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Background In nasal reconstruction, the paramedian forehead flap is traditionally performed in 2 stages. To minimize the risk of flap necrosis, Millard described a 3-stage technique in a series of 5 cases in 1974. In this technique, an intermediate step of flap thinning is performed after flap transfer and before pedicle division. In this article, we compare the 2- and 3-stage techniques of paramedian forehead flaps for nasal reconstruction to determine the type and prevalence of complications related to each procedure. Methods Here, we present a retrospective review of a prospectively maintained database of paramedian forehead flaps for nasal reconstruction performed during a period of 6 years. We included all patients with 2- (n=87) and 3-stage (n=100) paramedian forehead flaps who had consistent and complete electronic patient records and followed them up for at least 6 months after pedicle division. We performed a regression analysis to adjust for the unequal distribution of complex cases. Results Demographic factors and the causes for the nasal defects were similar in both groups. Although the nasal reconstructions were significantly more complex in the 3-stage group, the rate of partial forehead flap necrosis was similar in both groups (2-stage, 3.4%; 3-stage, 5%; P=0.601). A regression analysis showed that the relative risk of partial flap necrosis in complex cases did not differ significantly between groups (relative risk, 0.80; P=0.705). Conclusions To our knowledge, our study is the largest series published to date and the first one to compare the prevalence of forehead flap necrosis in the 2- versus the 3-stage technique for paramedian forehead flaps. We found no evidence that the use of a 3-stage forehead flap lowers the prevalence of necrosis. Until larger multicenter studies or meta-analyses can be conducted, smaller yet well-conducted studies such as the present one provide critical data and represent an important contribution to the field. Future research should investigate whether the 3-stage technique produces better aesthetic results than the 2-stage technique.

Restoring nasal lining is one of the essential parts during reconstruction of full-thickness defects of the nose. Without a sufficient nasal lining the whole reconstruction will fail. Nasal lining has to sufficiently cover the shaping subsurface framework. But in addition, lining must not compromise or even block nasal ventilation. This article demonstrates different possibilities of lining reconstruction. The use of composite grafts for small rim defects is described. The limits and technical components for application of skin grafts are discussed. Then the advantages and limitations of endonasal, perinasal, and hingeover flaps are demonstrated. Strategies to restore lining with one or two forehead flaps are presented. Finally, the possibilities and technical aspects to reconstruct nasal lining with a forearm flap are demonstrated. Technical details are explained by intraoperative pictures. Clinical cases are shown to illustrate the different approaches and should help to understand the process of decision making. It is concluded that although the lining cannot be seen after reconstruction of the cover it remains one of the key components for nasal reconstruction. When dealing with full-thickness nasal defects, there is no way to avoid learning how to restore nasal lining.

The nose represents the center of the face. The nasal shape changes with the progression from infancy to adulthood. In newborns, the main supporting structure of the nose is the dorsal septal cartilage; it is the facial growth center. The loss of septal cartilage at different ages leads to various facial syndromes involving the nose, maxilla, and orbita. Therefore, every surgical treatment can compromise not only the nasal growth but also the growth of the whole face. Childhood trauma or a malformation of the nose can also cause enormous functional impairments similar to those caused by surgical treatments. Our contribution represents different aspects of nasal deformities and their treatment. An individual concept is indispensable to reach the best compromise in all cases. The postulate of an early treatment gives priority to physical and mental damage control. The late therapy concept uses the inimitable potential of the growth of different tissues needed for a septoplasty and should be protected from iatrogenic impairment. We recommend a first-line pediatric nasal reconstruction, an attentive follow-up, and finally, a secondary nasal reconstruction in the adult patient if required for achieving normalcy.

Because of better public education and earlier diagnosis of skin tumors, the number of soft tissue defects of the nose with limited size and depth after tumor resection is increasing. A variety of surgical methods such as skin grafts, regional flaps such as forehead flap, and local flaps have been described. The method of choice is dependent on the defect size, localization, skin structure and the wishes and expectations, and general condition of the patient. Nasal reconstruction for soft tissue defects in the supratip area, dorsum, and sidewalls using local rotation and/or advancement flaps is our primary option. But achieving supreme results with these non-subunit-based techniques is still a challenge. Showing schematic figures and case studies, this article is aimed at assisting surgeons in the planning and decision making of which flap is appropriate for the reconstruction of soft tissue defects of the nose.

