The radix graft in cosmetic rhinoplasty.

Experience with rhinoplasty over time has shown that a detailed anatomic analysis of the nose is an essential first step in achieving a successful outcome. Failure to recognize a particular anatomic point preoperatively will often lead to a less than ideal long-term result. Deficiency in the radix is a commonly overlooked abnormality that may be found both in patients undergoing primary rhinoplasty and patients undergoing revision rhinoplasty after an overzealous bony hump removal. Whereas surgeons previously reduced the nasal dorsum down to the level of the radix on a routine basis, recent emphasis on a strong natural profile has focused attention on anatomic deficiency in the radix region. We describe a simple technique for treatment of the deep nasofrontal angle and present patient examples. Autologous cartilage grafts may be fashioned into a "radix graft" and reliably used to augment the region either with a precise pocket approach or without when a precise pocket is not possible, achieving a natural aesthetic result.

Risk of early renal allograft failure is increased for patients with antiphospholipid antibodies.

Renal allograft thrombosis can cause transplant failure. Because antiphospholipid antibodies (aPA) are associated with thrombosis, we investigated pretransplant sera from patients with early renal allograft failure to determine if aPA were present. Fifty-six final cross-match (FxM) sera from patients whose transplant failed within 16 days were compared to FxM sera from the next sequential transplant patients. The sera were tested for IgG, IgM, and IgA antibodies to cardiolipin, phosphatidylserine, and phosphatidylethanolamine. aPA were identified in 57% of FxM sera from patients with early non-function versus 35% of FxM sera from patients with functioning grafts (P = 0.02). Historical sera from 11 aPA-positive patients contained aPA up to 18 months prior to transplantation. Since aPA were present in historical sera, testing for aPA can identify certain patients at risk for early allograft failure. The involvement of aPA in early allograft loss is supported by studies demonstrating aPA recovery from an explanted failed transplant.

Treating the caudal septal deflection.

Caudal septal deflection can be a challenging nasal deformity. Although there are a number of maneuvers available to manage this functional and aesthetic abnormality, each approach is effective in only a limited number of cases. For over 25 years, the senior author (N.J.P.) has employed a "modified swinging door" technique for treatment of the deviated caudal septum. Using this technique, the septal cartilage along the maxillary crest is dissected free but is not excised. Instead, the caudal septum is flipped over the nasal spine, which acts as a "doorstop" and secures the caudal septum in a straighter position. This maneuver may be useful in the armamentarium of the surgeon managing this potentially difficult technical challenge.

The lateral osteotomy in rhinoplasty: clinical and radiographic rationale for osteotome selection.

A preferred osteotome for endonasal osteotomy would facilitate reliable, complete osteotomies with minimal soft-tissue trauma. In this report, a radiographic evaluation of the bony lateral nasal wall thickness along the track of a high-low-high osteotomy was undertaken to guide the determination of appropriate osteotome size. Bone window axial computed tomographic scans were evaluated in 56 patients with a mean age of 48 years (range, 19 to 86 years). The average thickness along the site of lateral osteotomy was determined to be 2.47 mm (standard deviation, 0.47) in male patients and 2.29 mm (standard deviation, 0.40) in female patients. On the basis of these data, clinical evaluation of prototype 3- and 2.5-mm low-profile guarded osteotomes was undertaken in comparison with a "standard" 4-mm low-profile guarded osteotome to assess both their reliability and the degree of intranasal trauma, as reflected by intranasal mucosal tears. Although 2- and 3-mm unguarded osteotomes are time-tested, they may be reliable only in the hands of the most experienced surgeons. Therefore, a low-profile guard was included in the osteotome design to allow the surgeon to engage the bone securely and minimize the risk of slippage. Forty patients underwent rhinoplasty, for a total of 80 lateral osteotomies; the mean age of the patients was 38 (range, 16 to 75). In all cases, lateral osteotomies were accomplished with one pass. The 4-mm osteotome causes intranasal mucosal tears in 95 percent of osteotomies, the 3-mm osteotome in 34 percent, and the 2.5-mm in 4 percent. Early postoperative edema and ecchymosis were comparable among the groups. One patient, who underwent osteotomies with a 4-mm osteotome, had excessive postoperative narrowing, possibly due to his wearing of eyeglasses earlier than directed. This report suggests that proper selection of osteotome and attention to proper surgical technique results in a reliable, minimally traumatic lateral osteotomy through the endonasal approach. The 2.5-mm osteotome was reliable and the least traumatic to soft tissue of the osteotomes evaluated.

Powered instrumentation for rhinoplasty and septoplasty.

Advances in surgical instrumentation are generally intended to allow the performance of a surgical maneuver more efficiently and accurately. Powered instrumentation may allow improved precision and ease in certain aspects of rhinoplasty and septoplasty. Through improved precision, tissue trauma can be minimized.

