Search

The nasal valve is an important consideration in patients presenting with nasal obstruction. Controversy exists regarding the anatomy, terminology, evaluation, and management of the nasal valve. Innumerable techniques with variable effects have been described in the literature. The evidence qualifying these techniques has been plentiful, though often lacking in quality. This article reviews the controversial aspects of nasal valve management applying the best available evidence to help clarify potential areas of confusion. Future research using standardized definitions, consistent methodologies, and validated outcome measures are necessary to improve the quality of evidence and impact surgical decision-making.

Describe the utility of osteocutaneous forearm flaps in reconstruction of naso-orbito-ethmoid (NOE) defects.Case series with chart review.Tertiary medical centers.The study was conducted on patients treated between the years 2000 and 2014 undergoing NOE resection with reconstruction using the radial forearm flap. Decision making, technical feasibility, need for revisions, and patient disease outcomes were included to assess the durability of reconstruction over remaining survival period.Fifteen patients underwent NOE reconstruction in the timeframe studied. Five recent patients reported poor nasal airway but no diplopia or immediately clinically evident enopthalmus after NOE reconstruction in mean follow-up of 17.3 months. One-third of patients succumbed to disease in the study period, 3 without revision, and all but 2 surviving patients required revisions.Osteocutaneous radial forearm flap (OCRFF) is a cosmetically acceptable method of reconstructing NOE defects. Though a 1-step reconstruction can be serviceable without multiple additional procedures, longer surviving patients frequently receive revision surgery as with more traditional planned staged procedures.

Numerous materials are available for use in augmentation rhinoplasty. For the moderate-to-severe saddle nose deformity, we prefer use of irradiated homologous costal cartilage. This method has been effective in augmentation of the nasal dorsum as well as nasal tip modification, when septal or auricular cartilage is lacking. During the past 25 years, we have used irradiated costal cartilage at our institution via the external rhinoplasty approach for robust and versatile reconstruction of the nasal framework and esthetic nasal tip modification. This article contains a detailed discussion of the technique as well as selected illustrative cases.

Objectives To review nasal alar support mechanisms, introduce the concept of tractional forces on the nasal ala, and describe a reconstructive technique to correct nasal tip deformities associated with weakened tractional force on the nasal ala. Design Photographic study and retrospective medical chart review. Results We noted that patients with weakened support at the dome of the lower lateral cartilage had lateral alar deformities. Strengthening the cartilaginous deficiency improved the nasal appearance and function in 90% of patients. Conclusions Deformities of the nasal tip are among the most difficult to correct. Tractional forces provided by dome strength help to maintain the ala in its normal anatomical position. Structural tip grafts restore the tractional force and, thereby, help to correct the alar deformity.

To evaluate long-term structural, functional, and cosmetic results as well as resorption with the use of irradiated homologous rib cartilage grafts (IHRGs).Cases in which IHRGs were used were reviewed for a long-term follow-up study for nasal and auricular reconstruction, dating back 18 years. A retrospective medical chart review was conducted in the cases in which the patients had returned for clinical examination with photographic documentation.A total of 118 patients who had undergone nasal reconstruction with a mean follow-up of 36 months were identified from our database. There were 12 patients who had undergone auricular reconstruction, with a mean follow-up of 82 months. Resorption with compromise in cosmesis was noted in 11% (11/102) of the grafts used in nasal reconstruction but in 71% (5/7) of those used in auricular reconstruction. Minor resorption without change in form or function was found in 29% (30/102) of the cases. Loss of support, which was related more to graft displacement rather than resorption, was identified in 19% (21/109) of the cases, and loss of support affecting cosmesis was observed in 8% (9/109) of the cases. Maintenance of form and function appeared to be unrelated to the amount of resorption noted for the nasal grafts but was significant for the auricular grafts (P.01).The longevity of IHRGs has been favorable for functional, structural, and cosmetic nasal reconstruction, with low levels of resorption identified clinically. The use of IHRGs was associated with an unacceptable rate of graft failure in auricular reconstruction; therefore, they are no longer selected for use in such cases.

