Skin Necrosis Following Rhinoplasty: A Review and Proposed Strategy on Identifying High-Risk Patients.

Vascular compromise leading to cutaneous loss following surgical rhinoplasty is a devastating complication. The objective of this review is to identify all reported cases in literature published in English and summarize the current evidence to identify the patients at risk of this complication following surgery. A comprehensive literature review using Medline and Embase databases was performed to capture all reported cases of cutaneous vascular compromise following rhinoplasty from database inception through September 2020. Nonsurgical rhinoplasty cases were excluded. We identified eight studies that featured vascular cutaneous compromise following surgical rhinoplasty. A total of 18 patients were included in the analysis. The majority of the patients were females with a mean age of 30.9. Risk factors included smoking in 23.5% patients and revision setting. Extensive tip thinning, tight splinting and taping with dorsal onlay grafting, or combining extended alar base excision with revision open rhinoplasty were among surgical techniques associated with vascular compromise. The most commonly affected aesthetic nasal subunit in our review was the dorsum followed by the nasal tip. Conservative management primarily was utilized in 72.2% of patients, allowing the defect to heal by secondary intention. Studies reporting on cutaneous vascular compromise following surgical rhinoplasty are of low level of evidence. This review is the largest summary reporting on this complication to date, aiming to caution surgeons about associated techniques and management options. We also share an expert opinion on preoperative assessment of nasal skin to guide surgeons to potentially avoid rhinoplasty surgery in this subset of patients.

Avoiding complications of microtia and otoplasty.

Congenital ear surgery constitutes one of the most challenging reconstructive procedures in plastic surgery secondary to the complex architecture of the auricle and the multiple factors involved in the reconstructive techniques. The most common complications encountered during microtia repair and otoplasty are described. Emphasis is placed on preventing these complications.

Reconstruction of congenital microtia-atresia: outcomes with the Medpor/bone-anchored hearing aid-approach.

Ideal surgery for congenital microtia-atresia would offer excellent cosmetic and hearing rehabilitation, with minimal morbidity. Classic approaches require multiple procedures, including rib cartilage harvest and aural atresia repair. Our facial plastic and otologic team approach incorporates a high-density porous polyethylene (Medpor, Porex Surgical, Newnan, GA) auricular framework, followed by single-stage bone-anchored hearing aid (BAHA) implantation. We evaluated the efficacy, safety, and morbidity of this 2-stage dual system approach. A prospective database of microtia patients was used to identify patients undergoing combined Medpor/BAHA auricular reconstruction and hearing rehabilitation between 2003 and 2006. The first stage involves placement of a Medpor framework beneath a temporoparietal fascia flap, followed by a second-stage procedure for lobule transposition and BAHA implantation. Twenty-five patients (28 ears) were evaluated. Aesthetic quality of the implants was excellent, with a high degree of framework detail visible, and a postauricular crease created in all patients. All patients were satisfied with the cosmetic result. There were no major Medpor complications such as infection, extrusion, loss of implant, or flap necrosis, and a 10.7% incidence of minor complications requiring operative revision. BAHA significantly improved hearing in all patients, with a complication rate of 31.8%, mainly skin overgrowth and cellulitis. The Medpor/BAHA dual plastic-otologic approach to microtia-atresia has produced excellent cosmetic results and hearing outcomes, which compare favorably to traditional microtia-atresia repair. This is a 2-stage aesthetic and functional protocol with an acceptably low rate of complications, which safely and efficiently achieves both aesthetic and functional goals.

Chin augmentation.

This article reviews chin augmentation, describing patient evaluation and management, surgical technique, autogenous and alloplastic chin implants, their advantages and disadvantages, and potential complications.

Nasal implants.

In this article, options for nasal implantation during rhinoplasty are discussed. The range of implant options currently available to the nasal surgeon is considered in detail. Various types of autografts, homografts, and alloplasts commonly used in the nose are introduced and described. Indications for each nasal implant type are considered, as are the advantages and limitations of each option.

Nasal grafts and implants in revision rhinoplasty.

Problems associated with primary rhinoplasty are often due to overresection of the nasal skeleton. One of the primary goals in revision rhinoplasty is to restore nasal architecture. To do so, the facial plastic surgeon can choose from numerous grafting materials. A key understanding of the benefits and limitations of each implant or graft and implants commonly used in revision rhinoplasty surgery.

Difficult revision case: Overaggressive resection.

This article reviews the case of a 45-year-old female who had undergone previous rhinoplasty in which there had been overaggressive resection of the nasal skeletal architecture. A revision rhinoplasty was preformed using available autogenous septal cartilage and various porous high-density polyethylene implants. One year after the procedure, the patient demonstrated restoration of nasal architecture and persistent aesthetic outcomes.

