Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity.

BACKGROUND: Nasal fractures are the most common facial fracture. Improper reduction is a common occurrence, resulting in a residual deformity that requires secondary surgery. A treatment protocol for nasal fracture management is presented with the aim of reducing secondary deformities requiring corrective surgery. METHODS: After institutional review board approval, a retrospective review of all closed nasal reductions performed by a single surgeon between 2006 and 2015 was conducted. Patient age, sex, presence of secondary deformity, and need for a correctional operation were recorded. Clinical records were analyzed for evidence of postoperative deformity and need for subsequent manipulation or surgery. RESULTS: A total of 90 patients with nasal bone fractures who underwent closed nasal reduction were identified. The mean age of patients was 24.9 years. The male-to-female ratio was 2.2:1. Postoperative deformity was reported in 14 patients (15.6 percent). Four of the 90 patients (4.4 percent) were found to have avulsion of their upper lateral cartilage from the nasal bone. Nine of the 14 subjects (64.3 percent) presenting with secondary deformity were managed with external manipulation, avoiding a secondary operation. Five patients (5.5 percent) from the original cohort of 90 underwent revision surgery. CONCLUSIONS: By using the described protocol to treat nasal fractures, we have seen a low rate of postreduction deformity and a small percentage of need for secondary operation. The overall success rate of closed nasal reduction with postoperative manipulation (when necessary) was identified to be 94.5 percent. Using this protocol, surgeons may see a decrease in secondary deformities following closed nasal reduction procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Creation of a vascularized composite graft with acellular dermal matrix and hydroxyapatite.

BACKGROUND: Biomaterials have shown promise as potential substitutes for human tissue. Studies have demonstrated that attachment of a vascularized pedicle to dermal matrix grafts yields tissues that are resilient enough to patch hernia defects in rats. The purpose of this study was to examine the possibility of creating a viable composite graft completely from biomaterials. METHODS: Acellular dermal matrix was enveloped around a square wafer of hydroxyapatite bone substitute. This composite graft was inserted into an extraperitoneal pocket overlying the abdominal musculature. In 30 Sprague-Dawley rats, the superficial epigastric arteriovenous pedicle was dissected free and placed within the midportion of the matrix construct on one side of each animal. A second graft was inserted on the opposite side without the addition of a vascularized pedicle. Each animal served as its own control. Animals were divided into three equal groups and euthanized at time points of 30, 60, and 90 days. RESULTS: Histologic evaluation of specimens was performed using hematoxylin and eosin and trichrome stains. At 30 days, the dermal matrices demonstrated full-thickness cellular infiltration in all specimens. Collagen deposition was significantly greater in the experimental group at every time point. Cellularity was significantly greater in the experimental group at 30 days, but there were no significant differences between groups at 60 or 90 days. CONCLUSIONS: These results suggest that provision of an arteriovenous blood supply to nonbiologic tissue grafts significantly increases collagen deposition and early cellular deposition. Based on these findings, biomaterials may offer an exciting new method for tissue engineering.