Dorsal Preservation Surgery: A Novel Modification for Dorsal Shaping and Hump Reduction.

BACKGROUND: A new technique for dorsal preservation rhinoplasty that minimizes recurrent hump deformity is introduced. OBJECTIVES: The authors sought to present a novel dorsal roof flap (DRF) technique for modifying the nasal hump and dorsum while reducing morbidity. METHODS: Twenty-two primary and 3 secondary rhinoplasty patients had 1 of 2 types of nasal DRF depending on hump composition. A triangular roof flap was created utilizing 2 incisions from W-point to lateral Keystone junction in cartilaginous humps (cartilaginous DRF) and to the nasion in osseocartilaginous humps (osseocartilaginous DRF). Then, septal strip excisions were conducted to lower the profile followed by nasal base narrowing. The DRF was then lowered to the desired profile line, any excess lateral wall height trimmed, and the DRF sutured to the upper lateral cartilages. Preoperative and postoperative nasolabial and nasoglabellar angles were measured on the photos. RESULTS: Mean follow-up was 10.3 (standard deviation, 4.41) months (range, 6-20 months). A total 22 humps were V-shape and 3 were S-shape. The composition of the hump was cartilaginous in 5 cases, bone in 7 cases, and combined in 13 cases. A cartilaginous DRF was utilized for the 5 cases with a cartilaginous hump and osseocartilaginous DRF was employed in the other 20 cases. There were no complications observed in the follow-up period and thus no revisions. CONCLUSIONS: The DRF technique allows preservation of the nasal dorsum and elimination of the dorsal hump while minimizing hump recurrence.

Reducing Dorsal Hump Recurrence Following Push Down-Let Down Rhinoplasty.

BACKGROUND: Hump recurrence is a commonly encountered problem following dorsal preservation (DP) rhinoplasty when surgeons are learning the procedure. OBJECTIVES: The aim of this paper was to compare the different methods for the prevention and treatment of dorsal problems following DP surgery. METHODS: One hundred and fifty primary rhinoplasty patients were included in our study. Their noses were classified in terms of both hump shape (V- or S-shaped) and height. All patients had a DP rhinoplasty by either a push-down (PD) or a let-down (LD) technique. The PD method was used for humps <4 mm and the LD for humps >4 mm. Follow-up evaluations were made with physical examination and photographs at 1 week, 3 months, and 12 months. RESULTS: Mean follow-up was 12.68 [1.78] months. Seventy-eight humps were V-shaped and 72 were S-shaped. PD was used for 67 cases, LD for 83 cases. Eight patients (5.3%, 8/150) had a visible dorsal hump problem after DP surgery. Based on their preoperative hump shape, 3 cases were V-shaped and 5 were S-shaped. All recurrent cases had a preoperative hump deformity >4 mm. The revision procedures were as follows: 4 patients had a PD procedure, 3 had a LD procedure, and 1 patient was treated by classic open resection rhinoplasty. CONCLUSIONS: There is a correlation between preoperative hump height and eventual hump recurrence. The complication rate can be decreased with additional technical maneuvers and proper patient selection.

The Probable Reasons for Dorsal Hump Problems following Let-Down/Push-Down Rhinoplasty and Solution Proposals.

