Are grafts necessary in rhinoplasty? cartilage flaps with cartilage-saving rhinoplasty concept

Cartilage grafts are used routinely in rhinoplasty, but are they necessary? Can we support the normal anatomy by preserving and transposing the adjacent tissues? In this study we hypothesize that during rhinoplasty, cartilage flaps can give adequate support and may decrease the need for cartilage grafts. Included in this study were 147 patients who underwent an open rhinoplasty technique under general anesthesia between January 2010 and May 2012. Mean operative time was 73 min (range = 44-120 min). After dissection and septoplasty (if needed), we performed dorsal bone and septal reductions. Following reduction, upper lateral cartilage superior segments were preserved and turned inward as cartilage flaps to replace the spreader grafts. Lower lateral cartilage cranial parts were not excised and were slid over the caudal part to replace the alar strut grafts. Cartilage from the caudal nasal septum was not excised; instead, lower lateral cartilages were cephaloposteriorly displaced with a tongue-in-groove technique to support the nasal tip. Mean follow-up time was 19.6 months (6-30 months). All patients but 12 were satisfied or completely satisfied with the results. Among the 12 unsatisfied patients, four complained of a one-sided inverted-V deformity (secondary spreader grafts were added), three had supratip deformity (secondary additional dorsal septal excisions), two demanded extra tip definition (secondary tipoplasty), two were unhappy with the bone symmetry (secondary osteotomies), and one complained of hanging columella (secondary excision from the caudal septum). Cartilage flaps have some advantages over cartilage grafts. First, graft harvest is not needed in the former; second, because flaps are a part of the normal anatomy, they provide a good tissue match, making fixation easier. However, the tongue-in-groove technique cannot be used in patients who do not need caudal excision, and cartilage flaps can be inadequate in some patients who may need additional grafts. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

DENERVASYON İLE YAPILAN ÖNKOŞULLANDIRMANIN İSKELET KASINDA İSKEMİ-REPERFÜZYON HASARINA ETKİSİ

İskemi-Reperfüzyon (İR) hasarının önlenmesi amacıyla birçok ajan deneysel çalışmalarda başarılı sonuçlar alsa da bunların pek azı klinik olarak ulanılmaktadır. Denervasyonun iskelet kasının enerji ihtiyacını azalttığı bilinmektedir. Bu çalışmada cerrahi denervasyon (CD) veya Botulinum Toksin Tip A (BTx-A) ile kimyasal denervasyonla gerçekleştirilen önkoşullandırmanın iskelet kasında İR hasarına etkileri incelenmiştir Çalışma 42 adet Wistar Albino Sıçanın sağ biseps femoris adalesinde gerçekleştirildi. Kontrol grubunda sadece İR hasarı gerçekleştirilirken, 2-4. gruplarda 30 gün (n=6) , 7 gün (n=6) ve bir gün önce (n=6) cerrahi denervasyon, 5-7. gruplarda ise 30 gün (n=6) , 7 gün (n=6) ve bir gün önce (n=6) BTx-A ile kimyasal denervasyon gerçekleştirildi. Dört saat iskemiyi takiben 4 saat reperfüzyona izin verildi. Reperfüzyonun sonunda hayvanlar sakrifiye edilerek biseps femoris kasları eksize edilerek dokuda histolojik inceleme, apopitoz yoğunluğu, malonildialdehit (MDA) ve reaktif azot ürünleri (NOx) çalışıldı. Otuz gün önce cerrahi veya BTx-A ile denervasyon yapılan gruplarda kontrol grubuyla karşılaştırıldığında histoloji ve apopitoz skorlarındaki düşüş anlamlı değilken, doku MDA ve NOx düzeylerindeki düşüş anlamlıydı. Yedi gün önce cerrahi veya BTx-A ile kimyasal denervasyon yapılan gruplarda ise kontrol grubuyla karşılaştırıldığında tüm parametrelerde İR hasarının etkilerinin azaldığı görüldü. Bir gün önce cerrahi veya BTx-A ile kimyasal denervasyon yapılan gruplarda kontrol grubuyla kıyaslandığında dejeneratif histoloji ve doku NOx miktarlarında anlamlı azalma saptanırken, bir gün önce cerrahi denervasyon yapılan grupta doku MDA, bir gün önce BTx-A ile kimyasal denervasyon yapılan grupta ise apopitoz skorlarındaki düşüş anlamlı bulunmadı Sonuç olarak kas naklinden en az bir gün önce yapmak koşuluyla denervasyon iskelet kasında iskemi direncini arttırır ve reperfüzyon hasarını azaltır. BTx-A ile kimyasal denervasyon, ek bir cerrahi girişim gerektirmemesi ve cerrahi denervasyon ile benzer etkiler oluşturması sebebiyle cerrahi denervasyona tercih edilebilecek bir yöntemdir.Many agents were studied for the prevention of Ischemia-Reperfusion (IR) injury but few of them are used in clinical cases. Denervation can reduce the energy consumption of a skeletal muscle and theoretically can increase its ischemia tolerance. In this study the effects of precontioning by surgical or chemical denervation with Botulinum Toxin A (BTx-A) on IR injury of a skeletal muscle was examined. Biceps femoris muscle of 42 Wistar Albino rats were used in this study. Only IR injury was done in control group. In groups 2-4, surgical denervation was done 30 days (n=6), 7 days (n=6) and 1 day prior to IR injury. In groups 5-7 chemical denervation with BTx-A was applied 30 days (n=6), 7 days (n=6) and 1 day prior to IR injury. For IR injury tourniquet was applied to right extremity of all rats for four hours. Then tourniquet was cut and reperfusion was allowed for 4 hours. Then all the animal were sacrificed and tissue samples were gathered. In these tissues histological examination, apoptosis presence with Caspas 3 stains, tissue malonyldialdehyde (MDA) and nitrit + nitrate levels were studied. The degenerative histology and apoptosis scores were not significantly decreased in groups that the surgical or chemical denervation was done 30 days prior to surgery. But the decrease was significant in tissue biochemical analysis in both groups. All the histological, apoptotic and biochemical parameters were significantly decreased in groups that surgical or chemical denervation was done 7 days prior to IR injury. Although the degenerative histology and tissue NOx scores were significantly decreased in groups that surgical or chemical denervation was done 1 day prior to IR injury, decrease in tissue MDA level in one day prior surgical denervation group and apoptosis score level in one day prior chemical denervation groups were not statistically significant. In conclusion, in a skeletal muscle; surgical or chemical denervation that applied at least one day prior to IR injury can increases the muscle tolerance for ischemia and reduces the effects of reperfusion injury. Chemical denervation with BTx-A can be a better choice for providing similar results without a secondary operation

