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Correction of the Wide Nasal Base

The Problem Wide alar base: aesthetically over-large sill and/or excess alar curve. The Background The widened alar base is a common anatomical variation that is often addressed in the routine rhinoplasty to address aesthetic changes for improving the overall appearance of the nose. These are basically involved with two distinct anatomical structures that are addressed surgically to reduce the widened nasal base. They are the nostril…

Alar Preservation Rhinoplasty

The Problem Traditionally, the resection of the cephalic portion of the lateral crura of the alar cartilages has been performed to improve the shape and rotation of the nasal lobule. However, this maneuver frequently leads to aesthetic and functional scar-induced sequelae. This chapter explains how to obtain the aesthetic and functional goals with maximum preservation of the alar cartilages and fewer possibilities of negative consequences. The…

Cephalic Malpositioning: Use of Alar Contouring Grafts

The Problem Cephalic malpositioning of lateral crura. The Background Tip refinement is one of the most demanding aspects of rhinoplasty. The tip is a tripod-like structure, of which the left and right lateral crura are the main two pillars. Lower lateral cartilages are vary extremely in configuration, inclination, and contour, and play a fundamental role in nasal function and aesthetics. From the craniocaudal view, the appropriate…

Reductive Rhinoplasty

The Problem Reductive techniques have become a mainstay in aesthetic rhinoplasty. Most commonly, reduction techniques are applied to the bony and cartilaginous dorsum, septum, and lower lateral cartilages. In this chapter we will discuss specifically reductive techniques to assist with tip rotation and refinement. The appropriate cephalic position and rotation are generally associated with an aesthetic nose and a youthful appearance. Nasal tip underrotation or ptosis…

Tip Rotating in a Droopy Tip: Endonasal Approach

The Problem Droopy tip with crowding of upper lip and elongated nose. The Background A droopy tip is one of the most common motivations for an aesthetic rhinoplasty. Drooping may be defined as a nasolabial angle of less than 90 degrees. In clinical practice this angle may be difficult to measure, because a curved transition of the upper lip profile to the columella. As for the…

Tongue-in-Groove Technique

The Problem 1. Caudal septal deviation 2. Excess columellar show 3. Ptotic nasal tip The Background The tongue-in-groove (TIG) maneuver is an adaptation of previously described techniques. In 1934, Rethi described elevation of the septal membranes along the septal angle and caudal septum and securing the exposed septum between the medial crura in order to prevent nasal tip ptosis. In 1950, Fred described the “invaginating technique”…

Tongue and Groove Technique for Nose Elongation

The Problem Elongation of the short nose adds to the complexity of the rhinoplasty. Presented in this chapter is an extremely reliable technique of nose elongation with or without alteration of the projection. The Background Many techniques have been introduced for nose elongation, all of which were tried by the author with limited success. Septal extension grafts are notorious for instability, including rotation, overlap causing loss…

Dynamic Adjustable Rotational Tip Tensioning Technique

The Problem A deprojected and superiorly rotated nasal tip complex with nasal valve collapse. The small or overresected nose. The Background Arden and Crumley described the history of structural grafting in rhinoplasty. In 1951, Foman et al. described a columellar strut to project the medial crura forward. Sheen popularized spreader grafts as a method of reconstruction of the internal nasal valve and recontouring the aesthetic appearance…

Conjoined twins

Introduction Conjoined twins are amongst the most uncommon, complex, and uniquely challenging patients to be cared for by plastic and reconstructive surgeons. A multidisciplinary team approach is paramount in the care of conjoined twins, and plastic surgery involvement is critical given the absolute necessity of adequate soft-tissue coverage at the time of operative separation. The advent of tissue expansion and advances in anesthetic and intensive care…

Pediatric tumors

Synopsis ■ Congenital masses: ■ Branchial cleft anomalies are congenital remnants of the branchial arches, pouches, or grooves found in the cervical region. ■ Dermoid cysts are present from birth and consist of both ectoderm and endoderm. They commonly arise in the head and neck. They can grow large to compress adjacent structures. Different types include nasal dermoids, intradural dermoids, extra-angular dermoids and dermoid cysts of…

Pediatric chest and trunk deformities

Access video content for this chapter online at Elsevier eBooks+ Introduction Pediatric chest and trunk wall abnormalities are oftentimes congenital in nature, however a significant portion of our expertise as plastic and reconstructive surgeons is utilized to solve problems that arise as a consequence of surgeries performed for other congenital anomalies. Because of this, reconstruction of the pediatric chest or trunk deformity frequently requires coordination with…

Vascular anomalies

Synopsis ■ Vascular anomalies are divided into tumors or malformations. ■ Vascular tumors are comprised of proliferating endothelium; the endothelial lining of malformations is more quiescent. ■ Infantile hemangioma is the most common tumor of infancy; it grows rapidly after birth and involutes during childhood. ■ Most infantile hemangiomas are observed; problematic lesions are treated pharmacologically or by resection. ■ Vascular malformations are present at birth,…

Congenital melanocytic nevi

Synopsis ■ Congenital melanocytic nevi (CMN) are composed of clusters of nevomelanocytes that are generally present at birth but occasionally arise as late as several years of age. These lesions arise from melanocytic stem cells that migrate from the neural crest to the embryonic dermis and upward into the epidermis. They may also migrate into the leptomeninges. ■ Although the bulk of these lesions are small…

Treacher Collins syndrome

Synopsis ■ Treacher Collins syndrome (TCS) is characterized by a facial dysostosis with an incidence of 1 to 9 per 100,000 live births ■ Dysmorphology is isolated to the craniofacial region with variable presentation ■ Successful treatment requires a specialized interdisciplinary team to meet all the needs of a patient with TCS ■ The chapter presents the results of a systemic literature review of the treatment…

Robin sequence

Synopsis ■ Robin sequence (RS) is a clinical triad consisting of glossoptosis, retro- or micrognathia, and airway compromise. RS is often associated with clefting of the secondary palate. ■ RS can be an isolated entity or found in association with many syndromes, most commonly Stickler syndrome. The spectrum of associations is broad, and multidisciplinary evaluation and management are necessary. ■ Respiratory abnormalities and feeding difficulties are…

Idiopathic progressive hemifacial atrophy

Synopsis ■ Initially described in the writings of Dr. Caleb Hillier Parry. ■ Exact etiology of PHA is not well understood, but is felt to have a strong autoimmune and neurogenic component. ■ The initial clinical manifestations include both cutaneous findings and subcutaneous atrophy. ■ Other forms of lipoatrophy are usually not localized to the face. ■ Extracutaneous manifestations are common and should be screened for…

Craniofacial microsomia

Synopsis ■ Patients with craniofacial microsomia (CFM) require the care of a skilled multidisciplinary clinical team. ■ Phenotypic features of CFM are highly variable. While the three structures most affected include the ear, mandible, and maxilla, abnormal development can occur in any of the derivatives of the first or second branchial arches. ■ Clinical evaluation of patients with CFM must include assessment for obstructive sleep apnea…

Neurosurgical and developmental issues in craniosynostosis

Introduction Cranial sutures are patent at birth and serve as the major sites of expansion in the skull during early brain development. Typically 400 g at birth, the brain doubles in size by 6 months and triples by 2.5 years. Although it reaches 90% of its adult size by age 6, the brain progressively expands throughout childhood and adolescence, with total cerebral volume peaking by 14.5…