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Objective: To determine the efficacy of alar batten grafts for the correction of internal and external nasal valve collapse. Design: In this retrospective study, a questionnaire was used to ask patients to rate their nasal breathing before and after application of alar batten grafts. Setting: Private practice and academic tertiary referral medical center. Patients: The questionnaire was given to 63 patients who underwent application of alar batten grafts between 1980 and 1995. Forty-six patients (73%) responded and were included in the study. Intervention: Alar batten grafts were applied into a precise pocket via a limited endonasal incision or via the external rhinoplasty approach. The grafts consisted of curved septal cartilage or auricular cartilage and were applied to the site of maximal lateral nasal wall collapse. The convex surface of the cartilage was oriented laterally to allow maximal lateralization of the collapsed portion of the lateral nasal wall. In most cases, alar batten grafts were applied caudal to the existing lateral crura and extended from the lateral one third of the lateral crura to the piriform aperture. Outcome Measures: The degree of nasal airway obstruction was determined by subjective scoring on a scale from 1 (no obstruction) to 5 (complete obstruction) before and after surgery. The patency of the internal airway was also assessed on physical examination. Results: The results of the study revealed that all but 1 of the 46 patients experienced an improvement in their nasal airway obstruction. The mean improvement in nasal airway obstruction was 2.5 on a scale of 5. Patients that had the least improvement had intranasal scarring in the region of the internal nasal valve, loss of vestibular skin, or excessive narrowing at the piriform aperture. Physical examination revealed a significant increase in the size of the aperture at the internal or external nasal valve after the application of the alar batten grafts. There was minimal postoperative fullness in the supraalar region, where the alar batten grafts were applied. With time, this fullness decreased, leaving little evidence of the graft and an overall improvement in the aesthetic result. Conclusions: Alar batten grafts are effective for longterm correction of internal and external nasal valve collapse that is not complicated by intranasal scarring in the region of the nasal valve, loss of vestibular skin, or excessive narrowing at the piriform aperture. Arch Otolaryngol Head Neck Surg. 1997;123:802-808

Objective: To determine whether fibroblast growth factor 1 implanted with viable nerve into atrophic muscle will stimulate formation of functional, acetylcholineproducing motor end plates. Design: Twelve male Lewis rats underwent predenervation of the hamstring muscle 8 weeks before implantation of the nerve at a site distant from the original motor end plate. Six animals underwent implantation of the tagged nerve ending into atrophic muscle with 50 μg of fibroblast growth factor 1 in a fibrin adhesive carrier (group 1). Three animals underwent implantation with nerve, fibrin adhesive, and no fibroblast growth factor 1 (group 2); and three animals underwent implantation with fibroblast growth factor 1 and fibrin adhesive with no nerve (group 3). Animals were killed 9 weeks after implantation and nerve and muscle specimens were harvested. Main Outcome Measures: Histoenzymologic methods for acetylcholinesterase and silver impregnation of nerve fibers were performed 9 weeks after fibroblast growth factor 1–fibrin adhesive implantation. Variables included the number of motor end plates per highpower field and motor end plate length. Results: Robust axonal sprouting and formation of multiple motor end plates were found arborized in serial fashion equidistant around the implanted nerve ending. Rare extrasynaptic staining occurred. End plate lengths were significantly shorter in the fibroblast growth factor 1–treated muscles (group 1) than in the specimens without fibroblast growth factor 1 (group 2) (31.2 vs 58.5 μm; P >.001, paired t test). The arborization of motor end plates, rare extrasynaptic staining, and shorter end plate lengths seen in group 1 were all consistent with mature motor end plates. Controls (group 3) displayed limited motor end plate formation and extensive extrasynaptic staining typical of denervation. Conclusions: This study presents encouraging evidence that fibroblast growth factor 1 with fibrin adhesive carrier can facilitate the reinnervation of atrophied muscle by enhancing the formation or revitalization of motor end plates. Future studies will address muscle function and use of different carrier materials. (Arch Otolaryngol Head Neck Surg. 1996;122:425-430)

