Role of Membranous Septum in the Alar-Columellar Relationship: Strategies in Closed-Approach Rhinoplasty.

A normal alar-columellar relationship is crucial for lower third finesse in rhinoplasty. Hanging columella is a common complaint in the alar-columellar relationship and membranous septum excision is frequently recommended for its correction. This paper focuses on the role of the membranous septum in achieving a normal alar-columellar relationship. It was aimed to present an algorithm that could be used for aberrancies in the alar-columellar relationship.Ninety-seven patients who underwent closed-approach rhinoplasty between January and December 2022 were included in this retrospective study. Routine tip plasty maneuvers were performed on all patients. Membrane septum excision was not performed in any of the cases. Standardized preoperative and postoperative 12-month lateral view photographs were scanned for hanging or retracted columella.Hanging columella was observed in seven patients preoperatively (n = 97). No hanging or retracted columella was observed postoperatively.Hanging columella can be successfully corrected with alternative surgical maneuvers without excision of the membranous septum in closed-approach rhinoplasty in appropriate cases. Complete preservation of the membranous septum does not cause hanging columella in the postoperative period.

Comparison of Different Suture Techniques on Nasal Soft Tissue Envelope to Prevent Supratip Deformity: A Histologic Study.

BACKGROUND: Studies have described various surgical maneuvers in rhinoplasty to limit thickening from excessive scarring in the supratip region. This study aimed to compare the effectiveness of three maneuvers-a simple suture, a U suture, and bolster dressing-used to avoid supratip deformity in a rabbit model. METHODS: Thirty-two male New Zealand white rabbits were included. The animals were divided into four groups, and dissection was performed in the supra-perichondrial plane up to the supratip region through an open rhinoplasty incision. After dissection, the following approaches were applied to the supratip region: Group 1, simple approximation suture; Group 2, U suture; Group 3, bolster dressing; and Group 4 (control group), no suture. All animals were sacrificed after 12 weeks. Histological analysis was performed. RESULTS: In Group 4, scar thickness was significantly greater than in the other groups (p < 0.05). Group 3 had greater scar thickness than Group 2 (p < 0.05). The ratio of scar thickness to skin thickness was higher in Group 4 compared with the other groups (p < 0.05). Finally, there was no difference in the ratio of scar thickness to skin thickness between Groups 1, 2, and 3 (p > 0.05). CONCLUSIONS: In this study, it was concluded that surgical methods using sutures in the supratip region reduced scar thickness in a rabbit model, and these surgical methods had similar levels of effectiveness. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of Polypropylene and Polydioxanone in the Hemitransdomal Suture: A Novel Rabbit Ear Cartilage Model.

BACKGROUND: Lower lateral cartilage reshaping is one of the basic steps in rhinoplasty. Hemitransdomal suture is frequently used for dome narrowing. Different suture materials can be used for hemitransdomal suture. In this study, we investigated the effectiveness of polypropylene and polydioxanone in hemitransdomal suture by designing a new experimental model in the rabbit ear cartilage. METHODS: Twelve young adult male New Zealand White rabbits were used. The bipedicled inverted-U-shaped cartilage was elevated in each ear of the rabbits. Two hemitransdomal sutures were applied using 5-0 polypropylene on one ear and 5-0 polydioxanone on the other ear randomly. A 5 mm high cartilage mound was created with two hemitransdomal sutures on each side. The sample size was twelve both in the polypropylene group and the polydioxanone group (n = 12). All animals were sacrificed after three months. Cartilage mound heights were measured. The samples were examined histologically regarding fibroadipose tissue, inflammation, foreign body granuloma, cartilage degeneration, and the presence of inclusion cyst. RESULTS: Cartilage mound height was significantly higher in the polypropylene group than in the polydioxanone group at the end of the third month [3.75 mm (± 0.68) vs. 3.03 mm (± 0.69); p < 0.05]. There was no significant difference between the two groups in histological analysis (p > 0.05). CONCLUSIONS: Polypropylene suture may be more effective in maintaining the shape given to the dome by hemitransdomal sutures in rhinoplasty. No Level Assigned This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.

Simplified Septal Stabilization in Closed-Approach Low-Septal-Resection Dorsal Preservation Rhinoplasty.

