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Introduction: The basis of dorsal preservation rhinoplasty goes back to the late 19th and the early 20th centuries. In that era, pioneers such as Drs. Goodale, Lothrop, and Cottle were prominent surgeons who reported on this technique. Currently, there has been a renewed interest of this technique that stems from the nasal anatomy and an interest in less destructive techniques. In this review, we discuss examples of the contributions of those surgeons, which represent some of the earliest experiences in this field. Methods: We reviewed several journals from the late 19th and early 20th centuries as detailed in the references section. We collected the related publications on closed reduction techniques performed by Drs. Goodale, Lothrop, and Cottle. Results: The publications on closed reduction techniques by Drs. Goodale, Lothrop, and Cottle described similar thought processes and techniques comparable to current dorsal preservation rhinoplasty techniques. The thought processes of these 3 renowned rhinoplasty surgeons appear to be very much relevant today. Conclusions: Although there has been recent resurgence in dorsal preservation rhinoplasty techniques due to anatomical and functional aspects of the nose, the basis of dorsal preservation rhinoplasty goes far back to more than 100 years ago.

Significant nasal septal deviation may require complex reconstruction to achieve complete correction. Subtotal septal reconstruction is a method for addressing deviations in the L-strut.To review the long-term outcomes of subtotal septal reconstruction and provide objective evidence of functional and aesthetic improvement.This medical record review obtained data on 144 patients who underwent subtotal septal reconstruction from September 1, 2008, to September 1, 2013. Data analysis was performed from September 1, 2013, to September 1, 2014.Functional outcomes were measured using the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, and objective aesthetic outcomes were measured using 3-dimensional (3-D) stereophotogrammetry. Follow-up times were classified as time point 1 (TP1; preoperative), time point 2 (TP2; early postoperative), and time point 3 (TP3; final postoperative).Of the 144 patients who underwent subtotal septal reconstruction, 104 (72.2%) were female; the mean (SD) age was 37.3 (13.7) years; 57 underwent primary septorhinoplasty; and 87 (60.5%) underwent revision septorhinoplasty. The NOSE scores improved in all 5 categories of nasal obstruction, with mean (SD) survey completion at 270 (260.1) days. Aesthetic results were measured with 3-D imaging after a mean (SD) follow-up of 613.5 (434.4) days postoperatively. No statistically significant loss was found in mean (SD) nasal length over time (TP2 to TP 3, -0.16 [1.36] mm; 95% CI, -0.54 to 0.22 mm; P = .41) or between mean (SD) postoperative loss of projection (TP2 and TP3, -0.19 [0.92] mm, 95% CI, -0.45 to 0.07 mm; P = .17). An increase in mean (SD) rotation (nasolabial angle) generated with septorhinoplasty (4.24° [11.08°]; 95% CI, 1.14°-7.34°; P = .01) and a mean (SD) decrease in rotation detected during postoperative healing (-2.63° [6.96°]; 95% CI, -4.63° to -0.63°; P = .01) were found. Although measurement of symmetry was improved in the early postoperative period (TP1 to TP2, -0.16 [1.26] mm; 95% CI, -0.52 to 0.20 mm; P = .40), this finding did not become statistically significant until the final measurement (TP1 to TP3, -0.43 [1.07] mm; 95% CI, -0.73 to -0.13 mm; P = .007; TP2 to TP3, -0.28 [0.87] mm; 95% CI, -0.53 to -0.03 mm; P = .03). A mean (SD) decrease in columellar show was achieved with surgery (-0.66 [1.37] mm; 95% CI, -1.05 to -0.27 mm; P = .001). No statistically significant change was found in the alar-columellar association from TP2 to TP3 in this patient population, confirming no unwanted alar or columellar retraction over time (0.10 [0.61] mm; 95% CI, -0.07 to 0.27 mm; P = .25). A total of 114 patients (79.2%) required costal cartilage harvest for adequate reconstruction.Subtotal septal reconstruction yields improved functional and aesthetic outcomes and has the potential to be a useful tool for the rhinoplasty surgeon in the treatment of severe septal deviation.4.

Resolution of ptosis is a key step to the success of many plastic surgery procedures. Ptosis is a manifestation of tissue stretch. Tissue stretch can occur as a result of the natural aging process or health of the patient, or tissue may stretch under added weight or volume, such as when implants are placed. Surgical rejuvenation of ptotic tissues is very effective and results in marked changes in the patient profile yet the tissue that resulted in the need for the procedure first place has not improved and ptosis can recur. Recent developments in long-term resorbable porous materials have provided surgeons with the opportunity to experiment with tissue reinforcement in plastic surgery procedures. These new materials have a low profile, rapid tissue integration, and a long-term strength retention profile. Long-term resorbable scaffolds such as poly-4-hydroxybutyrate (P4HB) natural scaffold (GalaFLEX scaffold, Galatea Surgical, Inc., Lexington, MA) have shown promise for a host of plastic surgery indications. This article presents clinical experience with GalaFLEX for soft tissue reinforcement in three different clinical applications; including the reinforcement of the superficial muscular aponeurotic system (SMAS) in minimally invasive facelift, reinforcement of the skin envelope in mastopexy, and reinforcement of the breast capsule (pocket) in revisional breast surgery. Soft tissue reinforcement has been shown to provide increased mechanical strength as well as improved maintenance of postoperative results. Level of Evidence 5![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

This cohort study compares the results of major augmentation rhinoplasty using autologous costal cartilage vs irradiated homograft costal cartilage and analyzes the histologic properties of both types of cartilage.

