Injection of Compressed Diced Cartilage in the Correction of Secondary and Primary Rhinoplasty: A New Technique with 12 Years' Experience.

BACKGROUND: There are instances where small or large pockets are filled with diced cartilage in the nose, without use of wrapping materials. For this purpose, 1-cc commercial syringes were used. The obtained results were partial and incomplete. For better and improved results, the author designed new syringes, with two different sizes, which compress the diced cartilage for injection. METHODS: The author presents his experience accrued over the past 12 years with 2366 primary, 749 secondary, 67 cleft lip and nose, and a total of 3182 rhinoplasties, using his new syringe design, which compresses diced cartilage and injects the diced cartilages as a conglutinate mass, simulating carved costal cartilage, but a malleable one. RESULTS: In 3125 patients, the take of cartilage graft was complete (98.2 percent) and a smooth surface was obtained, giving them a natural appearance. In 21 patients (0.65 percent), there was partial resorption of cartilage. Correction was performed with touch-up surgery by reinjection of a small amount of diced cartilage. In 36 patients (1.13 percent), there was overcorrection that, 1 year later, was treated by simple rasping. CONCLUSIONS: Compared with diced cartilage wrapped with Surgicel or fascia, the amount of injected cartilage graft is predictable because it consists purely of cartilage. The injected diced cartilage, because it is compressed and becomes a conglutinated mass, resembles a wood chip and simulates carved cartilage. It is superior to carved cartilage in that it is moldable, time saving, and gives a good result with no late show or warping. The injection takes only a few minutes.

Long-Term Results and Refinement of the Turkish Delight Technique for Primary and Secondary Rhinoplasty: 25 Years of Experience.

BACKGROUND: All grafts present the potential problem of late visibility, distortion, and (occasionally) absorption. To overcome these problems and obtain a smoother surface, in 1989, the author initiated the use of finely diced cartilage wrapped in Surgicel. It is well known that the resolution of edema at the end of 1 year postoperatively is approximately 90 to 95 percent. Complete resolution continues until the end of 4 years postoperatively. However, it is important to understand what occurs beyond 4 years, and how the nose changes as the face ages. METHODS: The author presents his experience of the past 25 years on 9398 primary and secondary rhinoplasty patients treated using his personal approach, the Turkish delight. Patients with a postoperative range from 4 to 25 years were selected. RESULTS: The Turkish delight type of cartilage graft (diced cartilage wrapped in Surgicel) has been free of late show complications often experienced with other types of tip grafts. Long-term results from 4 to 25 years are very satisfactory, with an acceptably low complication rate. CONCLUSIONS: This technique is safe, reliable, effective, simple, and easily applicable by plastic surgeons at all levels of experience. Early and long-term results from 1 to 25 years are very satisfactory. The overall complication rate is very low compared with other techniques. In addition, there is no late show as is sometimes seen with other types of cartilage grafts such as crushed, oval, or rectangular grafts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Microfat Grafting in Nasal Surgery.

BACKGROUND: Injectable fillers are sometimes necessary to correct slight skin irregularities. However, there have been reports of necrosis after injection of alloplastic materials and heterogeneous transplants. On the other hand, the advantages of autogenous tissue grafts over those fillers are well established. Volumetric reshaping of the face with autologous tissue injection is a popular and reliable method with good long-term results. However, procedures performed on the fragile skin of the nose are prone to complications. OBJECTIVES: The author conducted a study of injectable autologous microfat grafting to the nose in patients with secondary nasal deformities. METHODS: During a 5-year period, 313 patients who had secondary nasal deformities with slight skin irregularities or severe nasal skin damage were treated with microfat grafting. At each patient's first injection session, excess harvested fat was cryopreserved for subsequent injection. To correct minor irregularities, 0.3 to 0.8 mL of microfat was injected during each session; for major irregularities or defects, 1 to 6 mL was required for each session. RESULTS: One to 3 injections of microfat provided satisfactory results in all patients who had minor irregularities. For patients with multiple and severe irregularities, 3 to 6 injections were necessary and resulted in high patient satisfaction. In another group of patients, with severe traumatic skin damage, 6 to 16 injections were necessary for reconstruction. After repeated injections, each patient's skin damage was repaired. CONCLUSIONS: Autologous microfat injection appears to be safe and effective for correcting slight irregularities of the nose. LEVEL OF EVIDENCE: 4.

Tip rhinoplasty in broad noses in a Turkish population: Eurasian noses.

