Jorge Orlando Guerrissi

The palpebral border reconstruction constitutes a real challenge for plastic surgeons. The loss of palpebral tissues can be a consequence of congenital malformation, tumor resection, or traumatic injury. Not only the skin but also the tarsus, the conjunctival layer, and the eyelashes can be affected. The palpebral borders have an important function in ocular and corneal protection because of their tissue thickness and because the eyelashes act as a “hair barrier.” The aesthetic aspect is also very important because the anatomical discontinuity of the palpebral border produces an unaesthetic coloboma that cannot be camouflaged. Although many surgical techniques have been described for palpebral reconstruction, none of them achieves a reliable and specific reconstruction of the border according to aesthetic and functional considerations.1 Triangular border resection and end-to-end closure can be successful if the loss of palpebral border is less than one-third the length; however, when the tissue loss is more than one-third, it is necessary to use other surgical techniques. Usually, current flaps for lid reconstruction are also used for border repair. In the world medical literature, there is no description of a specific surgical technique for lid border reconstruction. In this article, a new surgical technique for palpebral border reconstruction is described using skin, orbicularis oculi muscle of the upper lid, and hairs of the eyebrow. This skill constitutes a modern indication of the upper lid musculocutaneous flap,2,3 permitting development of a hair-bearing island flap to repair different losses of upper and lower border lids. From 1988 through 2001, at the Plastic Surgery Department of Argerich Hospital, Buenos Aires, Argentina, 22 patients with loss of tissue in the border of the upper and lower lids underwent reconstruction using an upper lid musculocutaneous island flap. Six were male patients and 16 were female patients, with an average age of 28 years. The main causes were resection of malignant tumors in 14 patients (64 percent), congenital coloboma in four patients (18 percent), traumatic injury in three patients (14 percent), and necrosis postinfection in one patient (4.5 percent). Squamous cell carcinoma was found in four of the 14 patients (29 percent), basal cell carcinoma in nine patients (64 percent), and adnexal carcinoma in one patient (7 percent). In all patients, only one lateral pedicle was used; island flaps were basically composed of skin, subcutaneous fat, and orbicularis oculi muscle. In 20 patients (91 percent), the lowest lines of the hair eyebrow were included in the island flaps; in the other two cases, they were not. In 16 patients (73 percent), the reconstruction was performed in the border of the upper lid; in the other six (27 percent), in the lower lid. In all 22 patients, the conjunctival reconstruction was performed with undermining of the palpebral conjunctiva. A 45-year-old woman presented with a pigmented squamous cell carcinoma in the middle of the border of the upper lid (Fig. 1). Surgical tumor resection left a wide palpebral and border defect measuring 1.3 cm × 6 mm, including the eyelashes. A lateral pedicled upper lid musculocutaneous flap including hairs of the eyebrow was raised and sutured into the defect; the conjunctival layer was reconstructed by fornix undermining (Fig. 2). One year after the operation, an excellent aesthetic and functional result was obtained (Fig. 3).

A dermoid cyst is a tumor frequently located in the external third of the fronto-orbital region. It develops along the line of embryonic fusion of the naso-optic groove, infolding the ectoderm during embryonic development. The classic treatment is complete surgical resection by means of an external approach on the dome of the cyst; consequently, a visible scar is a permanent esthetic sequel. At present, a new technique for the resection of these cysts by means of endoscope-assisted surgery through one or two small incisions behind the front headline is described. The surgical endoscopic technique is made through three main steps: incision, exposure of the cyst, and removal of the cyst. Eighteen patients were operated on from 1999 through 2001 at the Plastic Surgery Service of Argerich Hospital in Buenos Aires, Argentine. In all 18 patients, local anesthesia was used and no peri-operative complications were observed; postoperative control showed minimal edema, and analgesics were not necessary. Sixteen patients (90%) were controlled 2 years after surgery, and no recurrence was detected. The advantages of endoscopic resection may be summarized as follows: 1) a small and occult hair incision; 2) better visualization and a magnified view of the dissected areas, with the result that injury of important anatomical structures can be easily avoided; and 3) the absence of a facial scar in young patients.