The aim of this paper is to delineate the importance of the correction of the nasal septum when attempting to improve the nasal shape and function in patients with cleft lip and palate (CLP) deformity. The particular problems of the nasal shape in CLP patients are assessed. Various approaches for adequate correction are reviewed and discussed. The method of extracorporeal septoplasty is presented in detail. This method was used between 1982 and 1997 in 141 out of 332 CLP patients who required septoplasties and appears particularly suited for this purpose since it offers the possibility of reconstructing an almost normal septum. This is necessary in order to achieve both a functionally and an aesthetically good result. Our experience over the past 16 years confirms the advantages of this approach.

Based on a review of the literature and our own experience, we propose criteria for the site of implantation that, in our eyes, is suitable for a silicon implant or a cartilage transplant. Special interest is focused on rhinoplasty and chin augmentation, as both determine the facial profile of the patient. During the last 17 years we have treated 443 patients with augmentation rhinoplasty, of whom 360 received autologous ear cartilage grafts and 83 received autologous rib cartilage grafts. At the same time we saw 30 patients requiring removal of artificial implant materials that were used by other surgeons for rhinoplasty augmentation purposes. Since 1986 we have performed 60 chin augmentations with anatomically shaped silicone implants (McGhan), of which 40 patients had a combined rhinomentoplasty done.

The correction of a nasal deformity is a decisive step in the secondary treatment of patients with cleft lip and palate. The complex nasal deformity in these patients is caused partly by the anormaly itself and is partly a result of previous corrective surgery. Correcting the nasal deformity involves solving four complex problems: the septal deformity; the malposition of the exterior nose; the deformity of the nasal tip; and the deviation of the ala on the cleft side. The stigma of the patients with a cleft is sustained mainly by the asymmetry of the nasal entrances. Many operations, some of which cause extensive additional scarring, have been suggested for removing this typical feature in patients with clefts. We developed a triple swinging flap technique which has proved successful when used with an open as well as a closed approach. This also enables us to achieve symmetry of the nostrils.

We present three cases of mucous cyst as a rare postrhinoplasty complication that were seen in our clinic during the last 16 years. They were located in three different positions of the nose: bony and cartilaginous part of the dorsum of the nose as well as over the alar cartilage part of the nose. We were able to treat all three patients successfully by excision of the cyst through intranasal or open approaches. In reviewing the literature and from our own experience we come to the conclusion that postoperative clearing of all tissue remnants, especially mucous parts, and a careful, atraumatic operation by forming an intact mucoperichondrial tube for intransal osteotomy as well as for hump removal are the best prevention of postrhinoplasty complications such as mucous cysts.

One of the most important preconditions for a straight nose is a straight and stable cartilaginous L-shaped frame with sufficient support for the nasal tip and the cartilaginous dorsum. Where the structure of the septal cartilage is destroyed, a sufficient L-strut must be reconstructed. This article presents a technique for reconstruction of an autogenous L-strut using double-layered conchal cartilages.A retrospective review was conducted with a subsequent follow-up evaluation 10.5-22 months later. The conchal L-strut was used for 26 patients to reconstruct a new septal frame. The full details of the planning process, L-frame construction, and technical data are described together with two typical cases.In all 26 cases, the authors were able to reconstruct a sufficient neoseptum. In 25 cases, the neoseptum remained straight. Only in one case did the anterior border deviate immediately after the operation. No slippage from the nasal spine was found. The anchoring to the nasal bones and the upper lateral cartilages was stable. However, one asymmetric columella base was found, caused by an asymmetric support to the footplates by the transplant. The osteocartilagenous vault was successfully reconstructed in all the patients. Of the 26 patients, 25 described a marked improvement in their nasal breathing.The reported technique enables the surgeon to reconstruct the complete cartilagenous L-frame with both conchal cartilages. For certain cases, this technique of autogenous reconstruction of the nasal septum could be a valuable alternative to reconstruction with rib cartilage.

The correction of nasal deformities in cleft patients presents a challenge in the secondary treatment of this malformation. The complexity of the nasal deformity in cleft patients partly depends on the congenital anomaly itself and partly on the surgical procedures which were previously carried out. The nasal deformities in unilateral CLP patients are typical. The nasal floor and the nostril sill are mainly constructed during primary lip repair. While the ala on the cleft side is repositioned, the septum deformity and the anterior spine dislocation are not touched. If large circular incisions are used at the time of primary operation to achieve symmetry, the situation usually deteriorates. One of the main characteristics of a classic cleft lip nose is the deviation of the external nose to the non-cleft side due to the typical septal deformity, where the anterior part of the septum and the caudal edge of the septum are subluxated to the non-cleft side (Fig. 1). Furthermore, there is a typical asymmetry of the nasal tip and the ala (Figs. 5 to 7). The columella is slanted and shortened on the cleft side. The ala cartilage on the cleft side is distorted and displaced. There are two important points in the concept of surgical rehabilitation: First, straightening the deviated nose, which often needs extracorporeal septum correction. This seems to be the prerequisite for correction of the external deviation. Second, rehabilitation includes the correction of the asymmetry of the tip and the nostril. A number of techniques have been suggested for this problem, which indicates that there is no ideal procedure. In our hands the triple-flap repair produced good and reliable results. There was no difference in the results, whether an open approach or an endonasal one was used.

