1032
LETTERS TO THE EDITOR
2. Oikarinen K, Altonen M, Kauppi H, et al: Treatment of mandibular fractures. J Craniomaxillofac Surg 17:24,
MANUAL PTERYGOMAXILLARY
1989 3. Wagner WF, Neal
the Editor:-1 read with interest the article by Dr Hadeed et al entitled “Reconstructive Rhinoplasty for Rhinophyma: Report of Case” (J Oral Maxillofac Surg 49:308, 1991). I would like to add the carbon dioxide laser to the list of modalities used to treat this troublesome entity. Large bulbous hyperplastic nodules may be excised using the cutting mode on the laser, and further shaping may be precisely performed with the vaporization settings. l-6 A major advantage of using the carbon dioxide laser as a cutting and vaporizing tool is improved hemostasis, which facilitates visualization of the highly vascular, hyperplastic sebaceous tissue. Thin, layer-by-layer removal of the hyperplastic tissue allows careful sculpting of the nasal contour. Healing is rapid and postoperative pain is minimal. Potential complications include scarring secondary to overvigorous vaporization. The procedure may be performed on an outpatient basis using a regional nerve block with additional local anesthesia, when needed, or general anesthesia, depending on the individual situation .
To Editor:-1 read with interest the technique described in the article “Pterygomaxillary Separation Without the Use of an Osteotome” by Precious et al (J Oral Maxillofac Surg 49:98, 1991), as I (and I suspect many of my colleagues) have not used an osteotome prior to maxillary downfracture during Le Fort I osteotomy for years. However, I would advise against the use of Tessier spreading forceps for the application of downward pressure on the osteotomy cuts as it is too easy to comminute the fragile bone edges with the instrument. Once the horizontal cuts have been made, using a saw or drill as preferred, firm down-pressure with the thumbs on the premaxilla is all that is necessary to distract the pterygomaxillary suture line. The hingeddown maxilla may then be grasped with Rowe or Epker disimpaction forceps and gently eased away from the pterygoid plates one side at a time. A finger on the pterygoid hamulus will confirm that separation has been achieved at the correct position, as the hamulus should remain immobile. If any reader doesn’t believe how easy it is to downfracture the maxilla with the thumbs, he should try it during the next Le Fort I operation and then discard the pterygomaxillary osteotome in the “unwanted instrument” box! In addition to the advantages of the nonosteotome technique described by Dr Precious and his colleagues, I would add one other. I believe there is still a place for post tuberosity bone grafting when a large anterior maxillary shift is planned, particularly if a graft is being taken anyway for placement at other osteotomy sites. With this atraumatic approach, a bone block may be neatly wedged between the intact posterior wall of the antrum and an intact pterygoid plate. In contrast, a surgeon who has resorted to the osteotome to achieve posterior maxillary separation will find it is usually a waste of time dropping a chunk of bone into the wound he has created, as it will assuredly disappear into the soft tissues and achieve nothing. JOHN TOWNEND, MB, FDSRCS Chichester, West Sussex, England
ALLISON T. VIDIMOS, RPH, MD Cleveland, Ohio
References 1. Ali MK, Callari RH, Mobley DL: Resection of rhinophyma with CO2 laser. Laryngoscope 99:453, 1989 2. Amedee RG, Routman MH: Methods and complications of rhinophyma excision. Laryngoscope 97:1316, 1987 3. Bohigian RK, Shapshay SM, Hybels RL: Management of rhinophyma with carbon dioxide laser: Lahey Clinic experience. Lasers Surg 8:397. 4. SS, EA. K: of laser electrosurgery the of J Acad 18:363, 5. GG: treatment rhinophyma. Plast 12:171. 6. RG, PL, JL: carbon oxide excision vaporization the of J Surg 13:172.
