Control system modification of an electromechanical pulsatile total artificial heart

OBJECTIVE: To demonstrate the persistent malar displacement and distraction of the zygomatic-sphenoid fracture line that is possible after alignment of the frontozygomatic and infraorbital rim fractures of a displaced malar fracture. DESIGN: Nonblinded cadaver study. SUBJECTS: Three fresh cadaver heads and 1 representative clinical example. INTERVENTION: The cadaver heads were subjected to blunt trauma to the malar eminence. Reduction of the malar unit was performed either with attention to the frontozygomatic and infraorbital rim fractures alone or with concomitant inspection of the zygomatic-sphenoid fracture line. The representative case was repaired with a trans-conjunctival approach for inspection of the zygomatic-sphenoid fracture line. RESULTS: Persistent malar asymmetry is possible after the reduction of displaced malar fractures when only the frontozygomatic and infraorbital rim buttresses are used for reference. In each case in our study, the zygomatic-sphenoid fracture line remained distracted. Alignment of the zygomatic-sphenoid fracture restored premorbid malar position. CONCLUSION: Inspection of the zygomatic-sphenoid fracture line can contribute significantly to the precise 3-dimensional reduction of displaced malar fractures.     

Distribution and immunohistochemical characteristics of neurons in the porcine caudal mesenteric ganglion projecting to the vas deferens and seminal vesicle

The subperiosteal browlift and midface lift combination is a total mobilization of the composite full-thickness soft tissues from the bony skeleton with superior suspension. The object is to correct midfacial ptosis and the "tired" look of the lateral eyelids. It is done in conjunction with a browlift so that a composite correction of the upper and midface is achieved. When indicated, a modified lower cheeklift and the usual procedures for correcting neck deformities are utilized in combination. We believe the procedure is safe and the results reported are natural and long-lasting. This review of 130 cases also stresses technical aspects and the safety of the procedure.     

Simultaneous malaroplasty with porous polyethylene implants and orthognathic surgery for correction of malar deficiency

PURPOSE: Patients with skeletal malrelationships caused by maxillary anteroposterior defect and midface hypoplasia may present with an alteration of cheekbone contour. High osteotomies, segmental osteotomies of the zygomatic complex, and malar expansion with alloplastic materials can be performed to improve facial aesthetics. This article describes the restoration of cheekbone-nasal base-lip contour by performing a malaroplasty using an alloplastic implant in addition to orthognathic surgery. PATIENTS AND METHODS: From 1995 to 1996, 17 patients with maxillomandibular malrelationships and deficient cheekbone contour were tested by malar augmentation with porous high-density polyethylene in association with maxillary advancement and mandibular setback. The diagnosis of cheekbone contour alteration was made after observing the patient from a lateral, frontal, and oblique point of view. The position of the implant was determined by using Mladick's point, with lateral or medial extension in relation to the depressed area. RESULTS: By the restoration of normal cheekbone-nasal base-upper lip contour produced excellent aesthetic results in all patients. CONCLUSIONS: Malaroplasty in association with bimaxillary orthognathic surgery seems to be an effective procedure for treating midface skeletal deficiencies.     

The zygorbicular dissection in composite rhytidectomy: an ideal midface plane

Traditional face lift and blepharoplasty techniques are based on two consistent principles. Conventional face lift techniques have always incorporated unopposed lateral vector tissue advancement, which is typical of subcutaneous lifts or rhytidectomies that include the platysma muscle (SMAS) or cheek fat (malar fat). When they are not adequately repositioned, the tissues of the lower eyelid and upper cheek continue to age, which may create a "lateral sweep" of the lower face as those malar soft tissues descend at a more rapid rate than the repositioned SMAS. Removal of the lower eyelid fat in conventional blepharoplasties may also lead to a more hollow-appearing lower eyelid. Hollow eyes and the lateral sweep could be prevented with a rhytidectomy technique that includes orbicularis repositioning and preservation of the lower eyelid fat with an arcus marginalis release. All patients who have been operated on who exhibit these unfavorable signs can have an impressive correction by utilizing the principles of superomedial vector orbicularis repositioning to counter the "lateral sweep" and arcus marginalis release to recreate a youthful shallow and narrow lower eyelid contour. This technique is invaluable to patients seeking secondary surgery to regain harmony of the rejuvenated face.     

