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The authors introduce the concept of favorable shadowing of the nasal tip surface. Contouring the nasal tip is an advanced concept in rhinoplasty. Several tip altering techniques exist, but proper selection of an appropriate technique or combination of techniques first requires understanding of the impact of manipulating underlying tip structure on nasal surface topography. Frequently, maneuvers that narrow the domes, inappropriately create a pinched or unnatural-appearing nasal tip. Many of these tip-narrowing techniques act to lower the caudal margin of the lateral crura below the cephalic margin and decrease support along the junction between the tip and alar lobule. The nasal tip skin can then collapse on this structure, creating a visible line of demarcation between the tip and alar lobule. Patients will describe their operated nasal tip as having the appearance of a round ball or bulbous tip, even thought their nasal tip may be narrow. This pinched appearance is due to the shadowing that isolates the nasal tip, creating a bulbous or pinched look to the nasal tip. Maneuvers such as dome sutures, lateral crural strut grafts, repositioning of the lateral crura, and alar rim grafts can create a favorable tip structure to support the underlying skin envelope. Using the methods described will enable the surgeon to focus less on narrowing the nasal tip and more on creating favorable shadowing of the nasal tip.

PubMed ID: 19451458, [No abstract available]

Histoacryl (butyl-2-cyanoacrylate) is one of the least histotoxic cyanoacrylate derivatives and is used as a tissue adhesive. Clinical applications primarily include skin closure (blepharoplasty incisions, etc.). In a recent study, we demonstrated that Histoacryl elicits minimal histotoxicity when used to glue bone grafts to rabbit-ear cartilage. Acute inflammation was limited to areas where Histoacryl escaped from between the bone graft and ear cartilage to contact well-vascularized soft tissue. In this study, Histoacryl was applied between bone graft and cartilage in one rabbit ear and adjacent to well-vascularized soft tissue with no graft in the opposite ear. Histologic analysis revealed minimal if any inflammation when small amounts of glue was used in the nonvascular region between bone graft and cartilage. However, subcutaneous implantation contacting well-vascularized soft tissue resulted in increased acute inflammation and prolonged foreign-body giant-cell response. Further studies are required to rule out any long-term problems associated with subcutaneous implantation of Histoacryl.

Aesthetic surgery of the non-Caucasian nose frequently requires aggressive surgical manuevers to attain the desired changes in nasal contour. Unfortunately, thick, sebaceous skin of the non-Caucasian nose is at great risk for increased scar contracture, which could deform an already weak nasal structure. To prevent deformity, we use the open structure rhinoplasty technique to add support to the nasal structure in the form of columellar struts and sutured-in-place tip grafts. In this article, specific modifications of the open structure rhinoplasty technique are described for management of the non-Caucasian nose.

• 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)

Recognition of the aesthetic range of acceptability of nasal projection is crucial to sophisticated rhinoplastic surgery. Within this article, various methods are discussed that use measurements of ratios and angles between facial landmarks to assist the surgeon in assessment of nasal projection. Chin projection, skin thickness, and patient age are further considerations when deciding how to best approach an aesthetic ideal for a particular patient's face. This article then discusses preoperative assessment and diagnosis and emphasizes steps taken to correct problems of projection that completely depend on the anatomic etiology of the deformity.

Most techniques that control tip projection involve relatively aggressive maneuvers that can compromise the integrity of the nasal structure by dividing major support mechanisms, or dramatically alter the shape of the nasal tip by cutting the lower lateral cartilage and re-orienting the domes. Decreased tip support can result in an iatrogenic loss in tip projection that may require compensatory over-reduction of the nasal dorsum. This series of events may result in a blunted nose with a poorly defined dorsum. Open structure rhinoplasty techniques emphasize preservation or reconstitution of major support mechanisms to attain a natural-looking nose that will not deteriorate with time. This technique uses the open (external) approach to the nose, sutured-in-place columellar strut, advanced lateral crural manipulation, and a sutured-in-place tip graft to provide tip projection, support, and a bidomal tip configuration. This article discusses the theory, major technical points, and use of this technique for precise control of tip projection.

• 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)

Asian rhinoplasty presents unique challenges to the surgeon. The aesthetic goals should be tailored for the ethnicity and culture of the individual patient. Unlike typical Caucasian rhinoplasty, primary Asian rhinoplasty is frequently augmentation rhinoplasty. Alloplastic implants have had a long history of safety in Asia, but many patients are not suitable for or not agreeable to the use of alloplastic materials and autologous costal cartilage should be considered. This procedure is safe and reliable when these techniques are properly executed.