Nasal ulcerations have many causes. Ulcerations that are self-induced are difficult to diagnose and treat. Two rare conditions with self-induced nasal ulceration are trigeminal trophic syndrome (TTS) and factitious disorder (FD). Trigeminal trophic syndrome is characterized by trigeminal anesthesia, nasal alar ulceration, and facial paresthesia. Appearance of the nasal ulcer after trigeminal ablation for neuralgia is diagnostic. Self-induced nasal lesions that occur in FD are primarily distinguished from those in TTS by the presence of normal trigeminal nerve function and frequent patient denial of lesion manipulation.To increase physician awareness of the disorders leading to self-induced nasal ulceration and to discuss management issues in our patient series.A retrospective review of 7 cases in which the patients presented for reconstructive consultation between March 1985 and October 1997 and were found to have self-induced nasal ulcerations.Tertiary university medical center.Five patients were identified with TTS and underwent nasal reconstruction an average of 43 months (range, 4-72 months) after nasal ulcer presentation. Four of the 5 patients developed ulcer recurrence between 1 and 58 months after reconstruction; secondary reconstruction resulted in recurrence in 2 of these patients. Two patients were identified with FD and self-induced nasal ulceration. One of these 2 patients underwent total nasal reconstruction 15 months after ulcer occurrence and developed recurrence 2 weeks after surgery.Self-induced nasal ulceration remains a difficult condition to diagnose and treat. Readily treatable conditions should be excluded, and diagnostic workup should include tissue biopsy and laboratory studies. Patients with TTS may have associated ocular findings, and those who do should be referred for ophthalmologic consultation. Surgical reconstruction can be considered in the highly motivated patient with TTS; however, delayed ulcer recurrence is common. Patients with FD should be treated primarily with local wound care and referred for psychiatric intervention. We strongly recommend nasal prosthetic devices as the primary means of aesthetic correction and discourage surgical repair in the patient with FD.

Objective: To describe a surgical technique (the conchal cartilage butterfly graft) which, when used in properly selected patients, has been found to be a dependable method for alleviation of postrhinoplasty internal nasal valve dysfunction. Study Design: Retrospective chart review. Methods: Analysis of consecutive patients with weakness and/or collapse of the upper lateral cartilages following rhinoplasty. Seventy-two patients (37 women and 35 men, age range 17-76 y) had severe nasal obstruction and were found to have indications for this procedure. All patients had undergone at least one rhinoplastic procedure. All patients were followed for a minimum of 2 years after surgery. Results: All 72 patients experienced significant subjective improvement in relative nasal obstruction. Two patients (3%) reported less than total resolution of their difficulty breathing through their nose; the remaining 70 patients (97%) reported complete resolution of their nasal airway problems. No patients reported their postoperative nasal obstruction as the same or worse than their preoperative baseline. Sixty-two patients (86%) reported improvement in the appearance of their nose, 8 patients (11%) felt that their appearance was unchanged, and 2 patients (3%) felt that the appearance of their nose was made worse by the procedure. Conclusions: Patients presenting with nasal obstruction after rhinoplasty are frequently found to have collapse and/or weakening of their upper lateral cartilages with resulting nasal valve dysfunction. The conchal cartilage butterfly graft is a technique which, when properly performed during revision rhinoplasty, yields predictable functional and cosmetic results with minimal morbidity.

Objective: The purpose of this study was to examine the perceptions of medical students regarding facial aesthetic surgery and those specialists most likely to perform aesthetic or reconstructive facial surgery. Methods: A survey was designed based on a review of the literature to assess the desirable characteristics and the perceived role of the facial plastic and reconstructive surgeon (FPRS). The surveys were distributed to 2 populations: medical students from 4 medical schools and members of the general public. Results: A total of 339 surveys were collected, 217 from medical students and 122 from the general public. Medical students and the public had similar responses. The results demonstrated that respondents preferred a male plastic surgeon from the ages of 41 to 50 years old and would look to their family doctor for a recommendation. Facial aesthetic and reconstructive surgery was considered the domain of maxillofacial and general plastic surgeons, not the FPRS. Conclusion: Integration of the FPRS into the medical school curriculum may help to improve the perceived role of the specialty within the medical community. It is important for the specialty to communicate to aspiring physicians the dedicated training of an otolaryngologist specializing in FPRS. (Otolaryngol Head Neck Surg 2001;125:478-82.)

The “open” (external) and “closed” (endonasal) rhinoplasty approaches remain a subject for debate. Advances in surgical techniques and improved understanding of rhinoplasty dynamics ensure that this topic remains contemporary. The addition of structural support to the nose has been one of the more important realizations of rhinoplasty surgery, with a greater trend for leaving intact, native nasal anatomy and reshaping structure with shaping sutures and grafting techniques. This is in contradistinction to older techniques in which resection and reduction methods were primarily used. The best results from rhinoplasty surgery remain the same over time, whether achieved by these different techniques or whether affected by the selection of the external or endonasal approach. In this article, differences between the two approaches are compared, and a subjective grading of their positive and negative attributes is presented and discussed to help guide and shape modern rhinoplasty concepts.