Pyriform augmentation as an ancillary procedure in facial rejuvenation surgery

A patient is presented in whom augmentation of the pyriform aperture of the maxilla was performed with porous hydroxyapatite in concert with a face and brow lift. Basic research has recently shown that remodeling of the facial skeleton continues throughout life and that this remodeling process leads to changes in the position of several key areas. The pyriform aperture was identified as one region that remodels in a posterior direction, leading to retrusion of the alar base in the older individual. This skeletal retrusion occurs in a very site-specific fashion, and its effects are reflected on the overlying soft tissues of the face. With aging, remodeling of the pyriform aperture posteriorly causes the alar base to appear recessed and decreases the nasolabial angle, changes that are noted on the profile of the older individual. Augmentation of the pyriform aperture can be achieved through a buccal sulcus incision and, when used in conjunction with standard facial rejuvenation procedures, can improve the overall result in facial cosmetic surgery.     

Central suspension technique of the midface

The central suspension technique is useful in addressing moderate nasolabial folds in the lower eyelid. It is limited by the amount of suspension that can be obtained on the cheek fat of the midface.     

Redraping the inferior orbicularis arc

The surgical technique of redraping of the inferior arc of the orbicularis oculi muscle is used primarily to produce lower lid and midfacial smoothing in patients undergoing aesthetic surgery. The midfacial fat compartments, suborbicularis oculi fat and malar fat, are bound to the orbicularis muscle by the superficial muscular aponeurotic system so that redraping the orbicularis muscle also repositions the midface. Orbicularis arc redraping should be accompanied by lateral canthoplasty to ensure stability to the shape of the eyelid fissure postoperatively. Modifications in orbicularis redraping and canthoplasty technique are necessary in patients with prominent eyes and distensible lower lids. Supraplacement of canthal fixation is needed in patients with prominent eyes, and lid shortening is needed in patients who have distensible lower lids. This technique also can be used in patients undergoing reconstructive surgery for correction of lower lid retraction because of its ability to recruit periorbital skin upward into the lower lid. For more severe cases of lower lid retraction after aesthetic surgery, adjunctive procedures such as spacer implants in the lower lid and periosteal flap canthoplasty can be used together with the orbicularis arc redraping to rehabilitate patients.     

Variability of the midfacial muscles: analysis of 50 hemifacial cadaver dissections

The region of the midface represents a challenging area to both reconstructive and aesthetic surgeons. An anatomic study was performed that attempted to identify patterns and variations of the muscular anatomy. The goals of this study were twofold: to identify patterns and variability of the midfacial muscles that might impact on reconstructive efforts and to attempt to correlate this anatomy with features of the overlying soft tissues, specifically the nasolabial crease. Fifty hemifacial cadaver dissections were performed. The information collected was assembled into a large data base, and statistical significance was analyzed using Fisher's exact probability test. Results demonstrated that, although a great degree of variability exists with respect to the midfacial muscles, seven distinct patterns of these muscles did emerge. The most common pattern was the presence of a levator alae nasi, levator labii superioris, and zygomaticus major, which occurred in 44 percent of specimens. Specimens that possessed a risorius, zygomaticus minor, or both, were relatively uncommon. The consistent presence of the levators suggests adding a superior vector to recreate a smile in facial reanimation surgery. Two important anatomic variations were noted. A bifid zygomaticus major was found to be present in 34 percent of individuals. Because the inferior bundle had a dermocutaneous insertion, this anomaly may represent the anatomic correlate of a cheek "dimple." A second anomaly noted was the lateral cheek crease, which appeared to be associated with a cutaneous attachment from the underlying platysma muscle. However, no correlation could be found for facial muscle pattern and the overlying nasolabial crease structure. This lack of correlation may indicate that the facial muscles alone do not dictate the structure of the nasolabial crease and that other dynamic factors are involved in determining this feature of the aging face.     

