Alar rim deformities.

Alar disharmony is one of the most common abnormalities observed after a rhinoplasty. This article describes three classes in addition to Gunter's classifications of alar/columella deformities, which include concave ala, convex ala caused by convex lateral crus, and convex ala caused by thick alar tissues. These deformities are best visualized from the basilar view. The different surgical techniques for correction of true alar abnormalities are presented. The alar convexity, when it is the result of a misshapen cartilage, is corrected using a lateral crura spanning suture, posterior transection of the lateral crura, or transdomal suture. A thick ala, resulting in convexity, can be thinned through either a direct incision on the ala or an incision in the alar base. A lateral crura strut, an onlay graft, or a rim graft eliminates the concavity. For a slight retraction, an alar rim cartilage graft is an optimal choice. For significant alar retractions, the author's preferred technique is an internal V-to-Y advancement, which is described in detail. An elliptical excision of the alar lining will effectively correct the hanging ala. These techniques have been used to correct alar disharmonies on 58 patients. One patient from the V-Y advancement group exhibited a small area of alar necrosis, and two early patients demonstrated an overcorrection; all were easily resolved with revision surgery. By carefully identifying nasal base and alar abnormalities, harmony can be established to correct an undesirable appearance.

Corrugator supercilii muscle resection and migraine headaches.

This study was conducted to determine whether there is an association between the removal of the corrugator supercilii muscle and the elimination or significant improvement of migraine headaches. Questionnaires were sent to 314 consecutive patients who had undergone corrugator supercilii muscle resection during endoscopic, transpalpebral, or open forehead rejuvenation procedures. The patients were queried as to whether they had a history of migraine headaches and, if so, whether the headaches significantly improved or disappeared after surgery. If the answer was affirmative, then the patients were further questioned about the duration of the improvement or cessation of the headaches and the relationship to the timing of the surgery. After an initial evaluation of the completed questionnaires, a telephone interview was conducted to confirm the initial answers and to obtain further information necessary to ensure that the patients had a proper diagnosis based on the International Headache Society criteria for migraine headaches. The charts of the patients who had migraine headaches were studied to ascertain and classify the type of surgery they had undergone. Patient demographics were reviewed, and the results were statistically analyzed. Of the 314 patients, 265 (84.4 percent) either responded to the questionnaire, were interviewed, or both responded to the questionnaire and were interviewed. Of this group, 16 patients were excluded because of the provision of insufficient information to meet the International Headache Society criteria, the presence of organic problems, and other exclusions mandated by study design. Thirty-nine (15.7 percent) of the remaining 249 patients had migraine headaches that fulfilled the Society criteria. Thirty-one of the 39 (79.5 percent) with preoperative migraine noted elimination or improvement in migraine headaches immediately after surgery (p < 0.0001; McNemar), and the benefits lasted over a mean follow-up period of 47 months. When the respondents with a positive history of migraine headaches were further divided, 16 patients (p < 0.0001; McNemar) noticed improvement over a mean follow-up period of 47 months, and 15 (p < 0.0001; McNemar) experienced total elimination of their migraine headaches over a mean follow-up period of 46.5 months. When divided by migraine headache type, 29 patients (74 percent) had nonaura migraine headaches. Of these patients, the headaches disappeared in 11 patients, improved in 13 patients, and did not change in five patients (p < 0.0001). Ten patients experienced aura-type headaches, which disappeared or improved in seven of the patients and did not change in three of the patients (p < 0.0001). This study proves for the first time that there is indeed a strong correlation between the removal of the corrugator supercilii muscle and the elimination or significant improvement of migraine headaches.

Dynamics in rhinoplasty.

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the results revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on frontal view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.

Supratip deformity: a closer look.

