Modified Central Pedicle in Breast Reduction and Mastopexy: The Dermal Suspension Technique.

BACKGROUND: Breast reduction and mastopexy surgery are among the most performed plastic surgery operations throughout the world. Despite development of a variety of surgical techniques for mastopexy surgeries, problems associated with this operation are not yet fully eliminated. OBJECTIVES: The aim of this paper is to show the favorable reliability of the central pedicle surgery and introduce the modification with dermal suspension flaps for glandular repositioning and skin envelope reinforcement. METHODS: The modified central pedicle reduction mastopexy with dermal suspension surgical technique is explained with details on flap planning, skin dissection, parenchyma resection, breast shaping and nipple-areola repositioning and skin re-drape and closure. RESULTS: The breast contour is formed by shaping of the central gland and wrapping of the central gland by the deepithelized dermal flaps like a brassiere after peripheric resection. This results in an aesthetically pleasant glandular shaping, better longevity of the breast shape and tensionless skin closure, followed by high quality scars. Results from over 1850 cases are discussed. CONCLUSIONS: Even though the central pedicle reduction mammoplasty technique requires more experience and has a steeper learning curve in comparison with other popular techniques used today, the long run advantages such as better projection, upper pole fullness and less breast sagging are far more satisfying. In this method, the envelope formed by the skin does not define the breast contour. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surface Aesthetics and Analysis.

Surface aesthetics of an attractive nose result from certain lines, shadows, and highlights with specific proportions and breakpoints. Analysis emphasizes geometric polygons as aesthetic subunits. Evaluation of the complete nasal surface aesthetics is achieved using geometric polygons to define the existing deformity and aesthetic goals. The relationship between the dome triangles, interdomal triangle, facet polygons, and infralobular polygon are integrated to form the "diamond shape" light reflection on the nasal tip. The principles of geometric polygons allow the surgeon to analyze the deformities of the nose, define an operative plan to achieve specific goals, and select the appropriate operative technique.

Recurrent Ameloblastoma in the Free Fibula Flap: Review of Literature and an Unusual Case Report.

Ameloblastoma is the second most common odontogenic tumor of the oral cavity with the primary site being the mandible. The ratio of maxillomandibular involvement however is 5:1 in favor of the mandible. The most common complaint is a painless swelling over the mandibular area. Despite its benign nature, ameloblastoma has a high local recurrence rate, with the most recurrences seen within 5 years after operation. Biopsy and radiological evaluation may be helpful in differentiating the subtypes of ameloblastoma. Differentiation is important because some subtypes are more aggressive than the others. Preoperative planning may be done according to this classification, which can help decrease the recurrence rate. In our case, a 26-year-old female patient with recurrent ameloblastoma which developed on the fibular flap is presented. The free fibular flap and the left parasymphyseal part of the mandible were totally excised. Ameloblastoma was confirmed on pathological examination. We reconstructed the left mandibular site with a reconstruction plate and recurrence was not seen during follow up period.

Saphenous vein sparing superficial inguinal dissection in lower extremity melanoma.

Aim. The classic inguinal lymph node dissection is the main step for the regional control of the lower extremity melanoma, but this surgical procedure is associated with significant postoperative morbidity. The permanent lymphedema is the most devastating long-term complication leading to a significant decrease in the patient's quality of life. In this study we present our experience with modified, saphenous vein sparing, inguinal lymph node dissections for patients with melanoma of the lower extremity. Methods. Twenty one patients (10 women, 11 men) who underwent saphenous vein sparing superficial inguinal lymph node dissection for the melanoma of lower extremity were included in this study. The effects of saphenous vein sparing on postoperative complications were evaluated. Results. We have observed the decreased rate of long-term lymphedema in patients undergoing inguinal lymphadenectomy for the lower extremity melanoma. Conclusion. The inguinal lymphadenectomy with saphenous vein preservation in lower extremity melanoma patients seems to be an oncologically safe procedure and it may offer reduced long-term morbidity.

The lateral crural rein flap: a novel technique for management of tip rotation in primary rhinoplasty.

BACKGROUND: An important consideration in rhinoplasty is maintenance of the applied tip rotation. Different techniques have been proposed to accomplish this. Loss of rotation after surgery not only results in a derotated tip but also can create a supratip deformity. OBJECTIVES: As a supplement to dorsal reconstruction, the authors introduced and applied the lateral crural rein flap technique, whereby cartilage flaps are created from the cephalic portion of the lateral crura to control and stabilize tip rotation. METHODS: Eleven patients underwent primary open-approach rhinoplasty that included the lateral crural rein technique; the mean follow-up time was 18 months. Excess cephalic portions of the lateral crura were prepared as medial crura-based cartilaginous flaps and were incorporated into the nasal dorsum (similar to spreader grafts) and stabilized to achieve the desired tip rotation. RESULTS: The lateral crural rein flap technique provided stability to the nasal tip while minimizing derotation in the postoperative period. Long-term follow-up revealed maintenance of the nasal tip rotation and symmetric dorsal aesthetic lines. CONCLUSIONS: The lateral crural rein flap technique is effective for controlling nasal tip rotation while reducing lateral crural cephalic excess. Longevity of the applied tip rotation is reinforced by secure attachment of the lower nasal cartilage complex to the midvault structures. LEVEL OF EVIDENCE: 4.

