David Kahn

Abstract

BACKGROUND: The major focus of research when addressing nipple reconstruction has been on developing new techniques to provide for long-lasting nipple projection. Rarely, has the outcome of nipple reconstruction as it relates to postoperative morbidity, particularly after implant-based breast reconstruction, been analyzed. METHODS: A "matched-pair" study was designed to specifically answer the question whether a history of radiotherapy predisposes to a higher complication rate after nipple reconstruction in patients after implant-based breast reconstruction. Only patients with a history of unilateral radiotherapy who underwent bilateral mastectomy and implant-based breast reconstruction followed by bilateral nipple reconstruction were included in the study. RESULTS: A total of 17 patients (i.e. 34 nipple reconstructions) were identified who met inclusion criteria. The mean age of the study population was 43.5 years (range, 23-69). Complications were seen after a total of 8 nipple reconstructions (23.5 percent). Of these, 7 complications were seen on the irradiated side (41.2 percent) (p = 0.03). CONCLUSION: While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy the presence of an irradiated field converts it to a procedure with a significant increase in postoperative complication rate.

View details for DOI 10.1016/j.bjps.2013.04.052

View details for PubMedID 23664573

Abstract

Facial bone aging has recently been described as primarily resulting from volume loss and morphologic changes to the orbit, midface, and mandible.The authors demonstrate how the facial skeleton bone mineral density (BMD) changes with age in both men and women and compare these changes to those of the axial skeleton. They also explore the aesthetic implications of such changes in bone density.Dual-energy X-ray absorptiometry (DXA) scans of the facial bones and lumbar spine were obtained from 60 white subjects, 30 women and 30 men. There were 10 men and 10 women in each of 3 age categories: young (20-40 years), middle (41-60 years), and old (61+ years). The following measurements were obtained: lumbar spine BMD (average BMD of L1-L4 vertebrae), maxilla BMD (the average BMD of the right and left maxilla), and mandible BMD (the average BMD of the right and left mandibular ramus).The lumbar spine BMD decreased significantly for both sexes between the middle and old age groups. There was a significant decrease in the maxilla and mandible BMD for both sexes between the young and middle age groups.Our results suggest that the BMD of the face changes with age, similar to the axial skeleton. This change in BMD may contribute to the appearance of the aging face and potentially affect facial rejuvenation procedures.

View details for DOI 10.1177/1090820X12462865

View details for Web of Science ID 000310718000002

View details for PubMedID 23012659

Abstract

Every surgeon operating on the face, and particularly around the eye, should possess a working knowledge of the critical details related to development of the human orbit and recognized changes that occur during the course of aging. The anatomy of the orbit and periorbital region is complex, and the diagnosis and treatment of patients with orbital/periorbital disease requires expertise in congenital differences and awareness of the changes that occur as individuals age.

View details for DOI 10.1016/j.coms.2012.08.001

View details for Web of Science ID 000311873900004

View details for PubMedID 23107427

Abstract

Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how the facial skeleton changes with age in both male and female subjects and what impact these structural changes may have on overall facial aesthetics.Facial bone computed tomographic scans were obtained from 60 female and 60 male Caucasian subjects. Twenty male and 20 female subjects were placed in three age categories (20 to 40 years, 41 to 64 years, and 65 years and older). Each computed tomographic scan underwent three-dimensional reconstruction with volume rendering. Edentulous patients were excluded. The following measurements were obtained: upper face (orbital aperture area, orbital aperture width, and curvilinear analysis of the superior and inferior orbital rims), midface (glabellar angle, pyriform angle, maxillary angle, and pyriform aperture area), and lower face (bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle).The orbital aperture width and orbital aperture area increased significantly with age for both sexes. There was a significant increase in orbital aperture size (increase in height of the superomedial and inferolateral orbital rim) in both sexes. The glabellar and maxillary angles decreased significantly with age for both sexes, whereas the pyriform aperture area significantly increased for both sexes with age. Mandibular length and height both decreased significantly for each sex. The mandibular angle significantly increased with age for both sexes.These results suggest that the skeletal morphology of the face changes with age. This change in skeletal morphology may contribute to the appearance of the aging face.

View details for DOI 10.1097/PRS.0b013e3181f95b2d

View details for Web of Science ID 000285992100051

View details for PubMedID 20871486

Abstract

Facial aging is a dynamic process involving the aging of soft tissue and bony structures. Much is known in regards to how the face loses volume as the soft tissue structures age. Epidermal thinning and the decrease in collagen cause skin to lose its elasticity. Loss of fat, coupled with gravity and muscle pull, leads to wrinkling and the formation of dynamic lines. The aging process has also been shown to affect the facial bones. Multiple studies suggest that the bony aging of the orbit and midface is a process primarily of contraction and morphologic change. This loss of bony volume and projection may contribute to the aged appearance. In this review, we will demonstrate how specific soft tissue and bony aspects of the face change with age in both genders and what impact these structural changes may have on overall facial aesthetics.