Background Many methods are available to the facial plastic surgeon for elevating and separating tissue, from cold steel to monopolar cautery to various laser-cutting technologies. Bipolar cautery has replaced monopolar cautery as the optimal hemostatic technique because of its decreased tissue damage and improved capabilities. Bipolar scissors concurrently offer a dissecting technique with hemostatic capability. Little exists in the otolaryngology literature on the use of bipolar scissors for soft tissue dissection. Objective To describe our experience using bipolar scissors in a variety of facial plastic and reconstructive procedures. Setting Tertiary care referral academic center. Design We retrospectively reviewed 78 procedures performed using bipolar scissors between June 1997 and August 1999. In facial plastic cosmetic surgery, bipolar scissors were used 31 times for deep plane face-lifts and 16 times for endoscopic browlifts. In facial plastic reconstructive surgery, bipolar scissors were used in 15 radial forearm free flaps, 10 fibula osteocutaneous flaps, 3 rectus abdominis free flaps, and 3 latissimus dorsi myocutaneous free flaps. Results In all procedures, bipolar scissors facilitated the dissection. By allowing for a drier field, less time was required to elevate the flap and obtain hemostasis. Complications were not increased compared with historical controls. In the harvesting of fibula osteocutaneous free flaps, use of bipolar scissors allowed harvesting without use of a tourniquet. Conclusion Bipolar scissors, a new technology in facial plastic surgery, allow the same control as sharp dissection and provide simultaneous hemostasis.

Objective To compare a new dermabrasion instrument equipped with a metal shield and hydration-suction apparatus with the standard instrument, with specific attention to the exposure of operating room personnel to potentially hazardous particles. Design A surgical trial with each of the instruments was performed with a skin model. The splatter caused by the 2 instruments was evaluated and compared statistically and graphically. Subjects Female hairless guinea pigs (450 g) were used as a skin model. Interventions Ten guinea pigs were treated with the standard dermabrading instrument, and 10 were treated with a shielded suction-irrigating dermabrader. The splatter was analyzed by counting the number of particles landing on strategically placed glass slides. Evaluations of histologic cross-sections of the dermabraded skin were compared in a blinded fashion. Results Statistical and graphic analysis showed the number of potentially hazardous particles generated by the suction dermabrader to be significantly less than that generated by the standard dermabrader. Histologic sections showed no difference between the 2 subsets. Conclusion The new shielded suction-irrigating dermabrader provides comparable surgical results while significantly decreasing exposure to potentially hazardous splatter particles.

To evaluate the safety and efficiency of and patient satisfaction with a 2-team approach for combined rhinoplasty and sinus surgery.We conducted a retrospective medical chart analysis of consecutive patients with sinus disease and functional nasal obstruction. Forty-four patients (29 women and 15 men; age range, 22-75 years) had severe nasal obstruction with chronic sinusitis and were found to have indications for this procedure. All patients were followed up for a minimum of 6 months after surgery. Patients completed a standardized questionnaire at the time of medical chart review, and 36 patients completed a telephone interview.All 44 patients underwent rhinoplasty with an endoscopic sinus procedure. Twenty-seven procedures (61%) were endonasal, whereas 17 (39%) were open rhinoplasty. Patients with internal nasal valve collapse underwent 28 butterfly grafts, 6 spreader grafts, and 8 batten grafts. The endoscopic sinus procedures consisted of maxillary antrostomy (30/44 [68%]) and ethmoidectomy (28/44 [63%]). Overall, 20 (65%) of 31 patients reported a postsurgical nasal airway that was significantly improved. Most sinus symptoms were resolved postoperatively, with 25 (71%) of 35 patients describing their improvement as significant. Thirty-two (92%) of 36 patients stated that they would recommend the concurrent procedure.Patients presenting with nasal obstruction and chronic sinusitis tolerated combined rhinoplasty and sinus procedures without added morbidity.

Although composite cartilage grafts are often used in conjunction with a midline forehead flap to repair full-thickness nasal defects, the timing of pedicle division, which optimizes cartilage viability, has yet to be determined. A rabbit animal model was designed to investigate this question. The skin flap pedicle was divided at 0 days, 4 days, 3 weeks, 6 weeks, and 10 weeks in each of five groups of five animals. Although early pedicle division led to partial skin flap necrosis, the cartilage grafts tolerated this ischemic period better. Cartilage viability was approximately 70% and did not differ significantly between the five groups. It is concluded that a larger composite graft and better definition of the skin flap's critical period are needed to determine optimum timing for pedicle division in this animal model.

