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Nasal dorsal augmentation in rhinoplasty using synthetic implants remains an intensely controversial surgical practice. The authors describe their experience with expanded polytetrafluoroethylene (e-PTFE) sheeting as an implant material in rhinoplasty. A review of the literature and detailed descriptions of techniques for creating synthetic dorsal implants are offered. Alloplastic implants are powerful tools which may be used by the thoughtful surgeon in carefully selected patients to achieve nasal dorsal augmentation.

Summary Various materials are available for facial reconstruction and augmentation. Autografts continue to be the gold standard of implant materials because they are nonimmunogenic, easily shaped, and readily available. Donor site morbidity and a limited supply of tissue limit the use of autografts. Homografts offer an attractive alternative if autografts are unavailable. Homografts are attractive because they are readily available, have a low rate of infection, and are easily shaped. Homografts must be used with caution because they have been associated with disease transmission, graft resorption, and graft warping. Alloplastic implants are enjoying increasing popularity, and many facial plastic surgeons routinely use them with success. In general, alloplastic implants should be used in immobile, non-load-bearing locations in the face. Cell culture technology in the future may offer a limitless supply of autogenous tissue. This continues to be an active area of research.

To determine on an ongoing basis the safety and efficacy of expanded polytetrafluoroethylene (Gore-Tex soft tissue patch and preformed nasal implants) as an implant in rhinoplasty.A retrospective study of 309 consecutive patients who underwent rhinoplasty, including augmentation with Gore-Tex, during a 10-year period.Two major academic medical centers and 2 private office surgical centers.One hundred sixty-two patients (52%) presented for primary rhinoplasty; the remaining 147 (48%) presented for revision surgery. All received Gore-Tex implants to augment the nasal dorsum and/or base. The grafts ranged from 1 to 10 mm in thickness. Follow-up ranged from 5 months to 10 years, 5 months, with an average of 40.4 months.Clinically noted complications and patient satisfaction.Ten (3.2%) of 309 grafts became infected and were removed. One graft was removed and 1 graft was modified and replaced postoperatively because of excessive augmentation. Infection requiring removal occurred in 8 patients (5.4%) undergoing revision rhinoplasty and in 2 patients (1.2%) undergoing primary rhinoplasty. Nasal septal perforation was present preoperatively in 3 of the patients who developed infection requiring removal, and we consider it a contraindication for nasal Gore-Tex implantation.Gore-Tex remains an effective implant material for nasal augmentation in rhinoplasty. The complication rate in primary cases is low. The risk of infection necessitating removal rises significantly in revision cases, where its use may still be desirable but must be weighed more carefully.

The term tension nose is known to many rhinoplastic surgeons, yet confusion exists as to its precise meaning. We define the tension deformity as excessive growth of the quadrilateral cartilage, resulting in a high nasal dorsum and anterior and sometimes inferior displacement of the nasal tip cartilages. A review of the surgical literature shows that little attention has been given to the evaluation and management of this problem. We reviewed 50 consecutive primary rhinoplasty candidates and found that 46 percent had some manifestation of tension deformity that required correction at the time of surgery. The techniques of open structure rhinoplasty are ideally suited to manage the tension nose. The essence of correction is a deprojection-reprojection process. First, excessive elements of the septal cartilage and anterior nasal spine, which comprise what we have termed the nasal pedestal, are reduced, resulting in tip deprojection. Open structure methods are then employed to achieve reprojection of the domes by using cartilage grafts and suturing techniques to build strength, support, and elegance into the nasal tip.