Despite the availability of efficient tear substitutes, many patients with dry eye syndrome experience severe corneal injuries and a subsequent loss of vision. Surgical techniques using mayor salivary glands to provide a substitute for tears have been reported; with this technique the drainage of saliva goes into the conjunctival fornix, permitting corneal and conjunctival humidification. The authors describe a new surgical approach in which minor salivary glands are autotransplanted into the conjunctival fornix by means of a graft of the intraoral mucosa-transporting salivary glands. This approach was used in a 56-year-old woman with a 2-year history of refractory and pharmacologically untreatable dry eye syndrome caused by Sjögren’s syndrome. The right eye had more severe corneal and conjunctival lesions than did the contralateral one, so the treatment was planned in the right eye only. A weekly follow-up during the first 6 months confirmed the significant improvement of dry eye symptoms in the surgically treated eye. Three months after surgery, a biopsy was performed in the minor salivary gland graft, and the histologic findings revealed the presence of glandular acinus, duct with mucin content, and lymphocyte infiltration. The significant improvement obtained in this patient suggests that the secretion from the grafted salivary minor glands was better in promoting homeostasis of the ocular surface than are artificial tears. This may be explained by: (1) The lacrimal and salivary secretions contain biologically active constituents that may protect from infection and promote normal growth epithelium; (2) The secreted mucin is thought to coat the epithelial surface, reducing the high surface tension of the eye wetted by aqueous tears; (3) The thick secretions of the minor gland might act in reducing the evaporation of the underlying tear layer and form a hydrophobic barrier along the lid margin that can retain the lid margin tear string and prevent its flow onto the skin. Minor gland salivary autotransplant is a new surgical technique with effectiveness demonstrated in one patient, but the scientific explanation is not clear; additional experience with more cases could confirm the initial success.

J. M. Converse described the scalping forehead flap in 1942 with the aim of using it in total nasal reconstruction. A rich net of arterial and venous vessels constitute the basic pattern of its blood supply through three principal pedicles: (1) temporal superficial, (2) supraorbital, and (3) supratrochlear. It was described for nasal reconstruction, but due to its characteristics, such as color of the frontal skin, texture, hairless skin, and reliable irrigation, it can be used in the reconstruction of other facial areas. According to these particularities, the Converse flap was used in the reconstruction of a total left lower lid and adjacent lateral nose and cheek areas in a patient with an extended squamous carcinoma. The tumoral resection included the removal of (1) complete lower lid, (2) lacrimal lower canaliculus, sac, and nasolacrimal duct, (3) lower ocular conjunctiva, (4) intraorbitary fat and both inferior oblique and inferior rectus muscles, and (5) adjacent skin of the nose and cheek. Postoperative controls showed an excellent aesthetic and functional result. A hypochromic frontal skin graft was the only sequela; definitive skin coloration was obtained by a dermopigmentation technique. The versatility of this forehead flap allows it to be successfully used for reconstruction not only in the nasal area but also in other facial ones.

Closed versus open reduction in condyle fractures is a dilemma that may torment the plastic surgeon. Although at present it is accepted that there are fractures that must be open reduced as when the middle cranial fossa or temporal fossa are involucrated, foreign body are in the joint capsule, lateral extracapsular deviation of condylar deviation, and open fractures. Risdon or retromandibular approaches are used for the treatment of fractures in the condyle neck and superior third of the lower ramus. When both approaches are used the correct placement of screws is very difficult for the following reasons: 1. Both drill and screwdrivers must be placed in an oblique direction to the bone surface; as a result, screws do not press the plate toward the bone and therefore a deficient stabilization results; 2. A distraction of too much soft tissue entrapped between the skin and mandibular bone is necessary for a good visual to surgical field and 3. The parotid tissue, the masseter muscle, and the facial nerve must be strongly distracted facilitating the nerve injury. A transcutaneous transparotid approach is the most appropriate for screws placement. By means of transbuccal set it is possible to reach the mandibular bone going through both the parotid tissue and the masseter muscle avoiding the injury the branches of the facial nerve. A case report illustrates the practical application of the above technique and it shows that as the lesion of branches of the facial nerve can be avoided.

The recent advent of endoscopic procedures has compelled both plastic and neck and head surgeons to reconsider the conventional methods by which the excision of cervical congenital cystic is classically achieved. An endoscopic approach for excision of the cervical congenital cystic is described. This procedure is anatomically safe and can be made with minimal morbidity through a small transcervical incision. Both specific instruments and solid anatomical knowledge are necessary to perform a safe and efficient cystic endoscopic excision. The essential surgical steps are as follows: 1. Minimal incision placed in natural cervical wrinkle over the dome of the cyst; 2. Intracystic or extracystic dissection; 3. Identification and protection of the sternocleidomastoid muscle, spinal nerve, hypoglossi nerve, and posterior belly of digastric muscle; 4. Careful dissection of the posterior surface of the cyst, avoiding injury on the carotid vessels and internal jugular vein. Eight patients were operated on with this technique and they were very pleased with postoperative comfort and aesthetic results. Inconspicuous scars and no complications were registered. With advanced endoscopic instruments and the development of new surgical technique and surgeon experience, the endoscopic surgery can be the method of choice in cervical excision of branchiogenic cysts.