View details for DOI 10.1055/s-0030-1265024

View details for Web of Science ID 000282253500003

View details for PubMedID 20853225

Abstract

Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how specific bony aspects of the mandible change with age in both genders and what impact these structural changes may have on overall facial aesthetics.Facial bone three-dimensional computed tomographic scans were obtained from 120 Caucasian subjects (60 women and 60 men). Our study population consisted of 20 male and 20 female subjects in each of three age categories (20 to 40, 41 to 64, and > or = 65 years). Edentulous patients were excluded. The following measurements were obtained: bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle. The data were analyzed with one-way analysis of variance and two-tailed t tests, with results considered significant at a value of p < 0.05.There was no significant change with regard to bigonial width or ramus breadth across age groups for either gender. Ramus height, mandibular body height, and mandibular body length decreased significantly with age for both genders, whereas the mandibular angle increased significantly for both genders with increasing age.These results suggest that the bony elements of the mandible change significantly with age for both genders and that these changes, coupled with soft-tissue changes, lead to the appearance of the aged lower third of the face.

View details for DOI 10.1097/PRS.0b013e3181c2a685

View details for Web of Science ID 000273417000040

View details for PubMedID 20048624

Abstract

Narrow palpebral fissures, short lower lids, and full cheeks are hallmarks of youthful periorbita. The presence of these features is predicated on a convex upper midface skeleton. Faces whose midface skeletons are flat or concave do not manifest these youthful attributes, tend to age prematurely, and are prone to lower lid malposition after blepharoplasty.Augmentation of the infraorbital rim with alloplastic implants can provide convexity to the deficient upper midface skeleton. Suspension of the cheek soft tissues (subperiosteal midface lift) on this now supportive framework narrows the palpebral fissure, shortens the lower lid, and gives fullness to the cheek. The addition of lateral canthopexy to skeletal augmentation and subperiosteal midface lift can restore lower lid position when previous blepharoplasty has resulted in lower lid malposition in patients with deficient midface skeletons.This concept has been utilized in 87 patients (65 female, 22 male) over the last 7 years. Of these 87 patients, four patients (5 percent) required revision surgery to correct implant malposition or prominence. Three patients (3 percent) required implant removal to treat infection. Implants were later replaced in two of these three patients.Augmentation of the infraorbital rim with alloplastic implants provides convexity to the upper midface skeleton. Together with lower lid and midface soft-tissue suspension, it creates or restores youthful periorbital aesthetics.

View details for DOI 10.1097/PRS.0b013e3181bcf5bc

View details for Web of Science ID 000272615600048

View details for PubMedID 19952674

Abstract

Facial aging is a dynamic process involving the aging of soft tissue and bony structures. The shape, size, and volume of the bony orbit have all been shown to change with increasing age.In this study, we demonstrate how specific bony aspects of the orbit change with age in both male and female subjects and what impact this may have on the techniques used in facial cosmetic surgery.Facial bone computed tomography (CT) scans were obtained from 60 white subjects (30 female, 30 male). Our study population consisted of 10 male and 10 female subjects in each of 3 age categories. Each CT scan underwent three-dimensional (3-D) reconstruction with volume rendering. Orbital aperture width was measured as a line drawn from the posterior lacrimal crest to the frontozygomatic suture. This line was then used as the x-axis from which the distance to the superior and inferior orbital rim at nine equal increments (labeled 10 to 90) was obtained. The orbital aperture area was also measured on each 3-D model. The Student t test was used to identify any trends between age groups.The orbital aperture width and area in both our male and female subjects showed a significant increase with increasing age. There was a significant increase in height of the superior orbital rim medially in both genders, suggesting that the superior orbital rim receded with age in this region. The inferior orbital rim receded significantly laterally in our female population, while our male subjects had a recession of the entire inferior orbital rim.These results suggest that the bony elements of the orbit change dramatically with age, and this, coupled with soft tissue changes, can lead to the appearance of the aged eye and orbit.

View details for DOI 10.1016/j.asj.2008.02.007

View details for PubMedID 19083535

Abstract

Distraction osteogenesis of the Le Fort I segment is advocated for patients who require significant advancement of the maxilla or who have a soft tissue envelope compromised by scar tissue. We present a technique for maxillary distraction using an interconnecting intraoral device anchored to the malar prominences above the osteotomy and either the maxilla and/or the dentition below the level of the osteotomy.Ten patients with nonsyndromic cleft lip and palate, mean age of 18, underwent Le Fort I maxillary distraction osteogenesis for management of maxillary hypoplasia. A Le Fort I osteotomy is performed and a Spectrum Intraoral Midface Multi-Vector Distractor (OsteoMed, Addison, TX) is placed leaving a 1 mm to 2 mm distraction gap. After a 2 to 4 day latency period, distraction begins at a rate of 1 mm a day. Once the desired occlusion is achieved the device is left in place for a minimum of 2 months for consolidation.Preoperative Sella-Nasion-A point measurements from lateral cephalograms averaged 74 degrees (range, 70-76 degrees). Postoperative Sella-Nasion-A point averaged 81 degrees (range, 75-89 degrees). Preoperative overjet averaged -7.4 mm (range, -3 to -13 mm). Postoperative overjet averaged 2.6 mm (range, 1-3 mm). Average distraction was 9 mm (range, 6-16 mm). The average vertical movement was 7.2 mm in an inferior direction (range, 0-15 mm). The results remained stable at a follow-up of 30 months.We report on distraction of the Le Fort I segment using an internal device. The device design allows the forces of distraction to be shared across a larger surface area delivering a uniform and reliable vector of distraction with increased stability.

