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This article describes the equipment and software used to create facial 3D imaging and discusses the validation and reliability of the objective assessments done using this equipment. By overlaying preoperative and postoperative 3D images, it is possible to assess the surgical changes in 3D. Methods are described to assess the 3D changes from the rhinoplasty techniques of nasal dorsal augmentation, increasing tip projection, narrowing the nose, and nasal lengthening.

To determine the impact of interventions on the degree of warping of costal cartilage.The project was conducted at a large university animal research laboratory. The costal cartilage of eight 30-kg domestic pigs was harvested. The cartilage was cut into central and peripheral segments with a standard cutting die. Two sizes of rectangular cubes were compared. The central portions of costal cartilage were segmented and glued with octyl-2-cyanoacrylate. The shape of the cartilage was documented with both digital and film photography. The cartilage was placed into subdermal pockets on the dorsum of the pigs. The animals were killed at 4 weeks, and the cartilage was photographed. Adobe Photoshop software was used to measure the degree of warping. Statistical analysis was calculated by t test analysis.A total of 115 rectangular costal cartilage blocks were treated. Large blocks warped less than small blocks (P.02). Centrally cut blocks warped less than peripherally cut blocks (P.03). The octyl-2-cyanoacrylate incited a significant sterile inflammatory response such that the blocks could not be accurately assessed for warpage.Costal cartilage can be effectively used for grafting in rhinoplasty with minimal warping if large grafts from the central portion of cartilage are used.

Caudal septal extension grafts (CSEGs) can be used to alter and secure nasal projection and length. Graft position and thickness play an important role in terms of both function and aesthetics. The limitations of harvesting cartilage from additional sites necessitate development of a more efficient method for securing CSEGs.To assess the efficacy and safety of polydioxanone absorbable plates used in primary and revision septorhinoplasty.We investigated all patients who underwent primary or revision septorhinoplasty with the use of absorbable plates to secure CSEGs at a tertiary academic medical center from 2010 to 2014. To standardize and objectify the symptoms of nasal obstruction, a validated quality-of-life instrument called the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, with 5 questions on a scale of 0 to 4, was implemented preoperatively and postoperatively. Preoperative and multiple successive postoperative measurements of nasal length and projection were taken using 3dMDvultus imaging software.Change in NOSE questionnaire score, change in nasal length and projection, and complications.There were no absorbable plate-related complications in the 95 included patients. Comparing preoperative and postoperative NOSE questionnaire scores, there was a statistically significant improvement in all 5 categories: mean (SD) change of -1.42 (1.59) in congestion, -1.56 (1.53) in blockage or obstruction, -1.60 (1.54) in breathing through nose, -0.90 (1.54) in trouble sleeping, and -1.28 (1.46) in breathing during exercise (P .001 for all) in the 50 patients with available data. In the 24 patients with greater than 180 days of follow-up, follow-up ranged from 183 to 717 days, and mean (SD) change in nasal length and projection was 0.64 (2.19) and 0.26 (0.96) mm, respectively, showing no statistically significant change over time (P = .17 and .21, respectively).In our study population, nasal length and projection maintained position over time when absorbable plates were used to secure CSEGs. Absorbable plates appear safe and effective when used to secure CSEGs and limit the requirement of harvesting additional cartilage. Nasal airway improvement can be obtained when absorbable plates are used to secure CSEGs.4.

The crooked nose deformity and the saddle nose deformity represent two of the most challenging complications of nasal trauma. Optimal management requires careful preoperative analysis and thoughtful surgical planning. The surgeon must make the mental and philosophical commitment to address the difficult cosmetic components and the functional problems related to these deformities. Because these conditions result from disruptions of the nasal septum, their surgical correction mandates use of techniques that modify the septum, and they might require reconstruction of the sacrosanct dorsal-caudal strut. By understanding the three-dimensional anatomy of this L-shaped strut, how its relationship to the other structural components of the nose determines external nasal contour, and the techniques available to stabilize this structure into an optimal position, the surgeon can correct these difficult cosmetic problems effectively while maintaining the overall structural and functional integrity of the nose.