Objective: To report a multi-institutional clinical experience with the liposhaver in facial plastic surgery. Design: Nonrandomized, nonblinded, multiinstitutional evaluation of the liposhaver in a clinical setting in patients presenting for cosmetic facial liposuction. Interventions: Cosmetic facial surgery with the liposhaver was performed in 19 patients (21 procedures) who underwent submental lipectomy, facelift with defatting beneath the facelift flap, and/or correction of deep nasolabial folds. Standardized preoperative and postoperative photographs were obtained. Fat obtained from the abdomen of 1 patient was also studied histologically. This fat was excised sharply and was then liposhaved at varying oscillation speeds. Outcome Measures: Subjective evaluation by the operating surgeons. Results: The liposhaver was used successfully in all cases. The fat was cleanly shaved and the contour results were even, without dimpling or asymmetry. Operative time was comparable to that for conventional liposuction. Preferred cannula sizes and settings were determined. There were no cases of facial nerve injury, no evidence of increased bleeding intraoperatively, and no hematomas in the immediate postoperative period. One patient developed a small hematoma on postoperative day 5 that was effectively treated with needle aspiration and a pressure dressing. Histologic evaluation of liposhaved abdominal fat showed normal fat cells and well-preserved architecture. Conclusions: The liposhaver offers a precise alterative to conventional liposuction. It may be less traumatic because it requires low suction pressures and does not rely on the potentially bruising, vigorous, back-and-forth motion for fat extraction typical of conventional liposuction. Arch Otolaryngol Head Neck Surg. 1996;122:1161-1167

Objectives: To evaluate the epithelial "turn-in" flap for reconstruction of the internal lining in full-thickness nasal defects. Highlighted are its indications, technique, complications, and clinical success, particularly in comparison with the other common modalities for reconstructing this nasal lining. Also, to determine how the random flap withstands vigorous thinning. Design: A retrospective chart review and clinical followup of all patients with full-thickness nasal defects of the nose. Setting: The patient pool comes from a tertiary care center that draws from a large geographic area in the Northwest. Both urban and rural demographics are represented. Patients: Fifty-six patients with large full-thickness nasal defects were reviewed, 18 of which were reconstructed with the epithelial turn-in flap. The causes of the original defect were varied. Intervention: Full-thickness nasal defects were reconstructed in a layered fashion. The turn-in flaps were aggressively thinned to the subdermal plane to minimize flap bulk and airway compromise. Main Outcome Measures: Attention was made to the size and precise location of the defect, the mode of reconstruction, flap viability, and nasal function. Results: Eighteen patients had turn-in flaps for reconstitution of the internal lining. Sixteen patients (89%) had 100% viability of their flaps. Seventeen (94%) reported normal nasal function. Conclusions: The epithelial turn-in flap is a robust flap that provides dependable and functional results. One of the major advantages of this flap over other methods is that often there is no donor site morbidity. For many select defects, the turn-in flap remains a method of choice for repair of the internal lining. (Arch Otolaryngol Head Neck Surg. 1995;121:1122-1127)

Objective: To assess the efficacy of sustained postoperative intramuscular ketorolac tromethamine (Toradol) at analgesic levels in the augmentation of acute, random-pattern skin flaps in rat. Design: Prospective, randomized, placebo-controlled, animal trial. Setting: Animal research laboratory, School of Medicine, Oregon Health Sciences University, Portland. Subjects: Forty-four adult male Sprague-Dawley rats (260 to 280 g). Interventions: Twenty-two treatment animals underwent modified McFarlane random-pattern skin flaps followed immediately by intramuscular loading doses of ketorolac. Treatment animals were then maintained on a regimen of intramuscular ketorolac using a three times a day dosing schedule for 14 days postoperatively. Twentytwo control animals underwent identical modified McFarlane random-pattern skin flaps and were given equivalent volumes of intramuscular saline on the same dosing schedule for the 14-day treatment period. Main Outcome Measures: Postmortem measurements of skin flap ischemia (expressed as a percentage of total flap surface area) were performed for both treatment and control animals by three independent, non-blinded observers using the acetate tracing technique. Both pooled and individual data were statistically analyzed using personal computer software. Results: Forty-three of the 44 animals successfully completed the experimental trial. One animal in the treatment group died on postoperative day 3 of unknown causes. During the study period, one postoperative hematoma was detected in both the treatment and control groups. The mean percentage of skin flap ischemic necrosis observed in control animals (35.4%) was consistently less than that measured in the treatment group (36.4%). However, the difference in ischemic flap necrosis between control and treatment groups was not statistically significant (P=.6919). Conclusions: Comparatively high-dose intramuscular ketorolac failed to augment acute, random-pattern skin flap survival in rat when initiated in the immediate postoperative period. Complications of prolonged, intramuscular ketorolac were not observed in this trial. Further studies using preoperative initiation of drug therapy may help to clarify the true efficacy of ketorolac in flap augmentation. (Arch Otolaryngol Head Neck Surg. 1995;121:673-677)

