Riverside Facial Plastic Surgery and Sinus Center

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Celebrity Plastic Surgery by Frank J. Scaccia, M.D., F.A.C.S.
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laser surgeryWelcome to Riverside's home page. As medical director of the facility, Dr. Frank Scaccia is a uniquely qualified Dual Board Certified Facial Plastic Surgeon and Otolaryngologist who specializes in cosmetic surgery, plastic surgery, rhinoplasty, facelift and treatment of sinus/nasal disorders. After a unanimous vote by his peers, Dr. Scaccia was appointed for 2012 as the Chairman and Section Chief for the departments of Ear, Nose and Throat, and Head & Neck Surgery at Meridian Health's Riverview Medical Center in Red Bank, NJ. Riverview is one of the busiest and most respected hospitals in the region being a 5 time winner of The J.D. Power and Associates Award. His list of honors in plastic surgery includes the Jack Anderson Award which he won in 1995 after receiving the highest score in the United States on the certifying exam given by the American Board of Facial Plastic & Reconstructive Surgery. In addition, his surgical abilities have been featured in Time, Newsweek, Channel 7 "Eyewitness News," and most recently this past June on the "Anderson Cooper Show" where a TV personality was commenting to Mr. Cooper how much she likes her new nose that Dr. Scaccia operated on for her and that he is an "amazing doctor." He has also contributed to the medical literature with publications in textbook and journals. Dr. Scaccia was one of the first to publish in a textbook a technique to perform simultaneous rhinoplasty and sinus surgery. Follow this link for a copy of this interesting book chapter.
MM More recently, Dr. Scaccia has been named as one of New Jersey's leading cosmetic surgeons in a special article on "Top Beauty Docs" by NJ Savvy Living Magazine magazine in the February 2006 through 2009 editions. Furthermore, he was cited as one of only seven cosmetic surgeons in New Jersey that was specifically recognized for his rhinoplasty nose skills. The criteria for selection of this honor was based on Castle Connolly's physician lead research team who uses a vigorous screening process to survey physicians and administrators at leading hospitals for recommendations of highly skilled, exceptional doctors in the field of cosmetic plastic surgery. In addition Dr. Scaccia has also earned the prestigious recognition of being listed in the 2006 to 2010 editions of "The Guide to America's Top Physicians," the 2006 through 2013 editions of "Top Doctors: New York Metro Area," the 2011 listing in "US News &World Report" of Top Doctors and 2012 edition of Top Doctors: The-Star-Ledger's Inside Jersey, the Marquis' 2007 through 2012 editions of "Who'sWho in America" and most recently, has been selected for inclusion in both the 2010 and 2012 editions of "Who'sWho in Medicine and Healthcare," and the 2011 through 2012 edition of "Who'sWho in the World." Finally, Dr Scaccia has the added distinction of being included in the 2013 list of "Top Cosmetic Doctors" in the nation by Castle Connelly Medical Ltd.
MM His new office is located in the historic town of Red Bank allowing convenient access from all northern and central New Jersey sites and the New York City metropolitan area. The plastic surgery NJ and sinus center NJ includes it's own federally approved and accredited ambulatory outpatient surgical suite built to hospital safety standards and is one of the first in Monmouth County to utilize Brain Lab's Image Guided Navigational Sinus System allowing for state-of-the-art endoscopic sinus surgery.
MMRiverside has also been awarded accreditation by JCAHO (Joint Commission on Accreditation of Healthcare Organizations) the nation's leading evaluator among hospitals and other healthcare groups for quality care and patient safety. The center underwent a thorough onsite evaluation against nearly 150 standards which demonstrates our mission to provide the highest level of care possible. Your safety, comfort and privacy are our top priorities. Procedures can be performed under various levels of anesthesia (including general and twilight sleep) and will be administered by only board certified physician anesthesiologists. You will find that Dr. Scaccia's commitment to safety and excellence is exemplified throughout this web site. One benchmark is the fact that in his 20 years (residency training and private practice) as a physician (which includes thousands of surgical procedures) no medical malpractice judgments or even settlements have ever been brought against him.
MMSome of the facial plastic surgery procedures performed at the center include facelift, rhytidectomy, mini facelift, midface lift, s-lift, platelet gel facelift, weekend neck lift, eyelid rejuvenation, blepharoplasty, eyebrow lift, forehead lift, lip enhancement/rejuvenation, chin/cheek implants, liposuction, snoring and sleep apnea correction, female nasal sculpturing, rhinoplasty, male nasal sculpturing, rhinoplasty, Asian nasal surgery, Afro-American rhinoplasty, Ethnic rhinoplasty, revision/redo nasal surgery and sinus surgery.
MMBotox injections, laser surgery for tattoos, moles, pigment, spider veins, wrinkles, skin resurfacing, hair removal and scars are also available. Other plastic surgery procedures performed include ear surgery (otoplasty), split earlobe repair, AlloDerm implants, sclerotherapy and chemical peels. Gentlewaves LED Photomodulation is a new technology that we are now using to reverse photoaging and potentially speeds healing after surgery.

