Cranio NY Blog
CranioNY is the blog of New York Craniofacial and Plastic Surgeon, Dr. Nicholas Bastidas.
The lips are the center of facial expression and reconstruction requires a thorough understanding of the anatomy. The upper lip is in the shape of a bow, and has a central fullness known as the tubercle. The depression above the center of the is known as the philtral dimple.
Plastic surgeons are often consulted for lip reconstruction for post-ablative tumor resection and for trauma. The reconstruction may consist of moving adjacent lip tissue and elements of the cheek to achieve a functional and aesthetic lip.
An ablative or non-ablative laser maybe used for removing lesions and for skin resurfacing.
Torn Ear Lobes
Heavy earrings worn for long-term can lead to stretching of the holes and sometimes complete tears of the earlobe. Torn ear lobes can be easily repaired under local anesthesia and the ears can be pierced again after 3-6 months.
Defects of the ear resulting from trauma or skin cancer may require extensive reconstruction of the cartilage and skin of the external ear. These reconstructions are typically performed in one or two stages.
Microtia –(small or absent ear)
Malformation of the external ear may require complex reconstruction requiring the use of cartilage from the rib. This reconstruction is usually postponed until a minimum age of eight to allow for growth of the rib cage. A new ear framework is sculpted from the cartilages and buried underneath the skin where the new ear is to be created. Approximately three months later the “new ear” is elevated from underneath the skin and grafted to create the “normal” projection. Prosthethics are also available, however, are prone to fall off and degrade requiring expensive replacements. The cartilage sculpted ear is the preferred “permanent” reconstruction recommended by most plastic surgeons and are more resistant to infections than synthetic ears.
Large ears may also be reduced using techniques involving removal of skin and cartilage. Scars are placed in the shadows of the ear creases to conceal any evidence of surgery.
Trauma from motor vehicle accidents and infection may often leave large defects in the skull creating significant irregularities and deformities in the scalp. Working with Neurosurgeons, Plastic Surgeons can utilize bone grafts, titanium or plastic implants to recreate the normal contour of the skull and protect the underlying brain. Tissue expanders (balloons) may need to be placed to stretch the scalp skin to accommodate the implant prior to the final reconstruction. Customized implants may be used designed based on 3D CT scans to personalize your reconstruction needs.
Chin projection is important in the facial profile, and the lack of adequate projection can lead to a sagging neck and the appearance of a larger than normal nose. The projection can be augmented using either a silicone implant or by cutting and moving the chin bone anteriorly. A small incision inside the mouth or under the chin can be used to achieve either purpose. Through a similar approach, removing the prominent bone can reduce a large chin.
Vascular malformations are abnormal growths of either arteries, veins, lymphatic vessels and capillaries. Port wine stain (see photos), is a capillary malformation, and may affect a significant area of the face. Capillary malformations may be more receptive to laser surgery treatment, though many laser procedures are often required to see a benefit and relapse is unfortunately common.
Arterial malformations are often pulsatile and can be very difficult to treat as recurrence is common. Surgical therapy is often combined with sclerotherapy (injections to clot off the feeding vessels) to help shrink the malformation and possibly reduce surgical bleeding.
A hemangioma is a benign vascular tumor that may be present at birth or appear shortly after birth. It may grow rapidly from a small pin sized red dot to a large mass (tumor) during the first few months of life. The tumors are composed of small blood vessels (capillaries) that may ulcerate causing pain or may even bleed. Most fade away to a fleshy colored fatty mass in later childhood (5-7yrs old) but often require surgical excision to improve the contour of the affected area. Medical treatment may involve a medication called propanolol to induce regression in areas where surgical treatment is not optimal. Laser treatment can also be used but since it only penetrates about 1mm, it is not optimal for thicker tumors.
Medical Treatment: Propanolol
Initially used to treat cardiac problems an amazing side effect of reducing the size of large hemangiomas was noted. Propanolol is now the gold standard for the treatment of complicated hemangiomas. Hospital admission for administering the drug is required for monitoring , and the results can be dramatic.
Removal of all, or part of the hemagioma is the goal of surgery. Surgery is indicated for hemagiomas that may bleed or are painful, are unsightly, or that are causing deformation of neighboring normal anatomic structures.
Treacher collins syndrome can be genetically inherited or occur as new mutations and cause a pattern of facial clefting as well as a small lower jaw. Treatment is aimed at first improving the anterior projection of the lower jaw and opening up the airway which is often using mandible distraction techniques. This will pull the tongue base forward and open up the airway, possibly reducing the need for tracheotomy.
- Excision of ear remnants (6mos)
- Defect in the lower lid (coloboma)
- Bone grafts can be placed in the cheek areas to augment the bony deficiency (age 5)
- Microtia (Age 8-10)
FACT: Any break in the skin that penetrates to the deep dermis will leave a scar
As mere mortals, there is almost nothing we can do to prevent scar formation, but we do have techniques that allow us to minimize the amount of scars formed. How much scar we form is based on many things, most importantly: genetics, tension on the skin when closed, anatomic location, and surgeon’s ability.
As a plastic surgeon, we are trained in techniques to help minimize scarring by manipulating the tissues to achieve tension free closure and skin edge eversion. Scars take 6 months to 1 year to fully mature (permanent result) and sometimes steroid injections and silicone tape may be needed to help soften these scars.
Plastic surgeons are often called to the emergency room to treat patients with complicated cuts (lacerations). Patients who are unhappy with their existing scars may benefit from a scar revision, where the old scar is removed and the tissues closed with plastic surgery techniques.
Cancers or trauma can leave large defects in the scalp or areas of missing hair (alopecia). Large rotational flaps or sometimes tissue expanders (balloons) are needed to re-establish the hairline (remove areas of alopecia) and close complex scalp wounds.