FPSAM - Roundtable 2022 - 5

forehead, just so that it's one clear convex plane, and
eliminate that valley, both superiorally and caudally.
Dr. Spiegel: And are you also using bone dust, bone
Dr. Alperovich: I have tried different things with the
bone scraper. I have tried just collecting the bone dust.
I have used demineralized bone matrix of the shelf.
I tend to use only autologous products around the
frontal sinus, just to fill in any gaps because I'm
worried about potential contamination or infection and
I'll use more off-the-shelf products for filling in any
gaps in the genio segments.
Dr. Spiegel: And how about for fixation?
Dr. Alperovich: I use two 2-hole mini plates that are
about 0.3, and 3-mm screws. Since it's nonweight bearing,
nonweight sharing, I have never had an issue with
that. Ijust want to fixate it. I have thought about using that
sonic weld that you use, and I have toyed around with
switching to that. So far, I've been using these two miniplates
and they are so small. With the soft tissue, I have
never had anyone complain that they are palpable.
Dr. Spiegel: All right. Dr. Schechter, what are they
doing in Chicago? We're talking about forehead
contouring, imaging or not, how you approach it,
any specific devices, and fixation.
Dr. Schechter: My partner and colleague, Amir Dorafshar,
is doing most of these now, he is a craniofacial
surgeon doingmost of the bony work. But historically, I
have always gotten a CT. Amir is also getting a CT.
And Amir has been very involved in virtual surgical
planning. We have a training program and he runs the
planning sessions with the residents and fellows, and I
think has found that very very helpful. Now when I was
doing this, it sort of predates most of the ultra at least the
U.S. experience with the ultrasound instrumentation.
So I use just traditional burrs for the frontal sinus
osteotomy. Fixation, I've usedmini plates to do that. As
Dr. Alperovich said, nonweight bearing. I don't think a
lot of heavy fixation, of course, is required there. We
have collected the bone dust and bone paste, and filled
in any of the gaps with that. I have used methyl methacrylate
when needed, to create the convexity in themid
forehead as well. But admittedly, this is not the focus or
emphasis of my practice at this point.
Dr. Spiegel: Dr. Knott? How about for you?
Dr. Knott: So, we use the Sonopet ultrasonic aspirator
around the mental nerve for the mandible work. But I
don't really use it for the forehead. I still use a sagittal
saw, much like you taught me. I drill off a lot of the
bone to collect the bone pate´ with a pineapple burr.
ª 2022 American Academy of Facial Plastic and Reconstructive Surgery, Inc.
I do get CTs. But I'm not sure I need them. I don't find
they are very useful or helpful to me. I kind of do the
same thing regardless. But I usually get them if I can
because I find it's reassuring, if nothing else. Then for
fixation, again, I usually use two 5-hole mini plates
with between four to eight screws per segment, depending
upon how the bone fixation occurs. We use
the bone pate centrally. It is nice to keep that central
fullness over the glabella and not have to be depressed
to get generalized contour around the whole area, and
that seems to have worked pretty well for us.
Dr. Spiegel: Dr. Garcia, how about for you? Any
imaging indication? Any templates? How are you
Dr. Garcia: I amfixating with 10 holemini plate split in
half with 3mm screws. I use usually about four screws. I
once had to use a bit ofmesh, mostly because the anterior
table was so thin and it fractured, I only actually used it
once. I am also collecting bone dust. I find that you can
collect about 2 sometimes 3 ccs of bone dust while
you re drilling. I use a small little round edged sagittal
saw to remove the frontal table. It has little rounded
edges to give me a little bit more roundedness whenever
I need it. I've had quite a few patients who had facial
trauma and poor dentition. I do have a very underserved
population so it is not unexpected. I'm currently seeing a
patient who still has plates from her fractures. If they tell
me they have a history of facial trauma, I will get a CT
scan. If they have poor dentition I palpate their mandible
thoroughly and I will get a CT scan to evaluate the
quality of the mandible. If the mandible does not look
age appropriate and looked older I will alter our surgical
plans. If they have no history of facial trauma, then I will
typically not get any imaging and I can blue line the
frontal sinus as I was taught in fellowship.
Dr. Spiegel: I will agree and disagree with all of you.
I never get imaging, unless there is something unusual
in their history, such as prior trauma, some sort
of congenital abnormality, or prior brain surgery. As
Dr. Knott said, I have never really understood what
it's going to do for me and it will not change my
surgical approach to know in advance the size of the
frontal sinus. I start, like Dr. Rodman said, laterally
and work my way in. We have discovered that the
radix-and Dr. Garcia, you are going to publish this,
I believe-is never posterior to anything intracranial.
So, it's a very safe landmark as far as where you
are and obviates the need for imaging. I have been
doing, like Dr. Alperovich said, single screws on
either side, for a long time now, because as mentioned,
it is not weight bearing. There's nothing
touching this. You just have to more or less keep it
in place and when I have a really perfect fit, I do not

FPSAM - Roundtable 2022

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