Tip-Oriented Closed Rhinoplasty Built on Septocolumellar Suture and a New Caudal Septal Graft Technique.

BACKGROUND: A beautiful and appealing nose receives the greatest contribution from the nasal tip subunit, which should be regarded as the primary center of attention during a rhinoplasty procedure. In achieving the desired shape and position of the nasal tip during closed rhinoplasty, the septocolumellar suture functions as the major determinant together with the caudal portion of the septal cartilage, which has a significant influence on the versatility of the septocolumellar suture. The purpose of this study was to present the analysis of the indications, the technical steps, and the advantages of caudal septal graft and septocolumellar suture utilization in closed rhinoplasty. METHODS: The septocolumellar suture with or without the caudal septal graft combination procedure has been performed in 2286 patients via a closed rhinoplasty approach. Intraoperatively, the septal cartilage at hand was thoroughly evaluated and one of the 5 types of caudal septal grafts was used when necessary. After the establishment of a strong and straight septal cartilage with sufficient height and length, 4 different septocolumellar sutures in a specific order were used to modify the relationship between the lower lateral cartilages and the nasal septum. RESULTS: Of the 2286 cases, 1837 (80.3%) were primary and 449 (19.7%) secondary rhinoplasties, which have been followed up for 9 to 48 months. The caudal septal graft was combined to the septocolumellar suture in 621 (27.1%) patients. Of the caudal septal grafts, 69.7% were used for primary rhinoplasty cases, and 30.3% for secondary rhinoplasties. At the 18th month postoperatively, tip projection was found to be satisfactory for 98% of the patients. CONCLUSIONS: The septocolumellar suture combined with caudal septal graft in closed rhinoplasty substantially facilitates the achievement of a cosmetically and functionally pleasing end result, bringing the solution for a wide array of problems such as short nose, supratip deformity, nasolabial angle change, or columellar bowing. Nevertheless, the technique has a steep learning curve; therefore, a meticulous preoperative evaluation should be exerted, a precise surgical planning should be prosecuted, and an excessive reduction of the nasal tip or exaggerated columellar retraction should be avoided.

Evaluation of the effects of losartan on a random pattern skin flap model in rats.

BACKGROUND: Losartan, a drug with antiinflammatory properties, has been shown to prevent ischemic injury in various organs. The purpose of the present study was to investigate the effects of losartan on ischemic skin flaps and on flap survival. METHODS: A 3x9 cm dorsal flap was elevated in 24 Sprague-Dawley rats. Rats received the following treatment for seven days: Group I (n=8): 10 mg/kg losartan; Group II (n=8): 40 mg/kg losartan; and Group III (n=8): nonionized water. At the end of the seventh day, the viable flap areas were calculated, and histological analysis was conducted to count cells and capillaries in microscopic fields. RESULTS: Mean flap survival was 61%, 56% and 60% in Groups I, II and III, respectively. Comparison of flap survival between groups did not yield any significant difference (p>0.05). Ischemic zones of the flaps in all groups demonstrated an increase in number of neutrophils, fibroblasts and capillaries (p<0.05), whereas no difference was seen in mast cells. The cell counts in the viable areas of the flaps showed a significant decrease in fibroblasts in the group treated with 40 mg/kg losartan (p<0.05). The number of neutrophils, mast cells and capillaries was not influenced by treatment. CONCLUSION: Losartan does not improve skin flap survival but it has a significant antiproliferative effect on fibroblasts.

Double helical rim advancement flaps with scaphal resection: selected cases over 10 years and review of the literature.

BACKGROUND: Auricular surgery is a challenging subject in plastic surgery due to the complicated surface topography of the external ear. Although various techniques for ear reduction and helical rim reconstruction have been reported in the literature, an ideal method is yet to be defined. Double helical rim advancement flaps with scaphal resection presented in this report represent a practical technique for correcting macrotia and reconstructing helical rim defects. METHODS: The amount of full-thickness resection at the helical rim is planned according to the desired reduction or extent of tumor. After helical excision, an incision that transects all the layers of the ear is carried out along the helical sulcus inferiorly and superiorly to yield two advancement flaps. Using scissors, a crescent from the scapha is excised through the full thickness of the ear. The flaps are approximated and sutured to the scapha by means of stitches that pass through skin and cartilage. RESULTS: The described technique has been performed successfully since 1998. It has been used for 12 cases of macrotia, 28 cases of tumor surgery, and 7 cases of ear reduction for asymmetric ears. No major complications have been encountered. Three cases are reported as examples of the procedure. CONCLUSIONS: Double helical rim advancement flaps with scaphal resection represent a versatile and safe technique that can be used for ear reduction, helical rim reconstruction, and correction for discrepancy in size of ears.

Benign chondroid syringoma: atypical presentation of a rare eccrine tumor.

Chondroid syringoma is a rare eccrine tumor that is often benign but has the potential for malignant transformation and distant metastasis. Histopathological analysis may not be definitive, and any patient with atypical features, an accelerated clinical course, or high suspicion for malignant transformation is a candidate for immediate surgical intervention and close follow-up. The purpose of this article is to review the clinical features of this rare tumor with a special emphasis on its atypical presentation.

