Practical Classification of Upper Lateral Cartilage in Middle Vault Asymmetry.

BACKGROUND: Middle vault asymmetry is a common reason for retained postoperative deviations. Although minor deformities can be camouflaged with cartilage, soft-tissue materials, or injectable fillers, comprehensive observation of upper lateral cartilage and subsequent topographic classification in major anatomical anomalies will help surgeons better plan their procedures to obtain better symmetry. METHODS: Photographs of 71 randomly selected primary open rhinoplasty patients were analyzed for anatomical presentation of their upper lateral cartilage. Photographs were taken before and after separation of upper lateral cartilage from the septum. Upper lateral cartilage was classified from class I to class V according to the width of the transverse subunits and curvature of the vertical subunits. RESULTS: The authors observed 142 upper lateral cartilages of 71 rhinoplasty patients. Upper lateral cartilage was classified as follows: class I, 53 cases; class II, three cases; class III, 40 cases; class IV, 36 cases; and class V, 10 cases. CONCLUSIONS: Upper lateral cartilage asymmetry is a common occurrence in rhinoplasty, and the upper lateral cartilage itself may be the source of nasal deviation. The middle vault requires special attention, and establishment of a classification system could enable surgeons to devise an effective plan for correction and prevention of retained postoperative nasal deviation.

Anthropometric Analysis of the Human Skull for Developmental Left-Sided Asymmetry, New Finding.

BACKGROUND: Facial and cranial asymmetry is common in bilateral vertebrates, particularly human beings. Through years of injecting fillers and performing face-lift operation on patients, we began to observe that more fillers were required on the right side to reach symmetry and also more loose skin and soft tissue was observed on the right side in the majority of patients (Fig. 5). Here, we conducted an analytical study to comprehensively measure human skulls in order to observe and quantify this difference. METHODS: We collected forty-one natural skulls available from five medical schools of Tehran province in Iran. Standard photography was conducted from the front, lateral, and superior views. Measurements and statistics were completed using Image J software (National Institutes of Health) for exact comparison of fixed-point distances on the samples. RESULTS: Comparison of right and left dimensions on the skulls revealed several fixed asymmetries. The most significant differences were measurements around the orbit. The distance between the upper orbit point and zygion (zy), zygion to sub-nasal, and orbital areas were significantly larger on the left side. Measuring the anterior gonion-pogonion distance showed a wider mandibular body on the left side. We did not find any considerable differences between any other left-sided and right-sided skull dimensions. CONCLUSIONS: Asymmetry of the face and body is a general rule in human anatomy, but correlation and consistency of this asymmetry between the left and right sides is a novel finding based on our measurements. Our findings showed that the orbit was significantly bigger in width, height, and surface area on the left side. We also quantified a narrower mandible on the right side. We hope these findings can be translated to aesthetic surgery practice to make the plastic surgeon and patient more familiar with the patient's specific anatomy in order to better predict, plan, and successfully implement aesthetic procedures such as injecting fillers or doing peri-orbital procedures. NO LEVEL ASSIGNED: 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.

Lower Lateral Cartilage Cephalic Malposition: An Over-Diagnosed Entity.

BACKGROUND: Lower lateral cartilage malposition is represented by anterior convexity of the lower lateral cartilage (LLC) dome with posterior pinch, as defined by Sheen and Constantian. This anatomic variation consists of cephalic, or upward and inward, rotation of lateral crura, particularly in bulbous tip patients. In most cases, "bulbous pinch" LLC is positioned toward the medial canthus, not laterally, so it is referred to as cephalic displacement. Accordingly, it is recommended to caudally displace cartilage in the majority of rhinoplasty cases in which variation is seen. OBJECTIVES: The purpose of this paper is to measure the exact angle of lateral crura with fixed reference points on the face. METHODS: We drew and marked LLC contours and vertical/horizontal lines in 40 consecutive rhinoplasty cases. We then divided them into two groups: (1) bulbous pinch and (2) flat LLCs. The right- and left-sided LLC angles to midline and horizontal lines were measured and compared to assess whether there was any significant difference between the two subgroups. RESULTS: There was no significant difference between the angles of LLC rotation in the bulbous and flat LLCs groups, measured both vertically and horizontally. CONCLUSION: Based on our findings, although cephalic malposition of LLCs may be present in some patients but in the majority of cases the etiology of nasal lateral wall pinching is not cephalic displacement of lateral crura but most probably is due, rather, to severe convexity of the posterior and lateral crura. According to our findings, cephalic malposition is an uncommon anatomic variation of LLCs that has been reported at high frequency (60-70% of their rhinoplasty cases). This finding may help to correct this deformity into a normal anatomic configuration. 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 .