Successful rhinoplasty requires a detailed understanding of the nasal structure needed to produce a functional and aesthetically pleasing nose. Recent advances in surgical technique have focused on cartilage repositioning and reshaping, often with the use of cartilage grafting.Newer techniques for strengthening the middle vault, stabilizing the base, and modifying the lateral crura are presented, as well as the M-arch model, a modification of the tripod concept.Technical advances in rhinoplasty provide numerous options for reconstruction and reshaping of the nose.

The scope of this article is directed toward strategic planning and surgical treatment of the postoperative short nose deformity. Emphasis is placed on controlled repositioning of the central compartment of the nose (tip and columella), followed by moving the nostrils back into a more natural position with the use of autologous grafting techniques. The overall goal is to achieve the desired esthetic transformation while maximizing nasal function with good long-term results.

This article reviews the case of a patient who had undergone two previous rhinoplasties and presented with a foreshortened nose and severe left alar retraction. She underwent excision of a skin lesion just above the left alar groove resulting in severe alar retraction.

Control of nasal tip contour has always been a key component of a successful rhinoplasty. Typically, this procedure is performed with an emphasis on narrowing the nasal tip structure. Creating a natural-appearing nasal tip contour is a complex task and requires a 3-dimensional approach. In an effort to identify the characteristics that make an ideal nasal tip, I evaluated numerous aesthetically pleasing nasal tips. After extensive study, I created a series of images to demonstrate how specific contours create highlights and shadows that will help guide the surgeon in creating a natural-appearing nasal tip contour. Many commonly used nasal tip techniques can pinch the tip structures if an overemphasis is placed on narrowing. These changes isolate the dome region of the nasal tip and can create an undesirable shadow between the tip lobule and alar lobule. Prior to contouring the nasal tip, the surgeon must stabilize the base of the nose with a columellar strut, suturing the medial crura to a long caudal septum, caudal extension graft, or an extended columellar strut graft. Stabilizing the nasal base will ensure that tip projection is maintained postoperatively. To contour the nasal tip, dome sutures are frequently used to flatten the lateral crura and eliminate tip bulbosity. Placement of dome sutures can deform the lateral crura and displace the caudal margin of the lateral crura well below the cephalic margin. This can result in a pinched nasal tip with the characteristic demarcation between the tip and the alar lobule. Alar rim grafts can be used to support the alar margin and create a defined ridge that extends from the tip lobule to the alar lobule. This form of restructuring can create a natural-appearing nasal tip contour with a horizontal tip orientation continuing out to the alar lobule. When dome sutures alone are inadequate, lateral crural strut grafts are used to eliminate convexity and prevent deformity of the lateral crura. Shield tip grafts can be used in patients with thick skin and an underprojected nasal tip. Whenever a shield tip graft is used, it must be appropriately camouflaged to avoid undesirable visualization of the graft as the postoperative edema subsides. When contouring the nasal tip, the surgeon should focus more on creating favorable shadows and highlights and less on narrowing. Nasal tips contoured in this manner will look more natural and will better withstand the forces of scar contracture that can negatively affect rhinoplasty outcomes.

To determine if a systematic, concentric graft-carving technique results in less warping than eccentric carving.Costal cartilage from ribs 3 through 9 were harvested from fresh human cadavers. Concentric dorsal grafts were carved from cartilage obtained from one side of the cadaver (n = 7) and eccentric grafts were carved from the opposite side (n = 11). After carving, grafts were placed in saline sponges (isotonic sodium chloride) for 1 hour, and photographs were then taken from a lateral and a frontal view. Identical photographs were taken after 2 weeks of incubation in saline (36.7 degrees C). The angle of curvature was measured from the photographs.More warping occurred in the eccentric group than the concentric group on lateral view at 1 hour (4.4 degrees vs 0.4 degrees; P.001) and at 2 weeks (5.8 degrees vs 1.4 degrees; P = .003). Eccentric grafts progressively warped between the 1-hour and 2-week points.Meticulous concentric carving of costal cartilage grafts may minimize the complication of graft warping.

Rhinoplasty and septoplasty are commonly performed surgical procedures that have as many variables in execution as the number of surgeons that perform them. Initially, these procedures were performed using manual instrumentation. Recently, however, powered instruments have been used to perform portions of the two procedures. Powered oscillating rasps have been described for reducing dorsal bony humps during rhinoplasty, and it has been suggested that powered osteotomes may reduce tissue trauma when performing nasal osteotomies. Powered burrs have also been used for taking down dorsal bony humps and refining boney irregularities. Although septal spurs have traditionally been excised manually, powered instrumentation has proved useful in this area as well. This article reviews the indications for using powered instrumentation in rhinoplasty and septoplasty.

