The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Correspondence
Department of Plastic Reconstructive and Aesthetic Surgery Faculty of Medicine Istanbul University Istanbul, Turkey [email protected]
REFERENCES 1. Abdollahifakhim S, Mousaviagdas M. Ectopic molar with maxillary sinus drainage obstruction and oroantral fistula. Iran J Otorhinolaryngol 2013;25:187–192 2. Mohan S, Kankariya H, Harjani B, et al. Ectopic third molar in the maxillary sinus. Natl J Maxillofac Surg 2011;2:222–224 3. Kasat VO, Karjodkar FR, Laddha RS. Dentigerous cyst associated with an ectopic third molar in the maxillary sinus: a case report and review of literature. Contemp Clin Dent 2012;3:373–376 4. Ramanojam S, Halli R, Hebbale M, et al. Ectopic tooth in maxillary sinus: case series. Ann Maxillofac Surg. 2013;3:89–92 5. Viterbo S, Griffa A, Boffano P. Endoscopic removal of an ectopic tooth in maxillary sinus. J Craniofac Surg 2013;24:46–48 6. Sammartino G, Trosino O, Perillo L, et al. Alternative transoral approach for intranasal tooth extraction. J Craniofac Surg 2011;22:1944–1946
Malformation, Deformity, and Discrepancy: Focus on Terminology To the Editor: As a branch of medicine becomes more developed, its terminology becomes more refined and more accurate. The specialty of oral and maxillofacial surgery is not an exception. As the specialty evolves, we should make a continuous attempt to rethink the concepts and refine the corresponding terminology. We must do our best to create a standard, consistent, and meaningful terminology for different aspects of our specialty. Precision in the use of terminology is not just pedantry; it is not only a sign of development but also a tool for further development. Accurate and consistent terminology allows for more effective knowledge representation and transfer. In a recent article,1 I discussed that dentofacial deformity is not an appropriate term and suggested that it is better to use the term maxillomandibular discrepancy instead. In that article, I described 2 reasons why maxillomandibular discrepancy is a more appropriate substitute. Aside from those 2 technical reasons, it is also noteworthy to consider the social implications of the terms we use in everyday practice. Most patients with maxillomandibular discrepancy are young and very sensitive to how their faces are judged. The rather pejorative connotation associated with the term dentofacial deformity highlights the need for a change toward a more socially neutral and clinically relevant term to describe their faces. Here, I want to propose a distinction between 3 different terms: malformation, deformity, and discrepancy. Malformation is an abnormality in shape with its roots in the morphogenesis period of the intrauterine life. A malformed structure shows abnormality in shape from the beginning of structure formation. Cleft lip and palate, maxillomandibular abnormalities associated with Treacher-Collins syndrome, and oculoauriculo-vertebral spectrum are examples of facial malformations. Malformations are always congenital. Deformity is an abnormality in shape that is created as a result of abnormal forces on a structure that have had normal shape in the
1928
beginning. They are most commonly created due to functional imbalances or abnormal forces during development. Trauma (a sudden force) is another possible cause of deformity in structures that have had normal shape. Abnormality in the cranio-orbital structures associated with craniosynostosis is an example of deformity. Nasal hump and crooked nose are examples of deformity in facial structures. These nasal deformities could be the result of abnormalities in respiratory functions, trauma, or previous surgeries. Deformities could be congenital (e.g., brachiocephaly) or appear after birth during infancy (e.g., positional plagiocephaly), or later in life (e.g., nasal hump). Discrepancy is an abnormality in size and/or position relative to adjacent facial structures, whereas the shape is generally normal. The main cause of discrepancy is abnormality in the amount and/or rate of growth due to genetic, environmental, and hormonal factors. Mandibular prognathism, maxillary excess, and jaw abnormalities associated with unilateral condylar hyperplasia are examples of maxillomandibular discrepancy. Discrepancy is usually not congenital. They may appear during childhood, adolescence, or even later in life. In contrast to malformation and deformity, in discrepancy, the abnormality is in size and/or position, not in shape. Furthermore, treatment of facial malformations and deformities generally involves reshaping; while, treatment of discrepancies generally involves resizing and repositioning. Majid Beshkar, DDS Department of Oral and Maxillofacial Surgery Tehran University of Medical Sciences Tehran, Iran [email protected]
