Reduction of the scar burden at the donor area of the radial forearm flap with the aid of an endoscopic pedicle preparation.

BACKGROUND: The radial forearm flap is one of the most commonly used flaps of reconstructive microsurgery with its long pedicle and thin structure. The donor site at the forearm is a visible anatomic region that has high mobility and functional importance. In this study, a longitudinal and large scar was avoided on the forearm during pedicle dissection of the conventional radial forearm flap with the utilization of an endoscope. Furthermore, arterial, venous, and nervous injuries were avoided by performing a separate inci-sion of 2-3 cm at the cubital fossa to reduce flap failure and donor site morbidity. METHODS: The patients who underwent pedicle dissection of the radial forearm flap with the aid of an endoscope for head-neck reconstruction between 2014 and 2021 were included in this study. The flap was harvested from the subfascial plane. The cephalic vein was used in all of the patients. When the pedicle dissection reached the antecubital region, an incision of 2-3 cm was performed from the skin. Two vein anastomoses were performed for each patient. RESULTS: This retrospective study consists of 51 patients. While 45 of the patients were the result of head and neck cancer, six of them had a defect caused by trauma. The average area of skin islands was 40.3 cm2, while the full-thickness skin graft size was 24.2 cm2. An average of 2.6 cm of scar tissue was formed at the antecubital region. No venous or arterial compromise was observed in the post-operative period. There was no partial or total flap loss in any patient. Localized numbness persisted in the skin area where the superficial sensory branch of the radial nerve is located in 6 (11.7%) patients. CONCLUSION: With endoscopic radial forearm flap harvesting, the longitudinal incision in the forearm and wound healing prob-lems are avoided. The absence of partial or total flap loss has shown that endoscopic harvesting of the radial forearm flap is a safe and reliable method.

The Comprehensive Evaluation of the Pinch Deformity due to Concave Alar Cartilages and Its Management.

INTRODUCTION: Acute angle between dome and ala causes alar concavity/pinch deformity. Breathing problems may accompany pinching. Here, pinch deformities were classified according to their severity and treatment modalities discussed. MATERIALS AND METHODS: Rhinoplasty patients with pinch deformities were included in study. Pinching without external nasal valve blockage (ENVB) was classified mild, pinching with ENVB was classified moderate, and extreme pinching and ENVB were classified severe deformity. In mild deformity, cephalic resection of ala was performed or cephalic resection was combined with onlay graft over ala. In moderate deformity, cephalic part was bent and sutured over lower ala. In severe deformity, cephalic part was bent, and lateral strut graft was inserted between lower and cephalic ala. In pinch deformities combined with hypertrophic lower lateral cartilage (LLC), medial crural overlay preceded above-mentioned treatment modalities. RESULTS: Thirty-eight patients (22 female, 16 male) with pinch deformities underwent rhinoplasty between January 2017 and December 2022. Mean age was 27 years. Mean follow-up was 32 months. Fifteen patients had mild deformities. Cephalic resection was enough in four patients. Camouflage grafts were settled over ala in eleven patients. Twenty patients had moderate deformities; cephalic ala was bent over lower part and sutured. Two patients had severe deformities; lateral strut graft was settled between lower and bent cephalic alar parts. One patient had LLC hypertrophy/pinch deformity. LLC hypertrophy was corrected by medial crural overlay, and concavity was corrected with cephalic resection. Satisfactory shape, better valve passage obtained in all cases. CONCLUSION: Pinch deformity could be classified according to its severity and appropriate treatment options could be determined for each class. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/journal/00266 .

Balancing the Anteroposterior Diameters of the Nostril Lengths in Cleft Rhinoplasty.

