Comparative Analysis and Long-Term Results of Various Septal Extension Graft Types.

Shape, tip projection, and position can be controlled by the use of septal extension grafts (SEG). A retrospective cohort study of patients undergoing primary and secondary rhinoplasty was reviewed. The purpose of this study was to analyze maintenance of nasal length, dorsal length, and nasolabial angle postoperatively comparing different types of SEG using standardized photography and digital measurement. Two-hundred twenty-one patients undergoing rhinoplasty were included. There was a statistically significant change regarding the nasolabial angle during the time of follow-up decreasing from 97.53 to 95.30 degrees. No changes could be found in dorsal and nasal length. There was no significant difference among the techniques used to fixate the SEG. The nasolabial angle appeared to decrease from the position 2 weeks postoperatively without changes in the dorsal and nasal length. This means that the decrease in the nasolabial angle depends on the swelling effect and not on drooping of the tip confirming the reliability of SEG over time.

[Faults and failure: aesthetic rhinoplasty plus brow, eyelid and conchal surgery]. / Fehler und Gefahren: Die ästhetische Rhinoplastik sowie Brauen-, Lid- und -Ohrmuschelkorrektur.

Within the last years aesthetic surgery enjoys greater popularity and acceptance. One of the most frequently asked operations has been the aesthetic rhinoplasty. Hardly any other field of surgery is exposed to such a critical analysis than aesthetic rhinoplasty because the results are so obvious. According to the "International Society of Aesthetic Surgery" (ISAPS) over 980 000 cosmetic rhinoplasties have been performed in 2010. This corresponds to 10.4% of all registered aesthetic procedures worldwide. Complications can not be eliminated in such a large number of nasal operations. Up to 15% of all patients re-consult a doctor for a revision because they are dissatisfied with their final rhinoplasty result. Findings of the tip followed by functional problems and irregularities of the nasal dorsum are named most frequently. The responsible rhinosurgeon has to regard all anatomical and physiological details and to consider ethical and psychological aspects in the preselection and postoperative care of the patient. Aesthetic surgeons should be acquainted with terms and definitions like body image, dysmorphophobia or Thersites complex. Acronyms, like "SIMON" or "SYLVIA", support the physician additionally to analyze and assess the patient. The following article describes the most frequent faults, complications and pitfalls after aesthetic rhinoplasty listed by the anatomical structure. Results will be analyzed, strategies and techniques will be suggested to correct the faults and to prevent them in the future. Furthermore psychologic, social and psychiatric aspects will be discussed and handling with aesthetic patients explained.

[Blepharoplasty and eyebrow lifting]. / Blepharoplastik und Brauenlift.

Upper eyelid blepharoplasty is one of the most common procedures in facial plastic surgery (in 2011 second place in the annual statistics of the American Association of Facial Plastic and Reconstructive Surgeons, AAFPRS). Nowadays, a simple resection of the excess skin is ineffectual if the aim is to achieve an optimal functional and aesthetic result. According to the treatment of the upper eyelid the surgeon has to examine and possibly treat the position of the eyebrow in order to correctly estimate the amount of excess skin of the eyelid. This article presents the state of the art techniques of surgical correction of dermatochalasis of the upper eyelids and eyebrow ptosis and clinical examples are demonstrated.

[Modern face lift surgery]. / Faceliftchirurgie heute.

Face lift surgery is generally considered the classical surgical procedure of plastic surgery. This is an extensive operation which has undergone a huge development since its first implementation more than 100 years ago. What began as a simple skin tightening procedure is today a sophisticated and complex technique which ideally combines different treatment methods planned with surgical precision. This article provides an overview of the history of the procedure to the present state of the art concept of pairing biplanar and bivectorial face-neck lifts with autologous fat transfer and dermabrasion.

[The sliding technique : a precise method for treating the overprojected nasal tip]. / Die Sliding-Technik : Eine präzise Methode zur Korrektur der überprojizierten Nasenspitze.

