The Keystone, Scroll Complex, and Interdomal Area of the Nose: Histologic and Anatomical Observations.

Comprehensive knowledge of nasal anatomy is essential for obtaining aesthetically and functionally pleasing results in rhinoplasty. In this study, the authors described the anatomy, histology, and clinical relevance of the interdomal region, keystone, and scroll complex. The current study examined these areas in 26 fresh cadaver heads. All cadavers were fresh, and no conservation or freezing processes were applied. All dissections were performed by the first author. It was determined that the structure that connected the middle crura in the interdomal region actually came together in the transverse plane and contained abundant capillaries within. It was observed that chondroblasts with high regenerative potential were present in the keystone area, and there was very tight attachment between periosteum and perichondrium. The scroll complex was found to be more flexible and thin and had fewer regenerative cells compared to the keystone region. With its unique anatomy and histology, the keystone acts as a transition area between the flexible and fixed units of the nose. The scroll complex should be taken into consideration during rhinoplasty because of its effects on fixation of the skin in the lateral supratip area and functional effects on internal and external nasal valves. The interdomal ligament, in contrast, acts as a transition between both middle crura rather than a real ligament.

Tip Reinforcement Flap: An Original Technique for Improving Nasal Tip Support and Definition.

BACKGROUND: Middle crura support deficiency and short middle crura can usually cause insufficient definition and projection of the tip and can sometimes result in a flat tip. The aim of this study was to investigate the effectiveness of a new technique involving a tip reinforcement flap to strengthen the middle crura and to achieve a well-projected and defined tip. METHODS: Twenty-nine patients who underwent primary open-approach rhinoplasty that included the use of tip reinforcement flaps were included in the study. Cartilage flaps that had been created from the excess cephalic portion of the lateral crura were prepared as medial crura-based cartilaginous flaps. RESULTS: There were 29 patients (17 women, 12 men) aged 18 to 44 years (mean age, 31 years). Follow-up time ranged between 3 and 25 months (mean, 21 months). Preoperative and postoperative average of nasal tip length was 10.84 (±1.07) mm and 14.32 (±2.34) mm, respectively (P = 0.0214). Preoperative and postoperative average of nasolabial angle was 97.42° (±9.84°) and 107.99° (±12.16°), respectively (P = 0.0344). Preoperative and postoperative average of nasal projection ratio was 0.53 (±0.04) and 0.57 (±0.03), respectively (P = 0.4347). The tip reinforcement flap technique provided strengthening and extra support for the middle crura and increased definition, projection, and stability to the domal area. CONCLUSIONS: The tip reinforcement flap technique offers advantages for tip plasty in those cases with middle crural deficiency, short middle crura, and middle crural weakness. The technique also provides an additional projection, stabilization, and definition to the nasal tip while reducing lateral crural cephalic excess. This technique improves nostril-lobular disproportion and has the advantage of hiding extra support grafted into the folded flap. Complications such as graft visibility, malposition, and asymmetry, which may occur with the use of classic tip grafts, can be eliminated with the tip reinforcement flap technique.

The lateral crural rein flap: a novel technique for management of tip rotation in primary rhinoplasty.

BACKGROUND: An important consideration in rhinoplasty is maintenance of the applied tip rotation. Different techniques have been proposed to accomplish this. Loss of rotation after surgery not only results in a derotated tip but also can create a supratip deformity. OBJECTIVES: As a supplement to dorsal reconstruction, the authors introduced and applied the lateral crural rein flap technique, whereby cartilage flaps are created from the cephalic portion of the lateral crura to control and stabilize tip rotation. METHODS: Eleven patients underwent primary open-approach rhinoplasty that included the lateral crural rein technique; the mean follow-up time was 18 months. Excess cephalic portions of the lateral crura were prepared as medial crura-based cartilaginous flaps and were incorporated into the nasal dorsum (similar to spreader grafts) and stabilized to achieve the desired tip rotation. RESULTS: The lateral crural rein flap technique provided stability to the nasal tip while minimizing derotation in the postoperative period. Long-term follow-up revealed maintenance of the nasal tip rotation and symmetric dorsal aesthetic lines. CONCLUSIONS: The lateral crural rein flap technique is effective for controlling nasal tip rotation while reducing lateral crural cephalic excess. Longevity of the applied tip rotation is reinforced by secure attachment of the lower nasal cartilage complex to the midvault structures. LEVEL OF EVIDENCE: 4.

The sandwiched lateral crural reinforcement graft: a novel technique for lateral crus reinforcement in rhinoplasty.