Setup of Columellar Height with Costal Cartilage Graft Modification in a Patient with Binder Syndrome

Binder syndrome is an uncommon disorder of unknown etiology. It is characterized by hypoplasia of the nose and maxilla and altered morphology of the associated soft tissue. We present a surgical technique for setting up the columellar height in a patient with Binder syndrome

Post-Burn Skin Deformities of the Face and Neck Region in Pediatric Patients: Single-Stage Treatment Using Collagen Elastin Matrix

Objective: Treating severe post-burn deformities of the face and neck region in pediatric populations is challenging because of technical difficulties (e.g., limited full thickness skin graft donor site, limited flap options, unavailability for expander placement) and increased donor site morbidity (e.g., related to flap and graft donor sites). In this study, we present the single-stage treatment of severe post-burn skin deformities of the face and neck region in pediatric patients using collagen-elastin matrix (Matriderm®) combined with partial thickness skin grafts. Material and Methods: The total number of cases was eight (four females, four males), and the ages were between two and 11 years. All cases were operated on for only one region. Following the release of contractures and/or excision of wide excessive/ unfavorable dermal scars, defects were reconstructed using collagen- elastin matrix (Matriderm®) combined with partial-thickness skin grafts. The final functional and aesthetic results were evaluated using photography and examination. Results: The deformities were in the form of contractures and/ or excessive dermal scarring. The involved regions were the face (n=3) and neck (n=5). The grafts yielded favorable plication and texture, and no recurrence of excessive dermal scarring was observed. All contractures healed unproblematically. Two patients were re-operated on for regrafting caused by minor graft loss (5% and 12% of the total area, respectively). Conclusion: In this study, we observed that collagen elastin matrix combined with partial-thickness skin grafts provides a favorable option for the treatment of pediatric late post-burn complications in the face and neck region with limited surgical options

Assessing the Expectations of Patients Demanding Rhinoplasty on Profile Photographs using Proportional Measurements and Simulation Programs

Objective: The aim of this study was to define the desired profile measurements in patients who demand rhinoplasty and to assess the needs of extra profile surgeries in these patients. Material and Methods: Overall, 100 patients (60 women, 40 men) demanding rhinoplasty between January and December 2013 were included in this study. Standard profile photos were taken. Rhinoplasty and extra profile surgeries were simulated in those photos with both patient and surgeon decisions. These simulated photos were assumed as the desired profile view. In those photos, some angles or measurements were calculated to understand the desired proportions on the profile view. Then, these desired proportions were compared with the universal ideal proportions to understand the needs of extra profile surgeries in those patients. Results: It has been found that 43% of women and 27.5% of men would benefit from fat injections to the forehead. Sagittal lowering of the nasion was necessary in 25% of both men and women. Respectively in women and men, demands in; nasolabial angle increase were 85% and 75%, projection increase according to Goode ratio were 35% and 32%, according to Baum ratio, 80 and 75%. Lower chins vertical height was longer than the nose in 18% and 17%, nose was longer than the lower chin in 17% and 7.5% in women and men respectively. Lower 2/3rds of the chin was longer than normal in 21% of the patients in both women and men. In two different proportions, the chin was found to be retruded in 23%–36% and 30%–35% and protruded in 23%–26% and 25%–30% in women and men, respectively. Conclusion: Personal demands may vary from the universal ideals. Therefore, pre-surgical simulations become necessary to assess the extra surgery needs in patients demanding rhinoplasty. These simulations may help the surgeon to personalize the surgery according to the patients demand, and patient satisfaction may increase as a result this approach