BACKGROUND: The aim of the present report is to demonstrate the sliding technique as a reliable and exact method to treat the overprojected nasal tip. METHODS: Between March 2003 and April 2008 we treated 271 patients (198 females, 73 males) using the sliding technique for isolated tip hypertrophy (n=88), rhinomegaly (n=146), asymmetry of the nasal tip (n=29) and ptosis with malformation of the alar cartilages (n=8). RESULTS: Medial sliding was performed in 100 patients, lateral sliding in 121 patients, and combined lateral and medial sliding in 12 patients. In total, 18 patients needed additional skin resection at the columella. After an average follow-up period of 8.4 months 77.1% of the patients (n=209) rated the result as "very good", 21.1% (n=57) as"good" and 1.8% (n=5) patients were"unsatisfied". Only 1.8% (n=5) had to be revised due to nasal tip projection. A retrospective study of our first 80 patients showed an average reduction in projection of around 11%. CONCLUSION: The sliding technique is a precise and effective method to treat the overprojected nasal tip.

[Overresection of the lower lateral cartilage. A frequent cause for revision rhinoplasty]. / Ausgedehnte Resektion der Flügelknorpel. Häufige Ursache für Revisionen nach Rhinoplastiken.

BACKGROUND: Overresection of the lower lateral cartilages to narrow the tip may give rise to a dysfunction of the external nasal valve and aesthetic deformities like alar pinching, alar retraction, tip asymmetry, lack of tip definition and projection, leading to parrot beak deformities resulting from drooping of the tip. PATIENTS AND METHODS: Between 1998 and March 2008 we performed 1670 secondary rhinoplasties on patients who had undergone previous surgery elsewhere. The lower lateral cartilages where found to be missing in 89 patients intraoperatively. It was necessary to rebuild the structure of the nasal framework in order to resolve the deformities. We prefer to use septal cartilage or, if unavailable, costal or auricular cartilage. The deformities were analysed pre- and postoperatively by the operator based on clinical evaluation and standardised photographs. Patient satisfaction was evaluated subjectively. RESULTS: The postoperative results as judged by the surgeon showed a clear improvement in tip definition (100%) and projection (100%), alar pinching (100%), tip deformities (95.2%), tip deviation (77.8%) alar retraction (87.5%) and tip ptosis (85.7%). The function of the external nasal valve as evaluated by the surgeon was completely restored in all cases (100%). The average follow-up period was 13 months. In all, 50 patients (59.6%) stated that the result was "excellent", 28 (33.3%) as "very good", five (5.9%) as "good" and one as "not satisfied" (1.2%). CONCLUSION: In the case of destroyed anatomical structures we completely rebuild the structure of the nasal tip, since only a correct anatomical configuration correlates with ideal aesthetics and physiological function.

[Principles of nasal defect repair]. / Prinzipien der Deckung von Nasendefekten.

The repair of nasal defects is a frequent challenge to facial plastic surgeons, mainly due to the high frequency of basal cell carcinomas. In general, small defects of up to 1 cm in diameter may be closed directly, whereas larger defects of up to 2.5 cm require the use of local flaps. For more extended defects, regional flaps such as the paramedian forehead flap are the method of choice. These rules have to be modified for the nasal tip, the alar region, the columella and the vestibulum where free skin grafts and auricular composite grafts have to be considered. In order to achieve pleasing aesthetic results, the aesthetic subunits of the nose have to be respected in each situation.

[Form stability after ear correction using the anterior scoring technique: a prospective study to compare anterior and the posterior approaches]. / Die Konturstabilität nach Otapostasiskorrektur durch anteriore Ritztechnik: Eine prospektive Vergleichsstudie von anteriorem und posteriorem Zugang.

BACKGROUND: Protruding ears are usually caused by an overdeveloped concha and the lack of an anthelical fold. To reconstruct this fold, we applied the open anterior cartilage scoring technique. There are two different approaches for this technique, anterior access or posterior access. We have used the latter for years. After finding some minor partial relapses, we started a prospective study to compare the objective results of both techniques. PATIENTS AND METHOD: Forty patients underwent surgery (20 with anterior access and 20 with posterior access). The position of the ear to the head, which was defined by several standardized points of the ear (distance between the helical rim and the mastoid), was measured preoperatively, 3 weeks postoperatively after removing the anchoring splint sutures, and 3 months postoperatively. RESULTS: The differences between the measurements in the third week and third month show postoperative stability. CONCLUSIONS: We could achieve the same stability using both techniques, but obtained more symmetrical results with posterior access.