REFERENCE 1. Beshkar M. Dentofacial deformity is not an appropriate term. J Craniofac Surg 2013;24:2221
Superiorly Based Nasolabial Island Flap: Indications and Advantages in Upper Lip Reconstruction To the Editor: We read with great interest the article of Bitik and Uzun1 on the use of superiorly based nasolabial (NL) for central upper lip defects. The authors describe a 1-stage reconstruction of transfixiant, postoncologic, central upper lip defects with the unilateral superiorly based NL island flap brought to the defect through a subcutaneous tunnel. We have previously used this flap in a similar manner and would like to share a few remarks about it. To our knowledge, we published the first description on the reconstruction of the philtrum in secondary cleft lip cases with unilateral superiorly based NL island flap.2 As mentioned by Bitik and Uzun,1 the reconstruction of the central upper lip is challenging and very difficult because of its unique anatomy in relief: the philtrum, Cupid's bow, and philtral columns. When this central part is destroyed, the appearance is unnatural. When the defect outranges the philtrum, the same problem is © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
present. Furthermore, in lip reconstruction, the recreation of the 3 anatomic layers of the lip (skin, orbicularis oris muscle sling, and mucosa) seems primordial. We have found in our experience that the superiorly based NL island flap, as described by Bitik and Uzun,1 can recreate a closeto-the-natural and pleasing central part of the upper lip. This is especially true for cutaneous defects. However, in transfixiant defects when muscle and mucosa are destroyed, their repair seems important both from the functional and aesthetic point of view. It is out of the scope of this letter to discuss the available methods for reconstruction of orbicularis oris muscle and mucosa. However, concerning central upper lip defects, the Abbe flap remains the classic solution, especially if the lower lip is bulky. This flap provides tissue for the 3 anatomic layers of the lip. The obtained philtrum or central upper lip resembles closely the normal anatomy. However, it is a 2-stage procedure. Bitik and Uzun1 use the cutaneous superiorly based NL island flap leaving “the raw surface underneath the flap to mucosalize.” Certainly, the great advantage of the proposed method is that it has only 1 stage. However, neither the mucosa nor the orbicularis oris muscle sling is recreated. In addition, the time needed for the raw surface to “mucosalize” would necessitate particular measures for hygiene and pain relief. Furthermore, this intraoral healing by secondary intention would cause some shrinkage of the flap and would, probably, interfere with the intention to maintain the deep labial sulcus mandated for the dental prosthesis. In our experience, the superiorly based NL island flap is indicated in the reconstruction of the upper lip skin (white lip), as follows: -In central defects, we use it as described by Bitik and Uzun1 and previously described by our team.2 In these cases, it recreates philtrum close to the natural one (although not exactly the same) with pleasing appearance. In defects that outrange the philtrum, the skin island recreates a central zone that resembles the philtrum. - The superiorly based NL island flap can be used in the same manner for more lateral defects of the white lip and can be even used to recreate anatomic subunits of the lip. The flap can be used bilaterally and provides skin with similar color and textures, which can be hair-bearing in men in a 1-stage procedure.2 For transfixiant defects, however, we would use some other method that would repair all 3 anatomic layers of the central lip with similar tissue. In summary, we would like to thank Drs Bitik and Uzun for their interesting report that would certainly enrich the possibilities for upper lip reconstruction. Hristo Shipkov, MD, PhD Department of Paediatric Surgery and Division of Plastic and Craniofacial Surgery St George University Hospital Plovdiv, Bulgaria Department of Plastic Reconstructive and Aesthetic Surgery Hopital de la Croix Rousse Lyon, France [email protected] Penka Stefanova, MD, PhD Department of Paediatric Surgery and Division of Plastic and Craniofacial Surgery St George University Hospital Plovdiv, Bulgaria
Correspondence
Dimitar Pazardzhikliev, MD, PhD Karen Djambazov, MD, PhD Department of ENT St George University Hospital Plovdiv, Bulgaria