Orthotopic cartilage transplants are performed in the course of numerous rhinosurgical operations. Precondition of a permanent success of the operation is preservation of vitality of the transplanted cartilage. Although numerous study results of heterotopic cartilage transplants exist, corresponding examinations in orthotopic transplants have not been done so far. Therefore, in 33 rabbits we did a partial submucous septumresection and put the cartilage back between the mucosal wall. After 1, 2, 3, 6, and 12 weeks, the animals were killed and the cartilage histologically proved. These results were compared to analogous human biopsies. Cartilage reintegration showed a characteristic picture. In the rabbit, the replanted cartilage was healed and stable after 3 months in each case. During reintegration, appositional growth started from the inner perichondrium. With microangiographical examinations, we were able to demonstrate that the speed of reintegration increased with decreasing distance of the cartilage cell from the blood vessels. We managed to confirm the experimental results in human cartilage biopsies.

The severely deformed septum remains a problem. We recommend removing the whole septum and reconstructing a new, straight, septum plane that will be replanted (i.e., extracorporeal correction). Until April 1993 we had used this technique in 1012 patients with functionally as well as aesthetically encouraging results. All septal replants healed primarily. A problem may occur with this technique in reconstructing the dorsum and in stabilizing the replant. The exact technique is explained in detail, and the results are compared with those reported in the literature. Even with this radical procedure, the rate of complication was only 2.2 percent. Biopsies provided the histologic proof of cartilage survival.

The aim of the paper is to report our experience of 60 ear reconstructions to correct the microtia with surgical technique. Autogenous rib cartilage was used to reconstruct the affected ear. Cartilage resorption was found in 10% of the cases, distortion and fusion of pinna in 20% of the cases and infection was found around 8% of the cases. Most of the patients were satisfied with the final result.

In general, septoplasty precedes all other procedures in rhinoplasty because a straight, stable septum dictates profoundly the aesthetic and functional outcome. The patient's history and expectations, proper preoperative analysis, and the surgeon's skills determine the way to proceed in septum correction. As a rule of thumb, slight deviations (e.g., single vomer spurs, maxillary crests, the septal tilt, and simple C-shaped deformities) may be managed endonasally using the hemitransfixion incision and procedures such as the swinging door technique, scoring incisions, batten grafts, or caudal septal replacement grafts. By contrast, for S-shaped and severe wavelike deviations, the cleft nose, the multiple fractured septum, and for most revisional cases, the open approach with extracorporeal septum reconstruction has been found to be the method of choice. After initial general remarks on the basic procedures, this article focuses on current concepts of septum correction that have to be adapted to the individual pathologic condition.

Oxidative stress, i.e., excessive production of oxygen free radicals and reactive oxygen species, leads to lipid peroxidation and to formation of reactive aldehydes which act as second messengers of free radicals. It has previously been shown that oxidative stress may be involved in the transcriptional regulation of cytomegalovirus (CMV) immediate early promoter, involved in viral reactivation from latency. In the current study we used a plasmid containing the yellow fluorescent protein (YFP) gene under the control of CMV-1 promoter to monitor the influence of hydrogen peroxide and reactive aldehydes, 4-hydroxy-2-nonenal (HNE) and acrolein, on CMV-1 promoter activation in human embryonic kidney cells (HEK293). While acrolein was ineffective, hydrogen peroxide slightly (50 %) stimulated the CMV promoter. In contrast, HNE had a strong, up to 3-fold, enhancing effect on the CMV-1 promoter within four as well as after 24h of treatment. The most effective was the treatment with 24 microM HNE. This effect of HNE suggests that stressful conditions associated with lipid peroxidation could lead to CMV activation.

Reconstruction of multilayer defects of the lower nose, using composite grafts from the ear is a widespread technique. Little information exists about important aspects of managing the ear as a donor site for composite grafts. In a retrospective study, patient data were worked up concerning special preoperative planning features (donor site, recipient site), defect closure techniques, donor site morbidity, and esthetic and functional long-term results. One hundred ten composite grafts from the auricle were harvested for different defects at the lower nose. Skin and soft-tissue defect reconstruction at the auricle was carried out by tissue advancement in 43 cases or local flaps in 66 cases. Donor site morbidity was low (5 cases of delayed wound healing, 1 abscess). No flap necrosis occurred. Long-term follow-up (2-5 years) revealed no esthetic or functional impairments. Composite graft harvesting from the auricle is safe with minimal donor site morbidity, proper implementation assumed.

