Dorsal Augmentation Rhinoplasty with Irradiated Homograft Costal Cartilage

Augmentation of the nasal framework requires a working knowledge of nasal and facial anatomy, as well as the principles of facial proportion and balance. Dorsal augmentation rhinoplasty is a valuable means of improving nasal appearance in patients with a low and/or concave nasal dorsum, obtuse nasofrontal angle, and low radix. It frequently is combined with other techniques, including columellar strut grafting, nasal tip grafting, and tip suturing, as dorsal deficiencies are often associated with poor tip projection and support and a shortened columella. Our experience with dorsal augmentation rhinoplasty, including the use of irradiated homograft costal cartilage for grafting in 56 surgeries, is described. A high level of patient satisfaction with a low percentage of complications has been seen

Sural nerve harvest: anatomy and technique.

A minimally-invasive technique of sural nerve harvesting using an initial blunt tip harvesting device, combined with a recessed sharp cutting mechanism for final severance of the nerve, has been developed. Important surgical landmarks have been established, based on a review of the anatomy of the sural nerve. Harvesting is begun through a small incision at the level of the lateral malleolus, thereby identifying the nerve and inserting the nerve-harvesting device. An additional small incision, if needed, is placed at the junction of the middle and distal thirds of the lower leg, a landmark at which an anastomosis between the medial and lateral sural cutaneous nerves is seen in at least 74 percent of patients. When this anastomosis is palpated, the lateral sural cutaneous nerve is visualized and divided, and the dissection of the medial sural cutaneous nerve proceeds in a proximal direction. At the distal end below the popliteal fossa, the cutting mechanism is safely deployed, transecting the nerve. This combination of a limited incision approach with the blunt harvester and sharp, protected division provides 30 to 35 cm of sural nerve graft in the great majority of patients, while reducing the complications often associated with open techniques and minimally-invasive techniques that rely on sharp or blunt instrumentation

Palmar arch revascularization for arterial occlusion of the distal upper extremity.

During a period of nine years, 10 patients, ages 42 to 66 years (55 +/- 7, mean +/- SD) underwent upper extremity bypass for ischemic changes to the hand not responsive to conservative management. Patients were referred from the vascular department at the authors\u27 institution. Preoperative angiograms were performed and attempts at angioplasty or intravenous attempts to dissolve clots were carried out (with tissue plasminogen activator-tPA) when appropriate. Patients with persistent upper extremity ischemia and an obvious occlusion with reconstitution in the hand were candidates for upper extremity bypass to the palmar arch. All patients had upper extremity bypasses performed with reverse saphenous vein grafts. The proximal anastomoses (end-to-side) were performed by either the vascular or plastic surgery team, while all distal anastomoses (end-to-side) were performed by plastic surgery team microscopic magnification to the deep or superficial palmar arch. Postoperative follow-up ranged from 3 months to 3 years. The bypass graft to the hand resulted in improved pain and resolution of tissue ischemia in all cases. Patients with preoperative ulcers were completely healed by 3 months. The results are in accordance with previous studies demonstrating that improved blood flow afforded by the procedure can improve the healing of recalcitrant ulcers and mitigate the symptoms of ischemic changes. In addition, end-to-side anastomosis to the palmar arch offers significant advantages, in that the continuity of the arch is maintained with all possible outflow vessels, and the problems associated with size discrepancy in the anastomosed vessels are eliminated

Single-stage maxillary and nasal floor reconstruction with the double-paddle rectus abdominis musculocutaneous free flap.

Palatal integrity is essential for useful speech, deglutition, good oral hygiene, and prevention of nasal regurgitation. Maxillary defects after tumor extirpation, therefore, can have serious functional and cosmetic implications. Given the often disappointing results obtained with local and regional pedicled flaps for maxillary reconstruction, a variety of microvascular free flaps have been utilized in recent years, including the rectus abdominis, fibular, radial forearm, and latissimus dorsi flaps. Experience with these techniques has been documented in a limited number of case reports. We describe our single-stage approach to maxillary and nasal floor reconstruction with the double skin-paddle rectus abdominis musculocutaneous free flap. A series of five patients is presented; six of these immediate free flap reconstructions were performed for defects resulting from tumor resection. A vertical rectus abdominis musculocutaneous free flap was used in all cases, designing two separate skin paddles to accommodate the measured maxillary and nasal floor deficiencies. Anastomoses of the deep inferior epigastric artery and vena comitans were performed end-to-end to the facial artery and vein, respectively. In addition, orbital floor reconstruction with calvarial bone grafts or titanium mesh was performed in all five patients. Separation of the oral and nasal cavities was maintained postoperatively. No intraoperative complications, perioperative mortalities, flap losses, instances of skin paddle necrosis, hematomas, or oronasal fistulae were observed. One patient required bedside drainage of a surgical site abscess that resolved without adverse sequelae. Over the past 4 years, the double skin-paddle rectus abdominis musculocutaneous free flap has provided reliable results at our institution for single-stage reconstruction of maxillary and nasal floor defects. This reconstructive technique should be considered a viable method that can alleviate the functional and cosmetic debility associated with these defects

Letters to the editor

SCOPUS: le.jinfo:eu-repo/semantics/publishe