Objective: To examine the use of autologous free dermal fat grafts (FDFGs) in the reconstruction of soft-tissue facial contour defects, an 8-year, retrospective, computerized medical chart review was conducted for 21 patients who underwent reconstruction with FDFGs. Setting: Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Oregon Health Sciences University, Portland, or affiliated hospitals. Patients: Twenty-one patients identified in the chart review were included in the retrospective evaluation. Follow-up periods ranged from 11 to 94 months. Five patients were unavailable for follow-up at the chart review, but all five had satisfactory results at their last evaluation. Design: Soft-tissue augmentation was performed using autologous FDFGs harvested from the abdomen following in situ de-epithelialization with a high-speed dermabrader. Facial contour defects resulted from tumor extirpation, congenital deformity, trauma, or degenerative disease. Main Outcome Measures: Outcome was considered satisfactory when the patient and the surgeon were pleased with the long-term results at the last evaluation. Results: Complications, including graft resorption (five patients) and epithelial cyst formation (two patients), were observed in seven patients and resulted in an unsatisfactory outcome. The remaining 14 patients demonstrated satisfactory results as determined by the patient and the surgeon at the last evaluation. Conclusions: Successful long-term augmentation of facial contour defects may be achieved with autologous FDFGs in an appropriate patient population. Careful patient selection and proper surgical technique are essential for satisfactory long-term results. Guidelines are provided for the augmentation of facial contour defects with autologous FDFGs. (Arch Otolaryngol Head Neck Surg. 1995;121:95-100)

Background:Theendoscopicbrow-liftisapopulartechnique for rejuvenation of the aging brow and forehead. Long-lasting results depend on readherence of the pericraniumtotheunderlyingskullinthenewlyelevatedposition. Determination of the time required for pericranialreadherencetooccurisimportantwhenconsidering optimalbrowfixationtimepostoperatively;however,few studies of pericranial healing exist in the literature. Objective: To quantify the time required for pericranialadherenceafterpericranialelevationinarabbitmodel. Design: Anesthetized New Zealand white rabbits underwent elevation of a pericranial flap on day 0. The flap was then repositioned and the skin sutured. One unoperated-on group served as a control. A tensiometer was used to measure the force required to separate the pericranial flap from the skull of the control animals and of test animals killed on postoperative days 3, 5, 8, 10, 13, 17, 20, 25, and 28. Statistical analysis was performed to determine the effect of healing time on the strength of pericranial readherence. Results:There was a statistically significant decrease in the force required for pericranial separation at 3 and 5 days after surgery compared with the control group. By 8 days postoperatively and throughout the subsequent times examined, no statistically significant differences from the control group were observed. Conclusion: In this rabbit model, pericranial adherence (as measured by tensile strength) is decreased postoperatively and does not return to baseline levels until postoperative day 8.

Nasal obstruction due to internal nasal valve (INV) collapse is relatively common. This article evaluates 2 different methods repairing the INV.Our subject population is a single-surgeon group of 82 patients who underwent a septorhinoplasty for nasal airway obstruction. Patients received either a spreader graft or butterfly graft. There are 30 patients who received spreader grafts and 52 patients who received a butterfly graft. All patients had a minimum of 3 months follow-up. All patients were evaluated with standardized questionnaire. Participants were asked to evaluate improvement in their nasal airway on an analog scale of 1 to 5. Participants were also asked to comment on changes in pre and postoperative snoring and sleep habits. Lastly, participants were queried regarding the ear cartilage harvest and if this bothered them.Patients undergoing both procedures demonstrated an overall improvement in their nasal breathing. Significant differences in improvement were observed for patients in the categories of postoperative snoring, sleep, and continuous positive airway pressure use. Patients were not bothered by the ear cartilage harvest.In select patients, the butterfly graft is a useful solution for INV collapse correction.

The structures of the nose are arguably the most complex within the face to reconstitute when absent. Total nasal reconstruction has evolved to encompass advanced surgical techniques in an effort to achieve increasingly satisfactory cosmetic results while restoring nasal function that mimics the function of a patient's natural nose. In this article, the history of total nasal defects and their reconstruction, relevant nasal anatomy, etiologies of the defect, and the surgical approaches to reconstructing each of the three-layered structure of the nose (ie, nasal skin, cartilage/bone, and lining mucosa) are explored.

Objective: To validate the use of the conchal cartilage butterfly graft in primary functional rhinoplasty and to review our experience using this technique. Study Design: A retrospective analysis of patients who underwent conchal cartilage butterfly graft reconstruction of the nasal valve in primary rhinoplasty. Method: A retrospective analysis using patient questionnaires was performed. Data were collected to determine patient satisfaction about nasal breathing and cosmesis after the procedure. Results: Among the patients, 90% (n = 90) had improved breathing, 88% (n = 88) were satisfied with their postoperative cosmesis, and 89% said they would recommend the procedure to a friend who had similar preoperative symptoms. Conclusion: Conchal cartilage butterfly graft has now been shown to be successful in primary functional rhinoplasty, just as it has previously been proven effective in secondary rhinoplasty. Although we have had success with many techniques for the correction of internal nasal valve collapse, we have found the conchal cartilage butterfly graft to be another outstanding technique for the appropriately selected patient. Laryngoscope, 2009