Antiphospholipid antibodies are a risk factor for early renal allograft failure.

BACKGROUND: Biopsy specimens of transplanted kidneys that fail to function reveal cellular infiltrates, infarcts, and thrombi. Because antibodies to phospholipids (aPA) and/or phospholipid-binding proteins have been associated with thrombosis, we asked whether aPA are a risk factor for early allograft failure. METHODS: Final crossmatch sera from 56 patients with primary nonfunctioning renal allografts were tested for aPA. Serum from the next consecutive patient to undergo transplantation served as transplantation controls. Both groups were compared with aPA values obtained from testing 252 control individuals. The ELISA was designed to detect IgG, IgM, and IgA antibodies to phosphatidylserine, cardiolipin, and phosphatidylethanolamine. RESULTS: Patients were evaluated based upon the aPA ELISA findings. aPA were present in 57% of the patients with early nonfunction renal allografts and 35% of the patients with functioning grafts (P=0.0234). aPA in previously hemodialyzed patients did not predict allograft failure or success (P=0.3766). In contrast, all nonhemodialysis patients who had aPA at the time of transplantation experienced early allograft failure (P=0.0022). CONCLUSIONS: These data show that aPA are an important risk factor for early renal allograft failure. Furthermore, aPA-positive patients who have no history of hemodialysis are at the greatest risk. Pretransplantation aPA screening of renal transplant candidates forewarns of early graft failure and indicates which patients may benefit from anticoagulant therapy.

A 3-year multi-institutional experience with the liposhaver.

OBJECTIVE: To report a 3-year multi-institutional clinical experience with the liposhaver in facial plastic surgery. DESIGN: Nonrandomized, nonblinded, multi-institutional evaluation of the liposhaver in a clinical setting. INTERVENTIONS: Seventy-two patients who presented for facial plastic surgical procedures underwent surgery with the liposhaver. Seventy-six liposhaving procedures and 74 concomitant procedures were performed. Standardized preoperative and postoperative photographs were obtained. OUTCOME MEASURE: Subjective evaluation by the surgeons who performed the procedures. RESULTS: The liposhaver was used successfully in all cases. The fat was cleanly shaved and the contour results were even, without dimpling or significant asymmetry. Operative time was comparable to that of conventional liposuction. There were no cases of facial nerve injury and no evidence of increased bleeding intraoperatively. Two male patients had small postoperative hematomas in the immediate postoperative period that were successfully treated with conservative measures. An additional patient developed a small hematoma on postoperative day 5 that was effectively treated with needle aspiration and a pressure dressing. CONCLUSION: This 3-year multi-institutional report suggests that the liposhaver continues to offer a precise alternative to conventional liposuction.

Aesthetic implications of surgical anatomy in blepharoplasty.

A successful outcome in rejuvenation surgery of the orbital region relies on a well-developed sense of the aesthetic goal and a critical understanding of the underlying anatomic basis for the deviation from this goal in a given patient. As the surgeon assesses the patient to determine the approach to achieve the best aesthetic result, careful consideration to both form and function must be undertaken. In this article we consider the orbital region by anatomic subunit with special attention to the anatomic causes for deviations from the aesthetic ideal. Exacting preoperative assessment of the patient's presenting anatomy is critical in guiding the surgeon to a proper approach. A conservative approach helps to minimize the risk of complications, which have both functional and aesthetic consequences. The implications of the specific anatomy for the surgical options to achieve the most desirable aesthetic result are discussed.

Thirty-five millimeter versus digital photography: comparison of photographic quality and clinical evaluation.

The objective of this article is to assess the quality of digital images versus standard 35-mm photodocumentation and to undertake a comparative assessment of 35-mm and digital photography in a clinical setting in facial plastic surgery. For evaluation of image quality, 10 subjects had images captured via a conventional 35-mm single lens reflex (SLR) camera and a digital camera under identical lighting conditions. The digital images were transferred to computer hard drive and processed for production of slides. Direct side-by-side comparison of projected images was performed by the authors. The standard photographic slides were of slightly finer detail and crispness than the computer-generated images. In a clinical setting, the quality of both the 35-mm and digital photographs enables complete preoperative evaluation and assessment of postsurgical outcome.

Standardized photography in facial plastic surgery: pearls and pitfalls.

Photographic images in facial plastic surgery play a critical role in photodocumentation, patient education, preoperative planning, and self-education. Consistent, uniform, high-quality photography allows the best opportunity for critical self-assessment and self-education. The purpose of this article is to review important elements in the production of standardized, uniform photographs with a 35-mm camera or with a digital camera. Equipment, lighting and background, film selection, and a standardized photographic technique are detailed. Principles of intraoperative photography are also reviewed.

