Correction of nasal valve stenosis with lateral suture suspension.

OBJECTIVE: To evaluate the effectiveness of using suspension sutures to relieve obstructed nasal breathing caused by nasal valve stenosis. SUBJECTS, MATERIALS, AND METHODS: A nonrandomized pilot study of postrhinoplasty patients presenting with symptoms of obstructed nasal breathing was conducted in a private facial plastic surgery practice. All patients demonstrated nasal valve stenosis with a positive Cottle maneuver, clinically evident nasal valve collapse, and lack of response to efforts at reduction in turbinate size. Follow-up ranged from 7 to 12 months. Four men aged 31 to 58 years (mean age, 43 years) and 5 women aged 26 to 52 years (mean age, 39 years) were included in this study in a 1-year period. The nasal valve was suspended with 2 permanent sutures on each side, which were tunneled within the facial soft tissue to an infraorbital incision to lateralize the nasal valve complex and relieve nasal airway obstruction. Subjective self-assessment data for nasal airflow were collected. Preoperative and postoperative observation and photographic analysis provided objective data. RESULTS: All patients exhibited improvement. CONCLUSIONS: Relief of nasal valve stenosis can be achieved with suspension suture technique as described. It is effective and, in our experience, has been the most predictable means of achieving improvement in nasal obstruction secondary to nasal valve stenosis.

Interdomal fat pad: an important anatomical structure in rhinoplasty.

OBJECTIVE: To describe the interdomal fat pad, an important anatomical structure that, to our knowledge, has not been reported in the rhinoplasty literature. DESIGN: Anatomical observations were made during a consecutive series of external rhinoplasties, and the existence of the interdomal fat pad was documented in patients with noses of varying nasal skin thicknesses. SETTING: Private facial plastic surgery practice. PATIENTS: One hundred consecutive white patients undergoing external rhinoplasty were analyzed. Thirty-seven patients were undergoing secondary rhinoplasty and were excluded. Sixty-three patients undergoing primary rhinoplasty were enrolled into the study. INTERVENTION: None. MAIN OUTCOME MEASURES: The nasal skin type of each patient was subjectively determined preoperatively to be thin, average, or thick. The presence or absence of a distinct fat pad between the domes of the lower lateral cartilages was observed and recorded in each group of patients. RESULTS: Among the 63 patients studied, 22 had thick skin; 31, average skin; and 10, thin skin. Well-defined interdomal fat pads were noted in 12 patients with thick skin, 13 patients with average skin, and 2 patients with thin skin. CONCLUSIONS: There is a distinct anatomical structure that we refer to as the interdomal fat pad that exists in noses of all skin types. The awareness of this structure should encourage a careful and direct examination of the undersurface of nasal tip skin. An unrecognized, extensive fat pad may interfere with tip narrowing and refinement. It may be the cause of persistent postrhinoplasty supratip fullness and excessive tip width. Arch Facial Plast Surg. 2000;2:260-263

Anatomical considerations in the management of the hanging columella.

OBJECTIVES: To review the anatomy and dynamics of the hanging columella and to describe a technique to correct the causative anatomical deformity. DESIGN: Case series. SETTING: A facial plastic surgery private practice in Highland Park, NJ. PATIENTS: Consecutive sample of 10 patients (6 women and 4 men), aged from 27 to 52 years (mean age, 32 years). INTERVENTIONS: Through an external approach, the principal method of repair used in all cases involved transecting the medial and lateral crura at their angles to allow straightening of the medial crura. MAIN OUTCOME MEASURES: Comparative, standardized measurements of the alar-columellar complex in preoperative and postoperative photographs. RESULTS: Angle transection changed the spatial relation of the medial and lateral crura to each other resulting in straightening of the excessively curved medial crura. All patients had successful correction of the hanging columella. CONCLUSIONS: In our prospective study of 10 patients who required correction of hanging columellas, we have found the primary cause to be C-shaped curvature of the medial crura and their relation to the lateral crura. We observed long medial crura that were excessively curved, of normal width, and held in place by their continuity with the lateral crura. Dividing the alar cartilages at the angle of the medial and lateral crura released the connection of these structures allowing the medial crura to assume a straighter configuration. Tailoring of the feet of the medial crura and minimal septal shortening were occasionally used. Columellar struts, which were often used for other reasons, also provided additional medial crural straightening.

Cartilage wound healing. An overview.