BACKGROUND: Historically, one of the most persistent challenges to the rhinoplasty surgeon has been the thick, heavy, and poorly defined nasal tip. In the Mediterranean, Anatolian, and Middle Eastern regions, rhinoplasty is the most frequently performed aesthetic procedure. In these regions, the ethnic characteristic of the nasal tip is mostly broad with thick skin, a poorly defined nasal tip, and weak lower lateral cartilages, which makes shaping the tip challenging. In this population, conventional rhinoplasty techniques may result in dissatisfied patients and surgeons. METHODS: The author presents his experience over the past 20 years with 3800 rhinoplasty patients with broad noses treated using his personal approach. RESULTS: Using the Turkish delight type of cartilage graft (diced cartilage wrapped in Surgicel) for the tip region and the columellar strut improved the author's results considerably, giving the tip the desired form and eliminating the complications of late show seen in other types of tip grafts. In patients with very short columellae, insertion of a secondary strut was necessary after 1 year. CONCLUSIONS: : This technique is safe, reliable, effective, simple, and easily applicable by plastic surgeons at all experience levels. Early and late results are very satisfactory, and there is no late show as is sometimes seen with other types of cartilage grafts such as crushed, oval, or rectangular grafts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Percutaneous electrothrombosis: a minimally invasive technique for the treatment of deep hemangiomas.

BACKGROUND: A percutaneous electrocauterization technique for the treatment of deep hemangiomas is introduced as an alternative and minimally invasive treatment mode. METHODS: Percutaneous electrothrombosis was applied through a needle-catheter that is a small silicone catheter with a needle guide in it. Thus, it is possible to do needle-point monopolar electrocauterization only at the needle tip because of the insulation of the other parts of the needle by the silicone catheter. By retracting the needle with catheter on it during electrocauterization, electrothrombosis was achieved through and around the channel of the needle, leaving vascularized tissue areas between the channels to perfuse the skin or mucosa covering the hemangioma. RESULTS: This technique was applied as a single treatment or before surgery for the treatment of cavernous hemangiomas to more than 40 patients. However, adequate documentation was found for only 10 patients. After percutaneous electrocauterization of deep hemangiomas, discrete areas of skin necrosis appeared in some patients during the healing period, but the subsequent debridement and surgical excisions were easier because of the thrombosis effect of the technique due to the diffuse denaturation and fibrosis through and around the electrocauterization channels. The follow-up period was 1-13 years. CONCLUSION: The proposed percutaneous electrocauterization technique for the treatment of deep hemangiomas achieved four effects: (1) volume reduction, (2) bleeding reduction, (3) anesthesia time reduction, and (4) cost reduction. The technique can be defined as a minimally invasive and effective alternative treatment for deep hemangiomas.

Delayed breast reconstruction with latissimus dorsi flap.

BACKGROUND: The ideal method of breast reconstruction should be safe, reliable, and have minimal or no donor-site morbidity. We present our experience with the latissimus dorsi musculocutaneous flap for delayed breast reconstruction with immediate permanent implant insertion. METHODS: The latissimus dorsi musculocutaneous flap was performed on patients who presented for delayed breast reconstruction. From 1999 to 2007, charts of patients were reviewed for age, type of mastectomy, history of chest wall irradiation, nipple-areola complex reconstruction, and complications at both the donor site and the reconstructed breast site. RESULTS: The latissimus dorsi was used as a musculocutaneous flap in 33 patients who had breast cancer surgery. The mean age was 51.14 (range = 30-63) years. Nine patients (27%) asked for nipple-areola reconstruction. Three patients had major complications (9%), including infection, partial flap ischemia, and liponecrotic pseudocysts. Eight patients required revision. Seroma was the most common problem observed at the donor site. CONCLUSION: The latissimus dorsi flap provides adequate soft tissue with a reliable blood supply for the enhancement of missing tissue after mastectomy. It is a safe method for breast reconstruction and an excellent alternative flap for patients at high risk for abdominal flap complications.

Calf augmentation with autologous tissue injection.

BACKGROUND: Lean or asymmetric calves may cause body image problems. These deformities can be corrected by inserting a silicone calf prosthesis or silicone injection, and also through the use of an autologous fat or tissue cocktail. METHODS: Thin and asymmetric parts of the leg are marked while the patient is standing. Depressed areas are observed at the anteromedial part of the tibia from the knee to the ankle. Fat tissue harvested under general anesthesia, using a syringe and a 4-mm cannula, is centrifuged to eliminate blood and lipids, antibiotic is added, and small amounts of fat grafts are injected into different layers using a cannula 15 or 26 cm in length and 3 mm in diameter. For the preparation of the tissue cocktail, tissue (dermis, fascia, fat) was cut into very small pieces measuring 0.5 mm to be passed through 16-gauge needles. The amount injected depends on the severity of deformity and the size of the legs. Rather than overcorrecting, injections are repeated if necessary, two to four times at 3-month intervals. RESULTS: Between 1992 and 2003, 77 patients underwent calf augmentations with autologous fat and tissue cocktail injections, with follow-up from 1 to 8 years. Outcome was satisfactory in most patients, with moderate improvement in 10 patients (13 percent) and good improvement in 67 (87 percent). In 12 patients, small irregularities or asymmetries were seen after the first injection and were corrected with a second injection. No infection was reported in any case. CONCLUSION: Autologous augmentation and shaping offers scar-free, long-lasting results, with no late complications, and with the possibility of touchup.