The Peruvian fisherman's knot: a new, simple, and versatile self-locking sliding knot.

BACKGROUND: In many plastic surgery operations that are undertaken through relatively small incisions resulting in deep-seated operating fields, sliding knots with a self-locking property are preferred by plastic surgeons for 3 reasons: simplicity, reliability, and versatility. We describe a new and versatile sliding knot that can be easily sledded and locked. METHODS: The technique of knot tying is described in detail as a stepwise approach with photographs. The main advantages of the Peruvian fisherman's knot are compared with other methods and summarized. RESULTS: In addition to its adjustment-related properties, knot security has been adequate with this knot as evidenced by its clinical performance and the authors' experiences to date. CONCLUSION: The Peruvian fisherman's knot is especially useful while working in deep seated operating fields through a small incision. Tension created during knot tying is adjustable, which makes it an ideal choice for various lifting procedures in plastic surgery.

The effects of the size of liposuction cannula on adipocyte survival and the optimum temperature for fat graft storage: an experimental study.

BACKGROUND: Determining the most advantageous size of liposuction cannula and injection needles in terms of adipocyte viability could help to increase fat graft survival. When recurrent injections are necessary, storing fat tissue which is harvested during the first operation could be a practical solution if it is stored at an appropriate temperature providing the highest amount of viable fat cells. METHODS: Fat tissue was removed from the abdomen of 10 consecutive female patients by 6-, 4- and 2-mm-diameter liposuction cannulas. Fat tissue harvested with the 6mm cannula was injected through 14, 16 and 20 g needles and collected in separate tubes. An additional three tubes of fat samples were prepared from fat tissue obtained with the 6mm cannula to be stored at +4, -20 and -80 degrees C for 2 weeks. Viability of the fat grafts was evaluated by fat cell isolation with collagenase digestion and staining with supravital dye and counting adipocytes with a haemocytometer. RESULTS: The viability of fat grafts harvested with the 6mm cannula was higher than grafts obtained with smaller cannulas. The viability of fat grafts injected through 14, 16 and 20 g needles were similar to each other. The viability of fat grafts stored at +4 degrees C was similar to fresh tissue whereas freezing fat grafts caused significant loss of viable adipocytes compared to fresh tissue. CONCLUSIONS: The use of larger liposuction cannulas for fat tissue harvesting provides more viable fat grafts. A temperature of +4 degrees C could be proposed as an effective and easily available way of storing fat grafts for at least 2 weeks.

Septocolumellar suture in closed rhinoplasty.

Several surgeons advise a variety of tip sutures and describe their own techniques in open approach. Septocolumellar suture is one of them and can be described as a loop suture between the medial crura and caudal septum. Although some of the articles mention that it can be applied in closed rhinoplasty, there is no description of the technical details. This paper presents indications, technical steps, and advantages of the septocolumellar suture in closed rhinoplasty. After completing the classic sequence of the endonasal extramucous technique, the medial crural cartilages are dissected from the overlying skin at the midcolumellar level, keeping the distal fibrous attachments between the anterior columellar skin and these cartilages intact. A 5/0 or 4/0 Prolene (Ethicon Ltd, UK) with a round needle is passed, penetrating both the medial crura and then the caudal septum. Depending on the penetration level of this suture, the tip projection can be increased or decreased, the tip can be rotated, and columellar show can be corrected. This suture also makes the medial crura of the alar cartilages and septum rigidly fixed together, thus providing stability. Depending on the experience gained in 433 primary and 62 secondary rhinoplasty cases since 2000, it can be claimed that this technique, presenting an alternative to the open approach in many cases and expanding the borders of closed approach, allows one to manipulate the tip and columella easily with closed rhinoplasty and provides a significant decrease in the suboptimal results and number of complications.

A case of skin necrosis as a result of cholesterol crystal embolisation.

Cholesterol crystal embolism is a multisystem disorder with a high mortality. It is usually seen following vascular surgery and long term anticoagulation therapy, but the diagnosis is often not considered. Skin manifestations are the first sign of cholesterol crystal embolism and recognition of the symptoms is a key element in early diagnosis and prevention of recurrences. We report a case who presented with acute renal failure, livedo reticularis and skin necrosis following angioplasty. Cutaneous biopsy revealed cholesterol crystals in the lumen of a vessel. Necrotic sites were treated with daily wound care and he was operated for reconstruction of tissue defects with cutaneous advancement flaps. One month after the operation healing was complete.

Medial pedicled orbicularis oculi flap.

Resurfacing of the medial canthal region and bony nasal dorsum is a problem frequently encountered after tumor excisions. Traditional flaps used in this region from the glabellar and frontal areas are bulky, and donor site scar may be unsightly. A medial pedicled orbicularis oculi myocutaneous flap is an alternative. A total of 12 flaps have been used to resurface the defects secondary to basal cell carcinoma excisions, with a mean follow-up of 10 months. All flaps survived. The flap elevation is easy and fast, and the flap can be extended to the contralateral site when needed. The skin match is good and donor morbidity is minimal.