A Blitzer, BE Benson, J Guss . Botulinum Neurotoxin for Head and Neck Disorders. New York: Thieme, 2012. ISBN-10: 1604065850 Botulinum Neurotoxin for Head and Neck Disorders is a moderately sized text covering a very specific, clinically relevant, and contemporary topic that is applicable to physicians in many specialties, including plastic surgery, facial plastic surgery, otolaryngology/head and neck surgery (Oto-HNS), neurology, and dentistry. An initial review of the contents of the text reveal several appealing color illustrations and diagrams and a moderately large, easy-to-read font. The 19 chapters are subdivided into 4 distinct topic sections: dystonia, other motor disorders, pain syndromes, and autonomic disorders. Following the Table of Contents is a listing of 22 online videos that demonstrate the injection techniques described in the text. The foreword provides the reader with a brief history of the medical uses of botulinum toxin (BoNT) to be described in the text, including strabismus, focal dystonias such as spasmodic dysphonia and blepharospasm, migraine headache, hyperhidrosis, and wrinkle reduction. The preface describes the intended audience for the book, which includes clinicians familiar with treating a variety of disorders affecting the head and neck—plastic surgeons, otolaryngologists, neurologists, dentists, and pain specialists. After reading this book, we would agree with the intended audience and add medical students and novice practitioners to the list. This book provides a comprehensive review of the more common clinical applications of BoNT, including the treatment of focal dystonias, pain syndromes, and cosmetic applications. Included in each section are descriptions of the pathology under consideration, important differential diagnostic considerations, accepted medical and surgical therapies for each condition, the role of BoNT in ameliorating …

Contour of the nose is determined by a series of shadows and highlights that emphasize the shape of the nose.1 The desired contours are curvilinear with smooth transitions from dorsum to mid-vault to nasal tip. Control of nasal contour requires precise management of the underlying nasal structures. The structure approach to rhinoplasty employs conservative reduction of the cartilage structures and reshaping using cartilage grafting.2 Cartilage grafts such as spreader grafts and lateral crural strut grafts help to control the shape of the middle nasal vault and lower third of the nose, respectively.3,4 Such grafts have helped surgeons improve their long-term outcomes as well as link nasal aesthetics and surgical technique. In the article entitled, “Rhinoplasty: Surface Aesthetics and Surgical Technique,” Dr Cakir and his coauthors have described how the nasal contour is composed of a series of polygons as aesthetic units and linked these concepts to their own techniques. The ideal contour on frontal view is typically described as having bilateral divergent concave lines that create symmetric “brow tip aesthetic lines.”5–7 In contrast, the authors describe the frontal view as a series of polygons, with a superior polygon that is narrow at the radix and widens toward the middle nasal vault and an inferior polygon that narrows at the supratip. This series of shapes more closely represents the shape of the underlying nasal structures (nasion, nasal bones, and upper lateral cartilages) rather than the superficial nasal contour. Transitions in skin thickness—from thick in the radix region, to …

Problem: Septal perforation is a troublesome complication of septoplasty. This complication may occur from damage to septal lining incurred during surgery. Many otolaryngologists are trained to elevate the septal lining in a subperichondrial plane. This may prevent trauma and preserve the strength of the lining flaps. When the surgeon elevates septal lining in a submucosal, supraperichondrial plane, the ensuing flap available for closure may be less robust and more prone to septal perforation. This study aimed to determine the relative strength of the constituent layers of nasal septal lining. This information is hoped to provide a scientific basis for the accepted subperichondrial approach to septal flap elevation in nasal surgery. Methods: The nasal septums from 5 fresh human cadavers were isolated. On one side of each septum, the lining flap over the quadrangular cartilage was elevated in a subperichondrial plane under microscopic visualization. These “composite” tissue flaps contained both mucosa and perichondrium. On the opposite side of each septum, the mucosal and perichondrial layers were dissected separately. Rectangular sections measuring 1 by 3 cm of each flap were then excised. The tensile strength of each specimen was then measured with an Instron 4301 Mechanical Testing System (Canton, MA). The data described the force in grams needed to tear each specimen. Results: The average tensile strength of the mucosal flaps (n = 8) was 598 gm; of perichondrial flaps (n = 11) 1370 gm; and of composite flaps (n = 14) 2340 gm. The differences between groups were determined to be highly significant (P Conclusion: The perichondrial layer imparts the majority of the biomechanical strength to the septal lining. Lining flaps containing both perichondrium and mucosa are significantly stronger than flaps with either perichondrium or mucosa alone. Significance: Dissection in a subperichondrial plane in the approach to septoplasty may lead to a stronger septal lining flap being available for closure and therefore a decreased risk of septal perforation. Support: None reported.