Treatment of hypertrophic scars and keloids using intense pulsed light (IPL).

BACKGROUND: Keloids and hypertrophic scars are extremely disturbing to patients, both physically and psychologically. This study prospectively assessed the safety and efficacy of intense pulsed light (IPL) on scars originating from burns, trauma, surgery, and acne. METHODS: Hypertrophic scars in 109 patients, originating from surgical incisions (n = 55), traumatic cuts (traffic accidents) (n = 24), acne scars (n = 6), keloids (n = 5), and burns (n = 19), were treated using an IPL Quantum device. Treatment was administered at 2-4-week intervals, and patients received an average of 8 treatments (range = 6-24). Using digital photographs, Changes in scar appearance were assessed by two physicians who were blinded to the study patients and treatments. The photographs were graded on a scale of 0 to 4 (none, minimal, moderate, good, excellent) for improvement in overall clinical appearance and reduction in height, erythema, and hardness. RESULTS: An overall clinical improvement in the appearance of scars and reductions in height, erythema, and hardness were seen in the majority of the patients (92.5%). Improvement was excellent in 31.2% of the patients, good in 25.7%, moderate in 34%, and minimal in 9.1%. Over half the patients had good or excellent improvement. In the preventive IPL treatment group, 65% had good to excellent improvement in clinical appearance. Patient satisfaction was very high. CONCLUSION: This study suggests that IPL is effective not only in improving the appearance of hypertrophic scars and keloids regardless of their origin, but also in reducing the height, redness, and hardness of scars.

Block and Surgicel-wrapped diced solvent-preserved costal cartilage homograft application for nasal augmentation.

BACKGROUND: Cartilage grafting has been used extensively to correct the nasal framework in traumatic and postrhinoplasty nasal deformities. Autologous cartilage grafts yield satisfactory reconstructive results, but their use is limited by donor-site morbidity, patient choice, the requirement for increased operative time, and the lack of a sufficient quantity and availability of tissue for more extensive deformities. Alternatively, preserved costal cartilage homograft represents a readily available, easily contoured material. METHODS: The preserved costal cartilage homograft has been used by the authors on 68 patients over the past 5 years: in 52 patients with postrhinoplasty deformity and in 16 patients with traumatic nasal deformity. In cases with more severe nasal depression, the cartilage graft was carved and placed over the remaining septum in block form. The "Turkish Delight" technique, which was initially described by Erol, was used in cases of mild to moderate nasal depression. The cartilage graft was diced into 0.5- to 1-mm pieces. The diced cartilage mass was then wrapped in Surgicel and inserted under the dorsal nasal skin. RESULTS: Follow-up ranged from 6 months to 5 years. During this period, no major complications were noted, and satisfactory results were obtained. Recurrence of the dorsal depression was seen in five patients and required repeated augmentation. The complication and revision rates were acceptable. CONCLUSIONS: This technique seems to be effective for augmentation of the nose, shortens the operative time significantly by eliminating graft harvest, and avoids donor-site morbidity. Therefore, it is recommended for nasal augmentation and contouring for traumatic and postrhinoplasty nasal deformities.

Augmentation mentoplasty using a custom-design wire cage.

Mentoplasty is often a complimentary procedure to rhinoplasty. At least 25% of all rhinoplasty patients may need a chin implant to balance facial features better. Augmentation mentoplasty using alloplastic implants such as silicone, rubber, or other materials provides a simple approach to the treatment of the hypoplastic chin. Although these types of implants are readily available in developed countries, there are parts of the world where they are unavailable or quite expensive. The authors have developed a chin implant made of wire that is available throughout the world and is custom designed to the mentum of the patient after a cephalometric evaluation. This technique has been used in 125 patients along with rhinoplasty over the last 20 years at our institution. In an initial series of 8 patients, the prosthesis became displaced and was removed in 2 patients. Since then, a new radiographic technique has been developed to demonstrate the shape of the mentum before surgery and new bone formation after surgery. By using this special radiographic technique, it was possible to detect four types of mentum before surgery and to construct a custom-design wire cage according to this shape. The prosthesis is constructed by an orthodontist according to the cephalometric measurements and shape of the mentum. By using the buccal approach, a pocket is prepared subperiosteally and a wire cage is inserted. In the last 20 cases, the wire cage was filled with diced cartilage wrapped with Surgicel. The results were esthetically satisfactory in most patients. After the shape of the wire prosthesis was modified to conform to the shape of the underlying bone better, no displacement of the prosthesis has been experienced. In 3 patients, it was necessary to remove the prosthesis when new tissue formation began to fill the prosthesis. These specimens were examined histologically, and the regenerating tissue was found to be connective tissue with a thin layer of bone formation. Most patients could be followed up for only 3 to 12 years. In all patients, the results have been consistent and the procedure has been safe.