BACKGROUND: Misshapen or weak lateral crura can cause an inward collapse of the lateral crus observed on deep inspiration. The lateral crural strut graft is a popular technique for reinforcing lateral crura. Failure to stabilize the graft properly can, however, result in graft displacement postoperatively and an accompanying aesthetic deformity. OBJECTIVES: The authors discuss lateral crus reinforcement with the sandwiched lateral crural reinforcement (SLCR) graft. METHODS: An SLCR graft was placed in 30 nonconsecutive primary open-approach rhinoplasty procedures by the senior author (I.K.) between February 2010 and May 2012. Cephalic excess of the lateral crura was incised and placed under the lateral crura; the lateral crural strut grafts were placed between the 2 cartilages, and the cephalic edges of both the superior and inferior lateral crura segments were sutured together. RESULTS: Of the 30 patients, there were 5 men and 25 women ranging in age from 22 to 45 years (median, 35 years). Half (50%) of the patients received the SLCR graft for external valve collapse; in 30% of the patients, it was placed to support the lateral crura after correcting cephalic malpositioning; and 20% had an SLCR graft placed for lateral crural reinforcement after deformity secondary to dome-shaping sutures. No graft displacement or tip disfigurement was observed in the follow-up period (mean, 24 months). CONCLUSIONS: The SLCR graft technique represents a powerful tool for reinforcing lateral crura without discarding the cephalic portion of the cartilage, thus securing a stable graft pocket while minimizing any postoperative structural dislocation. LEVEL OF EVIDENCE: 4.

Does hyperbaric oxygen administration before or after irradiation decrease side effects of irradiation on implant sites?

BACKGROUND: One of the main limitations of implant-based breast reconstruction is the high rate of complications such as capsular contracture and poor aesthetic outcome, due to adjuvant radiotherapy. Hyperbaric oxygen treatment (HBOT) has been used to assist wound healing in the prevention and treatment of the side effects of irradiation. We aimed to investigate this effect of HBOT on the capsule reaction and skin, applied before and after irradiation, following the placement of an implant under the dorsal skin of the rat. METHODS: Fifteen Wistar rats were randomly divided into 3 groups. A 18-mL smooth testicular implant was introduced into a subcutaneous pocket located on the dorsum of each rat. A single dose of 17-Gy irradiation was given to the implanted area of each rat at the third week. HBOT which lasted 3 weeks was administered to group I before irradiation, group II after irradiation. The control group did not receive HBOT. All of the rats were killed at the ninth week (6 weeks after irradiation). The dorsal skin with the capsule overlying the implant were excised for histopathological processing. The thickness of the capsule reaction of each group was evaluated statistically. RESULTS: Our histopathological examination revealed changes due to radiation in the control group. Many of these findings were found to be more subtle in group I and nearly absent in the group II. There was not any statistical difference between the thickness of the capsule reactions of the control group and group I, or group I and group II, but the capsular thickness of the control group was statistically higher than group II. CONCLUSION: It can be predicted that the use of HBOT following irradiation is an effective tool to reduce the capsule reaction of the implanted area and the tissue damage seen in radiodermatitis.

A retrospective study on the epidemiology and treatment of maxillofacial fractures.

BACKGROUND: Maxillofacial injuries constitute a substantial proportion of cases of trauma. This descriptive analytical study assesses the cause, type, incidence, and demographic and treatment data of maxillofacial fractures. METHODS: A retrospective study on maxillofacial traumas was carried out in the Department of Plastic and Reconstructive Surgery at Sisli Etfal Hospital (Istanbul, Turkey) between January 1, 2000 and December 31, 2005. The study included 216 patients with a mean age of 29.8 years. Sex and age distribution of patients, etiology of trauma, localization of the fractures, treatment modalities, time to treatment after the trauma, and postoperative complications were recorded. RESULTS: The male predilection was 75.5%. Road traffic accident was the most common causative factor (67.1%), followed by interpersonal violence (19.4%), falls (12.5%), and work- and sport-related accidents (0.9%). A total of 50% of the patients suffered isolated mandibular fractures, 23.6% had isolated midface fractures, and 26.3% had combined midface and mandibular fractures. Regarding distribution of mandibular fractures, the majority (26.8%) occurred in the parasymphysis, 14.8% in the angulus, and 11.1% each in the symphysis and corpus. Complications occurred in 6% of patients, and the most common was malocclusion followed by infection and nonunion. CONCLUSION: The causes and pattern of maxillofacial fractures reflect trauma patterns within the community and, as such, can provide a guide for the design of programs geared toward prevention and treatment.