OF
SPARKINGFROM the debonding high
a
BRACKETS
orthodontic the of 1156 bur produced “shower sparks” inadtouched the portion a ramic on adjacent Normally, porof ceramic that not off the special is off diaburs high with water Therefore phenomenon not noticed fore. would advisable practitioners steel carbide on patient ceramic to careful avoid contact. consequences patient/staff be if in vicinof anesthetics/gases should
LETTERS TO THE EDITOR
2. Oikarinen K, Altonen M, Kauppi H, et al: Treatment of mandibular fractures. J Craniomaxillofac Surg 17:24,
MANUAL PTERYGOMAXILLARY
1989 3. Wagner WF, Neal
the Editor:-1 read with interest the article by Dr Hadeed et al entitled “Reconstructive Rhinoplasty for Rhinophyma: Report of Case” (J Oral Maxillofac Surg 49:308, 1991). I would like to add the carbon dioxide laser to the list of modalities used to treat this troublesome entity. Large bulbous hyperplastic nodules may be excised using the cutting mode on the laser, and further shaping may be precisely performed with the vaporization settings. l-6 A major advantage of using the carbon dioxide laser as a cutting and vaporizing tool is improved hemostasis, which facilitates visualization of the highly vascular, hyperplastic sebaceous tissue. Thin, layer-by-layer removal of the hyperplastic tissue allows careful sculpting of the nasal contour. Healing is rapid and postoperative pain is minimal. Potential complications include scarring secondary to overvigorous vaporization. The procedure may be performed on an outpatient basis using a regional nerve block with additional local anesthesia, when needed, or general anesthesia, depending on the individual situation .
To Editor:-1 read with interest the technique described in the article “Pterygomaxillary Separation Without the Use of an Osteotome” by Precious et al (J Oral Maxillofac Surg 49:98, 1991), as I (and I suspect many of my colleagues) have not used an osteotome prior to maxillary downfracture during Le Fort I osteotomy for years. However, I would advise against the use of Tessier spreading forceps for the application of downward pressure on the osteotomy cuts as it is too easy to comminute the fragile bone edges with the instrument. Once the horizontal cuts have been made, using a saw or drill as preferred, firm down-pressure with the thumbs on the premaxilla is all that is necessary to distract the pterygomaxillary suture line. The hingeddown maxilla may then be grasped with Rowe or Epker disimpaction forceps and gently eased away from the pterygoid plates one side at a time. A finger on the pterygoid hamulus will confirm that separation has been achieved at the correct position, as the hamulus should remain immobile. If any reader doesn’t believe how easy it is to downfracture the maxilla with the thumbs, he should try it during the next Le Fort I operation and then discard the pterygomaxillary osteotome in the “unwanted instrument” box! In addition to the advantages of the nonosteotome technique described by Dr Precious and his colleagues, I would add one other. I believe there is still a place for post tuberosity bone grafting when a large anterior maxillary shift is planned, particularly if a graft is being taken anyway for placement at other osteotomy sites. With this atraumatic approach, a bone block may be neatly wedged between the intact posterior wall of the antrum and an intact pterygoid plate. In contrast, a surgeon who has resorted to the osteotome to achieve posterior maxillary separation will find it is usually a waste of time dropping a chunk of bone into the wound he has created, as it will assuredly disappear into the soft tissues and achieve nothing. JOHN TOWNEND, MB, FDSRCS Chichester, West Sussex, England
ALLISON T. VIDIMOS, RPH, MD Cleveland, Ohio
References 1. Ali MK, Callari RH, Mobley DL: Resection of rhinophyma with CO2 laser. Laryngoscope 99:453, 1989 2. Amedee RG, Routman MH: Methods and complications of rhinophyma excision. Laryngoscope 97:1316, 1987 3. Bohigian RK, Shapshay SM, Hybels RL: Management of rhinophyma with carbon dioxide laser: Lahey Clinic experience. Lasers Surg 8:397. 4. SS, EA. K: of laser electrosurgery the of J Acad 18:363, 5. GG: treatment rhinophyma. Plast 12:171. 6. RG, PL, JL: carbon oxide excision vaporization the of J Surg 13:172.
OF
SPARKINGFROM the debonding high
a
BRACKETS
orthodontic the of 1156 bur produced “shower sparks” inadtouched the portion a ramic on adjacent Normally, porof ceramic that not off the special is off diaburs high with water Therefore phenomenon not noticed fore. would advisable practitioners steel carbide on patient ceramic to careful avoid contact. consequences patient/staff be if in vicinof anesthetics/gases should