Objective: To characterize the venous, lymphatic, and arterial blood supply of the nose and determine the effect of the external rhinoplasty approach on this vasculature. We hypothesized that dissection in the areolar tissue plane below the musculoaponeurotic layer of the nose will preserve the nasal vasculature and minimize postoperative nasal tip edema. Design: The study included preoperative and postoperative clinical evaluation, cadaver dissection, and histologic examination. In the clinical section, lymphoscintigraphy was performed before and after rhinoplasty using the endonasal (transnostril) or external (open) approach. Additionally, nasal tip edema was subjectively quantified at specified intervals after surgery. In the cadaver dissection section, 15 fresh cadavers were dissected to identify the venous and arterial vasculature. In the histology section, fresh nasal tissue was examined by light microscopy to verify the anatomy of arteries, veins, and lymphatic vessels. Setting: Subjects for the clinical section of the study were volunteers undergoing primary rhinoplasty surgery at the University of Illinois College of Medicine at Chicago. Patients: Lymphoscintigraphy was performed on nine patients who underwent rhinoplasty surgery. Seven of these patients underwent postoperative lymphoscintigraphy. Interventions: The rhinoplasty procedures included three different methods of exposure of the nasal structures. Two patients underwent an endonasal (transnostril) nondelivery approach using a transcartilaginous incision. Five patients underwent the external approach with three receiving dissection in the areolar tissue plane below the musculoaponeurotic layer (preserving major nasal vasculature) and two undergoing dissection above the musculoaponeurotic layer (disrupting nasal vasculature). Main Outcome Measures: In the clinical section of the study, the outcome measures were tracer flow as seen on lymphoscintigraphy and tip edema scores subjectively quantitated on a scale from 1 (none) to 4 (maximal). Results: Clinical Section: Lymphoscintigraphy revealed flow of tracer along the lateral aspect of the nose (cephalic to lateral crura) to the preparotid lymph nodes. Postoperative scans revealed preservation of flow of tracer with the endonasal (transnostril) approach and the external approach with submusculoaponeurotic areolar tissue plane dissection. There was loss of normal flow of tracer with the external approach using dissection that disrupted the musculoaponeurotic layer with supratip debulking. The nasal tip edema scores for the transnostril and external approach using areolar plane dissection were significantly lower than the external approach with disruption of the musculoaponeurotic layer. Cadaver Dissection Section: Other than the lateral nasal veins, the major arteries, veins, and lymphatic vessels ran superficial to the musculoaponeurotic layer of the nose. The lateral and dorsal nasal and the columellar arteries comprise an alar arcade that provides the major blood supply to the flap elevated in the external rhinoplasty approach. Histologic Section: Light microscopy of plastic resin sections verified the lymphoscintigraphic and cadaver dissection findings. The lymphatic vessels were located primarily in the reticular dermis above the muscle layer. Conclusions: The major arterial, venous, and lymphatic vasculature courses in or above the musculoaponeurotic layer of the nose. In the external rhinoplasty approach, dissection in the areolar tissue plane below the musculoaponeurotic layer will minimize tip edema and protect against skin necrosis by preserving the major vascular supply to the nasal tip. (Arch Otolaryngol Head Neck Surg. 1996;122:24-34)

• Browlifting and forehead procedures are a critical element in the contemporary surgical management of the aging face. Esthetics of the upper third of the face will dictate brow position and its relationship to the supraorbital rim and eyes. Treatment of deformities of the upper third of the face can be varied according to the sex and age of the patient as well as contour of the hairline and forehead. The indications, advantages, disadvantages, and techniques of the coronal forehead, modified pretrichal forehead, midforehead, and direct browlifting procedures are discussed. ( Arch Otolaryngol Head Neck Surg . 1990;116:1137-1142)

• The osteoinductive properties of demineralized bone have stimulated its use in facial skeletal augmentation and reconstruction. Demineralized bone has been shown to induce phenotypic conversion of mesenchymal cells into osteoblasts, with bone formation within 29 days (osteoinduction). In this clinical study, 75 demineralized bone implants were followed up from 1 to 48 months (average follow-up, 14.3 months). There were 41 major dorsal implants, with an average degree of resorption of 50.7%. Eight dorsal implants were followed up for more than 24 months, with an 82.5% degree of resorption. Overall resorption for all implants was 49%. Major factors contributing to implant resorption included lack of surrounding mesenchymal cells and inadequate contact between host tissue and bone-inducing surface area. Other factors included infection, poor vascularity, and compression of the implant. Demineralized bone has an unacceptably high resorption rate and should only be used in highly selective cases where the implant can be positioned in a site rich in primitive mesenchymal or bone-forming cells. ( Arch Otolaryngol Head Neck Surg . 1990;116:676-680)

• Cyanoacrylate derivatives have been used as surgical adhesives for many years. Shorter-chain derivatives (methyl- and ethyl-cyanoacrylate) have proved to be histotoxic. Longer-chain derivatives (butyl- and isobutyl-cyanoacrylate) are much less histotoxic. Many surgeons continue to use ethyl-2-cyanoacrylate (Krazy Glue) despite the availability of a less toxic derivative, butyl-2-cyanoacrylate (Histoacryl). In this study, the histotoxicity and bone graft—cartilage binding ability of Krazy Glue and Hlstoacryl were compared. Bone grafts harvested from the anterior wall of the maxillary sinus were placed in a subcutaneous pocket and glued to auricular cartilage in the rabbit. Krazy Glue and Histoacryl were used in opposite ears, harvesting specimens at 1, 2, 4, 12, 24, and 48 weeks. The Krazy Glue—treated ears developed seromas with histologic evidence of acute inflammation, tissue necrosis, and chronic foreign body giant cell reaction. The Hlstoacryl-treated ears showed mild acute inflammation and mild foreign body giant cell reaction. The Krazy Glue was completely degraded within 12 months, while some Histoacryl was still present at 1 year. Histoacryl had minimal histotoxic effect and good bone graft—cartilage binding ability, whereas Krazy Glue demonstrated severe histotoxicity. ( Arch Otolaryngol Head Neck Surg . 1990;116:546-550)

