Correction of the deviated tip and columella in crooked nose

The primary procedural components of deviated nose correction are as follows: osteotomy to correct bony deviation, septal deviation correction, manipulation of the dorsal septum to correct upper lateral cartilage deviation, and correction of functional problems (manipulation for correction of internal valve collapse and hypertrophy of the inferior turbinate). The correction of tip and nostril asymmetry cannot be overemphasized, because if tip and nostril asymmetry is not corrected, patients are unlikely to provide favorable evaluations from an aesthetic standpoint. Tip asymmetry, deviated columella, and resulting nostril asymmetry are primarily caused by lower lateral cartilage problems, which include deviation of the medial crura, discrepancy in the height of the medial crura, and asymmetry or deformity of the lateral crura. However, caudal and dorsal septal deviation, which is a more important etiology, should also be corrected. A columellar strut graft, correction of any discrepancy in the height of the medial crura, or lateral crural correction is needed to correct lower lateral cartilage deformation depending on the type. In order to correct caudal septal deviation, caudal septal shortening, repositioning, or the cut-and-suture technique are used. Surgery to correct dorsal septal deviation is performed by combining a scoring and splinting graft, a spreader graft, and/or the clocking suture technique. Moreover, when correcting a deviated nose, correction of asymmetry of the alar rim and alar base should not be overlooked to achieve tip and nostril symmetry.

Correction of deviated nose

Deviated nose deformities have always been a surgical challenge, and it is essential to achieve both functional and esthetic improvements. Various techniques have evolved over time to correct deviated noses but no one method applies in all cases. Successful correction requires a complete understanding of the various surgical techniques and concepts, including the three-dimensional nasal structure and the time-related changes to surgically-treated noses.

L-Shaped Columellar Strut in East Asian Nasal Tip Plasty

BACKGROUND: Nasal tip support is an essential consideration for rhinoplasty in East Asians. There are many techniques to improve tip projection, and among them, the columellar strut is the most popular technique. However, the conventional design is less supportive for rotating the tip. The amount of harvestable septal cartilage is relatively small in East Asians. For an optimal outcome, we propose an L-shaped design for applying the columellar strut. METHODS: To evaluate the anthropometric outcomes, the change in nasal tip projection and the columella-labial angle were analyzed by comparing preoperative and postoperative photographs. The anthropometric study group consisted of 25 patients who underwent the same operative technique of an L-shaped strut graft using septal cartilage and were followed up for more than 9 months. RESULTS: There were statistically significant differences between the preoperative and postoperative values in the nasal tip projection ratio and columella-labial angle. We did not observe any complications directly related to the L-shaped columellar strut in the anthropometric study group. CONCLUSIONS: The L-shaped columellar strut has advantages not only in the controlling of tip projection and rotation, but in that it needs a smaller amount of cartilage compared to the conventional septal extension graft. It can therefore be an alternative technique for nasal tip plasty when there is an insufficient amount of harvestable septal cartilage.

Contracted Short Nose Correction Using Irradiated Homologous Costal Cartilage

Septal extension graft is a frequently used technique for correction of the contracted short nose, in which septal cartilage is a first choice for the graft. However, we sometimes encounter situations where septal cartilage is not available. Autogenous rib cartilage can be a good option, but some female patients fear of a bigger operation and do not want a scar around the breast. In such cases, irradiated homologous costal cartilage can be a useful alternative. 38 cases of contracted short nose deformities were treated using the septal extension graft with homologous costal cartilage (34 cases with Tutoplast(R)-processed cartilage, 4 cases with Allowash(R)-processed cartilage). Follow-up period ranged from 2 months to 32 months. Good aesthetic and functional results were obtained. Neither infection nor unfavorable results were found. There was no graft warping, except two cases of graft avulsion fracture and one case of minimal nasal obstruction. There was no definite evidence of greater graft resorption compared to the autogenous rib. Homologous costal cartilage can be a safe and reliable material for rhinoplasty, especially in the absence of available autogenous cartilage sources.

Neovascularization in the "Cross-Leg Fashioned" Muscular Free Flap

For the reconstruction of soft tissue defect combined with open fracture in the lower leg, free flap, especially muscle free flap which has abundant blood supply, is considered to be the most suitable method. Sometimes, however, injury to the main vessels in the lower leg makes it impossible to use a principal vessel as a recipient vessel. In such cases, vein graft or end-to-side anastomosis can be employed. To acquire a healthier vessel as a recipient,the authors performed crossleg muscle free flap, using a non-injured healthy vessel of the contralateral leg as a recipient vessel. Controversy still lingers over the angiogenesis of cross-leg muscle free flap and thus safety after flap detachment. There have been some clinical case reports on cross-leg muscle free flap, but flap survival after pedicle detachment has been known to be variable according to different authors. Because of the uncertainty of neovascularization in muscular free flap at the time of flap delay procedure,many surgeons hesitate to use a pure muscle free flap as a delay flap. Eight cases of cross-leg muscular free flap were performed by the authors using the rectus abdominis muscle, latissimus dorsi muscle and a combination of the latissimus dorsi and serratus anterior muscle flap. During the operation, the authors estimated the ratio of poorly vascularized bed in recipient soft tissue defect. Despite the high ratio of non-vascularized bed, there was no flap necrosis after pedicle detachment and ample neovascularization within the muscle was confirmed by post-division angiogran. As well, there was no recurrence of osteomyelitis. Conclusively, enough neovascularization in cross-leg free muscle flap, even placed on a poorly vascularized bed, could be induced through a delayed procedure.

Effect of Hyperbaric Oxygen & Allopurinol on the Survival of Irradiated Rat Skin Flap

The objectives of this study sere to investigate how the local irradiation affect the survival of random pattern skin flap, and whether or not hyperbaric oxygen and allopurional can improve the survival of the irradiated rat skin flap. There have been many reports about the effects of hyperbaric oxygen and allpurinol on skin flaps. However, very few reports have been presented on the effects of hyperbaric oxygen and allpurinol in treating irradiated skin flaps. The author examined the local irradiation effect on rat skin flap survival after irradiation of 20 Gy, 3 days postoperatively, on cranially based random pattern dorsal skin flap, which was 3 x 9cm in size. The flap survival length was measured in experimental groups treated with hyperbaric oxygen (2.5 atm absolute, 100% oxygen, once a day for 7days) after irradiation and with hyperbaric oxygen combined with allopurinol (100mg/kg, once a day for 7 days), in comparison with a radiation-only group. On reviewing the flap survival length 10 days postoperati-vely, the average flap survival length in the radiation-only group was 2.2+/-0.5cm, while in the non-radiation group it was 5.5+/-0.3cm. The reduction ratio of flap survival by irradiation was 60%. There was a significant increase in the mean flap survival length in the groups treated with hyperbaric oxygen (4.0+/-1.6cm) and hyperbaric oxygen combined with allopurinol (5.5+/-1.8cm). The increased ratio of flap survival in each group was 85% and 150% when compared to the radiation-only group. The author found that rat skin flap survival decreased, even at an early stage, as a result of high dose local irradiation and that decreased flap survival by irradiation could be restored by hyperbaric oxygen and allopurinol. The group treated with hyperbaric oxygen combined with allopurinol showed increased flap survival over the group treated with hyperbaric oxygen only. The results showed a method which could possibly increase flap survival in cancer patients who require early radiation after flap surgery.