Disseminated Cryptococcosis Post Eculizumab Therapy: A Case Report and Literature Review.

Eculizumab is a biologic medication used for the treatment of complement-related disorders including anti-acetylcholine receptor antibody-positive generalized myasthenia gravis. It targets C5 complement, preventing its cleavage into active terminal components. Thus, vaccination against encapsulated organisms is advised before starting this treatment. C5 also has a critical role against Cryptococcus neoformans infection. Here, we present a case of a 34-year-old man with a history of myasthenia gravis who was treated with prednisone and azathioprine in addition to eculizumab that was added to his regimen about a year ago, and who came to the hospital with headache, and was found to have Cryptococcus meningitis with disseminated cryptococcosis. The patient was negative for human immunodeficiency virus. He was treated with antifungal medications, and his condition improved. Although rarely reported, it is important to have a low threshold for diagnosis of cryptococcosis in patients on eculizumab given its complement inhibition mechanism of action.

Pharmacological and Non-Pharmacological Methods of Postoperative Pain Control Following Oral and Maxillofacial Surgery: A Systematic Review.

Background: We aimed to investigate the pharmacological and non-pharmacological interventions used for mitigating pain. Methods: We integrated randomized controlled trials (RCTs) chosen from PubMed, Google scholar, and Scopus and aimed at assessing the effectiveness of one or multiple variants of Non-steroidal anti-inflammatory drugs (NSAIDs), as well as Narcotic analgesics, compared to corticosteroids, curcumin, hyaluronic acid, and antibiotics. In addition, trials utilizing NSAIDs, including Rofecoxib, which have been withdrawn from market circulation, were deemed ineligible for inclusion. Result: A total of 9 RCTs were evaluated in this study, and the patients' postoperative pain was assessed using the visual analog scale (VAS) and the time measurement. Moreover, there were various approaches to alleviating pain and discomfort. Conclusion: The administration of ibuprofen prior to surgery leads to a marked reduction in pain. Pharmacological interventions, such as the administration of dexamethasone and oxycodone, alongside non-pharmacological interventions, such as laser therapy, have been shown to effectively alleviate the discomfort resulting from surgical procedures on the jaw and face.

The Effect of Tranexamic Acid Local Injection on Bleeding during and after Tonsillectomy: A Double-Blind Randomized Placebo-Controlled Trial.

Background: Tonsillectomy-related bleeding is one of the most prevalent and potentially fatal complications of this common surgical procedure. We aimed to assess the effect of tranexamic acid (TXA) local injection on bleeding during and after tonsillectomy. Methods: This double-blind, randomized placebo-controlled trial included 20 candidates for tonsillectomy referred to Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran, in 2022. The subjects were randomized into two groups. Ten patients received TXA on their left side and the other ten on their right side 10 min before surgery. Placebo was administered to the contralateral side. The primary outcome was the volume of blood loss during tonsillectomy and up to 24 hours post-tonsillectomy. The secondary outcomes were surgeon satisfaction (rated 0-10), hemodynamic complications (patients' heart rate (HR) and mean arterial pressure (MAP) were recorded every 10 min), and rebleeding. The duration of surgery was also noted. Results: The mean age of the patients was 21.35 ± 3.16 years, of whom 8 (30%) were male and 12 (60%) were female. there was no significant difference between groups in terms of HR and MAP at any time point. The median of surgery duration did not differ significantly between the two groups; however, the surgeon satisfaction with the procedure was significantly higher with TXA compared to placebo. None of the patients developed hemodynamic complications, and rebleeding did not occur in any of the subjects. Conclusions: TXA local injection was not superior to placebo in terms of bleeding control during and after tonsillectomy, hemodynamic complications, rebleeding, and surgery duration.

Loss of stromal cell Thy-1 plays a critical role in lipopolysaccharide induced chronic lung allograft dysfunction.