Surface Aesthetics in Tip Rhinoplasty: A Step-by-Step Guide.

Tip rhinoplasty is a key component of aesthetic rhinoplasty. An understanding of the correlation between tip surface aesthetics and the underlying anatomic structures enables proper identification and correction of tip abnormalities. Surface aesthetics of the attractive nose are created by certain lines, shadows, and highlights with specific proportions and breakpoints. In this Featured Operative Technique, the authors describe a stepwise process for tip rhinoplasty that conceptualizes aesthetic subunits as geometric polygons to define the existing deformity, the operative plan, and the aesthetic goals. Tip rhinoplasty is described in detail, from initial markings through incisions and dissection. The autorim graft concept is explained, and lateral crural steal and footplate setback techniques are described for the attainment of symmetric domes with correct lateral crural resting angles. Methods in columellar reconstruction are described, including creating the columella (C') breakpoint and the infralobular caudal contour graft. The principal author (B.Ç.) has applied these techniques to 257 consecutive "polygon rhinoplasties" over the past 3 years.

The sandwiched lateral crural reinforcement graft: a novel technique for lateral crus reinforcement in rhinoplasty.

BACKGROUND: Misshapen or weak lateral crura can cause an inward collapse of the lateral crus observed on deep inspiration. The lateral crural strut graft is a popular technique for reinforcing lateral crura. Failure to stabilize the graft properly can, however, result in graft displacement postoperatively and an accompanying aesthetic deformity. OBJECTIVES: The authors discuss lateral crus reinforcement with the sandwiched lateral crural reinforcement (SLCR) graft. METHODS: An SLCR graft was placed in 30 nonconsecutive primary open-approach rhinoplasty procedures by the senior author (I.K.) between February 2010 and May 2012. Cephalic excess of the lateral crura was incised and placed under the lateral crura; the lateral crural strut grafts were placed between the 2 cartilages, and the cephalic edges of both the superior and inferior lateral crura segments were sutured together. RESULTS: Of the 30 patients, there were 5 men and 25 women ranging in age from 22 to 45 years (median, 35 years). Half (50%) of the patients received the SLCR graft for external valve collapse; in 30% of the patients, it was placed to support the lateral crura after correcting cephalic malpositioning; and 20% had an SLCR graft placed for lateral crural reinforcement after deformity secondary to dome-shaping sutures. No graft displacement or tip disfigurement was observed in the follow-up period (mean, 24 months). CONCLUSIONS: The SLCR graft technique represents a powerful tool for reinforcing lateral crura without discarding the cephalic portion of the cartilage, thus securing a stable graft pocket while minimizing any postoperative structural dislocation. LEVEL OF EVIDENCE: 4.

Bone dust and diced cartilage combined with blood glue: a practical technique for dorsum enhancement.

UNLABELLED: The combination of dorsal nasal reconstruction and camouflage of surface irregularities is an important step in rhinoplasty. We hereby present our technique of delivering diced cartilage in combination with bone dust to the nasal dorsum using the patient's blood as a carrier. We advocate use of an autologous material (blood) as a scaffold for graft delivery, dismissing the use of a foreign material or fascial wrapping of the graft. Using the patient's blood for this purpose not only stabilizes the graft into a malleable structure that is easily applicable to the nasal dorsum, it also decreases the potential for reaction against foreign material. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Concurrent repair of orbital shallowness with craniosynostosis surgery: two late cases of simultaneous orbital decompression.

Early closure of cranial sutures results in various types of cranial vault deformities, named craniosynostosis. Although mostly associated with syndromic cases, bony orbit deformities such as exorbitism can be seen with various types of craniosynostosis. This condition can be associated with papilledema and besides its effect on the patient's appearance can cause subluxation of the globe, lagophthalmos or keratitis resulting in corneal ulcers and ultimately loss of vision. Various techniques have been proposed for repair or exorbitism such as fronto-orbital advancement procedures, orbital wall decompression, periosteum scoring and tissue excision. Orbital periosteal scoring covering the globe can be extremely efficient for orbital fat decompression when combined with other orbital volume expanding procedures. We hereby present two late cases of craniosynostosis associated with bilateral exorbitism due to orbital shallowness for which cranial vault reconstruction was performed simultaneously with combinations of fronto-orbital advancement, orbital decompression and periosteal scoring. The late referral of these patients at ages older than the usual time of operation indication made the surgical procedure for craniosynostosis repair and exorbitism treatment challenging. The combined and simultaneous use of bone advancement, orbital wall decompression and specially periosteum scoring can be highly efficient in the treatment of exorbitism associated with craniosynostosis.

Rhinoplasty: surface aesthetics and surgical techniques.