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Dr. Scaccia

70 East Front St., Third Flr., Red Bank, NJ 07701 • Tel: (732) 747-5300 / Fax: (732) 747-9922

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525 Route 70, Suite 3A, Brick Township, Ocean County, NJ 08723 •
Tel: (732) 262-3695
305 Seguine Avenue Suite #1 Staten Island, NY 10309 • Tel: (718) 967-2411
219 Taylors Mills Road, Manalapan, NJ 07726 • Tel: (732) 308-6000

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Content and photos are the intellectual property of Frank J. Scaccia, M.D., F.A.C.S. and Riverside Nasal & Sinus Center and may not be used or duplicated for any reason. ©2015

 

Ear Nose Throat Surgery Red Bank NJ 07701

 

The following rhinoplastic techniques are applied to the surgical management of: (i) partial-thickness defects; (ii) full-thickness defects; (iii) heminasal reconstruction; and (iv) total nasal reconstruction. Ear Nose Throat Surgery Red Bank NJ 07701.

I. Partial-thickness defects

A partial-thickness defect is a wound with adequate soft-tissue coverage of the underlying nasal skeleton, yet is too large for primary intention closure, with sutures. Based upon the locale of the wound, the surgeon has two (2) options for correcting such a wound: (i) healing the wound by secondary intention (re-epithelialisation); and (ii) healing the wound with a full-thickness skin graft. Moreover, because it avoids the patched appearance of a skin-graft surgical correction, healing by secondary intention can successfully repair nasal wounds up to 10 mm in diameter; and, if the resultant scar proves aesthetically unacceptable, it can be revised later, after the wound has healed. Ear Nose Throat Surgery Red Bank NJ 07701.

In the event, larger nasal wounds (defects) do successfully heal by secondary intention, but do present two disadvantages. First, the resultant scar often is a wide patch of tissue that is aesthetically inferior to the scars produced with other nasal-defect correction techniques; however, the skin of the medial canthus is an exception to such scarring. The second disadvantage to healing by secondary intention is that the contracture of the wound might distort the normal nasal anatomy, which can lead to a pronounced deformity of the alar rim area. For this reason, healing by secondary intention generally is not recommended for defects of the distal third of the nose; nonetheless, the exception is a small wound directly upon the nasal tip.

Full-thickness skin grafts are the effective wound-management technique for defects with a well-vascularized, soft-tissue bed covering the nasal skeleton. The patient’s ear is the preferred skin-graft donor site from which to harvests grafts of pre-auricular skin and grafts of post-auricular skin, usually with an additional, small amount of adipose tissue to fill the wound cavity. Yet, nasal correction with a skin graft harvested from the patient’s neck is not recommended, because that skin is low-density pilosebaceous tissue with very few follicles and sebaceous glands, thus is unlike the oily skin of the nose. Ear Nose Throat Surgery Red Bank NJ 07701.