To report the long-term results of 72 consecutive patients treated with Radiesse (BioForm Inc, Franksville, Wis) and 29 patients treated with Radiesse and Restylane (Q-Medical, Uppsala, Sweden) and to share recommendations based on our experience.A total of 72 patients were treated with Radiesse between October 2003 and December 2004. Of these patients, 29 also received Restylane for facial augmentation. Forty-six Radiesse-treated and 15 Radiesse and Restylane-treated patients completed questionnaires detailing their experience with the procedure, postoperative sequelae, overall satisfaction, and satisfaction at each site treated.On a 10-point scale, the overall satisfaction with Radiesse averaged 7.6, and 30 patients (65%) would recommend this procedure to others. Of the 72 patients, 2 (3%) reported persistent nodules, and both required removal of a small amount of the material. The overall satisfaction with the Radiesse and Restylane-combined treatment averaged 8.1, and 12 patients (79%) would recommend this procedure to others. No patients reported persistent nodules.The use of Radiesse and Restylane in combination is an excellent option for facial enhancement. With long-term experience, complications in the lip area with Radiesse treatment are now avoided with the use of Restylane. In contrast to patients treated with Radiesse alone, the combination treatment group in this study tended to have greater immediate and overall satisfaction scores and was more likely to recommend the combination procedure to others.

Augmentation of the chin is a long-standing and effective technique for facial enhancement. We have used preformed expanded polytetrafluoroethylene (Gore-Tex) implants for chin augmentation for several years. For this study, we collectively pooled data detailing our experiences with this material. From January 1, 1998, to March 30, 2001, a total of 324 Gore-Tex chin implants were placed. No resorption or visible movement of any implant occurred. Two (0.62%) of the 324 implants became infected and were ultimately removed. No other complications occurred. This complication rate compares favorably to other reports. Five implants (1.5%) were removed or changed in size due to patient requests. All remaining patients (97.8%) were satisfied with their result. We also describe technical points and procedure modifications that have helped us achieve beneficial results for our patients. Gore-Tex is a reliable implant material that helps the surgeon to achieve a high degree of patient satisfaction in chin augmentation.

Objective: To describe a face-lift technique with emphasis on extension of the temporal incision into the lateral orbital area. This modification serves several beneficial ends but must be used only in carefully selected patients. Gathering of excess skin in the lateral orbital area is prevented, eliminating the typical disparity between relatively tight lower and middle facial skin and flaccid upper facial skin, which is commonly seen after rhytidectomy. The anterior extension also helps to support the lower eyelid, which is helpful when lid laxity exists or when concomitant blepharoplasty is performed. Setting: A private cosmetic surgery center. Participants: Thirty-five patients undergoing rhytidectomy (15 primary and 20 revision procedures). Outcome Measure: Patient satisfaction at 3 months after surgery. Results: Thirty-four (97%) of 35 patients were pleased with their results. Conclusions: The anterior extension face-lift can provide excellent results in carefully selected patients. We have found this procedure to be especially helpful in patients undergoing revision surgery and in older patients with facial skin laxity. (Arch Otolaryngol Head Neck Surg. 1995;121:613-616)

• With the advent of the acquired immunodeficiency syndrome crisis, it has become imperative that all surgeons minimize their risk of direct contact with the patient's body fluids. In the course of performing surgery, perforations are frequently created in surgical gloves, which often go unnoticed. This study determined the frequency with which occult glove perforations occurred in 134 consecutive head and neck surgical procedures. One thousand fifty gloves (650 gloves used in surgery, 400 unused control gloves) were analyzed for the presence of perforations large enough to permit the passage of fluid. An unrecognized glove perforation was detected in 25% of surgical cases. The duration of surgery correlated strongly and positively with the incidence of perforation. Perforation rates varied widely for specific types of procedures, and are reported for each of the five subdivisions within otolaryngology—head and neck surgery. The implications of these results are described, and recommendations for the use of protective measures, especially in reference to the use of double-gloving, are made. ( Arch Otolaryngol Head Neck Surg . 1991;117:910-913)

• In an effort to determine if the endotracheal tube-leak pressure has prognostic value in relation to a successful outcome after one-stage laryngotracheal reconstruction or cricoid split surgery, a retrospective analysis was performed on 17 children who had undergone such surgery. The daily leak pressures, length of intubation, and ultimate outcome of attempts at extubation were noted. One hundred percent of patients with a leak pressure of less than 20 cm H 2 O on the day before extubation were successfully extubated. In contrast, the failure rate was 100% in children extubated with a leak of greater than 30 mm H 2 O. The difference between these two groups was statistically significant (χ 2 , 13.03). Sixty percent of patients with leak pressures in the range of 21 to 30 cm H 2 O were successfully extubated. The endotracheal tube-leak pressure is a parameter that has prognostic value, and should be considered in determining when to extubate children who have undergone tracheal reconstructive surgery. ( Arch Otolaryngol Head Neck Surg . 1991;117:880-882)