BACKGROUND: Nasal hump relapse and its probable reasons or mechanisms have been less discussed after dorsal preservation rhinoplasty. In this article, the authors would like to share their experiences and offer solutions regarding this subject. METHODS: Five hundred twenty patients who underwent primary rhinoplasty between the years 2016 and 2018 were included in the study. The push-down method was used for noses with a hump less than 4 mm and the let-down procedure was performed for others. Hump height was measured from profile photographs. The cases were evaluated in terms of nasal dorsal problems and their probable mechanisms. RESULTS: Five hundred twenty patients, 448 with a straight nose and 72 with a deviated nose, were enrolled in this study. Mean follow-up was 13 months (range, 9 to 16 months). Visible dorsal hump recurrence was observed in 63 patients, and they appeared at 1 to 4 months postoperatively. Forty-one of these had a dorsal hump more than 4 mm preoperatively. Hump recurrence was not more than 2 mm in 34 patients, and they did not wish to have any revision intervention because of cosmetic satisfaction. In 11 cases, the height of the hump recurrence was 2 to 3 mm. These patients were treated with only minimal rasping. The remaining 18 patients had a hump recurrence with a height of 3 to 4 mm. They underwent secondary surgery using let-down rhinoplasty. CONCLUSION: The authors recommend subperichondrial/subperiosteal dissection, subdorsal excision of cartilaginous and bony septum, scoring the resting upper part of the septum just below the keystone area, and performing lateral keystone dissection and preferring let-down procedure for kyphotic noses to prevent hump relapse after dorsal preservation rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

An Extremely Rare Condition: Unilateral and Isolated Temporalis Muscle Hypertrophy.

Unilateral and isolated temporalis muscle hypertrophy is an extremely rare condition causing cosmetic problems and pain in the temporal region. Up to date, 8 isolated and unilateral cases were reported in the English literature. In this article, the authors report 2 new cases of unilateral isolated temporal muscle hypertrophy.

Scapular Bone Grafts: Good Options for Craniofacial Defects?

INTRODUCTION: There is still no consensus on the ideal material to be used in craniofacial defects. Autogenous bone grafts are mostly preferred owing to their use with fewer complications. The aim of this study was to evaluate whether the scapular bone graft can be used with equal or more advantages to other bone graft resources in orbital, maxillary sinus front wall, and frontal bone defects. PATIENTS AND METHODS: Twenty-four orbital, maxillary sinus front wall, and frontal bone defects were reconstructed with scapular bone grafts. Sixteen patients presented with complicated orbital fractures, 5 patients presented with isolated orbital floor fractures, and 3 patients presented with frontal bone fractures. The grafts were radiologically evaluated 1 day, 6 months, and 12 months postoperatively by 3-dimensional computed tomography scan. RESULTS: All orbital, maxillary sinus front wall, and frontal bone defects were reconstructed successfully with scapular bone grafts. Clinical evaluation of the patients at 6 to 24 months of follow-up was considered satisfactory. Minimal donor site morbidity was observed. Scapular bone grafts adapted nicely to the recipient area, and bony union was complete as demonstrated by 3-dimensional computed tomography scans. CONCLUSIONS: Reconstruction of orbital, maxillary sinus front wall, and frontal bone defects with scapular bone grafts is an easy and safe procedure with minimal donor site morbidity. Scapular bone graft is a good reconstructive option for orbital, maxillary sinus front wall, and frontal bone defects.

The Effect of Autologous Fat Graft with Different Surgical Repair Methods on Nerve Regeneration in a Rat Sciatic Nerve Defect Model.

BACKGROUND: The aim of this study was to evaluate the efficacy of autologous fat graft with different surgical repair methods on reconstruction of a 10-mm-long rat sciatic nerve defect model. METHODS: One hundred forty-four sciatic nerves were operated on in 72 Wistar rats. The right limbs were assigned as group A (n = 72) and the left limbs as group B (n = 72). In group B, autologous fat graft was added to the surgical area so as to stay in contact with the coaptation site. Nerve regeneration was evaluated by walking track analysis, Sciatic Functional Index, pin-prick, and electrophysiologic and histologic tests at commencement and at 4 and 12 weeks after the operation. RESULTS: The rats receiving fat graft showed better regeneration, but the difference was only significant according to Sciatic Functional Index and pin-prick test (p < 0.05). Primary repair, autogenous nerve graft, acellularized nerve graft, vein filled with fresh and denatured muscle graft subgroups in group B showed significantly better regeneration than those in group A according to the Sciatic Functional Index (p < 0.05). In terms of latency and amplitude, all subgroups in groups A and B were found significantly different from the commencement of the study, but there was no difference between groups A and B (p < 0.05). CONCLUSIONS: Although there was no significant difference between the groups, rats receiving autologous fat graft showed better regeneration. Combined use of autologous fat graft with surgical repair methods induced significantly better regeneration. It was concluded that autologous fat grafting may have a beneficial effect on nerve regeneration when it is present in the coaptation site during healing.