Nasal reconstruction occupies a special position in facial plastic surgery because of the complex three-dimensional surface of the nose, the varying thickness of the skin covering it, its varying types of scaffolding ranging from rigid bone to flexible cartilage, and its inner epithelial lining. Burget and Menick have written a seminal text on functionally and esthetically superior nasal reconstruction (1). Other authors have described particular reconstructive techniques that can be used advantageously to repair defects at certain special sites. There are, as yet, no controlled studies on the quality of nasal reconstruction. The defects are too varied, and the reconstructions, though always based on the same basic principles, allow a great deal of room for creativity on the plastic surgeon’s part. This is an important characteristic of plastic surgery in general that makes it difficult to consider the types of therapy under discussion from the point of view of "evidence-based medicine." Inadequate results are not infrequently seen, particularly with more complex types of nasal reconstruction. Such experiences have motivated the authors to describe in this article, for the general medical public, the types of results that are attainable. In a later issue of the Deutsches Arzteblatt International, another article will appear on the subject of reconstructive surgery of the face, head, and neck.

This report aims to demonstrate the advantages of the sliding technique for reducing an overprojected tip.In this study 271 patients (201 females, 70 males) were treated using this technique. It was used for isolated tip hypertrophy (N = 93) and combined deformities (N = 147).A medial sliding was performed in 109 patients, a lateral in 125 patients, and a combined lateral and medial sliding was used in 9 patients. Twenty patients needed additional skin resection at the columella. Follow-up of our first 80 patients showed an average reduction of around 11%. Only one patient of 80 in this study had to be revised.The sliding technique is safe and reliable as well as a logical and effective technique to deproject the nasal tip.

One of the most difficult aspects in rhinoplasty is resolving and preventing functional compromise of the nasal valve area reliably. The nasal valves are crucial for the individual breathing competence of the nose. Structural and functional elements contribute to this complex system: the nasolabial angle, the configuration and stability of the alae, the function of the internal nasal valve, the anterior septum symmetrically separating the bilateral airways and giving structural and functional support to the alar cartilage complex and to their junction with the upper lateral cartilages, the scroll area. Subsequently, the open angle between septum and sidewalls is important for sufficient airflow as well as the position and function of the head of the turbinates. The clinical examination of these elements is described. Surgical techniques are more or less well known and demonstrated with patient examples and drawings: anterior septoplasty, reconstruction of tip and dorsum support by septal extension grafts and septal replacement, tip suspension and lateral crural sliding technique, spreader grafts and suture techniques, splay grafts, alar batten grafts, lateral crural extension grafts, and lateral alar suspension. The numerous literature is reviewed.

Even today, the difficult septum presents a surgical problem. A severe septum deformity is caused mostly by an accident or is seen in patients with malformations such as cleft lip and palate deformity. It is characterized by a massive malformation in all levels with consecutive blocking of one or both airways. Such marked septal deformities cannot be corrected properly by standard septoplasty techniques. Therefore, in such cases we suggest an extracorporeal septoplasty, where we take out the whole septum and reconstruct a new septal plate by different techniques followed by replantation and reconstruction of the cartilaginous dorsum. From January 1, 1981 to December 31, 2005, we operated on 2301 patients and improved this method constantly, especially the safe septal fixation and rebuilding of the cartilaginous dorsum. Follow-ups showed that even in severe deformities a revision rate of only 5% respectively 7% was found. Therefore, we conclude that the extracorporeal septoplasty with its refinements and the way we are doing it today can also be recommended to less experienced rhinosurgeons.

Bahman Guyuron . Rhinoplasty. Philadelphia, PA: Saunders, 2012. ISBN-10: 1416037519 ![][1] Bahman Guyuron is recognized throughout the world for his superb lectures and expertise in rhinoplasty surgery. Every live presentation is insightful, beautifully illustrated, and often includes original techniques that are validated by impressive clinical results, usually with long-term follow-up. For many years, his colleagues have awaited a publication summarizing his personal philosophy and surgical techniques developed during the past 31 years. Rhinoplasty is that text. Rhinoplasty is divided into 21 chapters, each clearly structured and ending with a “textbox” that summarizes the essential points. Each chapter begins with an outline of the contents both for the text and the specific video content, which means that information is easily found. Next, there is a list of 10 to 20 basic principles followed by a description of each technical step, with a list of the different surgical options. Instead of the more common inclusion of DVDs, this book is … [1]: /embed/graphic-1.gif

