Total nasal skeletal reconstruction disfigured by granulomatosis with polyangitis (wegener granulomatosis).

BACKGROUND: Nasal deformity is a common disorder in Wegener granulomatosis, which is produced by polyangitis of medium-sized vessels. This process may cause necrosis and destruction of the nasal mucosa and osteocartilaginous framework. At this time, there is a lack of published data on nasal deformities associated with Wegener granulomatosis. METHODS: We present a 53-year-old woman with completely necrotized nasal lining and osteocartilage. The patient had a history of granulomatosis with polyangitis that was currently in remission. We reconstructed the patient's nose with fifth and sixth rib cartilages over 3 successive surgeries over a 2-year period. RESULTS: During the 3-year follow-up period, neither infection nor significant cartilage graft resorption was observed, and the aesthetic result was acceptable both to the patient and her physicians. CONCLUSIONS: In spite of contamination to the nasal lining and immune-compromising medications, nasal reconstruction is usually successful when considering these factors. Access to strong and abundant fifth or sixth rib cartilage presents an opportunity to reconstruct nasal destruction due to iatrogenic or autoimmune processes.

Comparison of outcomes using diced cartilage with or without tensor fascia latae wrapping in rabbits.

BACKGROUND: Diced cartilage has been associated with several advantages and rewarding results, leading to its widespread application in various forms in rhinoplasty, but the outcomes of diced cartilage with and without tensor fascia latae wrapping have not been widely reported in evidence-based articles. OBJECTIVES: The authors compared changes in weight, size, and histology of both bare and fascia-wrapped diced cartilage in rabbits as a model for human surgical outcomes. METHODS: One auricle from each of 15 rabbits was divided into 2 pieces, and both samples were diced. The tensor fascia latae of the rabbit was wrapped around 1 cartilage specimen from each rabbit (group A specimen); the other specimen received no wrapping (group B specimen). A group A specimen and a group B specimen were implanted into separate subcutaneous pockets in each rabbit. After 3 months, samples were removed from the recipient beds and weighed to compare pre- and postoperative weights. All specimens were examined for evidence of cartilage viability by histologic methods. RESULTS: There was a significant decrease in the weight of cartilage in group A. A nonsignificant weight increase was observed in group B. Histologic analyses of 5 parameters revealed no significant differences between the 2 groups, except for a significantly greater amount of new cartilage formation in group B. CONCLUSIONS: Any type of wrapping around diced cartilage may inhibit its access to surrounding nutrients. Dicing increases the absorption surface, which may result in some overgrowth, but wrapping may have a negative impact on the viability of the diced cartilage. LEVEL OF EVIDENCE: 4.

Straight septum, crooked nose: an overlooked concept.

INTRODUCTION: Asymmetric facial skeletal growth is a common finding in the rhinoplasty patient population. This common abnormality affects all facial components, including the upper lateral cartilages (ULCs). The asymmetric growth also may produce uneven thickness, consistency, curvature, and elastic recoil of the ULC. Ignoring this asymmetry may have a marked impact on the outcome of any rhinoplasty operation, especially in the management of crooked noses. MATERIALS AND METHODS: The files of 89 consecutive rhinoplasty patients who underwent surgery by a single surgeon were reviewed for deformities of the middle vault and to tabulate the procedures performed in each individual case. RESULTS: Of the 89 rhinoplasty cases, 72 (81 %) had asymmetric ULCs. Approximately 30 % (27/89) of the cases had a straight septum with asymmetric ULCs which required appropriate correction. CONCLUSIONS: Awareness of an asymmetric ULC in a crooked nose and an attempt to correct this condition in addition to straightening of the septum is key to decreasing postoperative residual or recurrent mid-vault deviation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Correction of cleft lip nose deformity with rib cartilage.

BACKGROUND: Correction of cleft lip nasal deformities (CLND) is often unsatisfactory because of problems resulting from cartilage weakness and strong soft tissue forces. Therefore, strong cartilaginous support, such as rib cartilage, is mandatory. OBJECTIVES: The authors describe placement of rib cartilage grafts to create a more symmetric and aesthetically acceptable repair of CLND with improved nasal air flow. METHODS: Two groups of patients, including those with unilateral and bilateral CLND, underwent operations with different sources of autologous cartilage. Group 1 received grafts from the septum and ear, whereas group 2 received grafts from the septum and ribs. Results were evaluated by 2 independent physicians who rated improvement between pre- and postoperative photographs. RESULTS: There were significant differences in postoperative improvement between patients who received septal/ear cartilage grafts and those who received septal/rib cartilage grafts in both unilateral and bilateral cases (P = .028 and P = .043, respectively). CONCLUSIONS: The authors' results demonstrate that rib cartilage has a positive effect on the aesthetic outcome of CLND operations and provides a strong support structure for correcting this deformity with minimal postoperative complications.

Anterior scoring approach for prominent ear anomaly: a modified Chongchet technique.