Supratip deformity, a hallmark of a poorly executed rhinoplasty or an inauspicious healing, continues to plague the novice often and the experts on occasion. A clinical and histopathologic study was conducted to search for the surgical causes of this deformity and its histologic presentation. An organized, logical management program was then developed. Clinically, supratip fullness was observed in both primary (26 of 298 patients; 9 percent) and secondary (40 of 112 patients; 36 percent) rhinoplasty candidates. In primary patients, the deformity was the result of inadequate tip projection (pseudodeformity), an overprojected caudal dorsum, a combination of both, or cephalically oriented lower lateral cartilages. In secondary patients, the deformity was caused by an underresected or overresected caudal dorsum, overresected midvault, underprojected tip (pseudodeformity), or a combination of some of these factors. The histopathologic evaluation demonstrated significant fibrosis in the supratip soft tissue of 14 of 16 patients undergoing secondary rhinoplasty without the injection of triamcinolone acetonide and in only 13 of 23 patients who underwent primary rhinoplasty (p<0.05). A supratip deformity can be eschewed by proper resection of the caudal dorsum, avoidance of dead space, restoration of adequate projection to the nasal tip, and an approximation of the supratip subcutaneous tissue to the underlying cartilage using a supratip suture, hence eliminating the dead space. If the problem is noted shortly after surgery, in the presence of collapsible consistency of the supratip tissue and adequate projection, the treatment is taping the supratip tissue as often as it is practical. If no favorable response is elicited in 6 to 8 weeks, thejudicious injection of a small amount of triamcinolone acetonide (0.2 to 0.4 cc of 20 mg/cc) in the deep subcutaneous tissue (not in the dermis) is done. The injection is repeated in 4-week intervals until the desired effect is achieved. If supratip fullness is the consequence of inadequate cartilage resection or inadequate tip projection, surgical correction is needed. The recalcitrant soft-tissue excess in the supratip area is resected, and the subcutaneous soft tissue is approximated to the underlying cartilage. If the dorsum was previously overresected, a cartilage graft to the caudal dorsum or midvault will create an optimal dorsal frame and reduce the potential for a recurrent supratip deformity.

Shortening of the long forehead.

A long forehead disrupts the harmony among the facial components and may contribute to the semblance of facial aging. Slight forehead length disharmony on a senescent face can be corrected by placing the incision at the hairline, elevating the eyebrows through subcutaneous or subgaleal dissection, and removing excess skin without posterior scalp immobilization. For moderate to major reduction of the forehead length, the scalp is elevated back to the occipital region through a pretrichial incision, and relaxation incisions are made at a right angle to the vector of advancement. The entire scalp is then repositioned anteriorly, advancing the hairline caudally and shortening the forehead. Retraction of the scalp or excessive elevation of the eyebrows is prevented by anchoring the galeal fascia to the cranial bone using a bone-tunneling technique in one to three rows. The number of fixation rows is commensurate to the amount of advancement and rigidity of the scalp. The more immobile the scalp preoperatively, the more relaxation incisions and fixation tunnels are necessary. Following caudal repositioning of the scalp, the non-hair-bearing skin is excised, and a meticulous repair is done. These procedures have been performed in 180 patients with a high degree of satisfaction. Temporary hair loss was experienced in one smoker who underwent the most advancement through posterior scalp elevation and continued to smoke postoperatively. Also, on three patients in the subcutaneous forehead rhytidectomy group, two of whom were smokers, delayed healing was observed in the temple area because of compromised circulation requiring secondary revision.

A practical classification of septonasal deviation and an effective guide to septal surgery.