REFERENCES 1. Bitik O, Uzun H. Reconstruction of central upper lip defects with the subcutaneous pedicled nasolabial island flap: a single-stage alternative to Abbe flap in the elderly male. J Craniofac Surg 2013;24:e337–e338 2. Shipkov CD, Anastassov YK, Simov RI. Unilateral superiorly based nasolabial island flap for the reconstruction of the philtrum. Scand J Plast Reconstr Surg Hand Surg 2002;36:177–179
Herpes Simpex Infection After Septorhinoplasty To the Editor: Functional septorhinoplasty, which aims to open the nasal passages and correct the external deformities, is a surgical method used quite often in the ear nose and throat and plastic surgery practices. Patients who undergo this operation demand to seem and function better. Because of this fact, complications after this surgery are more important than other vital surgeries. The rate for major or noticeable complications is reported to be 8% to 15% that may be classified as hemorrhagic, infectious, traumatic, functional, and esthetic.1 Herein, we present a patient who had complications with herpetic lesions on the eyelid after rhinoplasty surgery. The 33-year-old male patient was admitted to our otorhinolaryngology department complaining of nasal obstruction and external deformity. The patient underwent septorhinoplasty through an external approach in general anaestesia and was discharged at first postoperative day without any problem. However, he came back to the hospital with severe pain and eudema on the nose and pustuler lesions on the right eyelid and right nasal cavity (Figs. 1A, C). Physical findings were as follows: tempereature, 37.5°C; pulse rate, 80 bpm; respiration, 20 breaths/min; and blood pressure, 130/80 mm Hg. Blood analysis showed the following: leukocytosis, 18.7 103/uL (74.9% of neutrophil, 16.9% of lymphocyte); high sedimentation rate, 57 mm/h (n < 15 mm/h); and high C-reactive protein, 13.29 mg/dL (n < 0.5 mg/dL). Aluminum nasal splint and silicone nasal tampons were removed. The patient was consulted to the clinics of dermatology and infection disease for evaluation and suggestions. The clinical diagnosis was herpes simplex reactivation with bacterial contamination. Antibiotic therapy (amoxicillin-clavulanate of 2 g 4 times daily and topical fusidic acid twice a day) and antiviral therapy (acyclovir of 200 mg 5 times daily) were begun. The skin biopsy showed giant cells
FIGURE 1. A and C, Pustular lesions on the right eyelid and right nasal cavity. B, Healed lesions with no scars or hyperpigmentation.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1929
Correspondence
Department of Plastic Reconstructive and Aesthetic Surgery Faculty of Medicine Istanbul University Istanbul, Turkey [email protected]
REFERENCES 1. Abdollahifakhim S, Mousaviagdas M. Ectopic molar with maxillary sinus drainage obstruction and oroantral fistula. Iran J Otorhinolaryngol 2013;25:187–192 2. Mohan S, Kankariya H, Harjani B, et al. Ectopic third molar in the maxillary sinus. Natl J Maxillofac Surg 2011;2:222–224 3. Kasat VO, Karjodkar FR, Laddha RS. Dentigerous cyst associated with an ectopic third molar in the maxillary sinus: a case report and review of literature. Contemp Clin Dent 2012;3:373–376 4. Ramanojam S, Halli R, Hebbale M, et al. Ectopic tooth in maxillary sinus: case series. Ann Maxillofac Surg. 2013;3:89–92 5. Viterbo S, Griffa A, Boffano P. Endoscopic removal of an ectopic tooth in maxillary sinus. J Craniofac Surg 2013;24:46–48 6. Sammartino G, Trosino O, Perillo L, et al. Alternative transoral approach for intranasal tooth extraction. J Craniofac Surg 2011;22:1944–1946
Malformation, Deformity, and Discrepancy: Focus on Terminology To the Editor: As a branch of medicine becomes more developed, its terminology becomes more refined and more accurate. The specialty of oral and maxillofacial surgery is not an exception. As the specialty evolves, we should make a continuous attempt to rethink the concepts and refine the corresponding terminology. We must do our best to create a standard, consistent, and meaningful terminology for different aspects of our specialty. Precision in the use of terminology is not just pedantry; it is not only a sign of development but also a tool for further development. Accurate and consistent terminology allows for more effective knowledge representation and transfer. In a recent article,1 I discussed that dentofacial deformity is not an appropriate term and suggested that it is better to use the term maxillomandibular discrepancy instead. In that article, I described 2 reasons why maxillomandibular discrepancy is a more appropriate substitute. Aside from those 2 technical reasons, it is also noteworthy to consider the social implications of the terms we use in everyday practice. Most patients with maxillomandibular discrepancy are young and very sensitive to how their faces are judged. The rather pejorative connotation associated with the term