BACKGROUND: Long-term survival of lung transplants lags behind other solid organs due to early onset of a fibrotic form of chronic rejection known as chronic lung allograft dysfunction (CLAD). Preventing CLAD is difficult as multiple immunologic and physiologic insults contribute to its development. Targeting fibroblast activation, which is the final common pathway leading to CLAD, offers the opportunity to ameliorate fibrosis irrespective of the initiating insult. Thy-1 is a surface glycoprotein that controls fibroblast differentiation and activation. METHODS: To study the role of Thy-1 in CLAD, we utilized the minor antigen mismatched C57BL/6 (B6wild-type) or B6Thy-1-/-→C57BL/10 (B10) model of murine orthotopic lung transplantation with postoperative bacterial infection modeled by intratracheal lipopolysaccharide (LPS) administration. The effects of LPS on Thy-1 expression, proliferation, and gene expression were assessed in fibroblasts in vitro and the therapeutic potential of Thy-1 replacement was assessed in vivo. RESULTS: More severe CLAD was evident in B6Thy-1-/- →B10 grafts compared to B6wild-type →B10 grafts. LPS further accentuated fibrosis in B6wild-type →B10 grafts with some, but limited, effects on B6Thy-1-/- →B10 grafts. LPS contributed to Thy-1 loss from Thy-1(+) fibroblasts in vitro due to a decrease in mRNA expression. In addition, LPS promoted proliferation and upregulation of multiple inflammatory pathways in Thy-1(-) fibroblasts by gene expression analysis. Most importantly, replacement of Thy-1 through exogenous administration ameliorated the fibrotic phenotype post-LPS mediated modeling of infection. CONCLUSIONS: Our findings suggest that the loss of Thy-1 on fibroblasts is a previously unrecognized cause of CLAD and its replacement may offer therapeutic applications for amelioration of this disease post-transplantation in the setting of infectious stress responses.

Retargeting IL-2 Signaling to NKG2D-Expressing Tumor-Infiltrating Leukocytes Improves Adoptive Transfer Immunotherapy.

Ex vivo expansion followed by reinfusion of tumor-infiltrating leukocytes (TILs) has been used successfully for the treatment of multiple malignancies. Most protocols rely on the use of the cytokine IL-2 to expand TILs prior to reinfusion. In addition, TIL administration relies on systemic administration of IL-2 after reinfusion to support transferred cell survival. The use of IL-2, however, can be problematic because of its preferential expansion of regulatory T and myeloid cells as well as its systemic side effects. In this study, we describe the use of a novel IL-2 mutant retargeted to NKG2D rather than the high-affinity IL-2R for TIL-mediated immunotherapy in a murine model of malignant melanoma. We demonstrate that the NKG2D-retargeted IL-2 (called OMCPmutIL-2) preferentially expands TIL-resident CTLs, such as CD8+ T cells, NK cells, and γδT cells, whereas wild-type IL-2 provides a growth advantage for CD4+Foxp3+ T cells as well as myeloid cells. OMCPmutIL-2-expanded CTLs express higher levels of tumor-homing receptors, such as LFA-1, CD49a, and CXCR3, which correlate with TIL localization to the tumor bed after i.v. injection. Consistent with this, OMCPmutIL-2-expanded TILs provided superior tumor control compared with those expanded in wild-type IL-2. Our data demonstrate that adoptive transfer immunotherapy can be improved by rational retargeting of cytokine signaling to NKG2D-expressing CTLs rather than indiscriminate expansion of all TILs.

Global, Regional, and National Burden of Calcific Aortic Valve and Degenerative Mitral Valve Diseases, 1990-2017.

BACKGROUND: Nonrheumatic valvular diseases are common; however, no studies have estimated their global or national burden. As part of the Global Burden of Disease Study 2017, mortality, prevalence, and disability-adjusted life-years (DALYs) for calcific aortic valve disease (CAVD), degenerative mitral valve disease, and other nonrheumatic valvular diseases were estimated for 195 countries and territories from 1990 to 2017. METHODS: Vital registration data, epidemiologic survey data, and administrative hospital data were used to estimate disease burden using the Global Burden of Disease Study modeling framework, which ensures comparability across locations. Geospatial statistical methods were used to estimate disease for all countries, because data on nonrheumatic valvular diseases are extremely limited for some regions of the world, such as Sub-Saharan Africa and South Asia. Results accounted for estimated level of disease severity as well as the estimated availability of valve repair or replacement procedures. DALYs and other measures of health-related burden were generated for both sexes and each 5-year age group, location, and year from 1990 to 2017. RESULTS: Globally, CAVD and degenerative mitral valve disease caused 102 700 (95% uncertainty interval [UI], 82 700-107 900) and 35 700 (95% UI, 30 500-42 500) deaths, and 12.6 million (95% UI, 11.4 million-13.8 million) and 18.1 million (95% UI, 17.6 million-18.6 million) prevalent cases existed in 2017, respectively. A total of 2.5 million (95% UI, 2.3 million-2.8 million) DALYs were estimated as caused by nonrheumatic valvular diseases globally, representing 0.10% (95% UI, 0.09%-0.11%) of total lost health from all diseases in 2017. The number of DALYs increased for CAVD and degenerative mitral valve disease between 1990 and 2017 by 101% (95% UI, 79%-117%) and 35% (95% UI, 23%-47%), respectively. There is significant geographic variation in the prevalence, mortality rate, and overall burden of these diseases, with highest age-standardized DALY rates of CAVD estimated for high-income countries. CONCLUSIONS: These global and national estimates demonstrate that CAVD and degenerative mitral valve disease are important causes of disease burden among older adults. Efforts to clarify modifiable risk factors and improve access to valve interventions are necessary if progress is to be made toward reducing, and eventually eliminating, the burden of these highly treatable diseases.