The Use of Vacuum-Assisted Closure and GranuFoam Silver® Dressing in the Management of Diabetic Foot Ulcer.

PURPOSE: The aim of this retrospective study was to evaluate the efficacy of vacuum-assisted closure (VAC) and GranuFoam Silver® dressing (KCI, San Antonio, TX) compared with conventional GranuFoam® dressing in the management of diabetic foot ulcers. PATIENTS AND METHODS: Twenty-one consecutive patients treated with conventional or silver-coated foam dressing were reviewed retrospectively. The wound duration was 6 mo. Group 1 (n=10) received conventional foam dressing (GranuFoam) and group 2 (n=11) received silver-coated foam dressing (GranuFoam Silver). The wound surface area, duration of treatment, bacteriology, and recurrence were compared between the groups. The mean age of the patients was 61.70±10.52 y in group 1 and 67.27±11.28 y in group 2. RESULTS: In group 1, the average surface area of the wounds was 45.30±46.96 cm2 and 18.40±23.48 cm2 in the pre-treatment and post-treatment periods, respectively. There was a statistically significant difference between two measurements (p=0.005). Average duration of the treatment was 25.50±27.13 d in this group. In group 2, average surface area of the wounds in the pre-treatment and post-treatment periods were 41.55±36.03 cm2 and 7.64±3.91 cm2, respectively. There was a statistically significant difference between two measurements (p=0.003). Average duration of the treatment was 10.09±3.51 d in this group. The patients treated with silver-impregnated polyurethane foam dressing had reduced recurrence (2 vs. 7 wounds, p=0.030) and increased number of the culture-negative cases at the end of the treatment. CONCLUSION: With the results of the study, it was concluded that VAC GranuFoam silver dressing can be superior to conventional GranuFoam dressing in reducing the recurrence rate of infected diabetic foot ulcers.

Reverse superior labial artery flap in reconstruction of nose and medial cheek defects.

BACKGROUND: Angular artery, lateral nasal artery, and infraorbital artery pedicled nasolabial flaps have been used for reconstruction of lower nose and medial cheek defects. An alternative pedicle to raise a flap in the nasolabial area is the superior labial artery. Superior labial artery is a constant branch of the facial artery, arising above or at the angle of mouth and anastomoses with its counterpart in the middle of the upper lip. This makes a reverse superior labial artery pedicle possible for elevation of a nasolabial flap. PATIENTS AND METHODS: Reverse superior labial artery island flaps were used for reconstruction of lower nose and medial cheek defects in 12 patients. Eleven patients presented with malignant skin lesions and 1 with a traumatic defect of the lower nose. Auricular cartilage graft to support the alar rim and nasal tip was combined to the flap in 3 patients. RESULTS: All flaps survived completely. Temporary venous congestion was observed in 3 flaps in the early postoperative period but this resolved in 3 to 5 days. All patients healed without any postoperative complications and the final results were considered satisfactory. CONCLUSIONS: Reverse superior labial artery pedicled nasolabial island flap proved to be a good choice for reconstruction of the lower nose and moderate sized medial cheek defects. This pedicle should be considered where the defect is located on the course of lateral nasal artery or angular artery. Arc of rotation and reliability of this new flap is considered superior to angular artery and infraorbital artery-based nasolabial flaps where these arteries could also be used as pedicle.

The use of temporalis muscle graft, fresh and cryopreserved amniotic membrane in preventing temporomandibular joint ankylosis after discectomy in rabbits.