BACKGROUND: Septal fixation is a basic step in low-septal-resection dorsal preservation rhinoplasty. Inadequate septal stabilization can lead to supratip depression or more severe saddle nose deformity. This paper presents a simple surgical maneuver to stabilize quadrangular septal cartilage instead of suture fixation to the anterior nasal spine. METHODS: Thirty patients who underwent closed-approach low-septal-resection dorsal preservation rhinoplasty between July and December 2021 were included in this retrospective study. Depending on the surgical maneuver performed to stabilize quadrangular septal cartilage, the patients were divided into 2 groups as follows: (1) a group in which the septum was stabilized with transfixion sutures (the transfixion suture group) and (2) a group in which the septum was fixed to the anterior nasal spine with suture (the anterior nasal spine suture fixation group). Standardized postoperative 12-month lateral-view photographs were scanned for the presence of supratip depression or saddle nose deformity that may indicate insufficient septum stabilization. RESULTS: Supratip depression was observed in 1 patient in the transfixion suture group (n = 16) and in 1 patient in the anterior nasal spine suture fixation group (n = 14; P > 0.05). No saddle nose deformity was observed in either group. CONCLUSIONS: Transfixion sutures seem effective in providing septal stabilization to prevent supratip depression or saddle nose deformity in closed-approach low-septal-resection dorsal preservation rhinoplasty. Transfixion sutures can be used for septal stabilization in closed-approach rhinoplasty, allowing the surgeon to take advantage of the ease of placement.

Lateral Crural Turn-Up Flap for Increasing the Volume of Cartilaginous Nasal Sidewall in Closed-Approach Dorsal Preservation Rhinoplasty.

BACKGROUND: Dorsal preservation rhinoplasty can also be applied in crooked nose cases. This article describes a lower lateral cartilage-based flap (lateral crural turn-up flap) used to correct cartilaginous nasal sidewall asymmetries. It was aimed to introduce a flap to be used in crooked nose cases operated with dorsal preservation rhinoplasty and to show possible modifications of this flap. METHODS: Eight patients who had lateral crural turn-up flap due to crooked nose between July and December 2021 were included in this retrospective study. Standardized preoperative and postoperative 12-month front-view photographs were analyzed and scored for correction of midvault nasal sidewall asymmetries by 2 plastic surgeons. The Rhinoplasty Outcome Evaluation (ROE) scale was applied at 12 months. RESULTS: The mean score given by the surgeons for correction of midvault nasal sidewall asymmetries was 4.18. The mean ROE score was 89, and all patients were satisfied according to their ROE scores. There were no major complications. CONCLUSIONS: Unilateral lateral crural turn-up flap seems to be effective in correcting cartilaginous nasal sidewall asymmetries in crooked nose cases operated with dorsal preservation rhinoplasty.

Comparison of the effectiveness and safety of the "endoscope-assisted polypropylene mesh lift" and "gliding brow lift" techniques for the treatment of lateral brow ptosis.

BACKGROUND: There are many techniques used to treat lateral brow ptosis. This study compared two techniques that are used for lateral brow rejuvenation in terms of effectiveness and safety-namely, endoscope-assisted polypropylene mesh lift (EAML) and gliding brow lift (GBL). METHOD: Eighty-six patients who underwent brow lift surgery between March 2018 and June 2020 were included in this retrospective study. Forty-four patients were operated on using the EAML technique, whereas 42 patients were operated on using the GBL technique. The measurement of defined distances in photographs was carried out using a software, and the Brow Positioning Grading Scale (BPGS) and Global Aesthetic Improvement Scale (GAIS) were applied in the pre and postoperative periods. RESULTS: The measurement results obtained in the postoperative period were better than those obtained in the preoperative period for both the techniques, whereas the results obtained at postoperative month 3 were found to be better than those obtained at month 12 (p < 0.05). The results were similar between the measurements at postoperative months 3 and 12 for both the techniques. The loss of brow height from postoperative months 3-12 was greater in the GBL group (p < 0.05). The postoperative scores on the BPGS were found to be better in both techniques than the preoperative scores (p < 0.05). The GAIS score at postoperative month 12 was found to be better in the EAML group. The two groups had similar rates of complications. CONCLUSION: The two techniques were found to have similar effectiveness and safety profiles for brow rejuvenation.