Vendor-specific microbiome controls both acute and chronic murine lung allograft rejection by altering CD4+ Foxp3+ regulatory T cell levels.

Despite standardized postoperative care, some lung transplant patients suffer multiple episodes of acute and chronic rejection while others avoid graft problems for reasons that are poorly understood. Using an established model of C57BL/10 to C57BL/6 minor antigen mismatched single lung transplantation, we now demonstrate that the recipient microbiota contributes to variability in the alloimmune response. Specifically, mice from the Envigo facility in Frederick, Maryland contain nearly double the number of CD4+ Foxp3+ regulatory T cells (Tregs ) than mice from the Jackson facility in Bar Harbor, Maine or the Envigo facility in Indianapolis, Indiana (18 vs 9 vs 7%). Lung graft recipients from the Maryland facility thus do not develop acute or chronic rejection. Treatment with broad-spectrum antibiotics decreases Tregs and increases both acute and chronic graft rejection in otherwise tolerant strains of mice. Constitutive depletion of regulatory T cells, using Foxp3-driven expression of diphtheria toxin receptor, leads to the development of chronic rejection and supports the role of Tregs in both acute and chronic alloimmunity. Taken together, our data demonstrate that the microbiota of certain individuals may contribute to tolerance through Treg -dependent mechanisms and challenges the practice of indiscriminate broad-spectrum antibiotic use in the perioperative period.

Eosinophils downregulate lung alloimmunity by decreasing TCR signal transduction.

Despite the accepted notion that granulocytes play a universally destructive role in organ and tissue grafts, it has been recently described that eosinophils can facilitate immunosuppression-mediated acceptance of murine lung allografts. The mechanism of eosinophil-mediated tolerance, or their role in regulating alloimmune responses in the absence of immunosuppression, remains unknown. Using lung transplants in a fully MHC-mismatched BALB/c (H2d) to C57BL/6 (H2b) strain combination, we demonstrate that eosinophils downregulate T cell-mediated immune responses and play a tolerogenic role even in the absence of immunosuppression. We further show that such downregulation depends on PD-L1/PD-1-mediated synapse formation between eosinophils and T cells. We also demonstrate that eosinophils suppress T lymphocyte responses through the inhibition of T cell receptor/CD3 (TCR/CD3) subunit association and signal transduction in an inducible NOS-dependent manner. Increasing local eosinophil concentration, through administration of intratracheal eotaxin and IL-5, can ameliorate alloimmune responses in the lung allograft. Thus, our data indicate that eosinophil mobilization may be utilized as a novel means of lung allograft-specific immunosuppression.

Introduction of a Less Invasive Revision Rhinoplasty Using Closed Nasal Chondrotome.

Rhinoplasty is the most common aesthetic surgical procedure in Iran. Dorsal bony and cartilaginous structures of the nose play an important role in nasal esthetics and function. Manipulation of nasal dorsum is one of the cardinal procedures during rhinoplasty operation. Some cases of primary rhinoplasty lead to various post-operative nasal imperfections. One of the most common imperfections is dorsal nasal spur which can cause dorsal irregularities. The accurate rate of imperfections relates to some factors like the surgeon's experience and his/her precision, and appropriate post-operative patient care. Alomost 15%of revision or secondary surgical manipulations are acceptable for an experienced plastic surgeon. Most of the revision rhinoplasties are due to minor deformities in nasal dorsum like cartilaginous spur or mild focal depression. We have introduced an innovative device "Closed Nasal Chondrotome" that can ease the procedure for treating of minor nasal dorsal deformities. we propose the use of closed nasal chondrotome for mild dorsal spurs and have presented the effectiveness of this device in one patient. This simple but very effective instrument can be an alternative for a revision rhinoplasty procedure in the operating room to an outpatient procedure with local anesthesia. This method has been used in one patient with the satisfactory result, permitting corrections of minor cartilaginous excess deformities, with a less invasive procedure.