View details for DOI 10.1016/j.joms.2007.09.006

View details for Web of Science ID 000254589200009

View details for PubMedID 18355590

Abstract

Capsular contracture is a common complication associated with reconstructive breast surgery. The optimal time interval between the completion of tissue expansion and placement of the permanent implant is arbitrary and incompletely studied in the literature. The aim of the study was to determine whether the time interval between completion of expansion and placement of the permanent implant would affect the incidence of capsular contracture.We conducted a retrospective study of 112 patients with breast cancer, including 140 breasts, who underwent postmastectomy tissue expander placement between 1997 and 2004. All patients underwent replacement of tissue expander with a permanent prosthesis. Data were collected retrospectively, including whether the patient smoked, underwent radiation therapy, had saline or silicone implant reconstruction, required reoperation after tissue expander placement or after permanent implant placement, Baker classification, and the interval between completion of expansion and placement of permanent implant.We used a logistic regression model to incorporate the predictors of capsular contracture. Keeping all other predictors constant, we found that the time interval between implant exchange had no effect on capsular contracture. The only significant predictor of capsular contracture was whether the patient required a reoperation after the permanent implant was placed (P = .0001).Allowing the capsule around a tissue expander to mature does not significantly affect development of capsular contracture. However, a complication that necessitates disrupting the periprosthetic capsule of the permanent implant with an operation significantly increases odds of developing contracture.

View details for PubMedID 18587490

Abstract

A persistent problem with nasal bone osteotomies is inadequate reduction of the width of the nasal dorsum. In addition, an algorithm as to which osteotomy to use has not been fully explored.Nine cadavers received a medial oblique osteotomy (15 to 30 degrees off midline) following a humpectomy in six. On one side, the osteotomy was performed on the medial side of the apex of the open roof. On the contralateral side, it was performed on the lateral side of the apex. The osteotome was then pried posteriorly. The resultant hemidorsal widths were compared. Clinically, 53 patients were classified into the following: type I, broad nasal base (lateral osteotomy only); type II, broad nasal base and broad dorsum (lateral and medial oblique osteotomy); and type III, broad dorsum only (medial oblique osteotomy only).The reduction in hemidorsal width was greatest when the osteotome was placed on the lateral side of the apex (t test, p < 0.008). The improved width reduction was attributable to the slippage of the lateral nasal bone under the dorsal hood of the nasal bone. A lateral osteotomy did not have to be performed to reduce the dorsal width alone. After 15 to 32 months, nasal bone width was satisfactory in all but three cases, one of which required a revision.Reduction of the nasal dorsal width is facilitated by a medial oblique osteotomy alone if it is placed at the lateral aspect of the apex of the open roof. A classification of broad nasal bones is given that emphasizes the distinction between dorsal width and nasal base width and suggests which osteotomy to use.

View details for DOI 10.1097/01.prs.0000252504.65746.18

View details for Web of Science ID 000244438700036

View details for PubMedID 17312512

Abstract

The face loses volume as the soft-tissue structures age. In this study, the authors demonstrate how specific bony aspects of the face change with age in both men and women and what impact this may have on the techniques used in facial cosmetic surgery.Facial bone computed tomographic scans were obtained from 60 Caucasian patients (30 women and 30 men). The authors' study population consisted of 10 male and 10 female subjects in each of three age categories. Each computed tomographic scan underwent three-dimensional reconstruction with volume rendering, and the following measurements were obtained: glabellar angle (maximal prominence of glabella to nasofrontal suture), pyriform angle (nasal bone to lateral inferior pyriform aperture), and maxillary angle (superior to inferior maxilla at the articulation of the inferior maxillary wing and alveolar arch). The pyriform aperture area was also obtained. The t test was used to identify any trends between age groups.The glabellar and maxillary angle in both the male and female subjects showed a significant decrease with increasing age. The pyriform angle did not show a significant change between age groups for either sex. There was a significant increase in pyriform aperture area from the young to the middle age group for both sexes.These results suggest that the bony elements of the midface change dramatically with age and, coupled with soft-tissue changes, lead to the appearance of the aged face.

View details for DOI 10.1097/01.prs.0000246596.79795.a8

View details for Web of Science ID 000243584300031

View details for PubMedID 17230106