An analysis of objective quality indicators on Year Book citations: implications for MEDLINE searchers

OBJECTIVE: To develop objective criteria with which to identify patients with zygomatic complex (ZMC) or midface fractures who require a surgical exploration and treatment of the orbital component of their fracture to prevent postoperative enophthalmos, diplopia, or malar depression. DESIGN: Nonrandomized, prospective management of facial trauma patients. SETTING: Urban, university referral center. PARTICIPANTS: Ninety-seven patients with facial fractures (72 with ZMC fractures and 25 with midface fractures) who presented to the maxillofacial and oculoplastics trauma teams at the University of Cincinnati, Cincinnati, Ohio, for management. INTERVENTION: The decision whether to include an orbital exploration as part of the management plan was made based on a specific set of physical and radiological criteria that are detailed in the text. OUTCOME MEASURE: Patients were evaluated postoperatively for possible complications related to the orbital and periorbital portions of their fractures. RESULTS: Thirty-four percent of the study patients (30% of the patients with ZMC fractures and 44% of the patients with midface fractures) underwent orbital rim exposure and orbital floor exploration as part of their fracture management. Sixt-six percent of these patients (70% of the patients with ZMC fractures and 56% of the patients with midface fractures) were managed without orbital exploration. Postoperatively, none of the patients who did not undergo exploration experienced diplopia or enophthalmos and only 1 patient had a residual malar depression. CONCLUSIONS: The criteria reported herein allow surgeons to identify the minority of patients with midfacial and ZMC fractures who require an orbital exploration for optimal fracture management. Orbital exploration, and its potential complications, can be avoided in the majority of patients with ZMC and midface fractures without significantly increasing the risk of morbidity related to the orbital component of their fractures.     

Computerized tomography in the assessment of metastatic facial adenopathy

The facial lymph nodes are classified in five groups: mandibular, buccinator, infraorbital, malar and retrozygomatic nodes. This paper reports the CT appearance of neoplastic involvement of these nodes, an unusual and not well documented event. The CT examinations of 62 patients with a history of primary or recurrent cancer of the epidermal structures of the face, oral cavity and sinonasal region were retrospectively reviewed to assess the presence of facial adenopathy. Nine cases of neoplastic involvement of facial nodes were found. Most commonly the buccinator nodes (4 cases) were involved, the infraorbital, mandibular (2 cases) and retrozygomatic nodes (1 case) being less commonly involved. No malar nodes were found. Neoplastic involvement of these nodes was caused by squamous cell carcinoma in 6 cases, by adenocarcinoma in 2 cases and by a lymphoma in 1 case. Normal nodes could not be confidently identified on CT studies. CT diagnosis of neoplastic involvement of facial nodes is based on the presence of a nodular lesion which lies along the lymphatic pathways of the primary neoplasm in an anatomically compatible location. CT diagnosis of facial nodes is very important for treatment planning if the nodes are deep or at a distance from primary cancer. This is especially true for retrozygomatic and buccinator nodes.     

Face lift without preauricular scars

A subperiosteal rhytidectomy is described that corrects aging of the forehead, the orbital region, the nasolabial fold, and the cheeks. It substantially improves muscular tone, consistency of subcutaneous tissue, and projection of malar volume. Its use with proper preoperative evaluation of the grade of facial aging reduces the indication for preauricular incision.     