dentofacial deformity highlights the need for a change toward a more socially neutral and clinically relevant term to describe their faces. Here, I want to propose a distinction between 3 different terms: malformation, deformity, and discrepancy. Malformation is an abnormality in shape with its roots in the morphogenesis period of the intrauterine life. A malformed structure shows abnormality in shape from the beginning of structure formation. Cleft lip and palate, maxillomandibular abnormalities associated with Treacher-Collins syndrome, and oculoauriculo-vertebral spectrum are examples of facial malformations. Malformations are always congenital. Deformity is an abnormality in shape that is created as a result of abnormal forces on a structure that have had normal shape in the
1928
beginning. They are most commonly created due to functional imbalances or abnormal forces during development. Trauma (a sudden force) is another possible cause of deformity in structures that have had normal shape. Abnormality in the cranio-orbital structures associated with craniosynostosis is an example of deformity. Nasal hump and crooked nose are examples of deformity in facial structures. These nasal deformities could be the result of abnormalities in respiratory functions, trauma, or previous surgeries. Deformities could be congenital (e.g., brachiocephaly) or appear after birth during infancy (e.g., positional plagiocephaly), or later in life (e.g., nasal hump). Discrepancy is an abnormality in size and/or position relative to adjacent facial structures, whereas the shape is generally normal. The main cause of discrepancy is abnormality in the amount and/or rate of growth due to genetic, environmental, and hormonal factors. Mandibular prognathism, maxillary excess, and jaw abnormalities associated with unilateral condylar hyperplasia are examples of maxillomandibular discrepancy. Discrepancy is usually not congenital. They may appear during childhood, adolescence, or even later in life. In contrast to malformation and deformity, in discrepancy, the abnormality is in size and/or position, not in shape. Furthermore, treatment of facial malformations and deformities generally involves reshaping; while, treatment of discrepancies generally involves resizing and repositioning. Majid Beshkar, DDS Department of Oral and Maxillofacial Surgery Tehran University of Medical Sciences Tehran, Iran [email protected]
REFERENCE 1. Beshkar M. Dentofacial deformity is not an appropriate term. J Craniofac Surg 2013;24:2221
Superiorly Based Nasolabial Island Flap: Indications and Advantages in Upper Lip Reconstruction To the Editor: We read with great interest the article of Bitik and Uzun1 on the use of superiorly based nasolabial (NL) for central upper lip defects. The authors describe a 1-stage reconstruction of transfixiant, postoncologic, central upper lip defects with the unilateral superiorly based NL island flap brought to the defect through a subcutaneous tunnel. We have previously used this flap in a similar manner and would like to share a few remarks about it. To our knowledge, we published the first description on the reconstruction of the philtrum in secondary cleft lip cases with unilateral superiorly based NL island flap.2 As mentioned by Bitik and Uzun,1 the reconstruction of the central upper lip is challenging and very difficult because of its unique anatomy in relief: the philtrum, Cupid's bow, and philtral columns. When this central part is destroyed, the appearance is unnatural. When the defect outranges the philtrum, the same problem is © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
present. Furthermore, in lip reconstruction, the recreation of the 3 anatomic layers of the lip (skin, orbicularis oris muscle sling, and mucosa) seems primordial. We have found in our experience that the superiorly based NL island flap, as described by Bitik and Uzun,1 can recreate a closeto-the-natural and pleasing central part of the upper lip. This is especially true for cutaneous defects. However, in transfixiant defects when muscle and mucosa are destroyed, their repair seems important both from the functional and aesthetic point of view. It is out of the scope of this letter to discuss the available methods for reconstruction of orbicularis oris muscle and mucosa. However, concerning central upper lip defects, the Abbe flap remains the classic solution, especially if the lower lip is bulky. This flap provides tissue for the 3 anatomic layers of the lip. The obtained philtrum or central upper lip resembles closely the normal anatomy. However, it is a 2-stage procedure. Bitik and Uzun1 use the cutaneous superiorly based NL island flap leaving “the raw surface underneath the flap to