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The causes of the short nose deformity vary greatly, from congenital malformations to acquired deformities. Despite this degree of variation, key commonalities exist, namely, a shortened nasal length, overrotation of the nasal tip, and increased nostril show. This article is designed to help the reader identify precise causes of the short nose, outline associated anatomy, and discuss reliable surgical techniques to correct this deformity.

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.

Dr. Coleman: The first patient is a 33-year-old woman with acne scarring of her cheeks. She complains that her face is too skeletal after a lower lid blepharoplasty (Figure 1). She may have had her buccal fat pads removed, and she is most bothered by the ice-pick scars and hollowing of her buccal cheeks. She believes her tear trough is a little bit more noticeable since her blepharoplasty. Dr. Hobar, how would you approach treating this patient? Figure 1 This 33-year-old woman with a history of acne scarring and lower lid blepkaroplasty complains of hollowness of the buccal cheek and lower eyelids. Dr. Hobar: She does have a very chiseled look. To fill out the cheek, I would use autologous fat injection. The deeply pitted acne scars could be excised individually. She could also possibly be a candidate for laser, depending on her skin type. Dr. Coleman: Dr. Terino, how would you approach treating the patient? Dr. Terino: An implant could be used to extend the fullness below the lower border of malar bone down into the submalar region probably 2 to 2.5 cm. That would give the impression that the fullness of her midface extends almost down to the lateral commissure of the mouth, at least on the anterior view. Around the commissure, fat injections might be appropriate. Or I might use fat in the buccal space, which may be a more favorable recipient site for fat than the subcutaneous plane. I have injected autologous fat directly into the buccal space, and even into the masseter muscle from inside the mouth. The sub-orbital problem the patient complains about is not very apparent on the photographs. However, a suborbital implant in the area of the tear trough, and maybe a midface suspension would improve that region. I have recently seen evidence that …

Differences between round and anatomic breast implants and the effects of each implant shape on the shape of the breast following augmentation have been a subject of considerable discussion during the past two years. In this article, the authors present their interpretation of data that conflicts with a previous published study and indicates significant differences between round and anatomic implants.

Hydroxyapatite is a biocompatible alloplast with the same chemical composition as bone. It is readily incorporated into host bone, does not undergo appreciable resorption, does not incite a clinically significant foreign body reaction, and resists infection. This article describes forms of hydroxyapatite, procedures for use, and clinical examples.

A retrospective review was undertaken of 126 consecutive craniofacial procedures involving a transcranial component, performed at the Children's Medical Center at Dallas, between 1990 and 1994. Standard postoperative axillary temperature measurements were recorded until discharge. Age at surgery of less than 24 months correlated very strongly with a postoperative temperature of greater than 38 degrees C (r = -0.92). The incidence of postoperative fever was high in all age groups, yet there was still a significant difference between the group younger than 2 years and the group in which surgery was performed after the age of 2 years across all postoperative temperature ranges, from >38 degrees C to >39.5 degrees C (p < 0.001, chi-square test). The white blood cell count was elevated above the age-related normal in 67 percent of febrile patients. There was no correlation between type or duration of surgical procedure, length of intensive care or hospital stay, or the need for blood transfusion and the development of a significant postoperative fever. There were minor infectious complications in four patients (3 percent), only one of which was a wound problem related to the surgery. All infectious complications were easily identifiable clinically. There was no mortality or serious infections. The development of postoperative fever, and an elevated white blood cell count, is to be expected in pediatric patients undergoing craniofacial procedures. The routine laboratory investigation of postoperative fever in pediatric craniofacial patients under 2 years of age without procedures involving transgression of the paranasal sinuses is not warranted unless there are associated clinical indicators.

Lengthening the short nose is a challenging area of rhinoplasty. The short nose can be a naturally occurring aesthetic disproportion, or the result of a congenital abnormality or traumatic deformity. The surgical approach depends mostly on the quality of the lining, skeleton, overlying skin, and the amount of correction desired.

In this case report of an unusual presentation of a metastatic pheochromocytoma as a large jaw mass, the anesthetic management of the resection of a vasoactive tumor in close proximity to the airwa...

The wide variety of craniofacial malformations makes classification difficult. A simple classification system allows an overview of the current understanding of the causes, assessments, and treatments of the most frequently encountered craniofacial anomalies. Facial clefts and encephaloceles are reviewed with respect to their diverse causes, pathogenesis, anatomical features, and treatments. Approaches to the surgical treatment of these conditions are reviewed.

The immature guinea pig was used to study the effects on growth of porous granular hydroxyapatite used as an onlay cranioplasty and inlay cranioplasty. to reconstruct full-thickness cranial defects in a growing craniofacial skeleton. Forty Hartley guinea pigs, 20 immature animals and 20 mature animals, were divided into four groups each containing five mature and five immature animals. The mature animals served as controls. Group I underwent elevation and replacement of the parietal periosteum. Group II underwent placement of hydroxyapatite between periosteum and parietal bone. Group III underwent elevation and replacement of autogenous bone flap after the formation of a 1 X 1-cm craniectomy defect in the parietal skull. Group IV underwent elevation of a 1 X 1-cm parietal craniectomy and reconstruction of the defect with hydroxyapatite granules placed between the dura and periosteum. Immature animals were killed at maturity at 3.5 months and mature animals were killed 2.5 months postoperatively. Macroscopic examination of the operative field, transverse and longitudinal cephalometric measurements, and histological sections encompassing the operative sites were compared. Macroscopically, all reconstructed operative sites were fully incorporated into the cranium. Histological staining of the sectioned operative site revealed no hydroxyapatite migration through the cranial bone or dura. No inflammatory or foreign body reaction was evident in the subcutaneous tissue, periosteum, or dura. No statistically significant cephalometric intergroup or intragroup differences were found at the conclusion of the study. The results of this study indicate that a granular porous form of hydroxyapatite may be used as an onlay or inlay cranioplasty in the immature guinea pig craniofacial skeleton without evidence of dural inflammation, granule migration, or growth restriction or retardation.

Tissue expansion in children has been associated with complication rates of 20 to 40 percent. A critical analysis of 6 years' (1988-1993) experience with 180 expanders placed in 82 consecutive children was performed to identify those factors which predispose to complications. Major and minor complications each occurred in 9 percent of patients. The factors associated with a statistically significant increase in complications were burns and soft-tissue loss, patient age under 7 years, use of internal expander ports, and a history of two or more prior expansions. In addition, complications were significantly more likely to occur within the first 90 days than during any subsequent expansion. Factors that did not influence complication rate included patient gender, wound drainage upon expander insertion or removal, intraoperative use of antibiotic irrigation, number of expanders placed, use of customized expanders, and operating surgeon.