Clinical study of alar anatomy and surgery of the alar base.

OBJECTIVES: To analyze and quantify specific aspects of alar base anatomy and to identify anatomic configurations that may be correlated with specific surgical manipulations. DESIGN: Analysis in a population of patients presenting for aesthetic nasal surgery. SETTING: Facial plastic surgery practice. PATIENTS: The photographic slides of 120 white patients who presented for consultation were reviewed. INTERVENTIONS: On the base view of photographic slides, observations were made on the width of the alar base, recurvature of the alar base, thickness of the alar lobule, thickness of the alar wall, and flare of the alar wall. On the lateral view, observations were made on the vertical insertion of the ala on the face (cephalic, normal, or caudal), contour of alar rim in profile (gentle S-shape or straight), size of alar lobule (small, normal, or large), and alar-columellar relationship, with special attention to the presence of alar hooding. MAIN OUTCOME MEASURES: A spreadsheet program was used to analyze the incidence of each configuration and any association between various features of the alar base. RESULTS: Anatomic diversity exists that requires a careful individual analysis for each patient. A planned surgical intervention must fit the patient's unique anatomy. Distinctive configurations of recurvature, vertical insertion, and other aspects of the alar base were observed, with special implications for the surgeon's approach. CONCLUSIONS: Anatomic diversity requires a thorough preoperative examination followed by selection of an approach that addresses the specific anatomic findings. The choice of the best alar reduction and sculpture technique ultimately relies on a precise analysis of the anatomic configuration of the patient's alar base.

Technical considerations in powered instrumentation.

This article reviews some of the technical engineering aspects of the soft-tissue shavers and bone-cutting drills. An improved understanding of these principles may allow the practicing surgeon to optimize the desired aggressiveness and precision of the instrument in his or her hands. Powered instrumentation has found extended uses beyond sinus disease, such as submental lipectomy (soft-tissue shaver) and modifying the bony nasal dorsum (bone cutting bur). Changes in drill design to address these and other surgical situations are discussed.

Follow-up of University of Virginia experience with the modified Lothrop procedure.

Current surgical treatment of the frontal sinus disease include external approaches to obliterate or ablate the sinus and both external and transnasal methods to restore drainage into the nasal cavity. The original Lothrop procedure resects the medial frontal sinus floor, superior nasal septum, and intersinus septum, creating a large frontonasal communication. However, as described, the external approach used in this procedure often allowed medial collapse of soft tissue and the stenosis of the nasofrontal communication. This report further relates our experience with the modified transnasal endoscopic Lothrop procedure using suction drills for cases in which frontal recess exploration had failed to relieve obstruction of the frontal sinus. We present an update of the University of Virginia experience in performing the modified Lothrop procedure in 20 patients from 10/93 to 4/95. Our findings over the follow-up period (average 12 months) have verified that this procedure is effective, with a 95% patency rate for the surgically enlarged frontal sinus ostium. When compared to osteoplastic flap with fat obliteration, the modified transnasal Lothrop procedure offers the advantages of a less invasive procedure with a shorter and usually no hospitalization, less morbidity, and the increased ability to evaluate post-operatively for recurrent disease. A patient charge analysis was also performed comparing patients undergoing frontal sinus obliteration during the same time period, revealing an additional benefit of decreased patient costs for the modified transnasal Lothrop procedure. None of our patients experienced complications, and all showed significant improvement, if not complete resolution of their symptoms. Although this procedure has produced favorable results, it should be noted that this procedure is technically demanding and will require further long term follow-up to verify its efficacy and proper role in the spectrum of surgical approaches for the treatment of chronic sinusitis.

Powered instrumentation for dorsal reduction.

We describe the use of powered instrumentation for precise modification of the bony nasal dorsum. Specific modifications were made to design a drill specifically for the bony nasal dorsum. This drill has a protective sheath that covers all but the active part of the drill, protecting the skin-soft tissue envelope, and it also has suction at the resection site. In some cases an osteotome is used to reduce the hump and the drill is used to achieve additional reduction and to smooth the exposed edges under direct vision. In other cases the entire bony hump is reduced using the drill. The nasal dorsum drill offers a precise alternative to the rasp. The precision of the drill is highlighted in cases in which limited reduction is needed, as in cases of a single or several spicules requiring reduction and smoothing after osteotomy, or a single 4 mm raised area requiring limited reduction. The design of rasps makes it difficult to work on these focal areas without unnecessarily rasping surrounding areas, whereas the drill may be used to reduce the entire hump, to smooth the edges after osteotomy, or in a more precise and limited fashion when indicated. The drill may be less traumatic to the skin-soft tissue envelope because it does not rely on the potentially bruising back and forth motion typical of rasping. The nasal dorsum drill may decrease the incidence of bony dorsal irregularities after rhinoplasty.