Over the past decade, rhinoplasty techniques have moved away from excisional methods and focused more on repositioning and restructuring existing tissues. These changes in surgical technique were made in part because of some of the untoward long-term complications noted in noses that were treated with excisional techniques. The incidence of many of these complications is greater in patients with certain nasal anatomy. It is the responsibility of the surgeon to identify these anatomic variants and make necessary adjustments in surgical technique to avoid complications.

The transconjunctival approach to removal of herniated orbital fat is the method of choice in patients with no evidence of dermatochalasis or hypertrophic orbicularis muscle. This technique has advantages in patients who have undergone previous blepharoplasty and is particularly appropriate in younger patients with good lid tone and favorable lid position. In cases in which horizontal lower lid laxity is present the transconjunctival procedure can easily be combined with horizontal lid tightening through a tarsal strip procedure. Because the external lamellae are not manipulated, eyelid retraction or ectropion is uncommon after this approach. subcutaneously into the center of the upper lid. The upper lid is retracted upward by a silk traction suture placed through skin, orbicularis muscle, and superficial tarsus. An incision is made in the inferior palpebral conjunctiva, midway between the inferior tarsal border and the inferior fornix, between the temporal and medial ends of the eyelid, using a disposable eye cautery (Fig 1). The lower edge of the divided conjunctiva is retracted downward by the surgeon, while the assistant retracts the adjacent superior edge upward and outward with forceps. Dissection through the underlying Muller's muscle and capsulopalpebral fascia is performed with a disposable

Objective: Recently, a two-dimensional Silastic Dacron stretching skin device has been developed for scalp reduction surgery. Attached subgaleally, this device stretches skin over time, while avoiding the visible volumetric distention that is typical of three-dimensional tissue expanders. Unlike three-dimensional expanders, the histological changes observed with a two-dimensional stretching device have not been described in the literature. The present study compares the histological effects of two-dimensional and three-dimensional skin tissue expansion in the porcine model. Study Design: A university Institutional Review Board-approved study in which 16 domestic piglets were used. The 16 piglets were divided evenly into four cohorts as follows: 1, 1-week control cohort; 2, 1-week experimental cohort; 3, 4-week control cohort; and 4, 4-week experimental cohort. Methods: Tissue expanders (three-dimensional) and Dacron Silastic tissue stretchers (two-dimensional) were surgically inserted into the lateral skin of 16 domestic pigs. Animals were killed at either 1 or 4 weeks based on group assignment. Light microscopic ocular micrometry and stereological point counting were used to determine the depth of the epidermis, dermis, and subdermal adipose tissue layer; width of the panniculus muscle; diameter of sweat gland follicles; percentage ratio of dermal collagen, blood vessels, and tissue space; and epidermal mitotic index in 100 specimens. One-way ANOVA was used to evaluate statistical differences. Results: Both tissue expanders yielded increased values compared with control subjects, with respect to epidermal, dermal, and fat widths and blood vessel counts, whereas adnexal structures in the panniculus muscle width were unaltered. Conclusions: Although statistically the two types of expansion produced histologically similar changes, the degree of change varied according to the type of expander that was used and the duration of tissue expansion. Most notably, three-dimensional expansion produced more tissue gain per unit area expanded at both the 1-week and the 4-week time intervals, and early (1-week) two-dimensional tissue expansion stimulated a greater angiogenic response than three-dimensional expansion. These findings will assist the surgeon in understanding the physical changes that occur with these two forms of tissue expansion, as well as the potential clinical advantages and shortcomings of each method.

