The correlation between structure and appearance is most straightforward when the skeleton is involved. Today’s case involved a young women after a motor vehicle accident more than a decade ago. The forehead was uneven, the brows in unequal position, old hardware palpable over the roof of the eye socket and the nose was crooked and deviated. She has chronic headaches.
Via an open forehead approach the o;d plates and screws are removed and the forehead muscles are released from scarring in various crevices of the malunited forehead bone. Subsequently, the corrugator muscles (which contribute to the expression of frowning) are dissected to release the compressed forehead nerves. The right orbital roof shows bone defects at the rim and further dissection circumferentially of the orbit shows an unrepaired naso-orbito-ethmoidal (NOE) fracture with missing bone at the medial orbital wall. As all these areas overlie sinuses and so artificial bone is not a good solution.
So a small craniotomy is performed and the outer and inner tables of the skull are split. The outer table is fixed back where it cam from with plates and screws so that essentially no donor defect remains. The inner table is cut and shaped to fit into the upper orbital rim and NOE defects. both are fixed with plates and screws. Spare bone is placed in a mill, ground up and used to caulk the remainig crevices from old fractures.
When closing the open forehead approach the side of the lower eyebrow is lifted by one centimeter.
Complete redraping and reprepping. The crooked nose is addressed by exposing the septum completely, which is deviated. To take the spring out a submucous resection is performed and the septum is disarticulated from its insertion into the bone of the palate. A small dorsal hump is rasped. The nasal bones are cut and moved into a more midline position. On preoperative photographs a slight hint of middle vault collapse was evident and there was respiratory obstruction. So spreader graft are placed fashioned from the removed septum to widen the internal nasal valve. The remaining septum at is lower edge is supported by a batten graft. It is sutured into a stable position. Crushed cartilage and bone from the ethmoidal plate of the septum are used as overlays over a remaining one sided depression at the sidewall of the nose. The widened medial crurae are sutured together. The lower lateral cartilages are trimmed leaving 6mm of rim strip to reduce bulbostiy of the tip. Interdomal sutures are placed to increase intrinsic tip projection.
All nasal incisions are closed and a nasal packing and splint are placed. Soft head dressing.
That’s what I call a case. All anatomic structural abnormalities addressed. Structure is beauty and structure is function. Mysteriously enough, we have had a surprising success rate with respect to improved headaches after repairing the skeletal defects and decompressing nerves and correcting nasal septal deviations.