The liposhaver in facial plastic surgery. A multi-institutional experience.

OBJECTIVE: To report a multi-institutional clinical experience with the liposhaver in facial plastic surgery. DESIGN: Nonrandomized, nonblinded, multi-institutional evaluation of the liposhaver in a clinical setting in patients presenting for cosmetic facial liposuction. INTERVENTIONS: Cosmetic facial surgery with the liposhaver was performed in 19 patients (21 procedures) who underwent submental lipectomy, facelift with defatting beneath the facelift flap, and/or correction of deep nasolabial folds. Standardized preoperative and postoperative photographs were obtained. Fat obtained from the abdomen of 1 patient was also studied histologically. This fat was excised sharply and was then liposhaved at varying oscillation speeds. OUTCOME MEASURES: Subjective evaluation by the operating surgeons. RESULTS: The liposhaver was used successfully in all cases. The fat was cleanly shaved and the contour results were even, without dimpling or asymmetry. Operative time was comparable to that for conventional liposuction. Preferred cannula sizes and settings were determined. There were no cases of facial nerve injury, no evidence of increased bleeding intraoperatively, and no hematomas in the immediate postoperative period. One patient developed a small hematoma on postoperative day 5 that was effectively treated with needle aspiration and a pressure dressing. Histologic evaluation of liposhaved abdominal fat showed normal fat cells and well-preserved architecture. CONCLUSIONS: The liposhaver offers a precise alterative to conventional liposuction. It may be less traumatic because it requires low suction pressures and does not rely on the potentially bruising, vigorous, back-and-forth motion for fat extraction typical of conventional liposuction.

Modified transnasal endoscopic Lothrop procedure: further considerations.

The Lothrop procedure resects the medial frontal sinus floor, superior nasal septum, and intersinus septum to create a large frontonasal communication. However, the external approach often allowed medial collapse of soft tissue and stenosis of the nasofrontal communication. We describe a modified transnasal endoscopic Lothrop procedure in which drills are used for cases in which frontal recess exploration fails to relieve obstruction of the frontal sinus. The lateral bony walls are preserved, and medial collapse does not occur. The mucosa of the posterior table and posterior nasofrontal duct is preserved, and a single common frontal opening is created. We have found this approach to be safe and reliable. Fourteen patients have undergone this procedure without complication, achieving resolution or improvement of their symptoms and maintaining wide patency of the frontonasal opening. We recognize that long-term follow-up will be required but remain encouraged with our favorable results to date.

The soft-tissue shaving procedure for removal of adipose tissue. A new, less traumatic approach than liposuction.

OBJECTIVE: To introduce the soft-tissue shaving cannula, a new, precise alternative to conventional liposuction that embodies an entirely different method of soft-tissue extraction and that appears to be less traumatic and more precise than methods currently used in liposuction. DESIGN: Nonrandomized, nonblinded comparison of the soft-tissue shaver and conventional liposuction devices in fresh cadavers, followed by clinical use of the liposhaver in selected patients undergoing cosmetic facial liposuction. INTERVENTIONS: Conventional liposuction devices and the soft-tissue shaving cannulas in fresh cadavers (< 8 hours old). A submental lipectomy and a melolabial fold liposhaving were performed in a clinical setting. OUTCOME MEASURES: Subjective evaluation by the operating surgeons. RESULTS: The fat was cleanly shaved and the contour result was even, without dimpling or asymmetry. CONCLUSIONS: Our early experiences suggest that this new liposhaving technique may offer a precise, less traumatic alternative to conventional liposuction. Fat can be shaved in an open fashion under direct vision. It does not rely on a vacuum seal. The soft-tissue shaving cannula shaves fat one layer at a time. The depth of each layer removed, the depth of soft-tissue injury, and the optimal settings and sizes for various procedures remain to be reported.

Comparison of topical fibrin glue, fibrinogen, and thrombin in preventing seroma formation in a rat model.

Fibrin glue has been shown to decrease seroma formation in animal models. To further delineate this mechanism, the efficacy of fibrin glue was compared to topical fibrinogen and thrombin in preventing postoperative seromas. A model consistently producing seromas was developed by bilateral neck dissection, lymphadenectomy, and submandibular sialoadenectomy in the Sprague-Dawley rat. Groups of 20 rats underwent this procedure and were blindly treated with either fibrin glue, fibrinogen, thrombin, or saline control. Necropsy on postoperative day 5 revealed a statistically significant (chi-squared) decrease in seroma incidence using fibrin glue (0%) and fibrinogen (15%), while thrombin (95%) and saline (100%) were ineffective in preventing seromas. The use of fibrin glue and fibrinogen in this role merits further investigation.