PURPOSE: The aim of the study was to evaluate the efficacy of temporalis muscle-fascia graft, fresh and cryopreserved human amniotic membrane as an interpositional material in preventing temporomandibular joint ankylosis in a rabbit model. MATERIALS AND METHODS: In this experimental study, 21 New Zealand white rabbits were used. The condyle and the joint disc were removed to induce ankylosis in left TMJs. Reconstruction was immediately performed with temporalis muscle-fascia graft (tMFG) in group I (n = 7), fresh human amniotic membrane (fHAM) in group II (n = 7) and cryopreserved human amniotic membrane (cHAM) in group III (n = 7). All rabbits were sacrificed at 3 months after the operation. The comparison was made among three groups by means of vertical mouth opening and weight measurements, radiologic and histologic findings obtained before and after surgery. RESULTS: In all rabbits, there was no statistically significant difference in the jaw movements and weight among groups at commencement and 3 months after surgery. The condylar surfaces were more irregular in HAM groups. There were mild osteophyte formations, sclerosis, fibrosis and calcification around the condyle in all groups however the joint gap was more preserved in group I. All interpositional materials were also seen to be partially present in the joint gap at 3 months. Ankylosis was not seen in the joint gap in any group. CONCLUSION: With the results of this study it was concluded that interpositional arthroplasty with HAM and tMFG have an almost similar effect in preventing TMJ ankylosis after discectomy in the rabbit model.

Loofah sponge as an interface dressing material in negative pressure wound therapy: results of an in vivo study.

Since the introduction of negative pressure wound therapy (NPWT), the physiological effects of various interface dressing materials have been studied. The purpose of this experimental study was to compare the use of loofah sponge to standard polyurethane foam or a cotton gauze sponge. Three wounds, each measuring 3 cm x 3 cm, were created by full-thickness skin excision on the dorsal sides of 24 New Zealand adult white rabbits. The rabbits were randomly divided into four groups of six rabbits each. In group 1 (control), conventional saline-moistened gauze dressing was provided and changed at daily intervals. The remaining groups were provided NPWT dressings at -125 mm Hg continuous pressure. This dressing was changed every 3 days for 9 days; group 2 was provided polyurethane foam, group 3 had conventional saline-soaked antimicrobial gauze, and group 4 had loofah sponge. Wound area measurements and histological findings (inflammation, granulation tissue, neovascularization, and reepithelialization) were analyzed on days 3, 6, and 9. Wound area measurements at these intervals were significantly different between the control group and study groups (P<0.05). Granulation and neovascularization scores were also significantly different between the control and treatment groups at day 3 (P=0.002). No differences in any of the healing variables studied were observed between the other three dressing materials. According to scanning electron microscopy analysis of the three interface materials, the mean pore size diameter of foam and gauze interface materials was 415.80±217.58 µm and 912.33±116.88 µm, respectively. The pore architecture of foam was much more regular than that of gauze. The average pore size diameter of loofah sponge was 736.83±23.01 µm; pores were hierarchically located--ie, the smaller ones were usually peripheral and larger ones werecentral. For this study, the central part of loofah sponge was discarded to achieve a more homogenous structure of interface material. Loofah sponge study results were similar to those using gauze or foam, but the purchase price of loofah sponge is lower than that of currently available interface dressings. More experimental, randomized controlled studies are needed to confirm these results.

Alternative nipple suspension technique in the treatment of inverted nipple: reverse s-shaped design.

The primary aim in the treatment of inverted nipple is to achieve a satisfactory and permanent projection of the nipple. The drawbacks of reported techniques include sensory disturbance of the nipple, marked scarring of the nipple and areola, destruction of breast function and incomplete correction. In the present study, the authors introduced a new modification of using two opposite nipple-based areolar dermal flap in the treatment of grades 2 and 3 inverted nipple cases. Nipple-based areolar flaps designed at 3 o'clock and 9 o'clock were raised by two linear incisions and the tip of each flap was sutured on the base of the nipple close to the base itself in a reverse S shape at 6 and 12 o'clock. Successful outcome was obtained due to a strongly suspending effect of the design of the flaps. The mean follow-up period was 6 months. The patients were satisfied with the result and the scars were minimal. The authors recommend the use of the technique that is a simple, reliable and with minimal scars for correcting grades 2 and 3 inverted nipples.