The recent advent of endoscopic procedures has compelled both plastic and neck and head surgeons to reconsider the conventional methods by which the excision of submandibular gland is classically achieved. An endoscopic intraoral approach for excision of the submandibular gland is described. This procedure is anatomically safe and can be made with minimal morbidity; a transcervical incision is avoided. Both specific instruments and solid anatomical knowledge are necessary to perform a safe and efficient glandular endoscopic excision. The essential surgical steps are as follows: 1) Careful identification of the Wharton duct and lingual nerve; 2) Retraction of the mylohyoid muscle; 3) Protection of the sublingual gland and lingual nerve; 4) Extraoral manipulation of the submandibular gland obtaining intraoral protrusion; and 5) Careful dissection of the posterior third of gland, avoiding injury on the facial artery and vein. Two patients were operated on with this technique and were very pleased with their results. No complications were registered. With advanced endoscopic instruments, new surgical technique, and surgeon experience, endoscopic intraoral excision of the submandibular gland can be the method of choice in benign neoplasia, sialolith, sialoadenitis and plunging ranula.

Closed and open reduction of fractures of the mandible constitutes an endless debate, and it is interesting that modern times have not brought a conclusion to this controversy. From 1995 to 1997 in the Plastic Surgery Department of Argerich Hospital in Buenos Aires, Argentina, 23 patients were evaluated with different fractures of the mandible in which neither closed nor open reduction was performed. Seventeen patients (74%) presented associated fractures in different areas of the mandible and 6 (26%) only had one fracture; 2 of them (9%) were edentulous. Three (13%) of the 23 patients had more than two fractures in different areas. Condylar fractures were the only lesion in 8 patients (35%), and they were associated with body fractures in another 6 patients (26%). Spontaneous healing of the fractures occurred in all 23 patients. No complications were found in any of them. All fractures presented the following characteristics: 1) Fractured fragments were aligned without displacement (or light displacement), 2) Occlusion was normal (or pretraumatic occlusion), 3) Facial symmetry was maintained, 4) Radiography demonstrated fractures without displacement, 5) Minor edema and hematoma were present in the area of the fracture, and 6) There was only pain during masticatory movements. The treatment was as follows: 1) Soft food and liquid diet (solid food was avoided 30 days after trauma), 2) Opening of the mouth was not permitted, 3) Oral antibacterial cleaning, and 4) Analgesic therapy. Spontaneous healing was produced by secondary bone repair mechanism as a "natural" process.

Aesthetic changes in the aging upper lip constitute a troublesome problem for modern women. During the process of aging, the following alterations appear in the upper lip: (1) vertical wrinkles, (2) reduction in height of the vermilion border along with lengthening of the skin area of the lip, and (3) “disappearance” of the Cupid's bow. In 1993, Guerrissi and Sanchez described a surgical technique that allowed them to correct the effects of these senile changes in 19 patients. With the use of this surgical technique, a strip of skin on the vermilion border was deepithelialized. The remaining dermal flap was buried in the pocket, which was performed by undermining the superior third of the skin of the upper lip. The short-term results were satisfactory, although a slight reduction in height of the vermilion border and a decrease in the thickness of the lip were observed in five patients (26 percent) 4 years postoperatively. Beginning in 1994, the authors began using a new approach combining dermal flap reshaping with simultaneous lip augmentation using dermal-fat grafts, Gore-Tex (W. L. Gore and Associates, Flagstaff, Ariz.) or AlloDerm (LifeCell Corp., Branchburg, N.J.). No serious or definitive complications were observed. Scars on the vermilion border were not conspicuous. A peel was necessary at the same time for complete elimination of rhytids. With this method, both the patients and the surgeons were satisfied with the results. (Plast. Reconstr. Surg. 106: 938, 2000.)

The purpose of this investigation was to evaluate the degree of efficacy of eliminating crow’s feet by means of direct injection of botulinum toxin A into orbicularis oculi muscles under direct surgical vision during either blepharoplasty or face lift operations. Eighteen patients were injected with Botox A-14 in each orbicularis oculi muscle. Dilution was obtained by adding 4 ml of preservative-free saline to 100 IU of Botox A. Doses ranged from 15 to 50 IU in each muscle, varying according to the severity of wrinkles and intensity of muscle contraction. In 10 patients (56 percent), the Botox was injected throughout the outer surface of both orbicularis oculi dissected during a face-lift operation. In eight other patients (44 percent), the toxin was injected into the inner surface of both orbicularis oculi exposed during classic blepharoplasty procedures. Most authors have demonstrated that the effect produced by transcutaneous Botox lasts between 4 and 6 months; the paralysis obtained by direct muscular injection was effective for 9 months in 14 patients (78 percent) and 10 months in the other 4 patients (22 percent). Results were documented by means of preinjection and postinjection photographs, videotapes, and electromyographs. Neither local nor general adverse effects were noted. The improvement obtained in crow’s feet was satisfactory to the patient and to us. The use of Botox intraoperatively permitted at the same time not only the treatment of crow’s feet by paralysis of orbicularis oculi muscles but also the correction of senile changes in the lids and face by means of either blepharoplasty or face-lift operations.