• Many facial plastic surgeons use • operative steroids to reduce postoperative edema and morbidity. This use of steroids is based more on theory and anecdotal experience than on controlled studies. We studied 49 patients undergoing rhinoplasty in a randomized, double-blind fashion to evaluate the effects of perioperative and postoperative steroid use. We found significantly less postoperative eyelid and paranasal edema in those patients receiving steroids. In addition, trends toward less ecchymosis, less intranasal edema, and less discomfort in the patients receiving steroids were noted. ( Arch Otolaryngol Head Neck Surg . 1991;117:990-993)

To describe our experience with coblation technology for facial resurfacingRetrospective chart review of all patients treated with coblation at our institutionTwenty-four patients (22 female) underwent a total of 29 coblation procedures for aging face (n = 21) or acne scarring (n = 3). The perioral region was the most frequently treated aesthetic subunit (n = 14), followed by the lower eyelid (n = 7). Five patients underwent full-face coblation. Three patients underwent a second coblation procedure for aging face while a single patient with severe acne scarring underwent 3 procedures. Repeat coblation was delayed at least 5 months (mean, 9 months). Seventeen coblation procedures (59%) were performed concurrently with procedures including, but not limited to, injection treatment, rhinoplasty, blepharoplasty, or combined face/necklift; no adverse events occurred. Seven procedures, including a full-face coblation, were performed in the office under local anesthesia and oral sedation without any adverse events. Mean follow-up was 6 months (range, 1 week to 24 months). No complications were observed. All patients were satisfied with the results after their final coblation treatment.Facial coblation is a safe and effective treatment modality for facial resurfacing.

• Substantial premaxillary augmentation is necessary as an adjunctive treatment in most cleft rhinoplasties and in those patients exhibiting an acute nasolabial angle due to retrusion of the premaxilla. We describe our technique of evaluation and treatment of this condition using a custom-carved piece of material made from a woven combination of Teflon and organic fibers (Proplast). Detailed technical illustrations as well as patient results are demonstrated. We have found this technique in our hands to be a simple, safe, and effective means of correction of significant premaxillary retrusion. ( Arch Otolaryngol Head Neck Surg . 1990;116:1197-1201)

Facial plastic surgeons commonly see patients with submental laxity and an excess of skin and fat in the upper neck. This has colloquially been called the "turkey gobbler" deformity. In some cases, this deformity is the patient's only aesthetic concern, and full face-lift surgery is not desired. In this study, we reviewed the English-language peer-reviewed literature for descriptions of direct excisional submentoplasty techniques. Various designs for skin excision and wound closure have been used by surgeons over the past several decades. This article summarizes the surgical technique as well as the advantages and disadvantages of each method. Furthermore, we propose an approach that incorporates many of the other designs but to our knowledge has not been described previously in the peer-reviewed literature. An understanding of these numerous approaches will better enable facial plastic surgeons to appropriately address and correct patient aesthetic concerns.

Total nasal defects present daunting challenges to the reconstructive surgeon. The nasal skeleton can be successfully fabricated with bone and cartilage. Reconstruction of the nasal skin with a forehead flap produces an excellent color match for nasal skin. Resurfacing of the internal lining is the most difficult of the 3 layers. Local tissue is often unsatisfactory in amount and/or vascular supply.A patient requiring total nasal reconstruction was prospectively examined. Intraoperative technique was recorded, and postoperative function was determined.A paramedian forehead flap was used to resurface the external defect. Split calvarium and conchal cartilage were used to reconstruct the nasal skeleton. A fascial flap harvested from the forearm was used to replace the intranasal lining. Turbinate grafts were placed to line the flap. Postoperative breathing was excellent.The intranasal portion of a total nasal defect can be successfully reconstructed with a fascial forearm flap. Placement of a turbinate or mucosal graft allows for a thin mucosalized lining with an excellent functional outcome.