The lateral periorbital area represents one of the earliest and most bothersome facial stigmata of aging. Although traditional techniques have had limited success in treating the static cutaneous component to rhytid formation in this region, they have been largely unsuccessful in addressing the dynamic hyperkinetic lines that are created by the activity of the lateral orbicularis oculi muscle. Botox A injection represents a safe and reproducible technique to selectively denervate muscle activity in this troublesome area. This minimally invasive technique has led to significant improvement of periorbital lines, either when used as a single agent or in combination with other methods (Fig. 3). As more experience is gained with this toxin, as well as other Botox serotypes, continued progress is likely to occur in this area, as well as in other facial regions.

David W. Kim, MD*, Dean M. Toriumi, MD Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, University of California at San Francisco, 400 Parnassus Avenue A-730, San Francisco, CA 94143-0342, USA Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, University of Illinois at Chicago, 1855 West Taylor Street, Chicago, IL 60612, USA

The various diseases and conditions of the head and neck region involve multiple organ systems and require a wide range of medical and surgical management. So the field of otolaryngology—head and neck surgery—unites several subspecialties to address this multitude of problems. In the past year, numerous developments in both basic science and clinical science have arisen. The most exciting recent developments are discussed and grouped into subspecialties: otology and neurotology, facial plastic and reconstructive surgery, laryngology, rhinology, general otolaryngology, and pediatric otolaryngology. Head and neck oncology is given special emphasis and is discussed in a separate section because of the large volume of significant research within this field and its relevance to other surgical disciplines. OTOLARYNGOLOGY Otology/neurotology A wide variety of research studies have been conducted on inner ear and middle ear diseases as they pertain to auditory and vestibular function. The development of new technologies has provided several novel options for hearing restoration. Venerable topics such as Meniere’s disease and idiopathic facial nerve paralysis have been revisited. As research on cochlear gene therapy grows, increasing routes of delivery into the inner ear, more numerous viral and nonviral vectors, and newly discovered candidate genes are emerging for human therapy of hearing loss of inner ear origin. 1 Genetic linkage studies in several families with hereditary, nonsyndromic sensorineural hearing loss have led to the identification of numerous causative genes. An important gene implicated in the development of certain forms of hereditary deafness encodes the gap-junction protein connexin-26 (GJB2). Up to one-half of patients with autosomal recessive nonsyndromic prelingual deafness have alterations in this protein. Of note, a significant percentage of these patients have only one mutant GJB2 allele, suggesting the presence of another unidentified accompanying mutation. Del Castillo and coworkers 2 sought to identify this missing mutation through evaluation of 33 subjects with nonsyndromic hearing impairment who had only one GJB2 mutant allele. DNA analysis from peripheral blood samples identified a novel mutation that truncates a separate gene encoding for connexin 30 (GJB6) in this group of patients. This gene, located on the same locus of chromosome 13q12 as the connexin 26 gene, is now believed to be the second most frequent mutation causing prelingual deafness in the Spanish population. This report and similar reports in New Zealand subjects 3 and Jewish subjects 4 prompts further study of the role of connexins in the cochlea and provide possible targets for eventual gene therapy. The degeneration of cochlear hair cells caused by ototoxic injury leads to the reduction of neurotrophic support to the innervating auditory neurons. In another application of cochlear gene therapy, Lalwani and associates 5 showed increased inner ear neuronal survival in animals subjected to ototoxic doses of aminoglycoside. Rat cochlear explants that were transfected with an adeno-associated virus-brain derived neurotrophic factor demonstrated increased neuronal survival as compared with controls. In vivo studies using a green fluo

Surgical tissue adhesives continue to evolve as an important technology for the facial plastic and reconstructive surgeon. Twelve years ago there was little routine use of these substances; however, in the past 5 years there have been significant advances. It is becoming increasingly important for the facial plastic and reconstructive surgeon to be familiar with the indications and shortcomings of these compounds. This article will summarize the evolution of surgical tissue adhesives to their present-day applications, including technical points for their successful use. An ideal surgical tissue adhesive must meet the following criteria: strong binding strength, ease of application, tissue biocompatibility, biodegradable byproducts, minimal tissue reactivity, and reasonable cost. Currently available surgical tissue adhesives can be categorized as either fibrin tissue adhesives or cyanoacrylates. Although fibrin tissue adhesives and cyanoacrylates are often discussed under the general topic of surgical tissue adhesives, these two substances have different indications and mechanisms of action. Fibrin tissue adhesives use naturally occurring substrates that are part of normal endogenous clotting mechanisms. In contrast, the adhesion achieved by cyanoacrylates is a result of synthetic compounds not naturally occurring in the human body. These two types of adhesives also have different clinical indications. Fibrin tissue adhesives are typically applied below the dermis as a biologic hemostat or as a sealant for use with skin grafts and flaps. Cyanoacrylates have been shown to be histotoxic when applied below the dermis and have been used most successfully at the level of the epidermis for superficial skin closure [1].