Tragal cartilage grafts in aesthetic rhinoplasty.

Ear cartilage is an important source of grafts for rhinoplasty. The majority of cartilage grafts is harvested from the concha of the ear. We describe indications in which the tragal cartilage is a more favorable graft source than conchal cartilage. The technique is fast, simple, and does not require special dressings.

[20 years' experience with extracorporal septoplasty]. / Zwanzig Jahre Erfahrung mit der extrakorporalen Septumkorrektur.

Even today the difficult septum presents a surgical problem. A severe septum deformity is caused mostly by an accident or is seen in patients with malformation like CLP-deformity. It is characterized by a massive deformation in all levels with a consecutive blocking of one or both airways. Such severe septal deformities cannot be corrected properly by classical septoplasty techniques. Therefore we suggest an extracorporal septoplasty, where the whole septum is taken out and by different techniques a new septal plate is reconstructed and then replanted. From 1981 to 2001 we operated 1855 patients and improved this method constantly, especially the safe septal fixation after replantation. Follow-ups showed that even in severe deformities a revision rate of only 5 % respectively 7 % was found. Therefore we conclude the extracorporal septoplasty with its refinements can also be recommended also to the less experienced rhinosurgeon.

Single-stage defect repair with latissimus dorsi free flap after extensive resection of terebrant ulcer of the head: three case reports.

Three cases of advanced ulcerating basal cell carcinoma (terebrant ulcer or ulcus terebrans) of the head are reported. Neglected basaliomas had deeply destroyed larger parts of the skull in three women ages 78, 69, and 65 years when the patients were first admitted for treatment. Death due to meningitis, hemorrhage, or brain damage was imminent. Wide resection and coverage by free latissimus dorsi flaps was carried out in single-stage procedures. The latissimus dorsi, a versatile and very reliable free flap with its constant vascular anatomy and long pedicle, is the ideal flap for the coverage of large defects on the head. The donor site can usually be closed primarily, and the functional deficit is acceptable. All three patients recovered completely. Although only palliative resection could be achieved, the procedures could be justified by the increased survival time and gain in quality of life.

[The value of various techniques for esthetic correction of the lower eyelid]. / Die Wertigkeit verschiedener Techniken zur ästhetischen Unterlidkorrektur.

Blepharoplasties are amongst the most commonly performed aesthetic procedures. Various lower blepharoplasty techniques have been described in the literature. Often, value and appropriate indication for each individual technique have not been sufficiently delineated. The recent renaissance of the transconjunctival blepharoplasty allowed the evolution of new and safe procedures for correction of the lower lid. Additionally, the technique of resection of the herniated orbital fat underwent certain improvements. The aim of this article is to describe the currently utilized surgical techniques and to discuss their indications.

Stenosis of the nasal vestibule and its treatment.

From our own experience and a review of the literature, we present a few techniques which, in our eyes, give the surgeon the possibility to treat most encountered cases of stenosis of the nasal vestibule. During 1991 to 1998 the author in Stuttgart (W.G.) performed simple z-plasty combined with local flaps in 6 patients and composite grafts only in 12 cases, to correct nasal vestibule stenosis. The author in Lausanne (R.M.), who first described the paranasal myocutaneous flap to correct not only nasal vestibule stenosis but also alar base malposition has treated over 50 patients with this technique and with composite grafts during the last 20 years.

[Clinical aspects and therapy of benign symmetrical lipomatosis--Madelung disease]. / Klinik und Therapie der benignen symmetrischen Lipomatose--Morbus Madelung.

The clinical picture, diagnosis, therapy, and theories on the etiology of benign symmetric lipomatosis (Madelung disease) are outlined. Personal experience from 62 operations on 28 patients is compared to the literature. Up to now, there is only palliative surgical treatment for this sporadically appearing disease of unknown etiology. Liposuction--a less traumatic treatment--has considerably facilitated the treatment of the circumscribed fatty hyperplasias. The surgical characteristics of different anatomical regions are pointed out.

[Orthotopic cartilage transplantation. Morphologic, angiography and histochemical studies of the vitality of free septum transplants]. / Die orthotope Knorpeltransplantation. Morphologische, angiographische und histochemische Untersuchungen zur Vitalität freier Septumtransplantate.