Nasal reconstruction based on subunit principle combined with turn-over island nasal skin flap for nasal lining restoration.

The reconstructive plan of full-thickness nasal defects should include recreation of internal nasal lining, skeletal and cartilaginous support and external cover. We performed nasal reconstruction combined with turn-over island nasal skin flap for nasal lining reconstruction in 12 patients who underwent full-thickness resection of nasal area because of skin cancer. The flap filled the nasal lining defect of the alar area and provided a good support for skeletal reconstruction. The external skin coverage, which was enlarged according to the subunit principle, was restored by the forehead skin flap at the same operation. Enlarging the nasal defect according to the subunit principle and using the residual skin as a turn-over skin island flap for nasal lining, combined with forehead skin flap for external coverage, provides an excellent nasal reconstruction in a single operation.

Vertical reduction mammaplasty: preventing skin redundancy at the vertical scar in women with large breasts or poor skin elasticity.

The authors describe a vertical reduction mammaplasty technique for avoiding skin excess at the vertical scar. Conical projection of the breast is achieved by cranial to caudal gland-shaping sutures. Excision of redundant skin is performed in a triangular pattern, creating bilateral dog ears. Resection of these dog ears results in a short, symmetrical horizontal scar located at the new submammary line.

[An alternative method for the correction of enophthalmos: deep lateral orbital approach]. / Enoftalminin düzeltilmesi için alternatif bir yaklasim: Derin lateral orbita girisimi.

Both increased orbital volume due to inadequate orbital floor reconstruction and loss of orbital volume may result in enophthalmos. Enophthalmos, vertical dystopia, and "lateral scleral show" deformity were detected in a 33-year-old female patient who presented with periorbital deformities after three operations for the correction of traumatic zygomatic fracture. First, vertical dystopia was repaired by reinforcing the orbital base with cranial bone grafting. Since enophthalmos was not successfully corrected, orbital volume augmentation was performed using the deep lateral wall through an upper eyelid crease incision. The only postoperative complaint was edema which was controlled by application of ice.

Evaluation of the effects of tip-binding sutures and cartilaginous grafts on tip projection and rotation.

BACKGROUND: Numerous approaches and techniques have been described to achieve a desired result in tip surgery, but there are few studies that define or analyze the changes that occur after surgery. Therefore, the authors planned a study to document changes in nasal tip projection, crural and lobular lengths of the columella, columellar length, and proportional relationships of tip projection and columella with dorsal length. METHODS: Analysis was based on data collected from preoperative and 1-year postoperative lateral views of 18 patients who were randomly chosen. The tip-binding suture group included nine patients and the cartilaginous graft group included nine patients. The measurements were obtained using the parameters regarding tip projection and rotation on standardized photographs. The values were statistically analyzed with paired and unpaired t tests. RESULTS: The changes in all parameters except crural length were statistically significant in the tip-binding suture group. In contrast, the statistical analysis of the cartilaginous graft group revealed prominent dimensional changes in tip projection and especially in crural and lobular segments. CONCLUSIONS: The authors believe that cartilaginous grafts should be considered if the dimensional changes have priority in the preoperative plan. The columellar strut graft provides satisfactory structural tip support and dimensional changes in crural length. Shield grafting causes augmentation in the lobular segment. If minor dimensional changes with more rotational alterations are planned, tip suture techniques should be preferred.

A new simple method used to prepare fat for injection.

Various clinical and experimental studies on harvesting techniques, donor sites, preparation, and preservation of fat for injection imply that there is no universal agreement on an ideal methodology. Unpredictable and irregular resorption of fat leads to uncertainty about volume maintenance of the transplanted fat necessitating repeat procedures. In this report, the authors present their 5-year clinical experience with facial fat grafting by isolated and combined procedures using a simple method that they developed for fat preparation. This technique includes fat harvesting with syringe aspiration and filtration of the fat aspirate instead of centrifugation. The idea for filtration was inspired by a yogurt concentration method used in Anatolia. The authors also aimed to increase fat survival by using multiple fat injections of minimal amounts into different levels.

Hair removal with the long-pulse alexandrite laser.