mucosalize.” Certainly, the great advantage of the proposed method is that it has only 1 stage. However, neither the mucosa nor the orbicularis oris muscle sling is recreated. In addition, the time needed for the raw surface to “mucosalize” would necessitate particular measures for hygiene and pain relief. Furthermore, this intraoral healing by secondary intention would cause some shrinkage of the flap and would, probably, interfere with the intention to maintain the deep labial sulcus mandated for the dental prosthesis. In our experience, the superiorly based NL island flap is indicated in the reconstruction of the upper lip skin (white lip), as follows: -In central defects, we use it as described by Bitik and Uzun1 and previously described by our team.2 In these cases, it recreates philtrum close to the natural one (although not exactly the same) with pleasing appearance. In defects that outrange the philtrum, the skin island recreates a central zone that resembles the philtrum. - The superiorly based NL island flap can be used in the same manner for more lateral defects of the white lip and can be even used to recreate anatomic subunits of the lip. The flap can be used bilaterally and provides skin with similar color and textures, which can be hair-bearing in men in a 1-stage procedure.2 For transfixiant defects, however, we would use some other method that would repair all 3 anatomic layers of the central lip with similar tissue. In summary, we would like to thank Drs Bitik and Uzun for their interesting report that would certainly enrich the possibilities for upper lip reconstruction. Hristo Shipkov, MD, PhD Department of Paediatric Surgery and Division of Plastic and Craniofacial Surgery St George University Hospital Plovdiv, Bulgaria Department of Plastic Reconstructive and Aesthetic Surgery Hopital de la Croix Rousse Lyon, France [email protected] Penka Stefanova, MD, PhD Department of Paediatric Surgery and Division of Plastic and Craniofacial Surgery St George University Hospital Plovdiv, Bulgaria
Correspondence
Dimitar Pazardzhikliev, MD, PhD Karen Djambazov, MD, PhD Department of ENT St George University Hospital Plovdiv, Bulgaria
REFERENCES 1. Bitik O, Uzun H. Reconstruction of central upper lip defects with the subcutaneous pedicled nasolabial island flap: a single-stage alternative to Abbe flap in the elderly male. J Craniofac Surg 2013;24:e337–e338 2. Shipkov CD, Anastassov YK, Simov RI. Unilateral superiorly based nasolabial island flap for the reconstruction of the philtrum. Scand J Plast Reconstr Surg Hand Surg 2002;36:177–179
Herpes Simpex Infection After Septorhinoplasty To the Editor: Functional septorhinoplasty, which aims to open the nasal passages and correct the external deformities, is a surgical method used quite often in the ear nose and throat and plastic surgery practices. Patients who undergo this operation demand to seem and function better. Because of this fact, complications after this surgery are more important than other vital surgeries. The rate for major or noticeable complications is reported to be 8% to 15% that may be classified as hemorrhagic, infectious, traumatic, functional, and esthetic.1 Herein, we present a patient who had complications with herpetic lesions on the eyelid after rhinoplasty surgery. The 33-year-old male patient was admitted to our otorhinolaryngology department complaining of nasal obstruction and external deformity. The patient underwent septorhinoplasty through an external approach in general anaestesia and was discharged at first postoperative day without any problem. However, he came back to the hospital with severe pain and eudema on the nose and pustuler lesions on the right eyelid and right nasal cavity (Figs. 1A, C). Physical findings were as follows: tempereature, 37.5°C; pulse rate, 80 bpm; respiration, 20 breaths/min; and blood pressure, 130/80 mm Hg. Blood analysis showed the following: leukocytosis, 18.7 103/uL (74.9% of neutrophil, 16.9% of lymphocyte); high sedimentation rate, 57 mm/h (n < 15 mm/h); and high C-reactive protein, 13.29 mg/dL (n < 0.5 mg/dL). Aluminum nasal splint and silicone nasal tampons were removed. The patient was consulted to the clinics of dermatology and infection disease for evaluation and suggestions. The clinical diagnosis was herpes simplex reactivation with bacterial contamination. Antibiotic therapy (amoxicillin-clavulanate of 2 g 4 times daily and topical fusidic acid twice a day) and antiviral therapy (acyclovir of 200 mg 5 times daily) were begun. The skin biopsy showed giant cells
FIGURE 1. A and C, Pustular lesions on the right eyelid and right nasal cavity. B, Healed lesions with no scars or hyperpigmentation.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1929