The technical advantages of nasal-defect correction with a skin graft are a brief surgery time, a simple rhinoplastic technique, and a low incidence of tissue morbidity. The most effective corrections are with a shallow wound with sufficient, supporting soft-tissue that will prevent the occurrence of a conspicuous depression. Nonetheless, two disadvantages of skin-graft correction are mismatched skin color and skin texture, which might result in a correction with a patch-work appearance; a third disadvantage is the natural histologic tendency for such skin grafts to contract, which might distort the shape of the corrected nose. Ear Nose Throat Surgery Red Bank NJ 07701.

II. Full-thickness defects

Full-thickness nasal defects are in three types: (i) wounds to the skin and to the soft tissues, featuring either exposed bone or exposed cartilage, or both; (ii) wounds extending through the nasal skeleton; and (iii) wounds traversing all three nasal layers: skin, muscle, and the osseo-cartilaginous framework. Based upon the dimensions (length, width, depth) and topographic locale of the wound and the number of missing nasal-tissue layers, the surgeon determines the rhinoplastic technique for correcting a full-thickness defect; each of the aesthetic nasal subunits is considered separately and in combination. Ear Nose Throat Surgery Red Bank NJ 07701.

(a) Medial canthus

The skin between the nasal dorsum and the medial canthal tendon is uniquely suited to healing by secondary intention; the outcomes often are superior to what is achieved with either skin grafts or skin-flaps and tissue-flaps. Because the medial canthal tendon is affixed to the facial bone, it readily resists the forces of wound contracture; moreover, the animation (movement) of the medial brow also lends resistance to the forces of wound contracture. Furthermore, the medial canthal region is aesthetically hidden by the shadows of the nasal dorsum and of the supraorbital rim, thereby obscuring any differences in the quality of the color and of the texture of the replacement skin (epithelium). Ear Nose Throat Surgery Red Bank NJ 07701.

Healing by secondary intention (re-epithelialisation) occurs even when the wound extends to the nasal bone. Although the rate of healing depends upon the patient’s wound-healing capacity, nasal wounds measuring up to 10 mm in diameter usually heal in at 4-weeks post-operative. Nonetheless, one potential, but rare, complication of this nasal correction approach is the formation of a medial canthal web, which can be corrected with two (2) opposing Z-plasties, technique which relieves the disfiguring tensions exerted by the scar tissue’s contracture, its shape, and location on the nose. Ear Nose Throat Surgery Red Bank NJ 07701.

(b) Nasal dorsum and lateral nasal wall defect

The size of the nasal defect (wound) occurred, in either the dorsum or the lateral wall, or both, determines the reconstructive skin-flap technique applicable to the corresponding aesthetic nasal subunits.