The fourth branchial pouch sinus is a congenital anomaly which most frequently manifests itself by recurrent episodes of neck abscess or acute suppurative thyroiditis. This lesion usually becomes symptomatic before the age of 10 years and is more common than has previously been suspected. It has been found on the left side in 93% of the 28 cases reported in the English literature. Barium swallow during periods of quiescence and nasopharyngoscopy have frequently been successful in identifying the presence of these embryological remnants. Definitive therapy consists of total excision of the sinus tract, which can be facilitated by direct endoscopic placement of a Fogarty catheter into the sinus lumen before surgical exploration. The embryological basis for the occurrence of these sinuses is discussed.

Although compression stockings have long been recognized as a physiologically significant tool for the promotion of venous return from the lower extremity, the role of nonprescription, commercially available support hose has not been assessed in this regard. The present study involved 100 consecutive women with no known prior history of vascular disease, who responded to an advertisement for free evaluation of the venous status of their legs. The subjects, all of whom wore commercial support hose routinely, were screened for the presence of venous disease by means of Doppler ultrasonography, phleborheography, and a detailed history focusing on risk factors and unrecognized symptoms of venous disease. Photoplethysmography (PPG) was then used to evaluate the efficiency of venous return from the lower extremity with and without the support hose in place. Worsening of PPG results occurred in 43% of the women with commercial stockings in place, whereas 23% improved and 34% showed no change. Women 50 years of age and older had a somewhat higher tendency toward poorer PPG results while wearing the support hose. Furthermore, measurements in women who showed evidence of venous disease by an abnormality in one or more of the screening tests were significantly different from the overall group (p = 0.025): 61% exhibited worsening of PPG results when wearing stockings, only 14% showed improvement, and 25% were unchanged. These results suggest that the use of a commercial support hose may be particularly deleterious to older women and is contraindicated in those with evidence of venous disease in the lower extremity.

Five patients, two of whom were diabetic, all of whom were smokers with heart disease, with an average age of 61.2 years, underwent internal jugular vein patch angioplasty after carotid endarterectomy because of extensive nar rowing of the internal carotid artery. The patients were followed for a mean of 32 months post-operatively, with no evidence of recurrent stenosis or symptoms.

Among the problems that confront the vascular surgeon, a pulsatile, right-sided neck mass requires a careful and logical evaluation. It has long been known that tortuosity of the right common carotid artery, frequently associated with advanced hypertension, can physically mimic a right carotid aneurysm. The question, then, is whether carotid angiography, with a higher attendant risk of morbidity and mortality, is preferable to less invasive diagnostic modalities such as computerized tomography (CT) and ultrasonography for initial evaluation. In our study, 31 consecutive patients with a pulsatile right neck mass, indistinguishable on physical examination from a carotid aneurysm, were evaluated using CT scan of the neck and either radionuclide scan or angiography. In all of the patients, the masses were confirmed to be tortuous right common carotid arteries and not aneurysms. Because a kinked carotid artery simulating an aneurysm occurs so frequently, noninvasive diagnostic techniques, such as CT and ultrasonography, should precede angiography. We also discuss demographic characteristics commonly associated with tortuosity of the right common carotid artery.

The transoropalatal approach to the atlantoaxial-clival area provides excellent exposure for neurosurgical decompression and fusion procedures. The technique has been effectively applied in the treatment of bony and soft tissue abnormalities of the anterior spinal region. Although this approach is safe and reliable, it is not part of the otolaryngologist's usual surgical armamentarium. In the present study, we describe the case histories of five patients who underwent resection of the odontoid process for cervicomedullary compression. Neurological compromise was manifested by progressive upper and/or lower extremity paresis in all patients. In each patient, a transoropalatal approach was used. The surgical technique is discussed, and the prevention of possible sequelae, including velopharyngeal incompetence and palatal or pharyngeal wound dehiscence, is addressed.