Transection of Pitanguy's Midline Ligament to Avoid Supratip Depression in Closed-Approach, Low-Septal-Resection Dorsal Preservation Rhinoplasty.

BACKGROUND: Supratip depression is a common complication after preservation rhinoplasty. OBJECTIVES: This aim of this paper was to present a simple surgical maneuver to prevent supratip depression. METHODS: Thirty-six patients who underwent closed-approach, low-septal-resection dorsal preservation rhinoplasty between January and June 2021 were included in this retrospective study. Depending on the operation performed on Pitanguy's midline ligament, the patients were divided into 2 groups as follows: (1) a group in which Pitanguy's midline ligament was transected (transection group); and (2) a group in which Pitanguy's midline ligament was preserved (preservation group). Standardized postoperative 6-month lateral-view photographs were scanned for the presence of supratip depression or pollybeak deformity. The Rhinoplasty Outcome Evaluation (ROE) scale was applied at 6 months. RESULTS: Supratip depression was observed in 4 patients in the preservation group (n = 16), but was not observed in any of the patients in the transection group (n = 20; P < 0.05). There was no pollybeak deformity in either group. With respect to the Rhinoplasty Outcome Evaluation scores and number of satisfied patients, no statistically significant difference was found between the transection and preservation groups (P > 0.05). CONCLUSIONS: Transecting Pitanguy's midline ligament reduces the likelihood of supratip depression and does not affect the likelihood of pollybeak deformity in closed-approach, low-septal-resection dorsal preservation rhinoplasty.

The Effect of Ultrasonic Liposuction Energy Levels on Fat Graft Viability.

BACKGROUND: The use of fat obtained from ultrasound-assisted liposuction is popular. However, no study has considered the effect of different energy levels on fat grafts. OBJECTIVES: We hypothesized that different ultrasonic energy levels could change the fat graft viability. METHODS: Both flanks of 15 CD1 nude mice (30 experimental areas) were used, with experimental areas randomly distributed into five groups. Using different energy settings, fat grafts were obtained from a patient's abdominoplasty material and applied to the mouse flank regions. Device settings were intermittent mode with 50% vibration amplitude in group 1, continuous mode with 50% vibration amplitude in group 2, intermittent mode with 90% vibration amplitude in group 3, and continuous mode with 90% vibration amplitude in group 4. The control group was grafted with fat obtained via the conventional method. After 6 weeks, all mice were sacrificed, and fat grafts were excised. Sections were stained with hematoxylin-eosin, Masson's trichrome, and anti-perilipin A antibody. RESULTS: The perilipin A immunostaining result was lowest in group 4, indicating the lowest viable cell count (p < 0.01). There was no significant difference between groups for the other parameters (p > 0.05). CONCLUSION: High ultrasonic energy may affect fat graft survival. If fat injection is planned, avoiding high energy settings (our recommendation is not to exceed 16 Watts.) should be considered. We also recommend increasing the vibration amplitude rather than switching from intermittent to continuous mode in body parts that are relatively resistant to liposuction. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of Erythropoietin and Fibrin Glue Mixture for Peripheral Nerve Repair.

BACKGROUND: Erythropoietin has neuroregenerative effects. Fibrin glue may be used for nerve repair and controlled release of substances. In this study, the authors investigated the effects of erythropoietin-containing fibrin glue on nerve repair, based on the hypothesis that erythropoietin-containing fibrin glue would positively affect nerve regeneration. METHODS: Thirty-six Long-Evans rats were used. The animals were divided into six groups. Their left sciatic nerves were isolated, transected, and repaired with saline-containing fibrin glue in group 1, with erythropoietin-containing fibrin glue in group 2, with saline-containing fibrin glue and two sutures in group 3, with erythropoietin-containing fibrin glue and two sutures in group 4, with two sutures in group 5, and with four sutures in group 6. Sciatic Functional Index calculation, pin-prick test, and toe-spread test were performed on days 21, 42, and 63. All animals were killed on day 63. The nerve sections were analyzed histologically. RESULTS: The Sciatic Functional Index, pin-prick test, and toe-spread test results were the best in group 4 and the worst in group 5. Group 4 showed superior Schwann cell proliferation (p < 0.05). Groups with epineural suture use (groups 3, 4, 5, and 6) had higher endoneurial collagen synthesis scores than the groups without suture use (groups 1 and 2) (p < 0.05). The myelin protein zero immunostaining results were significantly higher in the erythropoietin-treated groups (groups 2 and 4) (p < 0.05). CONCLUSION: The combined use of erythropoietin-containing fibrin glue and two epineural sutures (group 4) showed a statistically significant improvement in many parameters. CLINICAL RELEVANCE STATEMENT: Fibrin glue is already used in nerve repair. Adding erythropoietin to fibrin glue could be a safe and easy option to improve nerve regeneration.

