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.

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.

The uncommon combination of common variable immunodeficiency, macrophage activation syndrome, and cytomegalovirus retinitis.

Common variable immunodeficiency (CVID) is a heterogeneous group of disorders with varied immunologic phenotypes and clinical manifestations. Patients with CVID are mainly characterized by decreased serum immunoglobulin levels, and increased susceptibility to recurrent bacterial infections, autoimmune disorders, and malignancies. Here we present a CVID patient who has developed a clinical polyclonal lymphocytic infiltration phenotype associated with severe and irreversible pancytopenia with unknown etiology. Progressive unilateral loss of vision and cytomegalovirus retinitis indicated the cause of patient's pancytopenia.

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.

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.

Actinidia deliciosa (kiwifruit), a new drug for enzymatic debridement of acute burn wounds.

BACKGROUND: Actinidia deliciosa (kiwifruit) is used as a meat tenderizer. It acts rapidly and efficiently to soften meat, liquefying it if allowed to work for more than a few hours. Observing this effect and the lack of studies addressing this subject in the literature, the authors sought to investigate the use of this natural remedy in an animal model for eschar separation and debridement. METHODS: Thirty-five male rats were divided randomly into three groups. Under general anaesthesia, a limited standard full-thickness burn was produced on the back of each rat. For the intervention group (G1, 15 rats), the wounds were covered with fresh kiwifruit; for control groups 2 and 3 (G2, 15 rats; G3, five rats), the dressing was a neutral ointment (Emulsifier 1220). Weekly wound observations were documented for all the groups. G1 and G2 were sacrificed on Day 20, and group 3 was kept alive until complete eschar separation. The wounds of the rats in groups 1 and 2 were excised and subjected to microscopic evaluation. RESULTS: On Day 20, all eschars had detached and fallen off in the intervention group (G1), whereas in groups G2 and G3 the eschars were still firmly attached to the base of the wounds (except in two rats of G2); this finding was statistically significant (p<0.001). The average wound surface area in group G1 was 212 mm(2) (SD=88.80938) whereas in G2 it was 388 mm(2) (SD=140.6967). Thus, the wound surface area was significantly (p<0.001) smaller in the intervention group. The eschars in G3 separated spontaneously between days 30 and 42, while in all the rats of the kiwi-treated group, this phenomenon occurred before Day 20. The pathological study revealed no considerable differences between G1 and G2 (p<0.05). CONCLUSIONS: Debridement and scar contraction occurred faster in the kiwi-treated group than in the untreated group. Following rapid enzymatic debridement, healing appeared to progress normally, with no evidence of damage to adjacent healthy tissue.