Surface aesthetics of the attractive nose are created by certain lines, shadows, and highlights, with specific proportions and breakpoints. Our evaluation of the nasal surface aesthetics is achieved using the concept of geometric polygons as aesthetic subunits, both to define the existing deformity and the aesthetic goals. Surgical techniques have been developed and modified to achieve the desired surface appearance, and those are detailed in this article. The principles of geometric polygons allow the surgeon to analyze the deformities of the nose, to define an operative plan to achieve specific goals, and to select the appropriate operative technique. These aesthetic concepts and surgical techniques were used in 257 consecutive rhinoplasties performed in the past 3 years by the principal author (B.Ç.).

Ocular complication after trichloroacetic acid peeling: a case report.

UNLABELLED: Chemical peeling is a noninvasive technique currently used more frequently as a cosmetic procedure. Trichloroacetic acid (TCA) is one of the most popular chemical agents used for this purpose Stuzin et al. (Clin Plast Surg 20:9-25, 1993). Although this application commonly is used for the whole face, including the eyelids, the data in the literature referring to ocular complications if TCA leaks into the eye and the injury treatment thereafter are too sparse. The authors therefore report the treatment procedure and follow-up evaluation for a patient who sustained a chemical injury to the eye during rhytidectomy combined with TCA peeling. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Triphalangeal thumb with polydactyly: an alternative surgical method.

Triphalangeal thumb (TPT) is congenital hand anomaly which a thumb consists of three phalanges. Thumb appearance can differ widely; the thumb can be longer than usual or it can be deviated in the radio-ulnar plane. Thumb strength and function can be significantly diminished. The goals of surgical treatment are to reduce the elongated thumb length, establish normal thumb function, maintain a stable joint and improve thumb position if necessary. In general, surgical treatment is performed for improvement of thumb function. The case presented here had a TPT with pre-axial polydactyly. The TPT was well developed but it had no movement at the proximal or distal interphalangeal joints. The rudimentary thumb had a well-developed and functioning interphalangeal (IP) joint. So as an alternative surgical technique we planned to transfer the functioning IP joint of rudimentary thumb to the TPT.

A complete subperichondrial dissection technique for rhinoplasty with management of the nasal ligaments.

BACKGROUND: A complete subperichondrial and subperiosteal dissection technique during rhinoplasty may minimize soft tissue disruption, resulting in less scar tissue formation and preservation of ligamentous structures. OBJECTIVES: The authors describe their results with subperichondrial dissection of the nasal framework and manipulation of the preserved nasal ligaments. METHODS: The charts of 228 consecutive patients who underwent rhinoplasty with complete subperichondrial dissection via an open or closed approach between May 2008 and April 2011 with the senior author (BÇ) were retrospectively reviewed. Intraoperatively, the scroll ligament and Pitanguy's midline ligament were repaired to stabilize the internal valve and tip position, respectively. RESULTS: Patients in this series (182 women, 46 men) ranged in age from 18 to 54 years (mean, 24.3 years). A total of 203 procedures were primary rhinoplasties; 14 were secondary, and 11 were revisions. The open approach was used in 92 patients, whereas a closed dome delivery was used in the remaining 136 patients. Follow-up ranged from 9 months to 3 years. A complete subperichondrial dissection technique resulted in relatively limited edema and more rapid patient recovery compared with the authors' previous experience with the sub-superficial musculoaponeurotic system (SMAS) approach. Repeat elevation in the subperichondrial plane was easier and less traumatic in revision cases compared with secondary rhinoplasty cases. CONCLUSIONS: Subperichondrial dissection of the nasal framework allows reshaping and redraping of the nasal tip and controlled manipulation and repair of ligaments without disturbing the overlying soft tissue.

Concentric-needle cannula method for single-puncture arthrocentesis in temporomandibular joint disease: an inexpensive and feasible technique.

Management of temporomandibular joint (TMJ) disorders presenting with pain, restricted mouth opening, or simply asymptomatic clicking can be challenging even to the experienced surgeon. Many conservative and invasive techniques are available, but most cases can be treated by arthrocentesis of the joint locally. A simple process of joint irrigation enables lysis of intra-articular adhesions, change in the joint viscosity, and clearance of various substances in the joint fluid. Classically, arthrocentesis of the TMJ has been performed with 2 needles: an infusion needle and an aspiration needle. Various devices and techniques have been described in the literature, each with its own benefits and drawbacks. We introduce our technique of TMJ lavage using 2 different gauge needles placed in a concentric manner; hence, besides a less traumatic and easier puncture of the joint capsule, the lavage and aspiration of the joint space can be performed efficiently, with minimal morbidity. The use of a concentric-needle cannula system is the least traumatic and perhaps the most cost-effective method for TMJ lavage described to date. We believe that this technique is applicable and can be performed by even the inexperienced surgeon.

Isolated congenital partial absence of the left lower lateral nasal cartilage: case report.

Isolated congenital nasal anomalies are rare; the isolated absence of any specific nasal structure is even rarer. In this report, we present a patient with congenital isolated partial absence of the left lower lateral cartilage including only the lateral crura.