Orthotopic cartilage transplantation is a technique frequently used in modern septal surgery. The prerequisite for a stable long-term result is viability of the transplanted cartilage. Therefore, we studied the healing process histologically, angiographically, and histochemically. We found a characteristic picture. Due to chondronal structure of the cartilage, the healing process varied in time and location. Reintegration took place by chondroneogenesis, commencing at the inner perichondrium. Reintegration depended directly on the distance of the cartilage cells to the surrounding vessels. Histochemically, we found an intact respiratory chain in the mitochondria and thus, we were able to demonstrate the preservation of viability in orthotopic transplanted cartilage.

[Tripier bridge flap technique for lower eyelid reconstruction]. / Die Brückenlappentechnik nach Tripier zur Unterlidrekonstruktion.

Defects of the lower lid are more common than defects of the upper lid. Various methods for reconstruction of the lower lid have been published; we prefer the method of Tripier. The inner lining is reconstructed using a composite graft from the nose, and the outer defect is covered by a myocutaneous bridge flap from the upper lid. We have used this technique for defects of different sizes and have obtained good functional and aesthetic results.

Refinements in extracorporal septoplasty.

Septal deviations interfere with nasal airflow and contribute to deformities in the external appearance of the nose. An aesthetically and functionally satisfactory correction of severe septal deformities or "crippled" septal plates often requires a temporary intraoperative removal of the septal cartilage for appropriate remodeling. This article describes refinements to the previously described technique of extracorporal septoplasty; these refinements have proven useful and have made the procedure safer in the hands of less experienced surgeons. The refinements simplify the straightening methods for the explanted septal plate, achieving a stable and median fixation of the replanted septum while maintaining a satisfactory contour of the nasal dorsum. A milling cutter is used to straighten the irregularities of the explanted septal plate and to thin broadly based anterior nasal spines. When necessary, microplates are added to stabilize the osteotomized and medialized anterior nasal spine. The final positioning of the replanted septal plate is greatly enhanced by a rein stitch, transosseous sutures, and multiple quilt stitches. Additionally, direct fixation of the replanted septum to the edges of the upper lateral cartilages further improves the stability of the reconstruction. Finally, particular care should be taken to avoid residual irregularities of the nasal dorsum; it they occur, these irregularities can be covered with a thin cartilaginous splint or a layer of dehydrated fascia lata or autologous temporal fascia. A total of 436 patients who underwent rhinoseptoplasties at the authors' department during a 1-year period were reviewed. Of these patients, 108 presented with severe septal deviations and underwent an extracorporal septoplasty using the refined techniques described herein. Despite the complexity of the procedure, the patients' satisfaction rates were high, independent of the operating surgeon.

The relevance of extracorporeal septoplasty in cleft nose correction.

The aim of this paper is to delineate the importance of the correction of the nasal septum when attempting to improve the nasal shape and function in patients with cleft lip and palate (CLP) deformity. The particular problems of the nasal shape in CLP patients are assessed. Various approaches for adequate correction are reviewed and discussed. The method of extracorporeal septoplasty is presented in detail. This method was used between 1982 and 1997 in 141 out of 332 CLP patients who required septoplasties and appears particularly suited for this purpose since it offers the possibility of reconstructing an almost normal septum. This is necessary in order to achieve both a functionally and an aesthetically good result. Our experience over the past 16 years confirms the advantages of this approach.

The triple swing flap technique to correct the asymmetry of unilateral cleft lip nose deformities.

The correction of a nasal deformity is a decisive step in the secondary treatment of patients with cleft lip and palate. The complex nasal deformity in these patients is caused partly by the anormaly itself and is partly a result of previous corrective surgery. Correcting the nasal deformity involves solving four complex problems: the septal deformity; the malposition of the exterior nose; the deformity of the nasal tip; and the deviation of the ala on the cleft side. The stigma of the patients with a cleft is sustained mainly by the asymmetry of the nasal entrances. Many operations, some of which cause extensive additional scarring, have been suggested for removing this typical feature in patients with clefts. We developed a triple swinging flap technique which has proved successful when used with an open as well as a closed approach. This also enables us to achieve symmetry of the nostrils.