BACKGROUND: Osteocartilaginous deformities in cleft rhinoplasties may be restored with numerous techniques. However, the anteroposterior (AP) diameter lengths of the nostrils may still be unequal and should also be addressed. A technique was designed to balance nostril AP diameter lengths and apical shapes. MATERIALS AND METHODS: Balance between AP nostril diameters was accomplished by reduction of the AP diameter of the nostril at the non-cleft side by medial crural reduction and augmentation of the AP diameter of the nostril at the cleft side by three-parted mini-flap reconstruction at the soft triangle. The cleft-side AP diameter length was divided by the non-cleft-side AP diameter length of the same preoperative, per-operative and 1-year postoperative base view photographs of each patient, and "nostril balancing ratio" was obtained. The more this ratio was near to "one," the more the AP nostril diameters were equal. RESULTS: Seventy-eight unilateral-cleft rhinoplasty were performed between January/2019 and May/2022. Forty-two of them required nostril AP diameter equalization. Twenty-nine patients were female, thirteen were male. Thirty-three of them were operated for a primary cleft rhinoplasty. Nine of them for secondary cleft rhinoplasty. Mean age was 28 years (22-39 years). Mean follow-up was 25 months (6-40 months). The preoperative, per-operative and postoperative mean "nostril balancing ratios" were 0.714 (0.621-0.813), 0.743 (0.721-0.752) and 0.971 (0.943-0.976), respectively. CONCLUSION: Balancing AP diameter symmetry with MCO at the non-cleft side and three-parted mini skin flap reconstruction at the cleft side may provide the satisfactory results. Three mini-flaps at the soft triangle may remold the nostril apex in an oval shape, which may result in a better shape symmetry. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. 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 .

Technical Variations in the Management of the Medial Crural Reduction According to the Settlement of the Angulation Deformities Over Hypertrophic Lower Lateral Cartilages.

BACKGROUND: Medial crural (MC) overlay is reliable method used in tip deprojection. Most cases with lower lateral cartilage (LLC) hypertrophy present by variations of MC and dome shapes needing specific technical maneuvers. METHODS: Thirteen hundred fourteen primary rhinoplasties were performed between 2018 and 2021. Patients with LLC hypertrophy who underwent MC deprojection were analyzed. Three variations in LLC hypertrophy were recognized. In type I, tip-defining points (TDP) were localized at the median plane with no angulation deformities at the LLC, which was managed by horizontal cuts of the lobular segments 4 to 6 mm below the domes. The cut fragments overlapped for 2 to 5 mm. In type II, TDP was lateralized due to widened divergence angles at the columellalobular junctions, which were managed by horizontal cuts over columellalobular junctions. The cut fragments overlapped 4 to 6 mm. In type III, TDP was localized at the median plane, there were dense angulations at the medial genu, which was managed with symmetrical removal of 4 to 5 mm cartilage from lobular segments. The domes were sutured over the medial segments. RESULTS: Nineteen patients with LLC hypertrophy were included in the study among 314 patients. Twelve patients were female and 7 patients were male. The mean age was 32 years (25-42). Type I, II, and III LLC hypertrophies were detected in 10, 3, and 6 patients, respectively. A harmonious relationship between dorsum and tip and satisfactory tip stability was reached in all patients. CONCLUSIONS: By classification of variations of MC and domal shapes, LLC hypertrophies may be managed with proper technical maneuvers specific to each type.

Comparative clinical study with a novel technique for stabilization of the nasal tip projection and rotation: fixation of the septum and the strut graft through the septal cartilage autoextension.

PURPOSE: It is important to reinforce nasal tip support for long-term satisfactory results. Two workhorses of tip support are strut grafting and the tongue-in-groove technique. Tongue-in-groove causes retraction and stiffness; the strut causes loss of rotation and projection of tip. We introduced a novel technique that avoids these consequences. METHODS: Between February 2018-February 2019, 40 female underwent primary rhinoplasty. Mean age: 27 years (18-41 years). FOLLOW-UP: 1-2 years. In first group (20 patients), caudal septum was resected and strut was not fixated to caudal septum. In second group (20 patients), tongue-like extension (septal autoextension) was preserved at caudal septum and sutured to strut. Preoperative, peroperative, and postoperative images were compared. RESULTS: Tip projection ratio calculations, nasolabial angle measurements were evaluated by statistical analyses. The change in projection ratios between peroperative period and 1-year postoperative period of strut-only group was higher than septal autoextension group (p = 0.001). This result indicates that nasal tip projection loss in strut-only group was higher compared to septal autoextension group. The change in nasolabial angle measurements from peroperative period to 1-year postoperative period differed significantly between two groups (p = 0.001). Significant difference was observed between 1-year postoperative nasolabial angle measurements of two groups (p = 0.006); septal autoextension group measurements were higher than strut-only group. These results showed that fixation of strut graft to the septal autoextension provides better preservation of the nasolabial angle and stabilization of nasal tip projection. CONCLUSiON: Fixation of septum and strut graft through septal autoextension provides satisfactory stabilization of tip projection and rotation without stiffness or rigidity.