Laterality and Left-sidedness in the Nose, Face, and Body: A New Finding.

BACKGROUND: Asymmetry is a common occurrence in bilaterian animals, particularly human beings. Through examination of patients and their photographs during rhinoplasty, we noted wider left-sided nasal and facial features in most patients. This observation led us to hypothesize that this might be consistent to the whole body. METHODS: We conducted a study in 3 parts to test the question above. First, we analyzed operating notes of 50 rhinoplasty patients to determine the wider side of the upper, middle, and lower thirds of the nose. Second, we analyzed the width of the face and chest wall in 31 patients to discern any correlation between facial and bodily asymmetry. Third, computerized tomographic scans of the thorax and body of 48 patients were studied to measure the width of the hemithorax and hemipelvic bone. RESULTS: (1) Upper vault width was wider on left side (78%). Left middle vault width was wider (88%). The lower lateral cartilage, lateral crura convexity was more prominent on left side (48%), and a wider scroll area was found and trimmed in 21 (left) and 0 (right) cases. The alar base was wider on left side (56%). (2) In the body and face analysis, 64.5% had a wider left-sided face and body. (3) In the computed tomographic scan analysis, same-sided thorax and pelvis asymmetry was seen (85.35%), 33 and 7 of which were left- and right-sided, respectively. CONCLUSION: We observed generalized asymmetry of the face and body with left-sided predominance.

Sclerosing Mucoepidermoid Carcinoma of the Parotid Gland.

INTRODUCTION: Mucoepidermoid carcinoma represents one of the most common malignant salivary gland tumors. However, the sclerosing morphologic variant is extremely rare with only 23 reported cases in the English-language literature since it was discovered in 1987. CASE REPORT: Herein, we describe another case that was diagnosed in a 25-year-old woman presenting with a posterior auricular mass, as well as a review of the literature, which demonstrates that this is an extremely rare malignancy with no strict protocol for treatment. CONCLUSION: Pathologists must be aware of recognizing low grade sclerosing mucoepidermoid carcinoma which has metastatic potential and is frequently misdiagnosed as a benign lesion.

Introduction of inflammatory bowel disease biomarkers panel using protein-protein interaction (PPI) network analysis.

AIM: In the present study, a protein-protein interaction network construction is conducted for IBD. BACKGROUND: Inflammatory bowel diseases as serious chronic gastrointestinal disorders attracted many molecular investigations. Diverse molecular information is present for IBD. However, these molecular findings are not highlighted based on interactome analysis. On the other hand, PPI network analysis is a powerful method for study of molecular interactions in the protein level that provide useful information for highlighting the desired key proteins. METHODS: Cytoscape is the used software with its plug-ins for detailed analysis. Two centrality parameters including degree and betweenness are determined and the crucial proteins based on these parameters are introduced. RESULTS: The 75 proteins among 100 initial proteins are included in the network of IBD. Seventy-five nodes and 260 edges constructed the network as a scale free network. The findings indicate that there are seven hub-bottleneck proteins in the IBD network. CONCLUSION: More examination revealed the essential roles of these key proteins in the integrity of the network. Finally, the indicator panel including NFKB1, CD40, TNFA, TYK2, NOD2, IL23R, and STAT3 is presented as a possible molecular index for IBD.

Total nasal skeletal reconstruction disfigured by granulomatosis with polyangitis (wegener granulomatosis).