The choice of primary rhinoplasty technique is based on preoperative diagnosis, external nasal contour, nasal anatomy, and expected changes in nasal contour. The author matches technique to nasal anatomy, describing procedures that have resulted in a high success rate. (Aesthetic Surg J 2002;22:72-84.)

Ronald P. Gruber, MD Nicolas Tabbal, MD Jack H. Sheen, MD Dean Toriumi, MD Dr. Gruber: The first patient (Figure 1) is a 45-year-old man with a history of cocaine use. He presents with symptoms of whistling and a dropped nasal tip, and he also complains of difficulty breathing. To facilitate breathing, this patient manually pushes up the tip of his nose. He has a caudally located 2- to 3-cm perforation, which leaves him with a 1-cm horizontal strut and a 1-cm caudal (columellar) strut. Dr. Sheen, how does this compare with your experience in seeing patients with a history of cocaine use? Figure 1 A , Front, B , lateral, and C , intranasal views of a 45-year-old man with a history of cocaine use. He presents with symptoms of whistling and a dropped tip and complains of difficulty breathing. He has a caudally-located 2-cm perforation. Dr. Sheen: Of the 18 to 20 cocaine noses that I have reconstructed, only 1 was in a male patient; he had mid-vault collapse associated with a large perforation. The rest of the patients were female. I also treated one man who had complete erosion of the caudal septum, membranous septum, and columella and had only 1 mm of skin remaining, so he literally had no caudal support. However, what you describe here is somewhat different. If this patient has a significant amount of caudal septum remaining, it is unlikely that cocaine use caused his present condition. Has he had prior surgery? Dr. Gruber: No, he has not. Dr. Sheen: When I see a patient with this type of problem, I ask to see photographs that were taken before the nasal deformity developed to compare the original state of the nose with its current condition. I do not believe that this 2-cm perforation would produce …

Advances in surgical instrumentation are generally intended to allow the performance of a surgical maneuver more efficiently and accurately. Powered instrumentation may allow improved precision and ease in certain aspects of rhinoplasty and septoplasty. Through improved precision, tissue trauma can be minimized.

Dr. Guyuron: The main focus of this panel is the management of nasal length and projection. Dr. Gruber, how do you analyze a patient's nose in terms of length and projection? Dr. Gruber: In general, I take measurements with a video imager, which provides a one-to-one size. It is really by trial and error manipulation of the image using the video imaging system and then asking the patient what he or she thinks of my assessment that I determine a patient's ideal nose length and projection. I no longer use specific numbers because the distances and angles on the nose are different for each patient. I have found that it is best to use my aesthetic judgment with regard to how the particular length and projection of the nose relates to the rest of the face. Dr. Guyuron: Dr. Byrd, how do you determine the proper nasal projection and length for your patients? Dr. Byrd: First, I measure the patient directly. Then I measure life-size photographs of the patient. I correlate the measurements on the photograph with the ones that I've taken of the patient to avoid measurement errors that can occur as a result of the way in which the pictures were developed. This is a way of confirming my measurements. I determine the actual length of the nose by measuring roughly from the level of the supratarsal fold or 6 mm above the inner canthus down to the dome-projecting points. Basically I would like the nasal length to be equal to the chin vertical measured from where the lips come together (stomion) down to the undersurface of the chin (menton), or two thirds of the midfacial height. These are the ideal aesthetic relationships in the white female's nose. From my perspective, a nose is long if it exceeds …

PubMed ID: 19451458, [No abstract available]

A Blitzer, BE Benson, J Guss . Botulinum Neurotoxin for Head and Neck Disorders. New York: Thieme, 2012. ISBN-10: 1604065850 Botulinum Neurotoxin for Head and Neck Disorders is a moderately sized text covering a very specific, clinically relevant, and contemporary topic that is applicable to physicians in many specialties, including plastic surgery, facial plastic surgery, otolaryngology/head and neck surgery (Oto-HNS), neurology, and dentistry. An initial review of the contents of the text reveal several appealing color illustrations and diagrams and a moderately large, easy-to-read font. The 19 chapters are subdivided into 4 distinct topic sections: dystonia, other motor disorders, pain syndromes, and autonomic disorders. Following the Table of Contents is a listing of 22 online videos that demonstrate the injection techniques described in the text. The foreword provides the reader with a brief history of the medical uses of botulinum toxin (BoNT) to be described in the text, including strabismus, focal dystonias such as spasmodic dysphonia and blepharospasm, migraine headache, hyperhidrosis, and wrinkle reduction. The preface describes the intended audience for the book, which includes clinicians familiar with treating a variety of disorders affecting the head and neck—plastic surgeons, otolaryngologists, neurologists, dentists, and pain specialists. After reading this book, we would agree with the intended audience and add medical students and novice practitioners to the list. This book provides a comprehensive review of the more common clinical applications of BoNT, including the treatment of focal dystonias, pain syndromes, and cosmetic applications. Included in each section are descriptions of the pathology under consideration, important differential diagnostic considerations, accepted medical and surgical therapies for each condition, the role of BoNT in ameliorating …