Medpor alternative for microtia repair.

Autologous costal cartilage has been the material of choice for framework in auricular reconstruction. However, the advent of porous high-density polyethylene (Medpor) has provided an effective alternative in microtia repair. A ready-to-use allopastic material, Medpor has distinguished itself from other implants via its durability, tensile strength, biocompatibility, and malleability. Results from clinical experience and bench research support this claim. When using this material, the authors noted impressive results with low associated morbidity.

Modulation of wound response and soft tissue ingrowth in synthetic and allogeneic implants with platelet concentrate.

OBJECTIVE: To evaluate the modulation of wound healing and soft tissue ingrowth in synthetic and allogeneic implants with platelet gel. Attempts to influence wound healing with exogenous growth factors are highly dependent on the timing and dosing of treatment. Platelet gel made from autologous platelet concentrate (PC) and activated with calcium thrombin is increasingly used to enhance healing of surgical and chronic wounds, based on the assumption that proteins found in the blood can promote healing. METHODS: Adult New Zealand white rabbits underwent phlebotomy, and the blood was used to produce nonconcentrated autologous blood clot, platelet-poor plasma (PPP), and PC for each animal. Disks of porous high-density polyethylene (PHDPE) and acellular dermal graft (ADG) were implanted into each animal in a subcutaneous location. Implants of each type were treated with isotonic sodium chloride solution, PPP, PPP followed immediately with PC, or autologous blood clot (by means of manual impregnation). Animals were killed at 2, 7, 14, and 21 days after implantation. Implants were harvested with surrounding soft tissue and examined by means of light microscopy for evidence of acute and chronic inflammatory cells and vascular and fibroblast invasion. RESULTS: A platelet gel with platelet concentrations averaging 5.8 times greater than those of peripheral blood significantly improved wound healing and soft tissue ingrowth in surgically implanted grafts. Early inflammatory infiltrates were enhanced in PHDPE and ADG implants by PC and autologous blood clot compared with control implants, as evidenced by significantly increased neutrophil and macrophage counts at day 2. Compared with controls, statistically significant increases in fibroblast and endothelial cell counts were noted at day 7 in PC-treated implants (fibroblasts, 61% increase [P < .001] in PHDPE implants and 52% increase [P < .001] in ADG implants; capillaries, 95% increase [P < .05] in PHDPE and 97% increase [P < .001] in ADG implants). Lymphocyte counts were increased by PC in PHDPE and ADG implants (71% [P < .001] and 100% [P < .05], respectively). There were no statistically significant differences in any cell count variables beyond 7 days. CONCLUSIONS: Treatment with PC prepared at 5 times the baseline platelet count significantly accelerated maturation of experimental wounds. By 14 days, the degree and quality of wound cellularity were equivalent among all treatment groups. Rapid wound healing was expected with this surgical model, which was chosen to observe the biological effects on early wound healing of a platelet gel in a noncompromised wound. Treatment with PC may be useful in scenarios in which enhancement and acceleration of early wound healing is desired.

Cleft lip nasal reconstruction using porous high-density polyethylene.

BACKGROUND: The multitude of factors involved with a unilateral cleft lip nasal defect has spurred various surgical techniques in the past. Recently, synthetic materials have been introduced for use in nasal reconstruction. OBJECTIVE: To report on and illustrate the use of porous high-density polyethylene implants in cleft lip nasal reconstruction. DESIGN: A retrospective review of cleft lip nasal reconstruction using porous high-density polyethylene in patients with a unilateral cleft lip defect from January 1, 1993, through June 30, 2000. SETTING: Facial plastic surgery private practice. PATIENTS: Eighteen patients with a unilateral cleft lip without a history of formal rhinoplasty. INTERVENTIONS: All 18 patients required multiple implants, including a columellar strut, premaxillary and prealveolar plumper grafts, a dorsal tip implant, and a unilateral nasal valve batten, using the open rhinoplasty approach. RESULTS: Favorable aesthetic results, as judged by one of us (T.R.), were achieved in all patients. All implants were well tolerated. Postoperative follow-up ranged from 6 months to 7 years. A complication occurred in 1 patient (6%), which resolved with removal of a single implant and intravenous antibiotic therapy. No other complications, including skin erosion or implant extrusion, have been noted. CONCLUSIONS: Porous high-density polyethylene implants for cleft lip nasal reconstruction are well tolerated and achieve good aesthetic results. Porous high-density polyethylene implants lend stability through fibrovascular ingrowth, with integration of the implants to the surrounding tissue.