BACKGROUND: Nasal deformity is a common disorder in Wegener granulomatosis, which is produced by polyangitis of medium-sized vessels. This process may cause necrosis and destruction of the nasal mucosa and osteocartilaginous framework. At this time, there is a lack of published data on nasal deformities associated with Wegener granulomatosis. METHODS: We present a 53-year-old woman with completely necrotized nasal lining and osteocartilage. The patient had a history of granulomatosis with polyangitis that was currently in remission. We reconstructed the patient's nose with fifth and sixth rib cartilages over 3 successive surgeries over a 2-year period. RESULTS: During the 3-year follow-up period, neither infection nor significant cartilage graft resorption was observed, and the aesthetic result was acceptable both to the patient and her physicians. CONCLUSIONS: In spite of contamination to the nasal lining and immune-compromising medications, nasal reconstruction is usually successful when considering these factors. Access to strong and abundant fifth or sixth rib cartilage presents an opportunity to reconstruct nasal destruction due to iatrogenic or autoimmune processes.

Comparison of outcomes using diced cartilage with or without tensor fascia latae wrapping in rabbits.

BACKGROUND: Diced cartilage has been associated with several advantages and rewarding results, leading to its widespread application in various forms in rhinoplasty, but the outcomes of diced cartilage with and without tensor fascia latae wrapping have not been widely reported in evidence-based articles. OBJECTIVES: The authors compared changes in weight, size, and histology of both bare and fascia-wrapped diced cartilage in rabbits as a model for human surgical outcomes. METHODS: One auricle from each of 15 rabbits was divided into 2 pieces, and both samples were diced. The tensor fascia latae of the rabbit was wrapped around 1 cartilage specimen from each rabbit (group A specimen); the other specimen received no wrapping (group B specimen). A group A specimen and a group B specimen were implanted into separate subcutaneous pockets in each rabbit. After 3 months, samples were removed from the recipient beds and weighed to compare pre- and postoperative weights. All specimens were examined for evidence of cartilage viability by histologic methods. RESULTS: There was a significant decrease in the weight of cartilage in group A. A nonsignificant weight increase was observed in group B. Histologic analyses of 5 parameters revealed no significant differences between the 2 groups, except for a significantly greater amount of new cartilage formation in group B. CONCLUSIONS: Any type of wrapping around diced cartilage may inhibit its access to surrounding nutrients. Dicing increases the absorption surface, which may result in some overgrowth, but wrapping may have a negative impact on the viability of the diced cartilage. LEVEL OF EVIDENCE: 4.

Straight septum, crooked nose: an overlooked concept.

INTRODUCTION: Asymmetric facial skeletal growth is a common finding in the rhinoplasty patient population. This common abnormality affects all facial components, including the upper lateral cartilages (ULCs). The asymmetric growth also may produce uneven thickness, consistency, curvature, and elastic recoil of the ULC. Ignoring this asymmetry may have a marked impact on the outcome of any rhinoplasty operation, especially in the management of crooked noses. MATERIALS AND METHODS: The files of 89 consecutive rhinoplasty patients who underwent surgery by a single surgeon were reviewed for deformities of the middle vault and to tabulate the procedures performed in each individual case. RESULTS: Of the 89 rhinoplasty cases, 72 (81 %) had asymmetric ULCs. Approximately 30 % (27/89) of the cases had a straight septum with asymmetric ULCs which required appropriate correction. CONCLUSIONS: Awareness of an asymmetric ULC in a crooked nose and an attempt to correct this condition in addition to straightening of the septum is key to decreasing postoperative residual or recurrent mid-vault deviation. 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 .

Correction of cleft lip nose deformity with rib cartilage.

BACKGROUND: Correction of cleft lip nasal deformities (CLND) is often unsatisfactory because of problems resulting from cartilage weakness and strong soft tissue forces. Therefore, strong cartilaginous support, such as rib cartilage, is mandatory. OBJECTIVES: The authors describe placement of rib cartilage grafts to create a more symmetric and aesthetically acceptable repair of CLND with improved nasal air flow. METHODS: Two groups of patients, including those with unilateral and bilateral CLND, underwent operations with different sources of autologous cartilage. Group 1 received grafts from the septum and ear, whereas group 2 received grafts from the septum and ribs. Results were evaluated by 2 independent physicians who rated improvement between pre- and postoperative photographs. RESULTS: There were significant differences in postoperative improvement between patients who received septal/ear cartilage grafts and those who received septal/rib cartilage grafts in both unilateral and bilateral cases (P = .028 and P = .043, respectively). CONCLUSIONS: The authors' results demonstrate that rib cartilage has a positive effect on the aesthetic outcome of CLND operations and provides a strong support structure for correcting this deformity with minimal postoperative complications.