  • A wound of less than 10 mm in diameter can be managed either by primary intention healing (suturing) or by secondary intention healing (re-epithelialisation).
  • A wound measuring 10–15 mm in diameter can be reconstructed with a single-stage modified bilobed flap, because it best matches the skin color and the skin texture of the wounded aesthetic subunit. Although not every scar can be hidden at the margins of the aesthetic nasal subunits concerned, the superior scarring ability of those nasal skin areas minimizes such anhistologic disadvantage. In a patient whose basal-cell carcinoma was excised with Mohs surgery, the scar of the nasal reconstruction (an 11 mm full-thickness, laterally based, bilobed-flap applied down to the bone and the cartilage), was hidden by aligning the axis of the second lobe to and emplacing the skin graft at the junction of the nasal dorsum and the lateral wall of the nose. Ear Nose Throat Surgery Red Bank NJ 07701.
  • A wound greater than 15 mm in diameter can be corrected with a paramedian forehead flap, which will reconstruct either the entire nasal dorsum or the lateral wall of the nose, as required. The surgical management of such wounds (< 15 mm dia.) usually requires enlarging the wound as necessary, in order for the skin graft to comprehend the entire aesthetic subunit being corrected. Moreover, if the wound comprehends the dorsum and the lateral wall of the nose, then a cheek-advancement skin flap is the applicable correction for replacing the lateral nasal skin up to its junction with the dorsum; afterwards, a paramedian forehead flap is applied to resurface the nasal dorsum. Ear Nose Throat Surgery Red Bank NJ 07701.
  • A wound in the lateral nasal wall that is greater than 15 mm in diameter can also be corrected with a superiorly based, nasolabial-flap, which is especially suited for correcting distal defects that lay among the convexities of the nasal tip and the alar lobule. The nasolabial flap can correct defects that comprehend the distal two-thirds of the nose, if there is a supply of skin sufficient for constructing the base of the flap pedicle; and the donor sites cannot be closed primarily. Yet, bulkiness is the principal disadvantage of the nasolabial flap — except in elderly patients with atrophic cheek skin; nonetheless, it is technically effective for patients unsuitable for a two-stage rhinoplasty with a paramedian forehead flap.
  • Nasal defects involving either the bone or the cartilage of the lateral nose are best managed with free grafts of flat septal bone and of cartilage. Small defects of the nasal dorsum can be covered with cartilage grafts harvested from either the septum or the concha of the ear. The correction of large-area defects of the nasal dorsum requires the stable support of a bone graft affixed either with a lag screw or with a low-profile plate. A costal graft (from the rib cage) is ideal for such a repair, because it can be harvested with an attached extension of cartilage that can be sculpted to blend into the nasal tip; other potential donor sites for nasal dorsum reconstruction materials are the outer table of the skull, the iliac crest, and the inner table of the ilium proper. Ear Nose Throat Surgery Red Bank NJ 07701.
  • To correct a defect of the nasal lining of the upper two-thirds of the nose, the wound dimensions (length, width, depth) determine the technique. A nasal-lining defect of less than 5 mm in diameter can be closed primarily, with sutures. A nasal-lining defect 5–15 mm in diameter can be closed with a random transposition flap harvested from a nasal area that remains protected, either by the nasal bones or by the upper lateral cartilages; and the flap donor-site can be healed by secondary intention, re-epithelialisation. For a mucosa defect greater than 15 mm in diameter, the indicated correction is a superiorly based “trap door” septal mucosal flap, grafted to the roof of the nasal septum. Ear Nose Throat Surgery Red Bank NJ 07701.
(c) Nasal tip defect

The width of the human nasal-tip ranges 20–30 mm; the average width of the nasal tip, measured between the two alar lobules, is approximately 25 mm.

