Rhinoplasty Dissection Planes (Subcutaneous, Sub-SMAS, Supra-perichondral, and Sub-perichondral) and Soft Tissues Management.

Rhinoplasty as an operation is akin to a game of chess, where every maneuver will influence the eventual outcome. Undoubtedly, more than one approach to the nasal soft tissues envelop can produce beautiful and safe results as will be described in the paper namely, the subcutaneous, sub-superficial musculoaponeurotic system, supra- and sub-perichondral planes. For different justifiable reasons surgeons have their preferences, regarding dissection planes on the tip, middle and upper thirds, and regarding the manipulation of the soft tissue layers and nasal ligaments. The concept of the nasal layers and the presence of relevant ligamentous structures and how to restore them in an anatomical fashion, will help to understand the logic behind various approaches.

The effect of adipose derived stromal vascular fraction on stasis zone in an experimental burn model.

BACKGROUND: Stasis zone is the surrounding area of the coagulation zone which is an important part determining the extent of the necrosis in burn patients. In our study we aim to salvage the stasis zone by injecting adipose derived stromal vascular fraction (ADSVF). METHODS: Thermal injury was applied on dorsum of Sprague-Dawley rats (n=20) by the "comb burn" model as described previously. When the burn injury was established on Sprague-Dawley rats (30min); rat dorsum was separated into 2 equal parts consisting of 4 burn zones (3 stasis zone) on each pair. ADSVF cells harvested from inguinal fat pads of Sprague-Dawley rats (n=5) were injected on the right side while same amount of phosphate buffered saline (PBS) injected on the left side of the same animal. One week later, average vital tissue on the statis zone was determined by macroscopy, angiography and microscopy. Vascular density, inflammatory cell density, gradient of fibrosis and epithelial thickness were determined via immunohistochemical assay. RESULTS: Macroscopic stasis zone tissue viability (32±3.28%, 57±4.28%) (p<0.01), average number of vessels (10.28±1.28, 19.43±1.72) (p<0.01), capillary count (15.67±1.97, 25.35±2.15) (p<0.01) vascular density (1.55±0.38, 2.14±0.45) (p<0.01) epithelial thickness (0.014±0.009mm, 0.024±0.0011mm) were higher on ADSVF side. Fibrosis gradient (1.87±0.51, 1.50±0.43) (p<0.01) and inflammatory cell density (1.33±0.40, 1.20±0.32) (p<0.01) were higher on the PBS side. CONCLUSION: Macroscopic and microscopic findings determined that ADSVF has a statistically significant benefit for salvaging stasis zone on acute burn injuries.

Anterior superficial temporal artery island flap: intraoral defect repair.

UNLABELLED: There are many options for the repair of intraoral defects. Today, free radial forearm or anterolateral thigh perforator flap is the first choice for the repair of intraoral defects. However, the importance of regional flaps is still maintained for patients whose medical condition is inappropriate for a long surgery and anesthesia time. In this report, we present our clinical experience with 9 patients who underwent retromolar trigone, buccal mucosal, gingival, and mouth floor reconstruction with anterior superficial temporal artery island flap (ASTIF) which has not been described in the literature before. Their mean age is 49 (27-85) years. ASTIF dimensions used for the reconstructions ranged from 3 × 5 to 8 × 16 cm. No partial or total flap necrosis was seen in any of the patients; only 3 patients had venous congestion problem for the first 3 days of the surgery, but they all healed well. Five patients had squamous cell carcinoma, 2 patients had squamous cell carcinoma with local recurrence, 1 patient had adenocarcinoma, and 1 patient had mandibular osteocarcinoma. Patients were followed for a minimum of 6 months postoperatively (average 12 months, range 6 to 24 months). ASTIF provides an excellent alternative for reconstructing defects of the oral cavity for some patients who have significant comorbid conditions or specific contraindications to free tissue transfer. At the same time, the combination with the free flaps increases the success of the restoration. LEVEL OF EVIDENCE: Level IV therapeutic study.

Suction-assisted liposuction with a y-connector.

UNLABELLED: Liposuction appears to be one of the simplest aesthetic techniques to date, and its popularity has spread worldwide. The authors have been using a Y-connector that enables two plastic surgeons to work at the same with the same suction-assisted liposuction (SAL) machine. For 12 patients whose liposuction procedures were performed using one-cannula SAL, the mean surgical time was 114 ± 10.8 min, whereas for 11 patients whose liposuction procedures were performed with Y-connector SAL, the mean surgical time was 62 ± 7.8 min. This difference between the two groups is statistically significant (p < 0.05). The authors believe the Y-connector may be a less tiring alternative for plastic surgeons who still think SAL is the gold standard for liposuction. 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 .

Comparison of autogenous cartilage, acellular dermis, and solvent-dehydrated pericardium for the prevention and correction of dorsal nasal irregularities: an experimental study.

BACKGROUND: Numerous materials have been used for the correction and prevention of dorsal nasal irregularities. Experimental and clinical studies have been useful but have provided insufficient results for several reasons, including the impossibility of obtaining pathologic specimens from aesthetic patients and imprecise experimental models. In this study, an experimental model for rhinoplasty is used for the comparative evaluation of solvent-dehydrated pericardium, acellular dermal matrix, and autogenous ear cartilage as onlay grafts for the prevention and correction of nasal dorsal irregularities. We used an experimental rabbit rhinoplasty model that has a human nose-like osteocartilaginous junction. Thus, our goal is to get a more realistic idea about the features of these three materials. METHODS: Thirty New Zealand rabbits weighing 2,100-2,550 g were used. The noses of the rabbits were evaluated with computerized tomographic measurements, "pinch" tests were performed for skin properties, and all were photographed before the surgical procedures. They were divided into three groups: Autogenous cartilage grafts were applied after the rhinoplasty operation in group 1, acellular dermal matrixes were used after the rhinoplasty in group 2, and pericardium allografts were used after the rhinoplasty in group 3. The rabbits were followed up for 4 months before they were evaluated by photography, computerized tomography, and "pinch" tests for the skin properties of the nose. Then they were killed for histopathologic evaluation. Adhesion and resorption rates of the onlay grafts were observed and subdermal thickness measurements were made to determine the fate of the grafts as well as their effects on the overlying skin. RESULTS: The major advantages of the allografts used in groups 2 and 3 are the ease of obtaining them without any donor site morbidity, shorter operative procedures, and lower distortion rates due to lack of cartilage memory. The results of this study conform to those of previous reports and demonstrate that the used allografts had no adverse effects such as ulceration or extrusion. The evaluation of the internal nasal valve angles before and after the surgical interventions showed that cartilage grafts created a spreader effect as expected, but acellular dermis and solvent-dehydrated pericardium did not. Despite a moderate graft reaction, pericardium or acellular dermis remained intact. None of the materials caused adhesion to the overlying skin. CONCLUSION: The results of this experimental study showed that acellular dermis (AlloDerm®) or solvent-dehydrated pericardium (Tutogen) may be used successfully as an "onlay" graft for dorsal nasal problems compared to autogenous cartilage, which is commonly used for this purpose. There has been more cartilage resorption than thought. This should be considered when overcorrection is performed. LEVEL OF EVIDENCE III: 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 at www.springer.com/00266.