Anterior scoring approach for prominent ear anomaly: a modified Chongchet technique.

BACKGROUND: One of the most common facial anomalies is the presence of a prominent ear. Numerous surgical techniques have been introduced in the literature for correction of this anomaly, which include suturing and sculpturing the ear cartilage. However, each has different complications. The modified Chongchet technique is one of the less invasive methods and can correct the above abnormality with satisfying results. METHODS: From July 2001 to March 2011, 19 cases of prominent ear were corrected using the modified Chongchet technique. The mean follow-up period was approximately 4.5 years. We employed an anterior approach and partial-thickness scaphal cartilage scoring in these cases. RESULTS: We observed no recurrences and no sharp cartilage protrusions following the surgeries. Additionally, all patients expressed satisfaction with the results.  CONCLUSION: We propose that the modified Chongchet approach is less aggressive and has improved surgical outcomes. One of the adverse effects of this procedure is unpredictable warping of the cartilage, which may result in asymmetry.

Diced ear cartilage with perichondrial attachment in rhinoplasty: a new concept.

BACKGROUND: Diced cartilage is a valuable material that has recently been added to the graft options in rhinoplasty. Shaping, fixation, and resorption are the main concerns with this material. Perichondrially attached diced conchal cartilage may be a new possibility to solve some of these problems. OBJECTIVES: The authors evaluate the outcome of perichondrially attached diced cartilage in a rabbit model and compare the results with injectable cartilage grafting. METHODS: Ear cartilage was removed from 1 auricle in each of the 16 rabbits included in this study; samples were divided in 2 pieces. After precise weighing, both segments were diced. The perichondrium was left attached to 1 of the pieces. Both segments were inserted in 2 separate pockets in the dorsum of the animal. After a 3-month period, both samples were removed and measured for growth/resorption. RESULTS: At the beginning of this study, the difference in weight between groups was statistically insignificant (P = .213), but 3 months after insertion, significant growth was observed in the perichondrial group (P = .019). CONCLUSIONS: The vascularization and significant growth in weight of the perichondrially attached diced cartilage samples are evidence of the viability of this material. The structural integrity and solid framework afforded by this option suggest that the material should be used more frequently in nasoskeletal augmentation.

Epidural anesthesia as a thromboembolic prophylaxis modality in plastic surgery.

BACKGROUND: Epidural anesthesia (EA) is known to reduce postoperative thromboembolic complications, but the mechanisms are poorly understood. Review of the literature revealed no reports about the ability of epidural anesthesia (EA) to reduce the risk of venous thromboembolism (VTE) in abdominal contouring surgery and/or liposuction. Most medical publications in this field are based on orthopedic cases. OBJECTIVES: The authors investigate the hypothesis that the differential nerve-blocking effect of bupivacaine, which spares motor function and permits leg movement during the operation, is the most important mechanism by which EA prevents thromboembolism. METHODS: From June 1992 to August 1995, 24 cases of abdominoplasty were performed under general anesthesia (Group 1). From September 1995 to December 2009, 371 cases of concurrent abdominoplasty and liposuction were performed under EA (Group 2). Eighteen cases (4.8%) from Group 2 were ultimately excluded from the study because of unsuccessful EA. All surgeries were performed by the senior author (FH). RESULTS: One thromboembolic event (pulmonary embolism [PE]) occurred in Group 1 (4%). No cases of deep vein thrombosis (DVT) or PE occurred among Group 2 patients. CONCLUSIONS: Together, differential epidural nerve blocks and purposeful intraoperative movement of lower-limb muscles represent an effective prophylactic mechanism that may prevent devastating DVT and resultant PE.