Three cases of advanced ulcerating basal cell carcinoma (terebrant ulcer or ulcus terebrans) of the head are reported. Neglected basaliomas had deeply destroyed larger parts of the skull in three women ages 78, 69, and 65 years when the patients were first admitted for treatment. Death due to meningitis, hemorrhage, or brain damage was imminent. Wide resection and coverage by free latissimus dorsi flaps was carried out in single-stage procedures. The latissimus dorsi, a versatile and very reliable free flap with its constant vascular anatomy and long pedicle, is the ideal flap for the coverage of large defects on the head. The donor site can usually be closed primarily, and the functional deficit is acceptable. All three patients recovered completely. Although only palliative resection could be achieved, the procedures could be justified by the increased survival time and gain in quality of life.

From our own experience and a review of the literature, we present a few techniques which, in our eyes, give the surgeon the possibility to treat most encountered cases of stenosis of the nasal vestibule. During 1991 to 1998 the author in Stuttgart (W.G.) performed simple z-plasty combined with local flaps in 6 patients and composite grafts only in 12 cases, to correct nasal vestibule stenosis. The author in Lausanne (R.M.), who first described the paranasal myocutaneous flap to correct not only nasal vestibule stenosis but also alar base malposition has treated over 50 patients with this technique and with composite grafts during the last 20 years.

Using the indirect immunofluorescence method with a polyclonal antiserum raised in rabbits and directed against amylin (AMY), we have investigated the distribution of AMY-like immunoreactivity (-ir) throughout the central nervous system of the rat. The widespread distribution of AMY-ir was much more abundant than that previously reported for calcitonin gene related peptide (CGRP) immunoreactivity. In most brain areas there was no overlap between AMY- and CGRP-ir cell body groupings, with the exception of the motor nuclei of the hindbrain and spinal cord, which were found to contain large numbers of AMY- and CGRP-immunoreactive cell bodies. Areas with a moderate to dense appearance of AMY-ir were the rhinencephalon, the nucleus of the diagonal band, the magnocellular, dorso- and ventro-medial and mammillary nuclei of the hypothalamus, the habenula, the compact part of the substantia nigra, the ruber and pontine nuclei, and the inferior olive and the cerebellar nuclei. The widespread immunohistochemical distribution of AMY-ir in the rat brain is in partial agreement with the distribution of AMY-binding sites.Key words: calcitonin gene related peptide, amylin, central nervous system, immunohistochemistry, rat.

Several technical details of secondary nose correction in unilateral cleft lip procedure are presented. A new technique of total removal of distorted septal cartilage is described, correcting it under full vision and replanting it afterwards into the nose, thus clearing both airways and reshaping the nose profile at the same time. Also different cartilage-mucosal flaps are described as a way to create symmetry in the nasal tip region and both ala nasi.

New plastic materials are being developed continuously for use in nasal implants. In our experience, only autogenetic material should be used for such operations. We ourselves use exclusively cartilage from the rib, auricle or septum.

Rhinomanometry can still be considered as the standard technique for the objective assessment of the ven- tilatory function of the nose. Reliable technical requirements are given by fast digital sensors and modern information technology. However, the xyimaging of the pressure-flow relation typically shows loops as a sign of hysteresis, with the need for resolution of the breath in four phases. The three pillars of 4-phase rhinomanometry (4PR) are the replacement of estimations by measurements, the introduc- tion of parameters related to the subjective sensing of obstruction, and the graphical information regarding the disturbed function of the nasal valve. In a meta-analysis of 36,563 clinical measurements, we analyze the errors of the ''classic'' parameters (flow in 150 Pa) and reject the further use of these parameters as obsolete, because they correspond to an inaccurate estimation rather than proper measurement. In a pre-study of 1580 measurements, the logarithmic effective resistance (Reff) was found to have the highest correlation with values obtained from a visual analog scale. Next, we classify the inspiratory effective resistance in 20,069 measurements without treatment and 16,494 mea- surements after decongestion with xylometazoline 0.1 % spray in 20 % percentiles. The gradation of obstruction delivers not only ''normal'' values but also indications for the severity of the obstruction in adult Caucasian noses. Adoption of the distribution for the growing nose and analysis of the total nasal resistance is addressed, and typical findings of nasal valve phenomena are outlined.

Cleft lip/nose/palates are almost always accompanied by typical deformity of the inner and outer nose. The septum, which is usually considerably misshapen also influences the degree of deformity of the external nares. With extreme septum deformation it has proved expedient to remove the septum in its entirety and to replant it after suitable straightening. This technique is described.