Congenital abnormalities of the auricle span a spectrum of abnormalities from total anotia to slight asymmetries of an otherwise normal appearing ear. This article is dedicated to the management of the prominent, or protruding ear. A number of well-known surgical techniques have been described for the correction of the protruding ear. The ideal set of techniques must accomplish several goals. The desired post-operative results must include (1) a normal appearing auricular contour from both the frontal and lateral views, (2) an absence of unnatural sharp edges in the cartilage framework, and (3) symmetry of both ears. The techniques involved must be relatively easy to learn and must also yield reproducible results.

Cyanoacrylate and fibrin tissue adhesives can aid the facial plastic surgeon performing surgery in the outpatient setting. Octyl-2-cyanoacrylate is ideal for superficial skin closure and eliminates the need for suture removal. Subcutaneous sutures are needed in most cases to provide the best cosmetic outcomes. Fibrin tissue adhesives can be used to aid in attaining hemostasis or to seal or fixate tissues. Cyanoacrylate and fibrin-based adhesives can simplify office-based facial plastic surgery.

The choice of primary rhinoplasty technique is based on preoperative diagnosis, external nasal contour, nasal anatomy, and expected changes in nasal contour. The author matches technique to nasal anatomy, describing procedures that have resulted in a high success rate. (Aesthetic Surg J 2002;22:72-84.)

What is the single most difficult challenge in revision rhinoplasty and how do you address it? During revision rhinoplasty, when dorsal augmentation is necessary and septal and ear cartilage is not available, what is the best substance for correcting the problem? If rib cartilage is used for dorsal augmentation during revision rhinoplasty, what is the technique to prevent warping of the graft? Alloplast in the nose--when, where, and for what purpose? Does the release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid-one-third nasal pinching in reductive rhinoplasty?'Over the past 5 years, how has your technique evolved or what have you observed and learned in performing revision rhinoplasty?

When performing nasal tip surgery, a stable nasal base is critical in providing a good long-term outcome. Weakness in the nasal base can result in postoperative loss of nasal tip projection. Patients with a deficiency in the nasal base include those with inadequate tip projection, acute nasolabial angle, and dependency of the nasal tip. Maneuvers used to stabilize the nasal base include a sutured-in-place columellar strut, caudal extension graft, setting back and fixating the medial crura to an overly long caudal septum, or use of an extended columellar strut fixated to the periosteum about the nasal spine. Once the nasal base is stabilized, the lobule can be modified using domebinding sutures or a sutured-in-place tip graft. Use of these maneuvers can provide maximal tip projection with good tip contour. This article will discuss the principles behind the use of these techniques and discuss the nuances related to execution of the maneuvers.

In vitro, ex vivo, and in vivo studies were performed to investigate the effect of mixing upon the mechanical properties of a two-component tissue adhesive. The hypothesis investigated was that a more complete mixing of the two components would yield an increase in the mechanical performance of the adhesive. This in turn would be demonstrated by improved outcomes in models of clinical sealant application. In vitro stereological analysis of tissue adhesive mixed and delivered by several different applicators demonstrated variation in the amount of mixing provided by each type of delivery system. Ex vivo tensile adhesive strength showed that there was a correlation between the amount of mixing and bonding strength; that is, more thorough mixing demonstrated higher adhesive strength. No significant difference was seen, however, between the different applicator types and impact on in vivo dermal incisional closure strength. There was a correlation, though, in amount of mixing and in vivo hemostasis. In a rabbit spleen incision model, a more thoroughly mixed sealant corresponded with a decrease in time to obtain complete hemostasis, as well as less sealant used. The effects of mixing on tissue-adhesive mechanical performance were influenced somewhat by the amount of mixing provided by the applicator. This effect, however, was dependent upon the sealant formulation and the type of in vivo application.