The Effect of Lithospermum officinale, Silver Sulfadiazine and Alpha Ointments in Healing of Burn Wound Injuries in Rat.

BACKGROUND: Burn is the most devastating condition in emergency medicine leading to chronic disabilities. This study aimed to compare the effect of Lithospermum officinale, silver sulfadiazine and alpha ointments on healing of burn wounds in rat. METHODS: Ninety-five rats were divided into 5 groups. Group 1 just underwent burn injury, and groups 2-5 received alpha ointment, silver sulfadiazine (SSD), gel base and L. officinale extract, respectively. A hot plate was used for induction of a standard 3rd degree burn wound. Burn wounds were macroscopically and microscopically evaluated on days 7th, 14th and 21st after burn induction. RESULTS: A decrease in the number of inflammatory cells was noted when L. officinale and SSD were applied while the most inflammatory response was seen after administration of alpha ointment. The number of macrophages alone decreased after burn injury, while the frequency was the most when L. officinale and alpha ointment were applied. Re-epithelialization, angiogenesis and formation of granulation tissue were the best in relation to L. officinale and alpha ointment while, the worst results belonged to burn injury group and SSD regarding granulation tissue formation. Considering histological assessment, the best results were observed for scoring of inflammation, re-epithelialization, angiogenesis, formation of granulation tissue and number of macrophage when L. officinale and alpha ointment were used after burn injury. CONCLUSION: It can be concluded that topical application of L. officinale as a non-toxic, inexpensive and easy to produce herbal can lead to a rapid epithelialization and wound healing and these findings can be added to the literature on burn wound healing.

Can Skin Allograft Occasionally Act as a Permanent Coverage in Deep Burns? A Pilot Study.

BACKGROUND: Skin allograft is the gold standard of wound coverage in patients with extensive burns; however, it is considered as a temporary wound coverage and rejection of the skin allograft is considered inevitable. In our study, skin allograft as a permanent coverage in deep burns is evaluated. METHODS: Skin allograft survival was assessed in 38 patients from March 2009 to March 2014, retrospectively. Because of the lack of tissue specimen from the skin donors, patients with long skin allograft survival in whom the gender of donor and recipient of allograft was the same were excluded. Seven cases with skin allograft longevity and opposite gender in donor and recipient were finally enrolled. A polymerase chain reaction (PCR) test on the biopsy specimen from recipients and donors were undertaken. RESULTS: PCR on the biopsy specimen from recipients confirmed those specimens belong to the donors. All patients received allograft from the opposite sex. Two (28.57%) patients received allograft from their first-degree blood relatives, and in one (14.29%) case, the allograft was harvested from an alive individual with no blood relation. The rest were harvested from multiorgan donors. In eight months of follow up, no clinical evidence of graft rejection was noted. CONCLUSION: Long term persistence of skin allograft in patients is worthy of more attention. Further studies An increase in knowledge of factors influencing this longevity could realize the dream of burn surgeons to achieve a permanent coverage other than autograft for major burn patients.

The Potential of Menstrual Blood-Derived Stem Cells in Differentiation to Epidermal Lineage: A Preliminary Report.