The conventional designation of septal pathology is a deviated septum, and the common treatment of choice is submucous resection of the septum. These limited generic terms leave the surgery open to frequent failure and render the education of this topic suboptimal. During 1224 septal surgeries, we have observed six different categories of septal deviation requiring different surgical treatments. A study was conducted to investigate the frequency of different classes of septal deviation and to develop guidelines for a more successful surgical correction of each category. Ninety-three consecutive patients who underwent septoplasty were carefully evaluated for the type of septal deformity, age, gender, history of trauma, and previous septal surgery. The surgical technique was reviewed for each category of the septal deformity. Of the 93 patients, 71 were women and 22 were men. Ages ranged from 13 to 76, with an average age of 31.5. Most patients exhibited a "septal tilt" deformity (40 percent; 37 of 93) or a C-shape anteroposterior deviation (32 percent; 30 of 93). The other deformities were C-shape cephalocaudal (4 percent; 4 of 93), S-shape anteroposterior (9 percent; 8 of 93), S-shape cephalocaudal (1 percent; 1 of 93), or localized deviations or large spurs (14 percent; 13 of 93). Each of the six categories of septal deviation requires specific management. If a single procedure is selected for all of the septal deformities, disappointing results may ensue.

Upper lateral splay graft.

Middle vault collapse narrows the internal nasal valve and impairs airflow through the nose. Loss of structural integrity of the upper lateral cartilaginous vault, the cause of the middle vault collapse, is classically corrected by inserting anterior spreader grafts, resulting in variable success. The desire to reconstruct the natural "T" of the upper lateral and septal cartilages culminated in the development of the upper lateral splay graft. The splay graft spans the dorsal septum but is deep to the left and right upper lateral cartilages. The intrinsic spring in the splay graft elevates each upper lateral cartilage with the septum as the fulcrum, thus correcting the middle vault collapse and opening the internal valve. The procedure, a physiologic substitute for the device "Breathe Right" applied externally, has been performed on nine patients and proved to be a prodigious functional boon to all of them. The powerful splay effect, however, can result in excessive widening of the caudal portion of the dorsum with imprudent use of the technique. Two case reports illustrate the subjective and objective improvement that was shared in all but one patient. Excess widening in one patient resulted in a suboptimal aesthetic improvement, although the functional objectives were met. Identification of suitable patients, preoperative assessment, choice of cartilage donor site, and the surgical technique are discussed. Improved internal valve function, predictability, and reliability are some of the distinct advantages of using a splay graft.

Nasal osteotomy and airway changes.

The purpose of this prospective investigation was to evaluate the factors involved in the constricting effect of nasal bone osteotomy on the nasal airway. Immediately before the osteotomy, observations were made and recorded in regard to both the position of the inferior turbinates and the length of the nasal bones. During the osteotomy, the nasal bone movement was graded and the type of osteotomy was documented. The two types of osteotomy were defined as either high-to-low or low-to-low. Each side of the nose was assessed independently. Forty-eight consecutive patients, 8 men and 40 women, were included in this study, providing 96 nasal sides for evaluation. There were 42 normal, 32 short, and 22 long nasal bones. The patients with short nasal bones exhibited less diminution in the airway than those patients with normal nasal bones (p < 0.05). The position of the inferior turbinates was designated as anterior in 48 sites, 12 were considered normal, and 28 were deemed posterior. The narrowing of the airway was significant when the inferior turbinates were positioned anteriorly when compared with posteriorly positioned inferior turbinates (p < 0.05). Twenty-four nasal bones were shifted slightly, 48 intermediately, and 22 significantly. Major nasal airway constriction was observed when the medial positioning of the nasal bone was significant (p < 0.05). Eighty-four osteotomies were classified as low-to-low, and 12 were high-to-low. High-to-low osteotomies resulted in the least narrowing of the nasal passage (p < 0.005). It is concluded from this study that the nasal osteotomy does constrict the nasal airway in most incidences. The length of the nasal bones, the degree of nasal bone repositioning, the position of the inferior turbinates, and the type of osteotomy are definite factors contributing to airway narrowing after nasal bone osteotomy.

Footplates of the medial crura.