Ronald P. Gruber, MD Nicolas Tabbal, MD Jack H. Sheen, MD Dean Toriumi, MD Dr. Gruber: The first patient (Figure 1) is a 45-year-old man with a history of cocaine use. He presents with symptoms of whistling and a dropped nasal tip, and he also complains of difficulty breathing. To facilitate breathing, this patient manually pushes up the tip of his nose. He has a caudally located 2- to 3-cm perforation, which leaves him with a 1-cm horizontal strut and a 1-cm caudal (columellar) strut. Dr. Sheen, how does this compare with your experience in seeing patients with a history of cocaine use? Figure 1 A , Front, B , lateral, and C , intranasal views of a 45-year-old man with a history of cocaine use. He presents with symptoms of whistling and a dropped tip and complains of difficulty breathing. He has a caudally-located 2-cm perforation. Dr. Sheen: Of the 18 to 20 cocaine noses that I have reconstructed, only 1 was in a male patient; he had mid-vault collapse associated with a large perforation. The rest of the patients were female. I also treated one man who had complete erosion of the caudal septum, membranous septum, and columella and had only 1 mm of skin remaining, so he literally had no caudal support. However, what you describe here is somewhat different. If this patient has a significant amount of caudal septum remaining, it is unlikely that cocaine use caused his present condition. Has he had prior surgery? Dr. Gruber: No, he has not. Dr. Sheen: When I see a patient with this type of problem, I ask to see photographs that were taken before the nasal deformity developed to compare the original state of the nose with its current condition. I do not believe that this 2-cm perforation would produce …

Objective: To determine the degree of bone resorption and stability of 3-cm, full-thickness canine mandibular defects reconstructed with recombinant human bone morphogenetic protein 2 (rhBMP-2) and a bioerodible particle carrier followed for 30 months after reconstruction. Study Design: Nine dogs, divided into three groups, underwent reconstruction of surgically created 3-cm, full-thickness defects of the body of the mandible. Methods: Mandibular reconstruction was performed via a combined intraoral and extraoral approach. Using standard plating techniques, a unilateral full-thickness, 3-cm defect was created in the body of the mandible. After stabilizing the defects with titanium reconstruction plates, test implants composed of rhBMP-2 and poly(lactide-co-glycolide) bioerodible particles were placed in the mandibular defects of six animals. Reconstruction plates were removed from test animals at 10 weeks. Three short-term test animals were sacrificed 3 months after reconstruction. Three long-term test animals were sacrificed 30 months after reconstruction to determine the degree of resorption and long-term stability of the rhBMP-2-induced bone. Control implants (carrier without rhBMP-2) were used in three animals and were sacrificed at 3 months. At 9 months, long-term animals were advanced to a solid diet. Masticatory function and body weight were monitored periodically to assess diet tolerance. Roentgenographic photodensitometry was performed on serial dental roentgenograms of the reconstructed segments to determine bone density and the degree of bone resorption over 30 months. After sacrifice, reconstructed segments were harvested and embedded in plastic for histological analysis and histomorphometry to determine the percentage of the defect replaced by mineralized bone (area density) and degree of resorption from 3 to 30 months after reconstruction. The main outcome measures were bone density and bone height determined from serial roentgenograms and percentage of the reconstructed segment replaced by mineralized bone (area density) determined from histomorphometry. Results: Control animals without rhBMP-2 showed no evidence of bone formation across the defect. Histological examination revealed good bone formation in two of three of the short-term test animals with a mean area density of 41.0%. The long-term test animals treated with rhBMP-2 demonstrated good bone formation that was comparable to that of normal host bone by 3 months. The roentgenographic photodensity measurements stabilized at 5 months without evidence of persistent bone resorption. The height of the reconstructed segment (rhBMP-2-induced bone) initially decreased, then stabilized by 11 months after reconstruction with no indication of resorption or failure. Histological examination of the long-term test animals revealed good bone formation across the mandibular defects. However, there were localized areas of thinning of the cortical bone as compared with the short-term test animals sacrificed at 3 months. Histological examination verified the loss of height of the bone in the reconstructed segments. The area density (mean) of the long-term test animals was 56.5%. Despite the decrease in height of the induced bone, there was an increase in area density of the bone over time. Conclusions: This study demonstrated that rhBMP-2 in a bioerodible particle carrier induced new host bone formation across critical-size mandibular defects. The newly formed bone successfully integrated with existing host bone creating a stable union capable of withstanding the forces of masticatory function in a canine. There was some evidence of early bone resorption (thinning of the cortical bone and decrease in height) in the rhBMP-2-induced bone. The rhBMP-2-induced bone stabilized by 11 months after reconstruction and no further resorption was noted. The percentage of area of the defect replaced by rhBMP-2-induced bone (area density) increased over 30 months. Both roentgenographic photodensitometry and histomorphometry supported the ability of rhBMP-2 to induce structurally stable bone without evidence of bone failure or persistent bone resorption.