BACKGROUND: One of the most common facial anomalies is the presence of a prominent ear. Numerous surgical techniques have been introduced in the literature for correction of this anomaly, which include suturing and sculpturing the ear cartilage. However, each has different complications. The modified Chongchet technique is one of the less invasive methods and can correct the above abnormality with satisfying results. METHODS: From July 2001 to March 2011, 19 cases of prominent ear were corrected using the modified Chongchet technique. The mean follow-up period was approximately 4.5 years. We employed an anterior approach and partial-thickness scaphal cartilage scoring in these cases. RESULTS: We observed no recurrences and no sharp cartilage protrusions following the surgeries. Additionally, all patients expressed satisfaction with the results.  CONCLUSION: We propose that the modified Chongchet approach is less aggressive and has improved surgical outcomes. One of the adverse effects of this procedure is unpredictable warping of the cartilage, which may result in asymmetry.

Diced ear cartilage with perichondrial attachment in rhinoplasty: a new concept.

BACKGROUND: Diced cartilage is a valuable material that has recently been added to the graft options in rhinoplasty. Shaping, fixation, and resorption are the main concerns with this material. Perichondrially attached diced conchal cartilage may be a new possibility to solve some of these problems. OBJECTIVES: The authors evaluate the outcome of perichondrially attached diced cartilage in a rabbit model and compare the results with injectable cartilage grafting. METHODS: Ear cartilage was removed from 1 auricle in each of the 16 rabbits included in this study; samples were divided in 2 pieces. After precise weighing, both segments were diced. The perichondrium was left attached to 1 of the pieces. Both segments were inserted in 2 separate pockets in the dorsum of the animal. After a 3-month period, both samples were removed and measured for growth/resorption. RESULTS: At the beginning of this study, the difference in weight between groups was statistically insignificant (P = .213), but 3 months after insertion, significant growth was observed in the perichondrial group (P = .019). CONCLUSIONS: The vascularization and significant growth in weight of the perichondrially attached diced cartilage samples are evidence of the viability of this material. The structural integrity and solid framework afforded by this option suggest that the material should be used more frequently in nasoskeletal augmentation.

Epidural anesthesia as a thromboembolic prophylaxis modality in plastic surgery.

BACKGROUND: Epidural anesthesia (EA) is known to reduce postoperative thromboembolic complications, but the mechanisms are poorly understood. Review of the literature revealed no reports about the ability of epidural anesthesia (EA) to reduce the risk of venous thromboembolism (VTE) in abdominal contouring surgery and/or liposuction. Most medical publications in this field are based on orthopedic cases. OBJECTIVES: The authors investigate the hypothesis that the differential nerve-blocking effect of bupivacaine, which spares motor function and permits leg movement during the operation, is the most important mechanism by which EA prevents thromboembolism. METHODS: From June 1992 to August 1995, 24 cases of abdominoplasty were performed under general anesthesia (Group 1). From September 1995 to December 2009, 371 cases of concurrent abdominoplasty and liposuction were performed under EA (Group 2). Eighteen cases (4.8%) from Group 2 were ultimately excluded from the study because of unsuccessful EA. All surgeries were performed by the senior author (FH). RESULTS: One thromboembolic event (pulmonary embolism [PE]) occurred in Group 1 (4%). No cases of deep vein thrombosis (DVT) or PE occurred among Group 2 patients. CONCLUSIONS: Together, differential epidural nerve blocks and purposeful intraoperative movement of lower-limb muscles represent an effective prophylactic mechanism that may prevent devastating DVT and resultant PE.

Acid burn violence in Iran.

Background. Acid assault is one of the most brutal of crimes. This crime is not meant to kill but to punish the victim or to destroy the victim's social life. This violent act usually occurs in third-world countries. The aim of this paper is to assess the epidemiological factors that steer a person toward such a violent act. Method. From May 2004 to October 2010, the charts of victims of acid violence referred to the Motahari Burn Center in Iran were reviewed. During this 6-yr period, 59 patients were included in this retrospective study. We identified the aetiology and the extent of the damage that was produced as a result of throwing corrosive chemicals onto the victim's body for the purpose of revenge. Results. The cases reviewed concerned 51% male patients and 49% female. The face and upper body were the most commonly injured areas, and the most common assailant was a close family member. Conclusion. The authors believe that lack of information about the catastrophic outcome of this action, plus the widespread availability of strong, destructive chemicals, are the main reasons for the rising incidence of this crime.

Applied anatomy of the nasal lower lateral cartilage: a new finding.

BACKGROUND: In most references to the nasal anatomy, the shape of the lower lateral cartilage (LLC) is described as a two-dimensional structure. However, the authors have found different forms of LLC in at least 40% of their open rhinoplasty cases during the past 20 years. This cartilage was found to have a three-dimensional hemispheric appearance and to be connected to the upper lateral cartilage (ULC) at the scroll area by an inward limb of this hemisphere. This inward limb may have an important role in producing asymmetry and flare of the nostril. METHODS: The LLC of 286 patients was evaluated during open rhinoplasty over a 2-year period, with a focus mainly on the shape of this structure, especially at the LLC-ULC junction (scroll area). RESULTS: A dome-shaped appearance of the LLC was noted in 40.9% of cases, and 11.5% of cases had bilateral LLC variation. This different anatomic form was seen mostly in patients with a strong bulbous nasal tip, although it was observed less frequently also in patients with narrow nasal tips. CONCLUSION: At least one-third of the LLCs analyzed had a medial wall in addition to the lateral wall, which significantly increased the flare and recoil force of this structure. This makes this cartilage more redundant to reshaping procedures (straightening). Thus, special attention must sometimes be paid to this common anatomic variation to produce symmetric nostrils and to obtain a more aesthetically acceptable alar tip.