Relation between serum quantitative HBsAg, ALT and HBV DNA levels in HBeAg negative chronic HBV infection.

BACKGROUND/AIMS: In this study, we aimed to investigate whether quantitative HBsAg and alanine aminotransferase (ALT) levels correlated with Hepatitis B Virus (HBV) DNA levels in patients with HBeAg negative chronic HBV infection. MATERIALS AND METHODS: Ninetynine patients were divided into two groups; inactive HBsAg carriers (IC) and active carriers (AC) with HBV DNA>2000 IU/mL. These two groups were compared in terms of ALT and HBsAg levels. Quantitative HBsAg measurements were performed with Elecsys HBsAg II Quant assay (Roche Diagnostic). RESULTS: Mean age of patients was 43.11±14.79 years. HBsAg and ALT values of IC and AC patients were 2.47±1.35 log10 IU/mL, 3.59±0.97 log10 IU/mL (p=0.0001), and 25.94±13.06 IU/mL, 55.54±82.38 IU/mL (p=0.015), respectively and the difference was significant. When ROC analysis was performed to determine the most appropriate quantitative HBsAg value to define inactive carrier patients, the area under the ROC curve for HBsAg was 0.738 (95% CI:0.637-0.840). A cut-off of 2147 IU/mL revealed sensitivity of 76% and specificity of 70% for diagnosing the IC. Also, a significant correlation was also found between levels of HBV DNA (log) and HBsAg (log) (r: 0.503, p=0.0001). CONCLUSION: It has been concluded that quantitative measurements of HBsAg could be used to differentiate between IC and AC patients.

Clinical evaluation of gauze-based negative pressure wound therapy in challenging wounds.

The aim of this randomised clinical study was to evaluate the effectiveness and safety of gauze-based negative pressure wound therapy (NPWT) in patients with challenging wounds. A total of 50 consecutive patients who had wound drainage for more than 5 days, required open wound management and had existence of culture positive infection were included the study. In this study, gauze-based NPWT was compared with conventional dressing therapy in the treatment of patients with difficult-to-heal wounds. The patients were randomly divided into two groups. Group I (n = 25) was followed by conventional antiseptic (polyhexanide solution) dressings, and group II (n = 25) was treated with saline-soaked antibacterial gauze-based NPWT. The wounds' sizes, number of debridement, bacteriology and recurrence were compared between group I and group II. The mean age of the patients was 59·50 years (range 23-97). In group I, average wound sizes of pre- and post-treatment periods were 50·60 ± 55·35 and 42·50 ± 47·92 cm(2), respectively (P < 0·001). Average duration of treatment was 25·52 ± 16·99 days, and average wound size reduction following the treatment was 19·99% in this group. In group II, the wounds displayed considerable shrinkage, accelerated granulation tissue formation, decreased and cleared away exudate. The average wound sizes in the pre- and post-treatment periods were 98·44 ± 100·88 and 72·08 ± 75·78 cm(2) , respectively (P < 0·001). Average duration of treatment was 11·96 ± 2·48 days, and average wound size reduction following the treatment was 32·34%. The patients treated with antibacterial gauze-based NPWT had a significantly reduced recurrence (2 wounds versus 14 wounds, P = 0·001), and increased number of the culture-negative cases (22 wounds versus 16 wounds, P < 0·047) in a follow-up period of 12 months. There was a statistically significant difference between two groups in all measurements. As a result, we can say that the gauze-based NPWT is a safe and effective method in the treatment of challenging infective wounds when compared with conventional wound management.

Efficacy of dexamethasone with controlled hypotension on intraoperative bleeding, postoperative oedema and ecchymosis in rhinoplasty.