Objectives To e-amine the effects of fibrinogen concentration and application thickness of fibrin tissue adhesive on skin graft survival. Study Design Prospective controlled study. Methods Ten domestic pigs were included in the study. A 20 − 5-cm area of skin was harvested bilaterally along the flanks of the animals using a Padgett dermatome. The harvested grafts were trimmed into four 4 − 4-cm squares. Donor sites were treated according to group assignment and the non-meshed grafts were placed on the side opposite their initial orientation and secured with staples. Both single- and multiple-donor human fibrin tissue adhesive preparations, with low and high average fibrinogen concentrations of 30 mg/mL and 60 mg/mL, were used. Adhesive preparations were applied in either a thin layer (0.015 mL/cm2) or a thick layer (0.06 mL/cm2) using a spray applicator. A constant thrombin concentration of 10 U/mL was used in the study. No adhesive was used in the control group and grafts were stabilized with staples. No topical dressings were applied to any of the treatment sites. Animals were sacrificed 4 weeks after graft application. Results Based on statistical analysis, thickness of adhesive application had a significant effect on skin graft survival. Percent mean graft survival in the control and thin application groups was found to be 92% and 97.8% respectively; the mean survival rate in the thick application group was 63.1%. Fibrinogen concentration, when evaluated independently within the thin and thick application groups, was found to have no significant effect on graft survival. Conclusion Independent of fibrinogen concentration, a thin layer of fibrin tissue adhesive, when applied between two opposing surfaces, does not interfere with and may support the healing process, whereas a thick layer of adhesive inhibits skin graft healing.

When performing septorhinoplasty, deviated segments of septal cartilage can be straightened using cartilage or bone as splinting grafts. In some cases, autologous material is not available without an additional surgical procedure to harvest cartilage or bone. It is possible that resorbable plates can be used to splint and straighten deviated cartilage. Experience using bioresorbable rigid fixation devices on cartilage has been limited.To examine early histopathologic changes of rabbit ear cartilage and adjacent soft tissue following implantation with bioresorbable plates.Nonrandomized, placebo-controlled trial.Twelve adult New Zealand white rabbits.Ten adult New Zealand white rabbits (20 ears) underwent stenting of intact ear cartilage with LactoSorb plates (Lorenz, Jacksonville, Fla). Rabbits were killed 28 days after implantation, and the soft tissue, plates, and cartilage were harvested and prepared for histological examination. As controls, 2 rabbits (4 ears) underwent dissection and closure without stenting.Six rabbits experienced superficial skin breakdown on the ventral surface of the ear caused by excessive wound tension of the implant. The cartilage-plate interface and the surrounding soft tissues stenting the dorsal side of the ear remained free of inflammation or necrosis for all animals. Simple elevation of the perichondrium revealed no differences in the appearance of the cartilage between the control and test rabbits.Resorbable plates have no deleterious effects on cartilage during the first month of implantation. While short-term studies have documented the safety and efficacy of using bioresorbable plates, further studies are recommended.

Histology of plastic embedded undecalcified bone represents a challenging problem to the histotechnologist. We outline here an exploration of LR White resin as a suitable medium for histologic study of undecalcified rat tibia. A procedure was developed for light microscopy of rat tibia embedded in LR White and sectioned by sawing-grinding technics. The specimens were fixed in 10% neutral buffered formalin or alcohol-acetic acid-formol, dehydrated in ethanol, defatted in chloroform followed by resin infiltration and heat-curing of embedded blocks. The procedure of dehydration, defatting, infiltration, and polymerization can be completed within 10 days. Cold curing with accelerator provided by the manufacturer did not yield superior results compared to blocks cured with heat. Thick sections were obtained using a diamond wire saw, attached to plexiform slides, then ground and polished. Surface staining with Von Kossa silver reagent or toluidine blue revealed satisfactory morphological preservation of the mineralized bone sections. Artifacts like small bubbles appeared occasionally and could not be avoided despite prolonged infiltration or cold curing of blocks. Our method is relatively simple for base-line histologic study of rat tibia. The method offers advantages such as easy adaptability, reliable stainability, contrast, and resolution of bone architecture and marrow cells. Two other embedding media, Micro-Bed resin and Unicryl, were also tested, but produced inferior results.

In order to evaluate a new method for the direct application of a polypeptide growth factor to injured tracheal epithelium and to determine the effect of topical platelet-derived growth factor (PDGF) on tracheal wound healing, a controlled animal study was designed using six adult beagle dogs. Four 2×1 cm mucosal defects were created in the tracheal lumen of each dog for a total of 24 experimental sites. Twelve wounds were treated with PDGF in a collagen–fibrin composite tissue adhesive (CTA) carrier. Eight sites received CTA alone and four were left untreated. Healing was assessed by endoscopic exam on post-operative days 4, 7, 10, 14, 17 and 21. The animals were sacrificed on day 21 and the tracheas were harvested for histological examination of the experimental sites and adjacent unwounded trachea. By 21 days, complete healing of all sites was observed endoscopically. Wounds treated with CTA or PDGF-CTA healed at a faster rate than control sites. The PDGF-CTA treated wounds demonstrated excessive granulation tissue formation. Histological examination demonstrated a higher percentage of wound coverage with ciliated epithelium most similar to normal trachea in the PDGF treated wounds. CTA is effective as a carrier for the direct delivery of a growth factor to injured tracheal epithelium. The application of CTA or PDGF-CTA results in a more rapid rate of tracheal wound healing as compared with control wounds. PDGF-CTA led to increased acute local inflammatory changes but was associated with a structurally more normal respiratory epithelium after healing. Physiological studies are necessary to determine the functional significance of these findings.