  • A nasal skin defect of less than 15 mm in diameter can be managed with a bilobed flap; the surgeon trims the edges of the wound (defect) to match its dimensions (length, width, depth) to the natural curve at the border of the nasal tip. If the wound is eccentric, the skin-flap is positioned so that the lateral base of the graft occupies the largest portion of the wound’s surface. Ear Nose Throat Surgery Red Bank NJ 07701.
  • If the nasal-tip wound is greater than 15 mm in diameter, the surgeon enlarges it to comprehend the entire aesthetic subunit affected by the defect, and the reconstruction of the nasal subunit done with a forehead flap. If the nasal-tip defect also involves the nasal dorsum, a forehead flap is indicated for reconstructing the entire nasal-tip and dorsum.
  • If an alar cartilage is missing, either partially or entirely, it is reconstructed with cartilage grafts. The defect of an alar dome, which retains adequate anatomic support-tripod configuration, can be corrected with an onlay graft harvested either from the nasal septum or from the conchal cartilage of an ear. The surgeon forms the cartilage graft into the shape of a shield — its widest margins become the replacement alar domes. Typically, the shield cartilage graft is stacked in two layers, in order to transmit the desired light reflex characteristic of the nasal tip. Ear Nose Throat Surgery Red Bank NJ 07701.
  • Defects of the lateral crura can be corrected with a flat strut of formed cartilage, but, if the support of the medial crura is absent, then a columella strut must be inserted, and attached at the level of the anterior nasal spine. If a strut of nasal-septum cartilage proves too weak, then a rib cartilage strut can be applied to provide the adequate nasal support; afterwards, the strut is covered with onlay grafts.
  • Absent alar cartilages can be replaced using all of the conchal cartilage from both ears; two strips, each 10 mm wide, are harvested from the antihelical fold, and then are applied as replacement alar wings. The surgeon attaches them to the anterior nasal spine, and to each side of the (pear-shaped) pyriform aperture; the remainder of the harvested conchal cartilage is applied as onlay grafts to augment the nasal tip.
  • A nasal-tip lining defect is unusual, because of its midline location; yet, the reconstruction is with an anteriorly based septal mucosal flap that is rotated into place to provide adequate coverage and correction of the nasal lining defect.
  • Vertical lobule division (VLD) is a common technique for nasal tip refinement, which involves the medial crural angle and the lateral crural angle. Ear Nose Throat Surgery Red Bank NJ 07701.
(d) Alar lobule defect

The appropriate surgical management of an alar lobule defect depends upon the dimensions (length, width, depth) of the wound. Anatomically, the nasal skin and the underlying soft tissues of the alar lobule form a semi-rigid aesthetic subunit that forms the graceful curve of the alar rim, and provides unobstructed airflow through the nostrils, the anterior nares.

  • When most of the alar lobule tissue is missing, the nose collapses; the correction is with an ear concha cartilage-graft harvested from the antihelix, a donor site where the cartilage is most rigidly curved, thus is ideal for replacing an alar lobule.
  • Nasal skin defects can be corrected with a medially based bilobed flap, which is emplaced to provide adequate skin coverage for wounds limited to the alar lobule. If the entire lobule is missing, it might be necessary to leave the second-lobe donor-site wound partially open; it will close at 2–4 weeks post-operative; afterwards, the scar can be revised. Nonetheless, the alternative surgical correction is a two-stage, superiorly based, nasolabial flap. Ear Nose Throat Surgery Red Bank NJ 07701.
  • If the alar lobule defect also comprehends the lateral wall of the nose, the defect can be closed either with a superiorly based nasolabial-flap or with a forehead flap. If the cheek skin is thin and atrophic, a nasolabial flap is the recommended reconstruction; otherwise, a forehead flap is recommended, because the thickness of forehead skin is a superior match for nasal skin and tissue. Mucosal lining defects of the alar lobule can be resurfaced with a bipedicled mucosal advancement-flap harvested from inside the lateral wall of the nose. Likewise, larger defects of the mucosa do require correction with an anteriorly based septal mucosal flap. Ear Nose Throat Surgery Red Bank NJ 07701.
III. Heminasal and total nasal reconstruction

The reconstruction rhinoplasty of an extensive heminasal defect or of a total nasal defect is an extension of the plastic surgical principles applied to resolving the loss of a regional aesthetic subunit. The skin layers are replaced with a paramedian forehead flap, but, if forehead skin is unavailable, the alternative corrections include the Washio retroauricular-temporal flap and the Tagliacozzi flap. The nasal skeleton is replaced with a rib-graft nasal dorsum and lateral nasal wall; septal cartilage grafts and conchal cartilage grafts are applied to correct defects of the nasal tip and of the alar lobules.