BACKGROUND: Menstrual blood-derived stem cells (MenSCs) are a novel source of stem cells that can be easily isolated non-invasively from female volunteered donor without ethical consideration. These mesenchymal-like stem cells have high rate of proliferation and possess multi lineage differentiation potency. This study was undertaken to isolate the MenSCs and assess their potential in differentiation into epidermal lineage. METHODS: About 5-10 ml of menstrual blood (MB) was collected using sterile Diva cups inserted into vagina during menstruation from volunteered healthy fertile women aged between 22-30 years. MB was transferred into Falcon tubes containing phosphate buffered saline (PBS) without Ca2(+) or Mg2(+) supplemented with 2.5 µg/ml fungizone, 100 µg/mL streptomycin, 100 U/mL penicillin and 0.5 mM EDTA. Mononuclear cells were separated using Ficoll-Hypaque density gradient centrifugation and washed out in PBS. The cell pellet was suspended in DMEM-F12 medium supplemented with 10% FBS and cultured in tissue culture plates. The isolated cells were co-cultured with keratinocytes derived from the foreskin of healthy newborn male aged 2-10 months who was a candidate for circumcision for differentiation into epidermal lineage. RESULTS: The isolated MenSCs were adhered to the plate and exhibited spindle-shaped morphology. Flow cytometric analysis revealed the expression of mesenchymal markers of CD10, CD29, CD73, and CD105 and lack of hematopoietic stem cells markers. An early success in derivation of epidermal lineage from MenSCs was visible. CONCLUSION: The MenSCs are a real source to design differentiation to epidermal cells that can be used non-invasively in various dermatological lesions and diseases.

Concomitant Overlap Steal Tip-plasty: A Versatile Technique to Simultaneously Adjust the Rotation, Definition, Projection, and Symmetry of the Nasal Tip.

BACKGROUND: Tip-plasty is a particularly challenging stage of aesthetic nose surgery. The diversity of nasal tip deformities has necessitated the development of numerous surgical techniques that can be difficult to master and may yield unpredictable surgical results when combined. OBJECTIVES: The authors describe how concomitant overlap steal tip-plasty (COST) can enable surgeons to address all of the aesthetic characteristics of the nasal tip simultaneously. COST involves lateral crural steal followed by medial crural overlap. METHODS: The medical records of 1617 patients who underwent primary open septorhinoplasty with COST were evaluated in a retrospective study. Pre- and postoperative patient photographs were compared for nasal length, nasolabial angle, tip projection, and deviation of the nasal axis. RESULTS: Pre- and postoperative mean nasal lengths were 5.66 cm and 5.17 cm, respectively (P < .05). The mean nasolabial angle was 86.95° preoperatively and 101.8° postoperatively (P < .05). The projection of the nasal tip was reduced from 3.09 cm to 2.53 cm, and tip symmetry was achieved by decreasing the nasal axis deviation from 7.76° to 1.71° (both P < .05). CONCLUSIONS: COST does not obviate all other tip-plasty techniques for specific situations. Once mastered, however, COST can become the only procedure needed to achieve all of the aesthetic goals of the nasal tip in most cases. LEVEL OF EVIDENCE 4: Therapeutic.

Injectable Cartilage Shaving: An Autologous and Long Lasting Filler Material for Correction of Minor Contour Deformities in Rhinoplasty.

BACKGROUND: Filler materials are gaining popularity in nonsurgical rhinoplasty the major advantages are the ability to camouflage the surface deformities, and also the soft and malleable consistency; while the major drawback of the safe fillers such as hyaluronic acid is short durability. In this study, we evaluated the injectable cartilage shaving as an autologous filler material for correction of minor contour deformities in rhinoplasty. METHODS: Injectable cartilage shaving was used for correction of surface irregularities in primary or secondary rhinoplasty, and long term results of 128 patients were evaluated. The source of cartilage was autologous septum, rib or less frequently, the ear concha. The material was injected with 14 to 18 gauge needles or blunted tip lipofilling cannulas with 1.3-1.7 mm internal diameters. It was performed whether during the septorhinoplasty or as a separate single procedure without elevation of the flap. Success was defined as the long term survival of the graft in the desired site and absence of recurrent deformity or complications such as extrusion, infection or displacement. RESULTS: Twenty seven males and 101 females underwent the procedure from May 2008 to January 2014. Mean follow up period was 31 (13-58) months. Ninety five percent of patients were satisfied or very satisfied with the results at the last follow up visits and touch up procedure was performed for the unsatisfied patients. CONCLUSION: Injectable cartilage shaving is a reliable filler to correct and camouflage the surface irregularities, and it is durable and predictable in long term follow ups.

Nasal alar necrosis following hyaluronic Acid injection into nasolabial folds: a case report.

Injection of synthetic fillers for soft tissue augmentation is increasing over the last decade. One of the most common materials used is hyaluronic acid (HA) that is safe and temporary filler for soft tissue augmentation. We present a case of 54-year-old female who experienced vascular occlusion and nasal alar necrosis following HA injection to the nasolabial folds. She suffered from pain, necrosis, infection, and alar loss that finally required a reconstructive surgery for cosmetic appearance of the nose. The case highlights the importance of proper injection technique by an anesthesiologist, as well as the need for immediate recognition and treatment of vascular occlusion.