Objective: To describe a novel surgical protocol for the management of patients presenting with extruded nasal implants. Study Design: Retrospective chart review. Methods: Analysis of consecutive patients presenting with extruded nasal implants from 1986 to 2000. Patients were selected from a large database of revision rhinoplasty cases. Inclusion criteria were: 1) at least one previous rhinoplasty procedure, 2) an extruded nasal implant that was documented preoperatively, 3) immediate reconstruction that was carried out with irradiated homograft costal cartilage (IHCC), and 4) at least 1 year of follow-up recorded, including standard postoperative rhinoplasty photographs. A total of 18 patients met the inclusion criteria and form the basis of this study. Data gathered from the charts included date of surgery, last date of follow-up, location of implant extrusion, alloplastic material, specific use of IHCC for reconstruction, percent of clinical IHCC resorption at last follow-up, and presence of warping of the IHCC. Results: All 18 patients were satisfied with the cosmetic outcomes of their nasal reconstructions. The most common extruded alloplast was Silastic, followed by Gore-Tex (W.L. Gore & Associates, Inc., Flagstaff, AZ). There were no cases of extrusion or infection of the IHCC implant subsequent to immediate reconstruction of the extruded alloplast. Clinical resorption of the IHCC was minimal, with a mean follow-up of 26 months. Only one patient had a complication, warpage, resulting in removal of the IHCC. In that patient, the IHCC still had carving markings on the implant after 2 years in vivo. Conclusions: In this series of patients, a novel surgical protocol was used. The extruded implant was removed and immediate reconstruction with irradiated rib cartilage was done. All patients were evaluated for postoperative infection, graft extrusion, and satisfaction with cosmetic result. There was one major complication in this series of 18 patients, warping of the IHCC, which necessitated removal and replacement. This approach appears to be a reasonable method for reconstruction of extruded nasal alloplasts.

In repairing cutaneous defects, the facial plastic and reconstructive surgeon is faced with many specialized areas of tissue. Reconstruction of thin eyelid skin and thick, sebaceous nasal skin requires different methods. The unique characteristics of the scalp make it one of the greatest repair challenges in the head and neck region, sometimes requiring multiple different reconstructive techniques for the same defect.

Rejuvenation of the aging upper face can transform tired and angry features into youthful-appearing ones. This article presents the principles for analyzing and treating the aging forehead and brow. The esthetic dimensions and proportions of the brow and forehead are discussed, in context with the corresponding surgical anatomy. The goals of facial rejuvenation surgery as it relates to the upper third of the face are addressed. Various approaches, including their advantages and disadvantages, are presented. The appropriate approach is selected to eliminate unsightly features that are in need of correction while minimizing hairline shifts and forehead scarring and anesthesia. Following the principles and techniques illustrated in this article, the facial plastic surgeon may confidently treat the signs and complaints of the aging upper face.

The relative importance of reduced arterial inflow versus reduced venous outflow in determining flap necrosis remains undefined, even though this is critically important in understanding the effects of pharmacologic agents on flap survival. By means of a rat bipedicled ventral island flap, the amount of random flap necrosis was examined in four experimental groups: (1) unilateral arteriovenous ligation (n = 19), (2) unilateral vein ligation (n = 20), (3) unilateral artery ligation (n = 20), and (4) alternate side vein and artery ligation (n = 18). No necrosis occurred on the side of the vein ligation in groups 2 and 4, indicating that independently reducing venous outflow does not cause flap necrosis. A predictable necrosis occurred ipsilateral to artery ligation in groups 1 (37.63 +/- 17.34 percent), 3 (32.74 +/- 17.32 percent), and 4 (15.70 +/- 9.86 percent). These data indicate that the rat ventral island flap is more sensitive to a decrease in arterial inflow than to a decrease in venous outflow. This model may therefore be useful in clarifying the effect and determining the mechanism of action of pharmacologic agents that alter flap survival.

Educational objectives: To appreciate more fully the necessary interaction between functional and aesthetic considerations in rhinoplasty surgery and to be more knowledgeable of functional structural needs in achieving conservative rhinoplasty surgery with the multiple approaches and techniques available to today's rhinoplasty surgeon.

Objective: To evaluate the incidence of infection and extrusionofporoushigh-densitypolyethylene(pHDPE) and expanded polytetrafluoroethylene (ePTFE) implants used in rhinoplasty at a high-volume, academic facial plastic surgery practice. Methods: A total of 662 rhinoplasty procedures performed by 3 faculty surgeons from 1999 to 2008 were retrospectively reviewed. Patient demographics, medical comorbidities, operative details, and postoperative course findings were collected from patient records. Results: The incidence of postoperative infection was 2.8% (19 of 662 patients). In each case of infection, alloplastic material had been used. Infections occurred in 1 in 5 rhinoplasty procedures in which pHDPE implants were used. In patients in whom ePTFE was used alone, the infection rate was 5.3%. Exposure developed in 12% of patients in whom an alloplast was used during surgery. Factors notably not associated with infection on bivariate analysis included sex, surgeon, purpose of procedure (functional vs cosmetic), current tobacco use, or history of cocaine use (P.05 for all). Conclusions: To our knowledge, this study represents the largest evaluation of the use of pHDPE implants in rhinoplasty to date. Our findings are in contrast to those of previous studies regarding the use of pHDPE in rhinoplastyandparalleltothoseregardingtheuseofePTFE. Caution is strongly recommended when considering the use of pHDPE in rhinoplasty.