Advances in surgical instrumentation are generally intended to allow the performance of a surgical maneuver more efficiently and accurately. Powered instrumentation may allow improved precision and ease in certain aspects of rhinoplasty and septoplasty. Through improved precision, tissue trauma can be minimized.

The quest for nasal symmetry and balance with the face often mandates the need for implantable materials to sculpt and rebuild the nasal skeleton and the overlying tissues. A suitable implant must be biocompatible, strong, and elastic. Implant materials that may be used in the nose can be divided into four groups: autografts, homografts, xenografts, and alloplasts. Each type of implant is reviewed and discussed in the context of rhinoplasty and nasal reconstruction.

Background The management of cerebrospinal fluid (CSF) leaks can be challenging. Acellular dermal grafts derived from human cadavers can be used as a replacement material when autogenous materials are unavailable. Fibrin tissue adhesive (FTA) is a wound support product that has been used for hemostatic and tissue fixation purposes. The combined use of acellular dermis in conjunction with FTA for dural repair remains a subject of study. The aim of this study was to evaluate wound healing and tissue compatibility characteristics of acellular dermal substitute material when used both with and without FTA, for repair of a dural tear in a chinchilla model. Methods Forty-nine chinchillas were included in this randomized case-control study. The squamous portion of the temporal bone was removed to expose the tegmen. A 2 X 2 mm dural defect was removed to create an iatrogenic CSF leak. Then, animals were randomly assigned to one of three treatment groups: group 1, acellular dermis alone; group 2, acellular dermis with FTA; group 3, fibrinogen, acellular dermis, and FTA. Surgical sites were examined grossly at 1- and 2-week intervals. Temporal bones were examined histologically. Results Grossly, groups 2 and 3 had significantly less visible CSF leak and brain herniation noted at both 1- and 2-week intervals when compared with group 1. Histological results confirmed the gross results showing the best seal in group 2 and 3. Conclusion Acellular dermis combined with FTA provided superior support compared with acellular dermis alone in repair of induced dural defects.

To determine if recombinant human bone morphogenetic protein-2 (rhBMP-2) can be adsorbed onto porous ceramic hydroxyapatite (HA) and promote the integration of HA to host bone, 54 subperiosteal pockets were created on the skulls of 19 adult Pasteurella-free white rabbits. Fourteen HA implants were saturated with saline and placed in subperiosteal pockets (control), 22 HA implants were saturated with saline and placed into subperiosteal pockets after burring 1-2 mm of calvarium to expose bleeding cancellous bone, and 18 HA implants were saturated with rhBMP-2 and placed into subperiosteal pockets. The animals were sacrificed at 1 month with examination to determine implant mobility. Histology was used to determine the amount of bone growth into the implant. Of the 14 control sites, 10 implants were found to be freely mobile, five demonstrated host bone resorption, and only one exhibited bone growth into the implant. Of the 22 burred sites, eight were freely mobile and 10 demonstrated bone growth into the implant (p = 0.04). Of the 18 rhBMP-2 sites, only two were freely mobile, none demonstrated host bone resorption, and 16 exhibited bone growth into the implant (p = 0.00002). This study supports the use of porous ceramic HA as a biocompatible, osteoconductive implant material for use in craniomaxillofacial augmentation and reconstruction. It also provides evidence that rhBMP-2 enhances osseointegration, thereby fixing the implant in position against the host-bone interface. In the clinical setting, osseous fixation of the implant should aid in preventing displacement, minimizing host bone resorption, and decreasing the incidence of extrusion.

The region of the face where the nose, lip, and cheek join is both visually and three-dimensionally complex. Numerous skin flaps and grafts have been used to reconstruct this region. Such reconstruction often results in poorly defined or amorphous facial features. This article uses one prototype case to show how flaps and grafts can be turned into tissue forms that when truly normal look like the features of the face. The emphasis is on dimension, proportion, and form. A stable platform for the nose is first constructed. The nose is sited. A thin, flexible lining is created. A lamina of cartilage and bone grafts is established throughout the defect. Three-dimensional patterns and nasal models are used. Refinement of the contour is performed before the pedicle is divided. Incisions are placed in facial lines of deepest shadow. Important details of the facial bas-relief are carved out of flap tissues.