The head and neck surgeon is still in search for the ideal implant material that would be readily available, biocompatible, easily shaped, nonresorbable, and safe to use. Alloplastic implants (Silastic, Proplast) may have problems associated with their persistence in the host as a foreign body, implant movement, and resorption. Autologous bone and cartilage remain the materials of choice for implantation. As an alternative to autologous bone grafts, surgeons now can choose from one of several different types of bone implants. Osteoconductive bone implants undergo ingrowth of host bone from the margins of the defect with subsequent osseointegration of the implant. A major drawback of osteoconductive bone implants is that they remain in the host as a foreign body. Hydroxyapatite implants are a good example of an osteoconductive implant. On the other hand, osteoinductive implants actually stimulate host bone formation by transforming host mesenchymal cells into osteoblasts. These implants are ultimately

Vascular malformations and cavernous hemangiomas are common in childhood. Although cavernous hemangiomas may resolve spontaneously, aggressive intervention is required when their growth could damage vital adjacent structures, such as the orbit, nose, or tongue.To evaluate the efficacy of interstitial Nd:YAG photocoagulation as an adjunct to intralesional and systemic corticosteroids for treatment of hemangiomas and vascular malformations that had failed to respond to other therapies.Prospective, nonrandomized trial.Two referral practices of facial plastic and reconstructive surgery in tertiary care, academic medical centers.Ten consecutive pediatric patients with either hemangioma or vascular malformation of the head and neck.Laser photocoagulation with an interstitial technique. The Nd:YAG fiber was introduced into the lesion via a 14-gauge angiocatheter needle, and the laser fiber was advanced as coagulation proceeded within the tissue.Decrease in the area of the target lesion, amount of energy applied, and number of treatments required to achieve reduction in size.Long-term follow-up demonstrated regression of the lesion in all 10 patients with good cosmetic results. The range of reduction in size was 20% to 98%. No reexpansion of the lesions was noted after a mean follow-up of 13 months.Interstitial photocoagulation of hemangiomas and vascular malformations is an effective treatment for carefully selected patients. When properly applied, this technique can achieve reduction in the size of these lesions without compromising cosmesis.

Reconstruction in head and neck surgery has been greatly advanced with the use of the pectoralis major and trapezius myocutaneous flaps. Most surgical defects can be repaired with one of these flaps alone, or in conjunction with cutaneous flaps. Specific problems, however, occur that cannot be successfully reconstructed by these standard flaps. The traditional scalp flaps are cutaneous flaps. Use of these flaps is limited because of their shortened arc of rotation and accompanying forehead deformity. Three patients underwent reconstruction with a parietal occipital nape of neck myocutaneous flap. Its advantages include the following: large segments of hairless skin from the contralateral side of the neck can be used, an extensive arc of rotation and distance can be achieved with excellent vascularity in the overlying skin, and cosmetic results are superior. Angiographic studies were used to demonstrate the vascular pattern and supply to this flap. Cadaver dissections were performed to determine the pattern of distribution of the perforating vessels to the skin from underlying muscle.

• Complications of septorhinoplasty often involve adjacent structures, resulting in cosmetic as well as functional abnormalities. Dental complications of nasal surgery are rare. We describe a patient who underwent septorhinoplasty with a postoperative complication of a devitalized tooth. To our knowledge, this is the first report of such a dental complication. Bony manipulation in the region of the nasal spine may have resulted in the interruption of the neurovascular supply to the right central incisor, yielding a devitalized tooth. An aberrant vascular supply, or root apex situated high in the premaxilla, can predispose to dental injury while performing bony manipulation near the nasal spine. Preoperative evaluation of patients who are at risk for dental complications may allow the surgeon to safely achieve the functional and cosmetic goals of septorhinoplasty. ( Arch Otolaryngol Head Neck Surg 1987;113:765-767)

• Minoxidil is a potent peripheral vasodilator used to treat patients with severe hypertension that is unresponsive to other medications. Hypertrichosis of the forehead, face, neck, shoulders, upper part of the arms, and legs is a frequent side effect that occurs in the majority of patients that use this drug. This phenomenon appears to be due to increased blood flow to hair follicles, with resultant excessive hair growth. We describe a patient with severe hypertrichosis of the external ear canal resulting in chronic otitis externa and hearing loss. (Arch Otolaryngol Head Neck Surg1988;114:918-919)