Rejuvenation of the aging lip with an injectable acellular dermal graft (Cymetra).

OBJECTIVE: To evaluate the effects of Cymetra (micronized AlloDerm tissue) in rejuvenating the aging and atrophic lip. PATIENTS: Forty-four patients aged 32 to 80 years who reported age-related changes in the size and contour of the upper lip. METHODS: Patients were randomized to treatment with either Cymetra or glutaraldehyde cross-linked bovine collagen (Zyplast). Standardized photographs of each subject were taken before and after treatment initially and 3, 6, 9, and 12 months after initial treatment. Patients were monitored for signs of hypersensitivity, infection, and inflammation. MAIN OUTCOME MEASURES: Digital photographs were analyzed for changes in the nasolabial angle, percentage of the total lip accounted for by the exposed red lip in the midline and on the lateral view, the visible red upper and lower lip surface areas, and the anterior projection of the upper and lower lips. RESULTS: All patients tolerated treatment well without any significant local or systemic complications. Nineteen patients were treated with Cymetra and 25 with Zyplast. Cymetra-treated patients were more likely than Zyplast-treated patients at 12 months (3 months after the previous treatment) to have increased the percentage of red lip in the midline (84.6% vs 38.9%; P =.01), the vermilion height in the upper lip midline (84.6% vs 38.9%; P =.01), and the exposed red lower lip on the lateral view (69.2% vs 33.3%; P =.048) by at least 20%; increased the lower lip projection by 0.5 mm or more (69.2% vs 27.8%; P =.02); and decreased the nasolabial angle by at least 10 degrees (46.2% vs 16.7%; P =.07). CONCLUSIONS: Cymetra is a suspension of particulate dermal matrix that seems to increase the upper lip bulk, vermilion, and lower lip projection after a threshold of Cymetra has been administered. There are few differences in any measured long-term (3 months after treatment) variables until the 12-month visit, when there were statistically significantly more Cymetra-treated patients with improved lip aesthetics than those treated with Zyplast. With repeated treatments, Cymetra seems to accumulate, producing a long-term effect superior to Zyplast in many patients.

Gore-Tex chin implants: a review of 324 cases.

Augmentation of the chin is a long-standing and effective technique for facial enhancement. We have used preformed expanded polytetrafluoroethylene (Gore-Tex) implants for chin augmentation for several years. For this study, we collectively pooled data detailing our experiences with this material. From January 1, 1998, to March 30, 2001, a total of 324 Gore-Tex chin implants were placed. No resorption or visible movement of any implant occurred. Two (0.62%) of the 324 implants became infected and were ultimately removed. No other complications occurred. This complication rate compares favorably to other reports. Five implants (1.5%) were removed or changed in size due to patient requests. All remaining patients (97.8%) were satisfied with their result. We also describe technical points and procedure modifications that have helped us achieve beneficial results for our patients. Gore-Tex is a reliable implant material that helps the surgeon to achieve a high degree of patient satisfaction in chin augmentation.

Microtia reconstruction: autologous rib and alloplast techniques.

Microtia represents a spectrum of maldevelopment of the external ear. Reconstructive techniques may utilize an autogenous rib cartilage framework and require 2-4 stages; alternatively, an alloplastic framework can be used and typically requires 1-2 stages. Successful reconstruction of microtia with either technique can provide a significant quality of life improvement, and both techniques are described in this article.

Aesthetic microtia reconstruction with Medpor.

The complex architecture of the auricle makes it one of the most challenging structures for the reconstructive surgeon to re-create. Overlying the ear's unique cartilage framework are layers of varied soft tissues forming a three-dimensional organ, which is distinctively positioned on the head. Arguably, the most challenging auricle to reconstruct is third-degree microtia due to a near-total absence of native tissue and a need for lifelong durability of the reconstruction. Many methods of reconstruction have been studied; autogenous costal cartilage reconstruction has been one of the more traditional methods, with favorable long-term results reported by several surgeons. However, this technique requires tremendous artistic and technical skill on the part of the surgeon-sculptor to construct a realistic-appearing ear. High-density porous polyethylene (Medpor) is a stable, alloplastic implant that can integrate with host tissues, is resistant to infection, and has been successfully applied to reconstruction of the head and neck. For auricular reconstruction, Medpor--enveloped in a temporoparietal fascial flap with full-thickness skin graft coverage--is a durable and aesthetically gratifying alternative in microtic patients. This alternative surgical technique reduces surgical time and morbidity, standardizes results among surgeons, and facilitates an aesthetic, natural-appearing reconstruction of the auricle.

Revision rhinoplasty using porous high-density polyethylene implants to reestablish ethnic identity.