The purpose of this combined prospective and retrospective study was to review the abnormalities of the footplates of the medial crura, their surgical correction, and the dynamic changes that result from footplate alteration. Prospectively, measurements of 40 footplates were obtained during 20 consecutive primary rhinoplasties. The distance between the footplates at their most posterocaudal position was measured, along with the thickness, length, and width of the footplates. The shape of the nostrils was also observed and correlated to the form of the footplates. The distance between the footplates ranged from 7.5 to 15 mm, the average being 11.4 mm. The length of the footplates ranged from 4 to 7.5 mm, the average being 5.81 mm. The thickness of the footplates averaged 1.06 mm, ranging from 0.80 to 1.5 mm. The width of the footplates ranged from 2.5 to 7.0 mm, averaging 4.48 mm. In a retrospective review of 295 consecutive rhinoplasties, footplates were altered in 76 cases (25.8 percent). Of these cases, 29 procedures (9.8 percent) were performed to narrow the columella base and to advance the subnasale: on 24 patients (8.1 percent), the goal of this maneuver was to narrow the columella base only; on 5 patients (1.7 percent), the operation was conducted to aid in increasing the tip projection, provide a better foundation for the tip, advance the subnasale caudally, and narrow the alar base. Asymmetry of the columella was corrected in 16 patients (5.4 percent), and footplates were resected primarily to reduce the tip projection in 2 patients (0.7 percent). A detailed analysis of the nasal base will dictate one of the following courses pertaining to footplate alteration. If the patient exhibits an overprojected tip and divergent footplates, the lateral portion of the footplates will be resected partially, then approximated. If the tip is underprojected or has normal projection, the divergent footplates will be approximated without resection. Should the subnasale and the base of the columella be protruding, the soft tissue between the footplates will be removed to avoid excess fullness in this site as a result of the approximation of the footplate. However, when the footplates are divergent, the columella base and nasal spine area are often retracted, setting an auspicious stage for approximation of the footplates without having to excise the soft tissue. This maneuver not only narrows the columella base, it also advances it caudally. Longstanding caudal deviation of the septum may also create asymmetry of the footplates, which will not respond to mere repositioning of the septum, and often requires repositioning of the footplates with mobilization and fixation to the contralateral footplates.

Delayed healing of rhytidectomy flap resurfaced with CO2 laser.

Combining facial rhytidectomy with laser resurfacing, theoretically, provides the best opportunity for achieving an optimal facial rejuvenation result. Previous studies have demonstrated the pernicious effect of a deep peel on a skin flap, but the safety of treating the rhytidectomy flap with laser has not been investigated. This study was conducted to investigate the safety of using these techniques concomitantly. Sixty sites were selected on three Yucatan minipigs, a species of swine chosen because of its hairless nature and opportunity to raise a true skin flap (without the panniculus carnosus). The healing time of 20 laser-treated sites without flap elevation was compared with that of 20 areas treated with laser following flap elevation, shortening (to emulate a more realistic rhytidectomy process), and repair. Twenty flaps were elevated and shortened without laser treatment to serve as a control. The CO2 laser parameters were set at 500 mJ, 50 watts, and a density of 5. Two passes were made to penetrate the upper dermis. The mean healing time for areas treated with laser alone was 12.05 days, ranging from 11 to 14 days. In comparison, the healing time for the laser-treated areas subsequent to flap elevation averaged 17.95 days, with a range of 14 to 24 days (p < 0.05). Two flaps treated with laser (10 percent) failed to heal completely in 24 days. At the time that all 20 of the areas treated solely with laser had re-epithelialized completely, only one of the flaps treated with laser had re-epithelialized completely (p < 0.001). A delay in healing, as well as return of pigment, was demonstrated in the distal portions of all flaps receiving laser treatment. The control flaps all healed normally except for a 5-percent superficial loss on a single flap. It was concluded from this study, and from clinical observation of delayed healing on six of seven patients who underwent concomitant rhytidectomy and laser resurfacing at a conservative laser setting, that laser resurfacing of the rhytidectomy flap is unsafe and results in delayed re-epithelialization. This combination should be avoided altogether or performed with extreme prudence on patients undergoing a deeper plane facial rhytidectomy or by using very low laser settings.

Fire hazards and CO2 laser resurfacing.