Tissue engineered scaffolds in regenerative medicine.

Stem cells are self-renewing cells that can be differentiated into other cell types. Conventional in vitro models for studying stem cells differentiation are usually preformed in two-dimensional (2D) cultures. The design of three-dimensional (3D) in vitro models which ideally are supposed to mimic the in vivo stem cells microenvironment is potentially useful for inducing stem cell derived tissue formation. Biodegradable scaffolds play an important role in creating a 3D environment to induce tissue formation. The application of scaffolding materials together with stem cell technologies are believed to hold enormous potential for tissue regeneration. In this review, we provide an overview of application of tissue engineered scaffolds and stem cells for the development of stem cell-based engineered tissue replacements. In particular, we focus on bone marrow stem cells (BMSCs) and mesenchymal stem cell (MSCs) due to their extensive clinical applications.

A Comparasion in Graft Resorption between Three Techniques of Diced Cartilage Using Surgical Blade, Electrical Grinder and Grater in Rabbit.

BACKGROUND: In recent years, there is an increasing tendency to use diced cartilage grafts in rhinoplasty surgery for improving dorsum contour irregularities. This study was designed to compare graft resorption between three techniques of diced cartilage using surgical blade, electrical grinder and grater in rabbit model. METHODS: Thirteen New Zealand rabbits were divided into three groups. Three 2×2 cm cartilage specimens were harvested from one of their ears. In group one, the cartilage was diced by use of No:11 surgical blade to o.5 to 1 mm cube pieces. In group two, an electrical grinder was used and in group three, a grater was applied. The grafts were placed in three subcutaneous pockets in the back of rabbits and after 12 weeks, the implants were removed and their weight and volume were recorded and were evaluated by histological techniques. RESULTS: There was no difference between the three methods in the 3 groups for graft resorption. There was no change in the volume, but the weight showed a decrease in the control group. CONCLUSIONS: As the histological results had no statistically difference between groups, we may recommend use of these two techniques in reconstructive and in aesthetic cases.

How can bee colony algorithm serve medicine?

Healthcare professionals usually should make complex decisions with far reaching consequences and associated risks in health care fields. As it was demonstrated in other industries, the ability to drill down into pertinent data to explore knowledge behind the data can greatly facilitate superior, informed decisions to ensue the facts. Nature has always inspired researchers to develop models of solving the problems. Bee colony algorithm (BCA), based on the self-organized behavior of social insects is one of the most popular member of the family of population oriented, nature inspired meta-heuristic swarm intelligence method which has been proved its superiority over some other nature inspired algorithms. The objective of this model was to identify valid novel, potentially useful, and understandable correlations and patterns in existing data. This review employs a thematic analysis of online series of academic papers to outline BCA in medical hive, reducing the response and computational time and optimizing the problems. To illustrate the benefits of this model, the cases of disease diagnose system are presented.

Can we add auricular composite graft to our rhinoplasty armamentarium?

BACKGROUND: The ala of the nose, with its particular texture and characteristics, poses both aesthetically and functionally intriguing challenges and is rather problematic regarding choices for reconstructive methods. Both flaps and grafts have been used to restore natural structure of nasal ala. The present study summarizes a ten-year experience of reconstructive surgery using small composite grafts from non-cartilage bearing tissues, and large composite grafts, containing cartilaginous tissue, with a mean follow-up of 4 years and 8 months. METHODS: Cumulatively 56 patients were reported. Some of them required surgery due to previous cosmetic rhinoplasty. In 47 of the cases, a small graft from the non-cartilage bearing junction of ear lobule to helical rim sufficed. Nine patients had rather large defects for which grafts were harvested from the helical root. Donor sites were primarily closed and grafts were implanted in place in a single, rapid session. RESULTS: All small grafts had excellent take. Of 9 large grafts, 5 had excellent take, three had acceptable, and one, in a male smoker, failed to take. During follow-up, no gross deformity or poor scar was detected in either donor or recipient site. CONCLUSIONS: We have demonstrated that using both large and small auricular composite grafts has favorable long term results for reconstruction of alar rim deformities. However, use of small grafts seems more beneficial and applicability of large grafts requires further studies.