BACKGROUND: This study aimed to evaluate a surgical technique used for patients requiring revision rhinoplasty to reestablish their ethnic identity. METHODS: A retrospective review involved 29 patients who underwent revision rhinoplasty to reestablish their ethnic identity using residual septal cartilage and porous polyethylene implants. The follow-up period ranged from 6 month to 7 years. RESULTS: For all patients undergoing revision rhinoplasty, multiple porous polyethylene implants were used to reestablish ethnic identity and to restore nasal function. Implant extrusion developed in one (3.4%) of the 29 patients. There were no cases of postimplant infection. CONCLUSIONS: In our experience, patients who feel they have lost their ethnic identity after primary rhinoplasty tend to have overresected dorsal cartilage and bone and overresected tip cartilages. The use of multiple porous polyethylene implants in revision rhinoplasty to restore ethnic identity can provide the necessary grafting material needed for reconstruction. Many grafting options are available. According to our experience, porous polyethylene provides safe, effective, and reliable results.

Chin and prejowl augmentation in the management of the aging jawline.

The effects of aging in the lower face and neck are reflected in the contour of the jawline. Soft tissue atrophy, the formation of jowls, and retrusion of the chin are all age-associated changes that contrast starkly with the smooth harmony of a young lower face. These soft tissue changes in the jawline are exacerbated by the effects of aging on the bony portion of the mandible. Bone resorption of the mandible seen with aging can lead to the development of a hypoplastic mentum and the formation of an anterior mandibular groove. Rhytidectomy serves to address the soft tissue changes from aging but cannot counter the effects of aging on the bony mandible itself. Understanding the effects of bone resorption on the aging mandible allows the facial plastic surgeon to augment the mandible appropriately to achieve a more effective rejuvenation of the lower face. The aging process in the mandible and the development of the prejowl sulcus are reviewed. The use of chin and prejowl augmentation as a valuable adjuvant to facelift surgery is discussed.

Management of the severe bulbous nasal tip using porous polyethylene alloimplants.

Reliable outcomes in correction of the severely bulbous nasal tip remain elusive. Reduction and binding of the tip cartilages result in a partial external nasal valve collapse. If a concurrent dorsal hump reduction is accomplished and osteotomies are completed to close the open roof deformity, then a severe constriction of the external valve may result. This is best avoided by resection of the residual lower lateral cartilages and substitution with external valve batten implants. The tripod of nasal tip supports is then rigidly reconstituted. When autogenous graft materials are considered inadequate or undesirable, the surgeon may safely use porous polyethylene alloimplants to support the external nasal valve. A dependable surgical technique based on extensive experience with these materials is outlined.

Secondary cleft-lip rhinoplasty utilizing porous high-density polyethylene.

Secondary nasal deformity associated with cleft lip is a difficult surgical task. For more than 100 years, numerous surgical methods have been created to address the structural changes that occur over time after the primary surgery. Although early surgical methods have relied on various rotational flaps and local tissue manipulation, the recent advent of synthetic materials has provided facial plastic surgeons with more tools to correct the structural and supportive deficiencies. In this article, we describe our 10-year experience with porous high-density polyethylene (PHDPE) implants in secondary cleft-lip rhinoplasty. PHDPE implants have been well tolerated and achieved excellent long-term aesthetic results through fibrovascular ingrowth to the surrounding tissue.

Homologous collagen dispersion (dermalogen) as a dermal filler: persistence and histology compared with bovine collagen.

To assess the biological behavior and clinical efficacy of homologous collagen dispersion (Dermalogen) in augmenting human dermis, Dermalogen and bovine cross-linked collagen (Zyplast) were compared in a human postauricular injection model. Dermalogen (two sites implanted behind one ear) and Zyplast (two sites behind the contralateral ear) were injected into an upper to middermal level in 20 healthy adults. Digital photographs of all implant sites were taken over a 12-week period after injection. Biopsies of each implant type were taken at 4 and 12 weeks after injection. At 12 weeks after injection there was a small but significant difference in persistence rates between Dermalogen and Zyplast (4% vs. 2%; = 0.005). Histologically, Dermalogen was identifiable at 4 weeks after implantation, with evidence of neovascularization. Zyplast was identified more uniformly than Dermalogen in specimens 12 weeks after implantation, and more chronic inflammatory cells and foreign body giant cells were seen in the Dermalogen specimen. Clinical persistence and the histological behavior of Dermalogen appears to be at least as favorable as Zyplast bovine collagen. Dermalogen does not require pretesting and can also be used in the patient already sensitized to bovine protein. For these reasons, the authors think Dermalogen is a reasonable alternative to bovine collagen for facial soft-tissue augmentation.