The purpose of this study was to investigate the fire risk of laser resurfacing in the presence of supplemental oxygen. This study aims at defining safety parameters of variables such as laser energy level, oxygen flow rate, and "oxygen to laser target distance" when oxygen is delivered through a nasal cannula or nasopharyngeal tube. The typical operating room environment was simulated in the laboratory using the Yucatan minipig animal model. The energy source was a Coherent Ultrapulse CO2 laser. It was found that combustion did not occur at laser settings of 500 mJ, 50 W, 100 kHz, and a density of 5, used in conjunction with an oxygen flow rate of 6 liter/minute with the target area as close as 0.5 cm to the oxygen delivery. A total of 400 computer pattern generator treatments were delivered using this energy setting without observation of any combustion (p < 0.001). This provides evidence that while using even somewhat high laser settings and oxygen flow rate, laser induced fires can be avoided. We conclude that use of the laser in the presence of oxygen is safe, provided the target area is free of combustible fuels. Despite this assurance, laser mishaps are serious because they lead to both morbidity and mortality. It is our recommendation that close attention be constantly paid to all details, thus reducing the hazard potential of laser energy on local factors in an oxygen-rich environment.

The aging nose.

Mature adult rhinoplasty requires more sophisticated planning and flawless execution in order to achieve an optimal result. The improvement not only engenders a more pleasing feature, it also provides approximately 5 years' rejuvenation to the face. These patients possess thin skin, weak support structures, and vulnerable nasal function, rendering the rhinoplasty more enigmatic. The medical and emotional issues should be resolved prior to surgery.

Secondary rhytidectomy.

A postoperative questionnaire was sent to all secondary rhytidectomy patients inquiring about their social and physical recovery time, complications related to either the initial or secondary surgery, and the onset of any new medical problems or the commencement of any new medications between the two surgeries. The overall satisfaction rates for both surgeries, time interval between the two operations, and their perception of the years of youthful appearance gained from either operation were also investigated. The overall satisfaction rate was slightly higher for the secondary facial rhytidectomy (4.49) than for the primary rejuvenation of the face (3.97) (p < 0.06). Patients perceived themselves as looking an average of 9.31 years younger following primary surgery, as compared to an average of 10.19 years younger following the secondary rhytidectomy (p < 0.50). The average time interval between the primary and secondary rhytidectomy surgeries was 8.48 years (range = 1 to 16 years). Twenty-nine ancillary procedures were performed during the initial rhytidectomy and 70 ancillary procedures were selected during the secondary rhytidectomy (p < 0.001). There was no statistically significant difference for the physical and social recovery time between the two procedures. Fourteen of 33 patients (42.4 percent) requiring a secondary rhytidectomy had developed a new medical problem prior to the second surgery (p < 0.001) and 19 patients (57.6 percent) were started on a new medication (p < 0.001). It was concluded from this study that the secondary rhytidectomy patients are more inclined to be satisfied (approaching statistical significance), are more likely to undergo ancillary procedures, and, being 10 years older, are more prone to have medical problems with deleterious effects on surgery and to be on medications with potential ill effects. Also, observations have been made that the previous scars pose some limitations, with the anatomical changes from the previous surgeries often requiring masterful planning and execution. Skin circulation is, in general, superior, enduring more tension.

Ear projection and the posterior auricular muscle insertion.

Prominent ears is a common congenital anomaly affecting approximately 5 percent of the general population. The etiology has been attributed to three basic deformities in the ear structure: valgus of the concha with a cranioauricular angle greater than 40 degrees, underfolding of the anthelix, and rarely, hypertrophy of the concha. It is believed that by virtue of its insertion onto the ponticulus, the cranial surface of the concha, the posterior auricular muscle may function to pull the auricle back toward the head. A proximally (anteromedially) displaced insertion site would decrease the length of the effective momentum of the muscle, leading to protrusion of the auricle. This study was conducted to determine if indeed a relationship between the posterior muscle insertion site and ear projection could be established clinically by measuring these parameters intraoperatively in patients presenting for otoplasty and in patients without prominent ears who required conchal cartilage grafts for other procedures.