Kaposiform haemangioendothelioma associated with Kasabach-Merritt syndrome

PURPOSE: This report evaluates the efficacy of the modified supratrichial brow lift technique. The indications for the procedure, as well as the advantages, effectiveness, and complications are reviewed. PATIENTS AND METHODS: Thirty-six modified supratrichial brow lift procedures were performed bilaterally on 34 female and two male patients. The procedure was used in conjunction with a blepharoplasty in 32 patients and alone in four patients. RESULTS: The procedure improved the cosmetic result in the 32 patients with lateral brow ptosis who had a concomitant upper eyelid blepharoplasty. No complications were encountered. CONCLUSION: The modified supratrichial brow lift can improve the cosmetic result in patients with lateral brow ptosis undergoing an upper eyelid blepharoplasty.     

A virtual reality system for bone fragment positioning in multisegment craniofacial surgical procedures

This article reports our clinical experience since 1994 with rigid-motion tracking of bone fragments during craniofacial surgical procedures, using a virtual reality approach. Three noncollinear infrared diodes are fixed to the skull base. A pointer is used to register anatomic features on the patient to those on the computerized tomography-based model of the patient within a computer work station. Three diodes are then attached to each fragment just before the osteotomy is completed. Rigid motions of the fragment are thus tracked and reported to the surgeon by using virtual reality techniques. Errors in fragment positioning are reported both graphically and numerically with respect to a precomputed optimum fragment position. This guidance system allows multisegment midface osteotomies to be performed more precisely. The main problems encountered so far have been devascularization-infection and difficulties in maintaining correct position during application of rigid fixation. Devascularization-infection problems have been addressed by minimizing surgical exposure of the bone. Soft-fixation plates and temporary Kirschner wire fixation have helped with intermediate positioning, but an intraoperative mechanical positioning device would be useful in the future.     

Antiviral activity of FA-11H on the infectivity and replication of herpes simplex virus type 1 in cultured cells

A prominent malar complex results in a triangular facial shape. When combined with a prominent mandibular angle, the face appear to be aggressive and masculine. Surgical procedures to correct these features are commonly requested by Asian women. Baek introduced reduction malarplasty by under-positioning of the "osteotomized" zygoma. We modified Baek's procedure by sliding the osteotomized zygoma superoposteriorly. The posterior surface is not separated from the soft tissue to preserve the blood supply to the zygoma. Ten patients with prominent zygomas underwent reduction malarplasty from March 1994 through July 1996. Seven patients were female and 3 patients were male. All patients were satisfied with their results. A symmetrical appearance was achieved in all patients. This method provides for precise malar reduction under good exposure. Symmetry of the zygoma is easily achieved. There is no effect on the survival of the malar bone after the procedure because the osteotomized zygoma has its own blood supply on the posterior surface. The masseteric origin is preserved, which ensures minimal cheek drooping after reduction.     

Malar augmentation by osteotomy and advancement

We developed a modification of Tessier's zygoma plasty to increase anterior and lateral projection of the malar eminences in 8 patients with malar hypoplasia. The four steps of our modification are: (1) access solely through an intraoral upper sulcus incision; (2) osteotomy of the inferior orbital rim at a more medial site and of the lateral orbital rim more cephalad; (3) careful preservation of both the zygomaticomaxillary buttress and the zygomatic arch; and (4) use of a cranial bone graft alone, as a wedge, to stabilize the rotated zygoma, without the need for plate or screw fixation. Eight patients have undergone this procedure. Follow-up ranged from 4 to 15 months. There have been no complications. All 8 patients have achieved excellent accentuation of their malar eminences, with maintenance of symmetry. The increase in malar eminence projection has improved overall facial form in these patients. The modified Tessier zygoma plasty offers a stable and predictable technique for improving facial form. It provides a very natural correction for deficient malar projection, without introducing visible scars.     