Dr. Guyuron: The main focus of this panel is the management of nasal length and projection. Dr. Gruber, how do you analyze a patient's nose in terms of length and projection? Dr. Gruber: In general, I take measurements with a video imager, which provides a one-to-one size. It is really by trial and error manipulation of the image using the video imaging system and then asking the patient what he or she thinks of my assessment that I determine a patient's ideal nose length and projection. I no longer use specific numbers because the distances and angles on the nose are different for each patient. I have found that it is best to use my aesthetic judgment with regard to how the particular length and projection of the nose relates to the rest of the face. Dr. Guyuron: Dr. Byrd, how do you determine the proper nasal projection and length for your patients? Dr. Byrd: First, I measure the patient directly. Then I measure life-size photographs of the patient. I correlate the measurements on the photograph with the ones that I've taken of the patient to avoid measurement errors that can occur as a result of the way in which the pictures were developed. This is a way of confirming my measurements. I determine the actual length of the nose by measuring roughly from the level of the supratarsal fold or 6 mm above the inner canthus down to the dome-projecting points. Basically I would like the nasal length to be equal to the chin vertical measured from where the lips come together (stomion) down to the undersurface of the chin (menton), or two thirds of the midfacial height. These are the ideal aesthetic relationships in the white female's nose. From my perspective, a nose is long if it exceeds …

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

We describe the use of powered instrumentation for precise modification of the bony nasal dorsum. Specific modifications were made to design a drill specifically for the bony nasal dorsum. This drill has a protective sheath that covers all but the active part of the drill, protecting the skin-soft tissue envelope, and it also has suction at the resection site. In some cases an osteotome is used to reduce the hump and the drill is used to achieve additional reduction and to smooth the exposed edges under direct vision. In other cases the entire bony hump is reduced using the drill. The nasal dorsum drill offers a precise alternative to the rasp. The precision of the drill is highlighted in cases in which limited reduction is needed, as in cases of a single or several spicules requiring reduction and smoothing after osteotomy, or a single 4 mm raised area requiring limited reduction. The design of rasps makes it difficult to work on these focal areas without unnecessarily rasping surrounding areas, whereas the drill may be used to reduce the entire hump, to smooth the edges after osteotomy, or in a more precise and limited fashion when indicated. The drill may be less traumatic to the skin-soft tissue envelope because it does not rely on the potentially bruising back and forth motion typical of rasping. The nasal dorsum drill may decrease the incidence of bony dorsal irregularities after rhinoplasty.

Objective/Hypothesis: Nasal septal perforation is a common complication following surgery involving the nasal septum. Septoplasty, septorhinoplasty, and submucosal resection may result in the inadvertent resection of perichondrium, which may predispose the patient to septal perforations. Study Design: Controlled human cadaver study testing the biomechanical strength of the constituent layers of nasal septal lining. Methods: Uniform samples of nasal septal mucosa, perichondrium, and a composite of both layers were obtained from five fresh human cadavers. The mechanical tensile strength of these layers was evaluated and compared with the Instron 4301 Mechanical Testing System (Canton, MA). Results: Mixed-effects regression analysis demonstrated a significant difference in the tensile strength of the three groups (mean values ± SD: mucosa, 662 ± 308 g; perichondrium, 1370 ± 798 g; composite, 2340 ± 1252 g). All three pairwise comparisons among the three groups showed a significant difference in tensile strength. Conclusion: The perichondrial layer imparts the majority of the biomechanical strength to septal lining. Lining flaps containing both perichondrium and mucosa are stronger than flaps with either perichondrium or mucosa alone. Dissection in the subperichondrial plane during septal surgery provides a stronger septal flap and may prevent the development of nasal septal perforation during nasal surgery.

Three-dimensional (3D) imaging is a relatively new method of objectively evaluating surgical results, allowing the surgeon to accurately measure postsurgical changes with little inconvenience to the patient. Its accuracy and reliability has been consistently demonstrated in the literature. This article describes updated methods that we use with 3D imaging software to assess rhinoplasty results at our institution. The measurements described include the assessment of symmetry, tip projection, rotation, volume, width, and topographic width. We also apply these techniques to assess the surgical changes of patients with unilateral clefts who underwent secondary rhinoplasty performed by the senior author.