Does post septoplasty nasal packing reduce complications?

The main issues in nasal surgery are to stabilize the nose in the good position after surgery and preserve the cartilages and bones in the favorable situation and reduce the risk of deviation recurrence. Also it is necessary to avoid the synechia formation, nasal valve narrowing, hematoma and bleeding. Due to the above mentioned problems and in order to solve and minimize them nasal packing, nasal splint and nasal mold have been advised. Patients for whom the nasal packing used may faced to some problems like naso-pulmonary reflex, intractable pain, sleep disorder, post operation infection and very dangerous complication like toxic shock syndrome. We have two groups of patients and three surgeons (one of the surgeons used post operative nasal packing in his patients and the two others surgeons did not).Complications and morbidities were compared in these two groups. Comparing the two groups showed that the rate of complication and morbidities between these two groups were same and the differences were not valuable, except the pain and discomfort post operatively and at the time of its removal. Nasal packing has several risks for the patients while its effects are not studied. Septoplasty can be safely performed without postoperative nasal packing. Nasal packing had no main findings that compensated its usage. Septal suture is one of the procedures that can be used as alternative method to nasal packing. Therefore the nasal packing after septoplasty should be reserved for the patients with increased risk of bleeding.

Epidemiologic and clinicopathologic characteristics of tongue cancer in Iranian patients.

Oral cancer is considered a great threat to public health. Tongue cancer accounts for nearly 30% of all oral cancers and usually seen in 50 to 60 year old men. Oropharyngeal cancers account for 3% of all cancers in Iran; as reported in 2003. The present study was designed to assess the epidemiologic and clinicopathologic characteristics of tongue cancer patients in two Tehran's referral university hospital between the years 2003 and 2008. In a retrospective study 87 files of patients, diagnosed with tongue cancer who were referred to Imam Khomeini and Loghman Hospitals and Iranian Cancer Institute in Tehran-Iran from 2003 to 2008 were reviewed. Participants were selected from all the patients who had a record of their specimens in the pathology ward registry and their tongue cancer diagnosis was confirmed by a expert pathologist. Patients characteristics (age, gender and presence of risk factors) and chief complain at the time of diagnosis and their tumor related data (type of cancer, staging, grading, morphology and location of tumor) were recorded. Tongue cancer was most frequently seen in the eighth decade of life among both men and women, but had the lowest frequency among patients with less than 40 years of age. Squamous cell carcinoma had the highest prevalence in our patients. Tongue cancer was the most common cancer of oral cavity among Iranian patients and similar epidemiologic and clnicopathological characteristics of the disease were found in our patients. Assessing variables such as socioeconomic levels and religious believe require further studies with large sample sizes.

Eliminating frown lines with an endoscopic forehead lift procedure (corrugator muscle disinsertion).

BACKGROUND: In certain cases of endoscopic forehead lift without muscle resection, patients were incidentally noted to develop weakness or loss of their ability to frown during the postoperative period despite intact musculature. This finding suggested the possibility of decreasing frown strength using the disinsertion of the relevant muscles. This finding persuaded the authors to try to eliminate or decrease the sensory problems resulting from open or endoscopic frowning muscle resection by disinserting these muscles. We therefore sought to determine the efficacy of a brow/forehead lift that involved disinsertion rather than muscle resection. METHODS: From September 2004 through December 2006, 22 endoscopic forehead lifts (20 females and 2 males) were performed using the conventional corrugator muscle resection technique (group 1). From January 2007 through October 2009, 43 patients (38 females and 5 males) underwent endoscopic forehead lift with a muscle-preserving technique (group 2). In both groups, small scalp incisions were made, and an endoscope was used to elevate the brows and forehead to perform glabellar and forehead muscle resection in group 1 and disinsertion of the frowning muscles in group 2. The skin of the forehead was then reanchored to a more superior location using sutures attached to deep temporal fascia as well as outer table screws and skin staples. RESULTS: Aesthetically pleasing eyebrow and forehead with reduced power in the frowning muscles were achieved in the majority of patients in both groups. A significant decrease in the depth of vertical and horizontal glabellar creases was obtained in these patients. In group 1, 19 of 22 patients completely lost the ability to frown and 3 patients (13.6%) suffered permanent sensory loss. In group 2, 33 of 43 patients lost their ability to frown but only 2 cases (4.5%) developed minimal unilateral forehead partial sensory deficit after a 12-month follow-up period. CONCLUSION: Disinsertion of the corrugator supercilli, procerus, or orbicularis oculi muscles can decrease contractility with less chance of damaging nearby or intermingled sensory nerves than offered by resection.