BACKGROUND: Although laser depilation has been performed for removal or reduction of unwanted and dark-colored hair in recent years, techniques including the appropriate approaches for different skin types and body areas have not yet been optimized. OBJECTIVE: We review the principles of laser hair removal and report a retrospective study of 322 patients who received long-pulse alexandrite laser hair removal for 3 or more sessions between January 2000 and December 2002. METHODS: Prior to treatment, patients were evaluated by a physician and informed of the mechanism, efficacy, and possible side effects of treatment. Patients were classified by skin type according to the Fitzpatrick classification. Those patients with systemic disease, a history of sun sensitivity, or who had used drugs known to cause photosensitivity were excluded from laser treatment. All treatments were performed with a long-pulse alexandrite laser with a constant spot size (18 mm) and 3-ms pulse width that applied energy of 755 nm. Sessions were repeated at different intervals depending on the body parts to be treated. RESULTS: The overall hair reduction rate for all patients, independent of skin type, was estimated as 80.8%. There were 2 cases of hypopigmentation and 8 cases of hyperpigmentation post-treatment. No other complications were reported. CONCLUSIONS: Treatment with the long-pulse alexandrite laser can meet the expectations of patients who desire permanent hair removal. Careful examination of patients prior to therapy, as well as thorough patient education, are essential to patient compliance and success with this technique.

Comparison of accuracy of three-dimensional spiral computed tomography, standard radiography, and direct measurements in evaluating facial fracture healing in a rat model.

Complex maxillofacial fractures demand a detailed understanding of the three-dimensional (3D) pattern of injury. Evaluation of the outcome of the facial fracture repair additionally requires optimal demonstration of fracture gap, bony union, fibrous callus or incorporation of fracture ends, presence of incomplete fusion, or pseudoarthrosis. Although 3D computed tomography (CT) is reliably used for the diagnosis of complex facial fractures, its value in facial fracture healing is unknown. An experimental study was conducted to determine the accuracy of 3D spiral CT scans in evaluating facial fracture healing during the early and late postoperative periods. In 10 adult Wistar Albino rats, a standardized bone defect (3 mm) was created within the mid portion of each zygomatic arch (n = 20). At 10 and 20 weeks postfracture, gap distance displayed by 3D CT and plane radiography (posteroanterior) were measured. At 20 weeks postfracture, intraoperative measurement was also performed. A comparison between 3D CT, radiography, and intraoperative findings was performed. At 10 weeks postfracture, the fracture sites displayed larger bone defects in imaging with 3D CT than with plane radiography. The difference between groups was statistically significant (P < 0.05). The mean defect size imaged by 3D CT was 0.91 +/- 0.82 mm (standard deviation) and by plane radiography was 0.42 +/- 0.16 mm. At 20 weeks postfracture, the mean defect size imaged by 3D CT was 0.56 +/- 0.64 mm, and by plane radiography was 0.38 +/- 0.22 mm. The difference between groups was not statistically significant (P > 0.05). The defect size imaged by both plane radiography and 3D CT was significantly less than the measurement obtained from the intraoperative assessment (P < 0.05). It was concluded that 3D CT has limited benefit in the detection of newly formed bone at week 10 and in the detection of fibrous callus, which can eventually give rise to the bony tissue. Plane radiography is more valid during the early postoperative period (week 10), because it can detect the fibrous callus and newly formed bone more precisely. Gap distance between fracture ends could be determined by 3D CT accurately at week 20, although there was a tendency, which was not statistically significant, to overestimate the amount of bone defect measured by 3D CT when compared with that of plane radiography.

Effects of vinblastine on healing in microvascular anastomosis.

Reconstructive microsurgical procedures are getting more common in cancer patients. Adjuvant therapies, such as chemotherapy, radiotherapy, and immune therapy, are usually combined with surgical approaches to improve outcomes. This study was designed to investigate the effects of preoperative chemotherapy on healing in microvascular anastomosis. As a commonly preferred drug for neoadjuvant cancer treatment, vinblastine was used on rats in our study. Ninety-three Sprague-Dawley rats were used and randomly allocated into two groups as 72 experimental and 21 control rats. Vinblastine 2 mg/kg was administered as a single dose intraperitoneally on day 0 in the experimental group. Leukocytes and erythrocytes were counted on days 0, 1, 3, 5, 7, 10, and 15 in 6 rats of the experimental and 6 rats of the control group. We found that the neutropenia period ended on approximately day 7. After applying the medication, the experimental group (n = 72) was divided into three main groups (n = 24). We performed end-to-end femoral artery anastomosis on days 7 or 14 or 21, respectively, in each group. Each main group was divided into three subgroups (n = 8), and then we tested patency and took biopsies on days 7 or 14 or 21, respectively, in each subgroup. Histopathologic evaluation was carried out. The comparison of patency tests and pathologic examination indicated that there was no statistically significant difference between the two groups.