The nasal lining of the distal two-thirds of the nose can be covered with anteriorly based septal mucosal flaps; however, if bilateral septal-flaps are used, the septal cartilage does become devascularized, possibly from iatrogenic septal perforation. Furthermore, if the nasal defect is beyond the wound-correction scope of a septal mucosal flap, the alternative techniques are either an inferiorly based pericranial-flap (harvested from the frontal bone) or a free flap of temporoparietal fascia (harvested from the head), either of which can be lined with free grafts of mucosa to achieve the nasal reconstruction. Ear Nose Throat Surgery Red Bank NJ 07701.

Corrections of defect and deformity

  • Cancer — The excision of cancerous nasal skin can cause the loss of skin and internal support cartilage; such resections (surgical removal) usually are via the Mohs’ chemosurgical technique. After removing the cancerous tissues, the reconstructive rhinoplasty will provide skin coverage using either skin grafts or pedicle flaps, (seeNasal Reconstruction, Paramedian Forehead Flap). If the resection of the cancerous skin leads to losing the nose tip, cartilage grafts can be used for support, and to prevent long-term distortion consequent to the force of the contracture of scar tissue.
  • Congenital deformity — The correction of vascular malformations and cleft lip and palate abnormalities. In vascular malformations, the progression of the disease distorts the skin and the underlying structure of the nose. Cleft lip and cleft palate defects usually distort the size, position, and orientation of the nasal-tip cartilages. Reconstruction of vascular malformations can involve laser treatment of the skin, and surgical excision of the deformed tissues. When the underlying cartilage support structure is disturbed, cartilage grafts and suturing of the native nasal cartilages can help improve nasal aesthetics by re-orienting the nasal tip cartilages; and cartilage-graft refinements to the nose tip are performed as required. Ear Nose Throat Surgery Red Bank NJ 07701.
  • Obstructed airways — The restoration of normal breathing by correcting nasal obstruction caused by a cosmetic rhinoplasty wherein nasal cartilages were over-aggressively trimmed, and the nose appears pinched, which compromises nasal potency (airflow), especially when the patient attempts deep inspiration. These grafting techniques restore normal breathing by increasing the size of the nose tip with baton grafts (internal cartilage), and spreader grafts to widen the nasal middle vault. Furthermore, to improve breathing a septoplasty can be performed concurrent to the reconstructive surgery; likewise, if there is turbinate hypertrophy, an inferior turbinectomy can be performed.
  • Rhinophyma — The correction of late-stage Rosacea, wherein the nasal skin is infected with acne rosacea that reddens, thickens, and enlarges the nose tip; an exemplar case is the American actor W.C. Fields. Although antibiotic acne treatments (e.g. Acutane) can halt the progression of Rosacea, the thickened skin and the fleshy obscuring of the nasal tip can only be corrected with rhinoplasty. Laser excision of abnormally thickened skin is the best rhinoplastic treatment for Rhinophyma; theCO2 laser and the infrared Erbium: YAG laser are the most effective treatments.
  • Wide nose — To narrow a too-wide nose, the plastic surgeon cuts, contours, and rearranges the craniofacial bones to achieve the desired functional and aesthetic outcome of a narrower, straighter nose. To leave no visible, surgical scars upon the new nose, the surgeon effects the osteotome (bone chisel) incisions to the nasal bones beneath the facial skin.

Illustration 1: The surgeon cuts the excessively wide bones of the upper nasal dorsum (violet) with anosteotome (bone chisel), then detaches, corrects, and relocates them inwards, to a position, between the ocular orbits (red), that narrows the width of the nasal dorsum. Ear Nose Throat Surgery Red Bank NJ 07701.


Illustration 2: The surgeon chisels two cuts (incisions) to the nasal bones, each incision begins at the nasal cavity. The first incision begins at the yellow dot and extends upwards, along the green arrow, until meeting the zig-zag line (red). The second incision begins at the blue dot and extends upwards, along the black arrow, until meeting the zig-zag line (red). Once cut and loosened from the face, the nasal bone pieces are corrected, then pushed inwards and re-set, thus narrowing the nose. Ear Nose Throat Surgery Red Bank NJ 07701.