Neuro-otologic manifestations of multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) has numerous neurologic signs and symptoms, including hearing impairment. The reports concerning the type and severity of hearing loss in MS patients vary and little is known about an association of the disease characteristics with changes in hearing status. OBJECTIVE: To find the otologic and neuro-otologic manifestations of MS with the use of routine hearing assessment tools. METHODS: The presence of neuro-otologic signs and symptoms were studied in 30 patients diagnosed with MS. Patients underwent pure tone audiometry, speech audiometry and acoustic brain stem response (ABR) tests. The results were compared with 30 healthy age and sex matched controls. RESULTS: The most common finding was sensory-neural hearing loss followed by dizziness and nystagmus. The shape of the audiogram and severity of hearing loss was associated with both chronicity and disease activity. There were abnormal latencies in ABR waves which were more significant with high velocity stimulus. CONCLUSION: Hearing status deserves careful attention in MS patients. It may be used as a diagnostic means or an indicator for evaluating the characteristics of the underlying disease.

Applied anatomy of the nasal lower lateral cartilage: a new finding.

BACKGROUND: In most references to the nasal anatomy, the shape of the lower lateral cartilage (LLC) is described as a two-dimensional structure. However, the authors have found different forms of LLC in at least 40% of their open rhinoplasty cases during the past 20 years. This cartilage was found to have a three-dimensional hemispheric appearance and to be connected to the upper lateral cartilage (ULC) at the scroll area by an inward limb of this hemisphere. This inward limb may have an important role in producing asymmetry and flare of the nostril. METHODS: The LLC of 286 patients was evaluated during open rhinoplasty over a 2-year period, with a focus mainly on the shape of this structure, especially at the LLC-ULC junction (scroll area). RESULTS: A dome-shaped appearance of the LLC was noted in 40.9% of cases, and 11.5% of cases had bilateral LLC variation. This different anatomic form was seen mostly in patients with a strong bulbous nasal tip, although it was observed less frequently also in patients with narrow nasal tips. CONCLUSION: At least one-third of the LLCs analyzed had a medial wall in addition to the lateral wall, which significantly increased the flare and recoil force of this structure. This makes this cartilage more redundant to reshaping procedures (straightening). Thus, special attention must sometimes be paid to this common anatomic variation to produce symmetric nostrils and to obtain a more aesthetically acceptable alar tip.

Asymmetric facial growth and deviated nose: a new concept.

Deviated nose correction is difficult and constitutes a very different issue from septal deviation. When correcting this deformity, traces of asymmetry can be detected. The authors demonstrate facial asymmetry accompanying deviated noses, and such asymmetry is usually ignored by surgeons who typically concentrate only on nose deformities.A total of 5822 pre- and postrhinoplasty photographs related to 547 women and 124 men were reviewed. Out of the total population, the following 3 groups were selected: group A, gross nose and face asymmetry; group B, nose asymmetry with no facial deformity; group C, facial asymmetry with straight nose. Different measurements were applied to the selected photos, presented in . These included measurement from the lateral canthi to the lateral mouth corners (D1) and from the midface to each most lateral part of the zygomatic arch (D2). Measurements from one side were compared with those from the contralateral side to identify true anatomic differences, as presented in .(Table is included in full-text article.)(Figure is included in full-text article.)There was a significant difference in the nose and face deformity group, as evidenced by a meaningful difference in both the D1 and D2 measurements.We report a significant growth retardation of the midface and orbit on the concave side of the nose. This impediment may serve as the etiology for many asymmetries of the face and nose.