Flexible Tongue-in-Groove Technique and Its Effectiveness Compared to Classic Tongue-in-Groove and Columellar Strut Graft Techniques: A Retrospective Analysis of 237 Open Rhinoplasty Cases.

BACKGROUND: The medial crura are almost always supported in tip surgery using columellar strut graft placement or tongue-in-groove suturing to the caudal septum. In this study, the authors present a modified tongue-in-groove (called "flexible tongue-in-groove") technique. METHODS: A total of 237 patients who underwent open rhinoplasty between January of 2016 and June of 2018 were included in this retrospective study. The patients were divided into three main groups: (1) flexible tongue-in-groove, (2) classic tongue-in-groove, and (3) columellar strut. Using standardized preoperative and postoperative (1-, 6-, and 12-month) lateral view photographs, the nasolabial angle and Goode ratio were measured for nasal tip rotation and projection, respectively. RESULTS: Flexible tongue-in-groove (n = 53) and classic tongue-in-groove (n = 107) techniques showed a significantly smaller decrease in the nasolabial angle from month 1 to month 12 than did the columellar strut technique (n = 77) (p < 0.05). These statistically significant differences were not found when the time intervals were narrowed (p > 0.05). Flexible and classic tongue-in-groove techniques showed significantly higher Goode ratios than did the columellar strut technique at 1, 6, and 12 months (p < 0.05 for all). In various analyses using the nasolabial angle and Goode ratio, no statistically significant difference was found between flexible and classic tongue-in-groove techniques (p > 0.05). CONCLUSIONS: Flexible and classic tongue-in-groove techniques provide more durable results in nasolabial angle and Goode ratio measurements than does the columellar strut technique in primary open-approach rhinoplasty. The flexible tongue-in-groove technique is as robust as the classic tongue-in-groove technique in appropriate cases. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Technical Aspects and Difficulties in the Management of Head and Neck Cutaneous Malignancies in Xeroderma Pigmentosum.

BACKGROUND: Xeroderma pigmentosum (XP) is an autosomal recessive disorder characterized by xerosis, ultraviolet light sensitivity, and cutaneous dyspigmentation. Due to defects in their DNA repair mechanism, genetic mutations and carcinogenesis inevitably occurs in almost all patients. In these patients, reconstruction of cutaneous malignancies in the head and neck area is associated with some challenges such as likelihood of recurrence and an aggressive clinical course. The aim of this study is to discuss the therapeutic options and challenges commonly seen during the course of treatment. METHODS: Between 2005 and 2015, 11 XP patients with head and neck cutaneous malignancies were included in this study. Demographic data and treatment options of the patients were evaluated. RESULTS: The mean age of the patients was 32 years (range, 10-43) (4 males, 7 females). The most common tumor type and location were squamous cell carcinoma (6 patients) and the orbital region (4 patients), respectively. Free tissue transfer was the most commonly performed surgical intervention (4 patients). The average number of surgical procedures was 5.5 (range, 1-25). Six patients were siblings with each other, 5 patients had local recurrences, and one patient was lost to follow-up. CONCLUSIONS: Although genetic components of the disease have been elucidated, there is no definitive treatment algorithm. Early surgical intervention and close follow-up are the gold standard modalities due to the tendency toward rapid tumor growth and possible recurrence. Treatment must be individualized for each patient. In addition, the psychological aspect of the disease is an important issue for both patients and families.