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)

Cartilage suturing techniques used to alter nasal tip shape are reliable and effective in patients who may be difficult to manage because of variant anatomy. Patients with thin nasal tip skin may present problems with visible deformity (edges, bossae, etc) after aggressive cartilage excision, dome division, or tip grafting. Cartilage suturing techniques (transdomal suture, domal suture, etc) are particularly effective in patients with strong cartilages and tip bulbosity. These techniques can also provide increased tip projection and rotation. Cartilage delivery or the external rhinoplasty approach provides the exposure necessary to place these sutures. This article describes several different techniques of suturing tip cartilages that will provide precise narrowing of the nasal tip as well as increase tip projection and rotation. Modifications of the suturing techniques are based primarily on the anatomy of the lower lateral cartilages and desired contour changes.

The incidence of aesthetic and functional complications of rhinoplasty can be decreased by preserving supportstructures of the nose. This is particularly important in patients at high risk for collapse of the middle nasal vault (cartilaginous nasal vault). Aggressive surgical manipulation of the upper lateral cartilages can result in excessive narrowing of the middle vault and collapse of the internal nasal valve. Spreader grafts can be used to provide appropriate width to the middle vault and preserve nasal valve function. This paper will discuss indications and technique for application of spreader grafts using the open rhinoplasty approach. Spreader grafts can be used in high risk patients with short nasal bones, long weak upper lateral cartilages, thin skin, and narrow projecting nasal vault. These patients are at higher risk for excessive narrowing of the middle vault (inferomedial collapse of upper lateral cartilages) because of loss of medial support after hump removal. Spreader grafts will support the lateral nasal wall, preserve nasal width, and prevent deformity. Spreader grafts can also be used to add width to the cartilaginous vault in disproportioned noses that have an excessively narrow middle vault and broad nasal tip. This maneuver will allow the surgeon to perform conservative narrowing of the nasal tip and prevent deformity or compromise of nasal function. Spreader grafts can be used in combination with lateral crural grafts or alar batten grafts to correct secondary deformities of the internal and/or external nasal valve. Conservative reduction and thoughtful augmentation in rhinoplasty will preserve nasal support and function with improved long-term results.

Alar base retraction is a common yet difficult problem faced by the rhinoplasty surgeon. It may be caused by weakened, overresected lateral crura, vestibular lining deficiencies, or congenital alar malpositioning. Methods of correction include soft tissue manipulation, auricular composite grafting, and cartilage grafting. We present the senior author's graded approach to alar retraction using auricular composite grafting, alar rim grafting, and lateral crural strut graft placement with caudal lateral crural repositioning.

The concept of non-surgical implantation of injectable filler materials for soft-tissue augmentation has always been an attractive option for the head and neck surgeon. The ideal injectable soft tissue filler material would be easy to use, biocompatible, nontoxic, and long-lasting. Presently available filler materials present significant drawbacks to their use. The most favorable filler materials appear to be autologous fat and microparticulate alloplasts. This article reviews presently used injectable filler materials and those that may be used in the future.

The primary surgical tissue adhesives used in otolaryngology-head and neck surgery include the cyanoacrylate derivatives and the fibrin tissue adhesives. The cyanoacrylate derivatives are effective for superficial skin closure. Use of this material below the level of the skin can result in acute and chronic inflammation and tissue necrosis. Fibrin tissue adhesives can be used for wound closure, tissue sealing, and hemostasis. Drawbacks noted with the fibrin tissue adhesives include method of preparation, relatively low binding strength, and variable resorption time. This article discusses the properties, methods of preparation, and clinical indications of the cyanoacrylate derivatives and fibrin tissue adhesives.

Asian rhinoplasty differs from traditional rhinoplasty approaches in preoperative analysis, patient expectations, nasal anatomy, and surgical techniques used. Platyrrhine nasal characteristics are common, with low dorsum, weak lower lateral cartilages, columellar retraction, and thick sebaceous skin often noted. Typically, patients seek augmentation of these existing structures rather than reductive procedures. Autologous cartilage, in particular use of costal cartilage, has been shown to be a reliable technique, which, when executed properly, produces excellent long-term results. An understanding of cultural perspectives, knowledge of the nasal anatomy unique to Asian patients, and proficiency with augmentation techniques are prerequisites in attaining the desired results for patient and surgeon.