Cartilage wound healing is a tentative balance between deposition of type I collagen in the form of scar tissue and repair by expression of type II collagen and proteoglycans. Small full-thickness cartilage defects are replaced by fibrocartilage, whereas partial-thickness defects are normally repaired by deposition of fibrous scar tissue. The mechanism of fibrocartilaginous repair appears to be mediated by proliferation and differentiation of mesenchymal cells of the marrow. Biologic grafts such as perichondrium have been successfully used to repair full-thickness defects, probably because they contain progenitor cells that can differentiate into chondroblasts. Other grafts composed of fibrocartilage, such as meniscus, appear potentially useful because they serve as a source for chondrocytes. When graft material is unavailable or cannot be easily fashioned to fit the defect, cell-cultured materials containing chondrocytes or progenitor cells appear promising. Finally, growth factors such as somatomedin-C have growth-promoting effect on cartilage and offer a future means of promoting cartilage repair.

Performance standards for medical device approvals.

As a result of the controversy concerning the safety of silicone and other permanent implants, the Food and Drug Administration's Center for Drug Evaluation and Research has conducted a rereview of a small sample of applications by manufacturers. The Food and Drug Administration's "Final Report of the Committee for Clinical Review" found that clinical trials were carried out with little planning or attention to the purpose of the study. It is urged that the medical profession assist in the establishment of complication rates associated with each type of implant and surgical procedure and that surgeons and professional societies need to be more critically involved in the setting up of performance standards for implants prior to their approval by the Food and Drug Administration. To avoid a repeat of the silicone gel-filled breast implant problem, scientists and clinicians are urged to take a more proactive position on the development of performance standards for implants currently being used.

Intraoperative custom contouring of the mandible.

OBJECTIVE: The purpose of this study was to apply a quantitative approach to augmentation mentoplasty with Silastic implants to achieve consistently accurate results. A Silastic extension wafer was introduced for custom contouring implants as part of this technique. DESIGN: Case series. SETTING: Private practice. PATIENTS: One hundred patients undergoing elective facial cosmetic surgery. For the main outcome measure, ideal profile augmentation was defined as projecting the most anterior point of the patient's chin on profile to within 2 mm of a vertical line dropped from the lower lip. RESULTS: Using a quantitative approach, 98 of 100 patients were able to achieve ideal profile augmentation. CONCLUSIONS: A quantitative approach to augmentation mentoplasty can provide consistently accurate results. Easy intraoperative customization of Silastic implants is necessary for this type of technique. A Silastic extension wafer is an effective method for intraoperative customization of implants.

The use of Collagen Matrix to enhance closure of facial defects.

Facial defects created by removal of various types of skin cancer are usually closed primarily. There are some areas of the face where primary closure produces less than optimal results. We have utilized a non-reactive collagen sponge (Collagen Matrix) to enhance closure by secondary intention following removal of skin cancers. This presentation describes the properties of Collagen Matrix as well as the technique we utilized for closure of facial defects following tumor removal.

Mechanical properties of septal cartilage homografts.

The compressive mechanical properties of untreated and chemically and physically treated nasal septum homografts were determined. Mechanical properties of control, saline-, thimerosal (Merthiolate)- and Alcide-treated specimens were similar. At high strains, the stiffness of treated cartilage ranged from 12.8 to 22.5 MPa and was unaffected by storage time. In comparison, irradiated and freeze-dried nasal septum exhibited stiffnesses of 35 and 37.5 MPa, respectively, after approximately 1 month of storage. These values of stiffness were significantly different from controls at a 0.95 confidence level. On the basis of these results, it was concluded that Alcide and Merthiolate treatment did not alter the compressive mechanical properties of cartilage and that a combination of these treatments may adequately sterilize and preserve nasal septum homografts.

Clinical applications of electron microscopy in the analysis of collagenous biomaterials.

Scanning and transmission electron microscopy are of clinical value in assessing the interaction between biomaterials and ingrowing tissues. Ultrastructural information allows the clinician and biomaterials specialist to determine events occurring during wound healing and the biocompatibility of prosthetic devices. This paper reviews some of the experimental and clinical studies done in our laboratory on the use of natural and reconstituted collagen as replacements for connective tissues. Consideration is given to collagen flakes used for the treatment of dermal ulcers, a collagen fiber prosthesis used for tendon and ligament replacement, the effects of chemical preservatives on cartilage used for replacement of tissues during plastic surgery and the growth and orientation of nerve cells on reconstituted collagen fibers. Our results show that reconstituted collagen can be prepared into prosthetic devices which encourage cell attachment and orientation thereby facilitating healing of injured tissues. Furthermore chemical preservation of cartilagenous tissues kills chondrocytes resulting in eventual resorption by inflammatory cells.