The technique of rapid intraoperative tissue expansion has been used with increasing frequency in the clinical setting over the last several years. This technique takes advantage of the skin's ability to immediately stretch and increase in surface area when expanded under a constant load. Sixteen random-pattern, rapidly expanded skin flaps on 10 domestic male pigs were studied to assess the predictive value of the fluorescein test for flap viability after rapid intraoperative tissue expansion. Partial fluorescence was found to be a more accurate predictor of flap survival in the experimental rapidly expanded flaps when compared to full fluorescence. Partial fluorescence was found to under-predict flap survival by 0.3 to 0.5 cm, whereas full fluorescence was found to under-predict flap survival by 2.5 cm. Additionally, histologic and ultrastructural changes were examined in rapidly expanded skin from the hip region in three pigs. The only microscopic change noted between control and experimental flaps was dilated capillaries in the dermis of expanded skin, which was noted by electron microscopy. Collagen and elastic tissue changes were not demonstrated in rapidly expanded pig skin by electron microscopy, direct immunofluorescence, collagen, and elastic tissue stains.

• The midface has long served as a focus for creativity in surgical reconstruction. Full-thickness skin grafts, split-thickness grafts, and distal flaps have long been used to attempt to reduplicate existing anatomy in this area. Recent reconstruction efforts have focused on the creative use of microvascular free flaps for this purpose. This article reports on the use of extensively developed regional rotation flaps as an excellent reconstructive modality for use in this area of the face. The details of surgical incisional planning are given. The nuances of surgical creation of these flaps and their rotation and suspension into place are given. The cases we have done using this technique for the past 3 years are reviewed. Our present indications for use of these flaps and their limitations are given. ( Arch Otolaryngol Head Neck Surg . 1991;117:77-82)

Objective To evaluate the effect on snoring of structural nasal valve dilatation with butterfly spreader grafts in patients with nasal valve insufficiency. Design Retrospective medical chart review and telephone follow-up; mean ± SD follow-up time, 20.7 ± 11.34 months (range, 3-48 months). Settings Tertiary care referral center. Subjects A total of 37 snoring patients with nasal valve insufficiency who underwent nasal valve dilatation with a butterfly spreader graft. Interventions The conchal cartilage butterfly graft technique was performed during rhinoplasty through either an external or endonasal approach. Main Outcome Measure To establish through a retrospective review that butterfly graft conchal cartilage nasal reconstruction is effective in reducing snoring. Results After surgery, 30 patients (81%) had significant improvement in breathing, 5 (14%) had slight improvement, and 2 (5%) had no benefit in breathing. Snoring stopped completely in 11 (30%) of the patients after surgery. The improvement in snoring was significant in 13 patients (35%) and slight in 3 (8%). Twenty-six patients (70%) reported tiredness and grogginess on awakening before the surgery. Surgery significantly improved patients’ tiredness and grogginess on awakening in 15 cases (58%), slightly improved them in 5 (19%), and did not change the patients’ tiredness and grogginess in 6 cases (23%). Conclusion The conchal cartilage butterfly graft yields successful results not only in breathing but also in snoring symptoms in patients with nasal valve insufficiency.

Objective To assess the effectiveness of replantation in the treatment of nasal amputations. Design Retrospective chart review. Setting A university medical center. Results In no case did the replant survive completely, and in all cases revision surgery was required. However, in all cases, the resulting deformity was less than the original defect. In our pediatric patients, reconstruction with cartilage grafting and a midline forehead flap was successful and demonstrated proportionate and appropriate growth. Conclusions It is our belief that replantation serves many therapeutic functions. At the very least, there is the psychological/emotional factor that is involved in attempting to replace a native body part that has been severed. Also, it is difficult to persuade parents and patients that the amputated tissue that has been handled with kid gloves by paramedics, maintaining its pink "alive" color, is ultimately doomed to failure. Forehead flaps and conchal cartilage grafts are more willingly accepted after a "failed" replantation than as primary reconstructions. In every instance, we believe, the ultimate defect will be smaller than the original deformity. Certainly, the need for vestibular lining reconstruction is far less. Thus, the ultimate healed defect from the replantation greatly facilitates final nasal reconstruction.

We share Dr Shiffman's emphasis on the importance of safety in cosmetic surgery. As he points out, liposuction in the head and neck with blunt cannulas is relatively safe but is not completely without risk. Sharp curettes and cannulas use a scraping motion; we have advised that the soft tissue shaver should not be used in this manner. The surgeon can use this instrument in a closed fashion, or, with the aid of an endoscope or a headlight, the surgeon can directly visualize the tissue as it is being shaved. To date, in a nearly 3-year combined experience, none of the authors have experienced damage to the surrounding nerves or vessels. Liposuction is often inadequate for optimal removal of septated adipose tissue in the upper midline of the neck between the 2 anterior borders of the platysma muscle. Many surgeons currently augment blunt liposuction in this area with