Growth factors are proteins that help regulate the inflammatory response and wound healing in tissues. After laryngotracheal surgery, proper wound healing is important in maintaining the reconstructed airway. The application of growth factor to the respiratory mucosa of the larynx and its effect on wound healing within the airway have not been studied. This study was designed to establish a model for the evaluation of wound healing after the application of growth factor to composite respiratory mucosa and cartilage surfaces at the time of laryngotracheoplasty. Forty rabbits underwent anterior cricoid cartilage split with or without the use of a cartilage graft. Platelet-derived growth factor or a placebo substance was applied to the wound at the time of surgery. This study offers a model for studying wound healing in the airway that is reproducible with limited morbidity. (Otolaryngol Head Neck Surg 1999;120:78-83.)

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

Octyl-2-cyanoacrylate is a long carbon chain cyanoacrylate derivative that is stronger and more pliable than its shorter chain derivatives. One hundred and eleven patients underwent elective surgical procedures by the same surgeon using either octyl-2-cyanoacrylate or sutures for skin closure at the University of Illinois at Chicago. Most patients underwent excision of benign skin lesions with a mean wound size of 112 mm3. Patients were randomized into either control (vertical mattress suture closure) or test groups (closure with octyl-2-cyanoacrylate). Surgical judgment was used to determine which wounds in each group required application of subcutaneous sutures to relieve tension and aid in skin edge eversion. Generally, full-thickness (through dermis) wounds larger than 1 cm3 required the use of subcutaneous sutures. The time required to close the epidermis with suture (mean, 3 minutes and 47 seconds) was about four times that of octyl-2-cyanoacrylate (mean, 55 seconds). Wounds were evaluated at 5 to 7 days for infection, wound dehiscence, or tissue reaction, and at 90 days using the modified Hollander wound evaluation scale. At 1 year, photographs of the wounds were evaluated by two facial plastic surgeons that graded the cosmetic outcome using a previously validated visual analog scale. There were no instances of wound dehiscence, hematoma, or infection in either group. Results of wound evaluation at 90 days determined by the modified Hollander scal revealed equivalent cosmetic results in both groups. Results of the visual analog scale ratings showed scores of 21.7 +/- 16.3 for the 49 patients treated with octyl-2-cyanoacrylate and 29.2 +/- 17.7 for the 51 control patients treated with sutures. The lower visual analog scale score represented a superior cosmetic outcome at 1 year with the octyl-2-cyanoacrylate as compared with sutures. This difference is statistically significant at p = 0.03. Additionally, patient satisfaction was very high in the group treated with octyl-2-cyanoacrylate.

Purpose: In an effort to show the differences between neurotrophic factors, laminin and acidic fibroblast growth factor (aFGF) were compared in terms of their abilities to regenerate axons in vivo over an extended distance. Materials and Methods: The sciatic nerve was transected in 15 Sprague-Dawley rats. A 15-mm Silastic tube (Dow Corning, Midland, MI) was placed between the ends of the cut nerve and filled with either laminin, aFGF, or buffer applied to collagen sponges. Results: Ten weeks postimplantation, mean axon counts showed that both laminin (2432) and aFGF (1612) produced significantly higher numbers of axons than controls (1009) (P < .05) and that laminin showed significantly more nerve regeneration than aFGF (P < .05). Conclusion: These results indicate that laminin and aFGF enhance peripheral nerve regeneration across a large gap, presumably through their neurotrophic effects and mitogenic properties on supporting cells. Furthermore, it is concluded that the transient nature of aFGF's effect on the regenerative environment limits its effectiveness at regenerating axons over a prolonged period of time.

Educational objectives: To use open rhinoplasty approach to gain exposure to correct deformities seen in secondary rhinoplasty, posttraumatic deformities, and reconstructive cases, and to use structural grafts to correct aesthetic and functional deformities of the nose.