Feasibility of collecting disease reports from relatives for genetic epidemiologic investigations

BACKGROUND: For many years, the treatment of facial wrinkles has been performed exclusively by dermabrasion, chemical peeling, or surgical face lifting. However, the recently introduced carbon dioxide lasers which emit ultrashort coherent light beams enable the cosmetic surgeon to ablate superficial epidemic layers with absent or very limited side effects. The purpose of this paper is to compare laser skin resurfacing with classical face lifting and discuss the potentials and limitations of each method. METHODS AND PATIENTS: Three patients suffering from facial wrinkles on photoaged skin were treated with the ultrapulsed CO2 laser (UltraPulse 5000 C; wavelength 10,600 nm, pulse duration 0.6 to 0.9 ms, maximum pulse energy 500 mJ). This laser guarantees vaporization of very thin superficial skin layers without scarring and with minimizing lateral thermal injury due to extreme short pulse duration. A special handpiece (CPG) permits an exact approach and a bloodless ablation of relatively large areas of facial skin. The fourth patient underwent a surgical face lift due to the depth of wrinkles. RESULTS: Excellent cosmetic results were achieved in all three patients with superficial wrinkles who were treated by laser skin resurfacing. When treating deeper wrinkles, e.g., glabella or nasolabial fold, the surgical face lift is the preferred method. CONCLUSION: Ultrapulsed CO2 laser treatment expands the therapeutic options for superficial facial wrinkles, especially for perioral, periorbital, forehead, and cheeks wrinkles. It proves to be a safe and effective method with very limited if any side effects. Nevertheless, deeper wrinkles are still a domain of the classical face lift. The combination of both methods may improve the overall outcome in the future.     

Wide polytef (Gore-Tex) implants in lip augmentation and nasolabial groove correction

OBJECTIVE: To describe a new technique of polytef (Gore-Tex) implantation into the upper and lower lips and nasolabial grooves by using large implants as a method that achieves effective cosmetic improvement. SETTING: A private cosmetic surgery center. PARTICIPANTS: Thirty-three (female) patients who desired fuller lips and 62 patients (52 female and 10 male) who requested less prominent cheek lip grooves. MAIN OUTCOME MEASURE: Significant patient satisfaction after 12 to 54 months. RESULTS: Conspicuous aesthetic effect that related to both lip and nasolabial groove correction was documented. All patients but 4 (2 in each group) were pleased with the final outcome of the treatment. CONCLUSIONS: In the opinion of the authors, the threading technique of polytef implantation creates inconspicuous improvement-both in lip augmentation and nasolabial groove correction. Large polytef implants that were inserted through a tunneling technique produced consistently good results. Implants (lip augmentation: width, < or = 10 mm, and thickness, 4 mm; nasolabial groove correction: width, 8 mm, and thickness, < or = 8 mm) were found to be safe, simple, and effective.     

Repositioning a slumped person in a wheelchair. A biomechanical analysis of three transfer techniques

The purpose of this study was to determine the effect of three lifting techniques (unassisted lift, vertically assisted lift, and horizontally assisted lift) and two patient masses (65 kg and 75 kg) on loads acting on the lifter's spine when repositioning a wheelchair bound patient to a more upright sitting position. A static biomechanical model was used in conjunction with ground reaction force and videographic data to estimate compression and shear forces at the lumbosacral (L5/S1) joint. Results indicated that: L5/S1 compression forces associated with both unassisted and assisted transfers were of sufficient magnitude to warrant mechanical assistance; the two person technique with the assistant pushing the legs toward the back of the chair was associated with the lowest spinal loads; and L5/S1 compression forces were significantly greater for the vertically assisted lift compared to the unassisted lift. If a manual transfer is to be performed, the horizontally assisted lift is recommended to minimize loads on the lumbar spine of the lifter.     

Paranasal implants for correction of midface concavity

Central midface concavity was corrected with the placement of porous polyethylene implants in the paranasal area. This simulated the effect of skeletal osteotomies and advancement without altering dental occlusion. Implants were placed to correct congenital, posttraumatic, and cleft-related skeletal midface retrusion in nine patients. In seven of the patients, paranasal augmentation was performed in conjunction with rhinoplasty. There have been no implant-related complications during a mean 33-month follow-up (range 5 to 83 months). Screw fixation of these implants ensures stable positioning and allows precise final contouring during surgery.