Refinements in endoscopic forehead rejuvenation.

Endoscopic forehead technique provides an effective method for rejuvenation of the upper face. Distinct advantages of this technique over classic methods of forehead rejuvenation such as coronal or subcutaneous approaches include significant reduction of incisional scars. Described here are three refinements related to (1) control of hair, (2) differential release of the periosteum, and (3) advanced fixation methods. Control of hair can be achieved simply by braiding and the use of an Endoscopic Access Device. Extensive release of the periosteum and arcus marginalis is recommended laterally, while elevating the medial periosteum either intact or with conservative release. Different and technologically more advanced fixation methods are described to provide better control of elevated forehead. Incorporation of these refinements strives to optimize aesthetic results while minimizing operative morbidity. These refinements have been implemented during the care of 29 patients and have proven to be of major value in achieving greater patient satisfaction and technical advancement.

Problems following genioplasty. Diagnosis and treatment.

Both alloplastic and osteoplastic genioplasty harbor the potential for outcomes that may mandate a revision. A successful reversal of this often enigmatic situation requires a thorough and trenchant analysis of the clinical condition, as well as the emotional motive leading the patient to seek a revision surgery. The selected corrective procedure has to offer the highest potential for success with the least invasion possible. The goals should be set with the scar tissue, distorted anatomy, and reduced circulation in mind. The limitations should be recognized, and the related concerns should be shared with the patient. Many of these, often imperfections and sometimes gross deformities, can be corrected, as long as the problem is identified and a suitable solution is culled out.

Yucatan pig: an optimal hairless model for a true random cutaneous flap.

Porcine models have been used extensively for skin flap research because of the established similarity between the cutaneous blood supply of the swine and humans. The Yucatan minipig provides an excellent model for researching the properties of random cutaneous flaps, offering several advantages over other breeds of swine. In this study, a total of 67 random cutaneous dorsal flank flaps measuring 4 x 14 cm were raised on nine Yucatan minipigs. The mean survival length (10.03 +/- 1.60 cm) of the nondelayed flaps was greater than others reported in the literature. The well-defined plane between the subcutaneous tissue and the panniculus carnosus facilitated flap elevation consistently above the level of the panniculus carnosus thereby ensuring the creation of a true random cutaneous flap. Furthermore, the hairless nature of the skin, particularly beneficial in studying chemical peels, permits easy visualization and monitoring of any external skin changes. These advantages make the Yucatan minipig a more desirable alternative to other breeds of swine for use in skin flap research.

The fate of preserved autogenous bone graft.

Certain clinical conditions exist in which a section of cranial bone is removed but not immediately replaced at the initial procedure. Preservation of this bone can provide a valuable autogenous donor source for a future reconstructive procedure. The purpose of our study was to compare the volume retention of fresh autogenous bone with that of preserved autogenous bone as inlay and onlay cranial grafts. Two bone grafts were harvested from the skull of 15 adult New Zealand White rabbits. The graft volumes were calculated, and the graft were preserved in a normal saline-antibiotic solution at -20 degrees C. Three months later, during the second procedure, a fresh graft was harvested and then placed in the preexisting occipital defect as an inlay graft. Also at this time, the preserved grafts were placed, one as an inlay graft in the fresh occipital defect and the other as an onlay graft in the frontal region. The animals were sacrificed 3 months later, and the percentage of graft volume retention was determined. The fresh inlay grafts had a mean volume retention of 85.1 percent, while the preserved inlay nad onlay grafts had 61.8 and 75.9 percent mean volume retention, respectively. It is concluded that while fresh cranial autograft remains the "gold standard" for craniofacial reconstruction, preserved autogenous cranial bone is a viable alternative for inlay and onlay grafting of the craniofacial region.