Anais Cerci Forceps: A Novel Instrument for Shaping the Nasal Dome Before Transdomal Suture Placement.

One of the most important components of an attractive nasal tip is the cephalocaudally conical form of the dome at the sagittal plane. With respect to this fact, the author tried to design a new forceps which holds the dome in a convex shape on a transverse plane and cephalocaudally conical in shape on the sagittal plane. Before grasping the dome in the desired position with Anais Cerci forceps, some degree of lateral steal is suggested and can be performed to increase the tip rotation and projection. With the help of its specific shape and template forming function, this novel instrument may also help to prevent the excess strain of transdomal suture which is crucially important to prevent the formation of pinching. This newly designed forceps can also help to provide the opportunity of the required acute angle between two domes. Slight oblique grasping of the dome reciprocally provides nice acute angle between 2 domes. Additionally, this forceps may also help to provide formation of symmetrically and reciprocally designed dome curvatures. In several secondary rhinoplasty cases with highly destroyed lower lateral cartilages, septal, auricular or costal cartilages are used for alar reconstruction. Mimicking the lower lateral cartilage anatomy from a straight cartilage graft piece is not an easy way of restoration. In such cases, Anais Cerci forceps may facilitate reshaping of the dome from an amorphous cartilage graft.

Upper extremity replantation results in our series and review of replantation indications.

BACKGROUND: Upper extremity amputations are usually not life-threatening, but they negatively affect the life quality of the victim. In addition to the functional disabilities of upper extremity amputation, disfigurements frequently cause psychological and social debilitations. METHODS: Between 2007-2015, fourteen cases were admitted to emergency with total major amputation of the upper extremity. All cases were male (22-45 years of age. Mean age: 29.6). Replantation was applied to all except three cases with multileveled crush injuries. RESULTS: All replantations were successful. Additional interventions were needed in four cases with replantation at elbow level and replantation at the distal arm level. The postoperative functional results were evaluated. The patient's overall satisfaction, the recovery of flexor and extensor mobility, the extent of the active motion of digits, the recovery of thumb opposition, active movements of wrist and elbow joints, recovery of sensitivity in the median and ulnar nerve, the ability of the surviving hand and/or forearm to perform daily works are all evaluated. The results were satisfactory in hand replantations. However, some ulnar nerve distal motor problems were encountered in three cases with replantation at elbow level, and one case with replantation at the distal arm level with a crush injury, acceptable and excellent results were obtained in other cases. CONCLUSION: Despite the availability of prostheses, cadaveric upper extremity replantations, replantation of the native extremity is still the most appropriate treatment for amputated cases. However, surgeons should realize that the ultimate goal is not merely to save the viability of the extremity through replantation, but rather to preserve the life quality by improving the function.

Classification of Angulation Deformities of Lower Lateral Cartilages and Their Restoration.

BACKGROUND: Shape of the tip is supplied by lower lateral cartilages (LLC) which are divided into 3 crura each composed of 2 segments divided by junction lines (JL). Tip restoration becomes more complicated with the presence of angulation deformities (AD) over LLC. It is aimed to classify AD based on their relationship to JL, to clarify their causes of the formation and to discuss restoration techniques for each of them. MATERIAL AND METHODS: Between 2016 and 2018, 375 primary rhinoplasties have been performed. All types of the AD have been retrospectively determined, renamed. Six different types of AD have been encountered in this series. Four of AD (types A, B, C, and D) have been located over JL and 2 of AD (types S and T) have not been located over JL. RESULTS: Type-A AD diverging the footplates were observed in 9 patients, type-B AD resulting in a boxy-nose were observed in 18 cases, type-C AD resulting in acute angulation of the dome at the medial genu were observed in 4 patients, type-D AD resulting in a pinched tip and concave alar wings were observed in 6 patients, type-S AD resulting in a weak, and short columella were observed in 5 patients, type-T AD that creates a bulge over ala was observed just in 1 patient in our series. The total number of patients with AD was 39 (10.4% of all cases). CONCLUSION: Classification of AD over LLC based on their relationship to certain JL provides ease for recognition of these deformities and immediate per-operative planning for their restoration.

Comparison of Patient Satisfaction Between Composite and Dorsum Augmentation-Only Nasal Reconstructions With Diced Cartilage Graft Wrapped in Fascia.

