Anatomic basis and clinical implications for nasal tip support in open versus closed rhinoplasty.

Successful rhinoplasty depends on nasal tip support and its influence on nasal tip projection. The factors involved in nasal tip support are numerous; however, the role of the anterior septum versus the lower lateral cartilages has been debated in the literature. The purpose of this study was to quantitate, using fresh cadavers, the critical elements for nasal tip support with open versus closed rhinoplasty techniques. Multiple nasal manipulations, including cephalic trim, cephalic trim and interruption of the lower lateral cartilages, dorsal hump resection (1 to 4 mm), submucous resection of the septum, and complete septal removal, were performed using fresh cadaver heads and using both the open and closed rhinoplasty approach. Changes in nasal tip support were recorded. In comparing similar procedures, the mean loss of tip projection for the open approach was 3.43 mm versus 1.98 mm for the closed approach (p < 0.001). There was a significantly larger loss of tip projection in open versus closed procedures for cephalic trim, cephalic trim and interruption of the lower lateral cartilages, and cephalic trim with interruption of the lower lateral cartilages and septum removal (p < 0.001, 0.001, and 0.001, respectively). We attributed the differences between the open and closed approaches to the increases in ligamentous disruption and skin undermining that occur when using the open approach. Septum manipulation in general resulted in larger losses in tip support in both the open and closed approach. We conclude that the open approach for rhinoplasty results in a significantly increased loss of tip projection when compared with the closed technique due to the larger disruption of ligamentous support. Contrary to previous data, septal manipulation resulted in significant losses of tip projection, most likely secondary to lowering the nasal septal angle, and this effect may be more significant in closed rhinoplasty. The apparent clinical implications are that active measures, such as columellar struts and/or suture techniques for adding or maintaining nasal tip support during rhinoplasty, are indicated, especially when using the open approach and when any anterior septal alteration is performed using the open or endonasal approach.

Anatomy of the nasolabial fold.

An anatomical evaluation involving the nasolabial fold was performed on three fresh cadavers. Both gross and histologic analyses were made. The mimetic muscles were noted to have dermal extensions to the skin overlying the nasolabial fold. The dynamics of these mimetic muscles were evaluated subsequently in the clinical setting. Marked dimples and contour irregularities could be elicited by selectively contracting these muscles. Our findings suggest that it may be possible to improve the contour over the nasolabial fold during rhytidectomy procedures by severing the dermal extensions of the mimetic muscles along the nasolabial fold. This may allow better gliding of the skin and subcutaneous tissue over the nasolabial fold, thereby resulting in a smoother crease.

CO2 laser safety considerations in facial skin resurfacing.

Carbon dioxide lasers have been used increasingly in the field of aesthetic plastic surgery, specifically for facial resurfacing procedures. As many plastic surgeons are now venturing into the arena of laser surgery for the first time, it is paramount to understand basic laser safety principles to protect our patients, the operating room personnel, and the laser surgeon. This article reviews basic laser principles and practices and delineates the safety requirements needed to perform laser resurfacing using the CO2 laser system. We subjected several common objects present in the operative field during resurfacing procedures to multiple passes of both the Coherent 5000 C laser and the Laser Industries (Sharplan) model 150XJ laser Silktouch to assess flammability and margins of safety. We tested endotracheal tubes, wet and dry towels, wet and dry gauze sponges, cottonoids, eye protectors, and ophthalmic ointments. Neither flame nor burn was incited in the moistened preparations. The dry objects tested produced flame. The plastic corneal protectors began to melt by the third pass and produced significant heat. Lastly, both the Lacrilube and Bacitracin ophthalmic ointments began to vaporize after three laser passes. On the basis of our findings in this study, we recommend guidelines for prudent and safe CO2 laser usage in facial skin resurfacing.

Saline made viscous with polyethylene glycol: a new alternate breast implant filler material.

Silicone shell implants filled with either saline or polyethylene glycol 20,000 at 85 percent weight/volume were placed subcutaneously on the dorsal aspect of 20 rabbits, and after 2 weeks, selected implants were ruptured by subcutaneous insertion of a hypodermic needle. After 6 weeks and 6 months, histologic analyses of tissue samples from both groups showed no deviation in any organ from the norm. Further physical and chemical experiments on these devices showed no contradiction to their use as potential alternative filler material for breast implants in plastic surgery.