrado, MD.
Highlights of Archives of Facial Plastic Surgery. Arch Facial Plast Surg. 2004;6(2):77. doi:10.1001/archfaci.6.2.77