The comparison of patient satisfaction with the use of diced cartilage graft wrapped in fascia (DCF) graft in composite versus dorsum augmentation-only reconstructions (DAOR), technical hints and complications in our series, affecting the end-result and the patient satisfaction (PS) has been presented.Between 2013 and 2018 the DC-F graft is used in 32 rhinoplasty cases. Nine of patients have had composite reconstruction (CR). The DAOR has been needed for 23 of patients.The follow-up period has been 2 months to 3 years. The authors have obtained satisfactory results in 24 cases but some untoward progress in 8 cases. A questionnaire was prepared and asked all patients for the assessment of the satisfaction from appearance, breathing, self-esteem, and positive psychological effect.The learning curve for rhinoplasty should be calculated for, hump reduction, crooked nose, augmentation rhinoplasty, and so on. separately which is also relevant for the use of a DC-F graft. Placing the DC-F over a straight platform, choosing the accurate graft and fascia material wisely, proper tailoring of DC-F, sliding it under the skin-superficial musculoaponeurotic system properly etc. determine the quality of the end result and the degree of PS. Operating on the DAOR are relatively more comfortable compared to CRs but responses to our questionnaire denote higher degrees of satisfaction in CR cases.Utilization of the DC-F graft in secondary rhinoplasties for dorsum augmentation provides satisfactory results. The degree of PS with the DC-F reconstruction seems to have an adverse correlation with the extent of deformities that you start with.

Clean-Cut Smoothing of the Visible Cartilage Grafts by Sanding With a Scalpel.

The visibility of cartilage grafts underneath the skin is a complication of rhinoplasty particularly in patients with thin nasal skin. Preparing the graft with optimum dimensions, symmetry, and smoothness is crucial for the fine crafting of the cartilage to prevent visibility. The camouflage of the visible cartilage graft with a crushed cartilage, a resected cephalic portion of the lower lateral cartilage, fascia, connective and/or fatty tissues is another option for hiding the visibility. The nasal tip is the most common location where the graft visibility is of concern.The authors introduce the smoothing of the cartilage graft by sanding it with a scalpel. This technique safely provides perfection and precision of smoothing of the cartilage in very desired shape. It is possible to obtain 3D super clean-cut shining surface.The tangential sculpting of the cartilage graft with a scalpel carries the risk of over resection. However, the sanding with a scalpel moves forward so gentle that over resection is not possible.It is also possible to smooth non-visible structural grafts such as strut and spreader grafts to reduce surface irregularities.Additionally, the sand-dust caused by cartilage sanding is a 'cartilage pâté' which can be used for camouflage of minute irregularities of the nasal dorsum.

"Dual-Knot Fixation" Technique for Better Stabilization of the Extended Columellar Strut Graft with the Anterior Nasal Spine.

INTRODUCTION: Extended columellar strut graft (ecsg.) is one of the most crucial cartilage tissues used especially in secondary rhinoplasties. Stabilization of an ecsg. with the anterior nasal spine (ans.) is very important. Regular suture placement is the most common practice. Nevertheless, this kind of suture fixation may result in sliding of the ecsg. through either side of the ans. Suture placement like the figure of eight may prevent sliding of the ecsg. to sides. However, the figure of eight suture forces the graft to turn around during its fixation. METHOD: I have tried to solve these two problems with a simple still better suture technique. After passing the suture through the hole of the ans., a stabilization knot is tied over the spine tip. Then passing the suture through the lower end of the ecsg. and fixating it with a second knot named as the "fixation knot" results in very good stabilization and prevents both side sliding and rotation of the graft. This stabilization technique can be called "dual-knot fixation" (dkf.). Opening a small notch at the lower tip of the graft may help to hide the "stabilization knot" inside the graft which will help to obscure the tiny space between the cartilage and the bone, and thus the bonding process between the graft and spine would be better. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. 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 .

Supercooled Liquid Serum Physiologic Solution Instantly Crystallized on the Nurse Table Used for Cooling of Periorbital Region During Rhinoplasty.