PURPOSE: The aim of this retrospective study was to evaluate the efficacy of dexamethasone with controlled hypotension on intraoperative bleeding and postoperative morbidity in rhinoplasty. MATERIALS AND METHODS: Sixty rhinoplasty patients required hump resection and lateral osteotomy were included in this study. The patients were randomized into four groups. In group I (n=15), a single dose of 10mg/kg dexamethasone was intravenously administered at the beginning of the operation. In group II (n=15), the patients were given 2 doses of 10mg/kg intravenously dexamethasone at the beginning of the operation, and 24 hours after the operation. In group III (n=15), 3 doses of 10mg/kg intravenously dexamethasone were given at the beginning of the operation, before osteotomy and 24 hours after the operation. Group IV (n=15) was assigned as control group and the patients were neither administered dexamethasone nor applied hypotension. All cases in groups I, II and III were operated under controlled hypotension. Systolic arterial pressure was aimed to keep between 65 and 75 mmHg for controlled hypotensive anaesthesia. Controlled hypotension was achieved by a remifentanil infusion of 0.1-0.5 microg/kg/min, following a bolus of 1 microg/kg. Degree of eyelid oedema and periorbital soft-tissue ecchymosis was evaluated separately using a scale of 0-4. Intraoperative blood loss was recorded for each patient. Patients were evaluated at 24 hours and postoperative days 2, 5, 7, and 10. RESULTS: In groups I, II and III, intraoperative bleeding was more decreased and the operation time was significantly shorter compared with control group (P<0.001). Eyelid oedema and periorbital ecchymosis were significantly decreased in groups I, II and III at the following postoperative 7 and 10 days (P<0.001). There was statistically significant difference between group III and other groups at the postoperative 5 and 7 days in lower eyelid oedema (P<0.001), upper and lower eyelid ecchymosis (P<0.001 and 0.004, respectively). There were no postoperative complications with using steroid in any of the groups. CONCLUSION: Three doses of dexamethasone with controlled hypotension considerably reduced postoperative morbidities of rhinoplasty with osteotomy as well as intraoperative bleeding. Thus, in group III receiving 3 doses of steroid, when compared to other groups, more uneventful postoperative period were provided for surgeon and the patients.

Digital anthropometric shape analysis of 110 rhinoplasty patients in the Black Sea Region in Turkey.

PURPOSE: The aim of the study was to describe the average values of the nasal anthropometric measurements by using the landmark-based geometric morphometric technique in young male patients who applied for rhinoplasty in the Black Sea Region in Turkey. MATERIALS AND METHODS: The study group consisted of 110 healthy male patients all were born in the Black Sea Region, Turkey. The landmark-based geometric morphometric technique was used to analyze the nasal shapes as described in the literature. The mean age was 29 years (ranging from 23 to 35). All patients underwent primary rhinoplasty in our clinic between 2006 and 2011 years. All data were obtained from standardized digital photographic images. Anterior and worm's eye view photos of the patients were analyzed by using standard anthropometric measurement methods. RESULTS: The mean total length and nasal bridge length of the noses were 58.90 and 57.35 mm, respectively. The mean nasal bridge width and the morphologic nose width were 32.65 and 35.50mm, respectively. The average width of the anatomic nose was 26.25 mm. The mean length and width of the ala were 22.72 and 4.73 mm, respectively. The mean length and width of the columella were 11.35 and 5.20mm, respectively. The mean frontonasal angle was 137.88° and the mean nasolabial angle was 87.34°. CONCLUSION: Black Sea nose was characterized by being considerably longer than average in nasal length and columellar height. Also nasolabial angle was found to be more acute than average when compared to other noses.

The Use of a Nasolabial Island Flap in Vestibulo-sulcoplasty in a Patient with Recurrent Depressed Scar on the Modiolus.

A 56-year-old woman with a recurrent depressed scar of the commissure, treated with a nasolabial island flap, is presented. On examination, the scar was located on the right modiolus involving the right upper gingivobuccal sulcus. A history of recurrent canine abscess was obtained. After excision of the scar and release of the vestibular fold, reconstruction of the defect was performed with a nasolabial island flap from the same side. The postoperative course was uneventful, with a good aesthetic and functional outcome.