INTRODUCTION: Formation of less periorbital ecchymosis in post-operative period of rhinoplasty is a popular trend. We present the use of instantly crystallizing supercooled serum physiologic solution for periorbital cooling. PHYSICS OF SUPERCOOLING: There are circumstances in which water temperature drops below its freezing point, but no phase transition happens while water remains in the liquid phase. This is called supercooling. Pure water can be supercooled below the freezing temperature without transforming into ice. Tap water will not supercool because it contains impurities that serve as nucleation sites for crystallization. For freezer temperatures in the range of - 4 °C, - 6 °C, and - 8 °C, nucleation was not observed and pure water remained in the supercooled condition for a long time. DESCRIPTION OF THE TECHNIQUE: Sterile serum physiologic solution at + 5 °C can be supercooled in the freezer at - 14 °C only between the 257 and 277 min time interval. But when it is supercooled in the freezer at - 8 °C it is possible to save it in liquid form for at least 7 days as we have observed in our trials. CLINICAL USE AND DISCUSSION: It is easily possible to transform this supercooled liquid sterile serum physiologic within a few seconds into moldable snow-like ice that can be used safely and more nicely rather than solid ice for periorbital cooling in rhinoplasty operations. Its sterile inner bag is held tight and struck over the sterile nurse table and it crystallizes within a few seconds. For frozen solutions, tearing of the inner plastic bag and extracting the ice and then crushing of big masses of ice to small pieces is exhaustive and a time-consuming process. The temperature of the supercooled fluid will be zero at the moment of nucleation with no risk of frostbite. The crystallized serum physiologic solution preserves its ice-gel form for nearly 25 min. CONCLUSION: The instant crystallization of supercooled liquid serum physiologic solution can be applied as a tissue cooling method in rhinoplasty and in several other surgical procedures. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. 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 .

Cerci-Adson-Brown Tissue Forceps: A New Design for Better Crafting the Grafts in Rhinoplasty.

Supplemental Digital Content is available in the text.

Rhinoplasty Setsquare Device: A Novel Instrument to Verify Columellar and Nasal Dorsal Position at the Midsagittal Line.

Even a mild degree of postoperative deviation of the nasal dorsum and/or columella from the midsagittal plane could be enough to displease a patient. Postoperative judgment of the nasal dorsum and the columellar positioning on the midsagittal plane is somewhat of a subjective decision determined by the surgeons' naked eye. Most innovations tend to evolve from necessities. The risk and reality of misjudging the positioning for both the nasal dorsum and/or the columella led me to develop a device for the objective measurement of the midsagittal axis of the nose. I have called it the rhinoplasty setsquare device. This device is made from 316 quality stainless chrome. It is completely sterilizable. It consists of 4 main parts. During the finishing touches of the operation, the correct placement of the rhinoplasty setsquare device will provide the surgeon with an objective decision that will help make the positioning of the nasal dorsum and the columella more precise. When I conducted my research on literature and device catalogs for possible devices designed for measurement in rhinoplasty operations, I ran into devices such as the Castroviejo caliper, calibrated lateral crus stabilizer, Joseph measuring rod, and Thorpe Marchac caliper. All of them are unique in their function and design. However, as far as I could see, there is no device similar in form and function to my rhinoplasty setsquare device. I have been using this device for 8 months for all my rhinoplasty patients. I am more confident now in my postoperative results due to its objective measurement of the midsagittal line.

Monobloc Reconstruction of Dome, Medial Crura, and Columella with Gamma-Shaped Costal Cartilage Graft.

In severe nasal deformities, the original cartilages are removed, or they become unusable because of previous operations. Costal cartilage (CC) is one of the most important tools for the replacement of deficient nasal osteocartilaginous framework. In 4 secondary and 1 tertiary rhinoplasty cases with severe deformities of medial and lateral crura of the lower lateral cartilages, we have prepared a long strut graft from a CC and then split the graft tip 5-6 mm vertically into 2 equal halves to create a gamma (ϒ)-shaped strut graft. We have sutured the base of this graft to the nasal spine and/or the bases of the medial crural remnants. Then, we have prepared lateral crural grafts and secured the grafts over lateral crural remnants. Then we curved the split tip winglets of the ϒ-shaped strut graft to both sides and sutured them to lateral crural grafts in order to create a new dome. Splitting of the CC strut graft reduces the need for extensive suturing at the tip, obtains smoother contours and ensures graft economy, and provides an original and stable dome shape. The bending capacity of the CC is limited in middle-aged patients. Costal allografts from a young cadaver can be a good alternative. ϒ-shaped costal crural graft is useful for medial crural and domal monobloc reconstruction in secondary and tertiary cases.