Contour of the nose is determined by a series of shadows and highlights that emphasize the shape of the nose.1 The desired contours are curvilinear with smooth transitions from dorsum to mid-vault to nasal tip. Control of nasal contour requires precise management of the underlying nasal structures. The structure approach to rhinoplasty employs conservative reduction of the cartilage structures and reshaping using cartilage grafting.2 Cartilage grafts such as spreader grafts and lateral crural strut grafts help to control the shape of the middle nasal vault and lower third of the nose, respectively.3,4 Such grafts have helped surgeons improve their long-term outcomes as well as link nasal aesthetics and surgical technique. In the article entitled, “Rhinoplasty: Surface Aesthetics and Surgical Technique,” Dr Cakir and his coauthors have described how the nasal contour is composed of a series of polygons as aesthetic units and linked these concepts to their own techniques. The ideal contour on frontal view is typically described as having bilateral divergent concave lines that create symmetric “brow tip aesthetic lines.”5–7 In contrast, the authors describe the frontal view as a series of polygons, with a superior polygon that is narrow at the radix and widens toward the middle nasal vault and an inferior polygon that narrows at the supratip. This series of shapes more closely represents the shape of the underlying nasal structures (nasion, nasal bones, and upper lateral cartilages) rather than the superficial nasal contour. Transitions in skin thickness—from thick in the radix region, to …

Objectives To e-amine the effects of fibrinogen concentration and application thickness of fibrin tissue adhesive on skin graft survival. Study Design Prospective controlled study. Methods Ten domestic pigs were included in the study. A 20 − 5-cm area of skin was harvested bilaterally along the flanks of the animals using a Padgett dermatome. The harvested grafts were trimmed into four 4 − 4-cm squares. Donor sites were treated according to group assignment and the non-meshed grafts were placed on the side opposite their initial orientation and secured with staples. Both single- and multiple-donor human fibrin tissue adhesive preparations, with low and high average fibrinogen concentrations of 30 mg/mL and 60 mg/mL, were used. Adhesive preparations were applied in either a thin layer (0.015 mL/cm2) or a thick layer (0.06 mL/cm2) using a spray applicator. A constant thrombin concentration of 10 U/mL was used in the study. No adhesive was used in the control group and grafts were stabilized with staples. No topical dressings were applied to any of the treatment sites. Animals were sacrificed 4 weeks after graft application. Results Based on statistical analysis, thickness of adhesive application had a significant effect on skin graft survival. Percent mean graft survival in the control and thin application groups was found to be 92% and 97.8% respectively; the mean survival rate in the thick application group was 63.1%. Fibrinogen concentration, when evaluated independently within the thin and thick application groups, was found to have no significant effect on graft survival. Conclusion Independent of fibrinogen concentration, a thin layer of fibrin tissue adhesive, when applied between two opposing surfaces, does not interfere with and may support the healing process, whereas a thick layer of adhesive inhibits skin graft healing.

Vascular malformations and cavernous hemangiomas are common in childhood. Although cavernous hemangiomas may resolve spontaneously, aggressive intervention is required when their growth could damage vital adjacent structures, such as the orbit, nose, or tongue.To evaluate the efficacy of interstitial Nd:YAG photocoagulation as an adjunct to intralesional and systemic corticosteroids for treatment of hemangiomas and vascular malformations that had failed to respond to other therapies.Prospective, nonrandomized trial.Two referral practices of facial plastic and reconstructive surgery in tertiary care, academic medical centers.Ten consecutive pediatric patients with either hemangioma or vascular malformation of the head and neck.Laser photocoagulation with an interstitial technique. The Nd:YAG fiber was introduced into the lesion via a 14-gauge angiocatheter needle, and the laser fiber was advanced as coagulation proceeded within the tissue.Decrease in the area of the target lesion, amount of energy applied, and number of treatments required to achieve reduction in size.Long-term follow-up demonstrated regression of the lesion in all 10 patients with good cosmetic results. The range of reduction in size was 20% to 98%. No reexpansion of the lesions was noted after a mean follow-up of 13 months.Interstitial photocoagulation of hemangiomas and vascular malformations is an effective treatment for carefully selected patients. When properly applied, this technique can achieve reduction in the size of these lesions without compromising cosmesis.

Despite advances in head and neck surgery, reconstruction of the pharynx and cervical esophagus continues to be troublesome. Classic pedicled flaps are often too bulky and difficult to position for repair of pharyngeal and esophageal fistulas. An ideal flap would be local, well-vascularized, compact, and capable of being sutured into a tension-free, watertight seal. In selected cases, the sternocleidomastoid myoperiosteal flap can meet these requirements in a single-stage procedure for repair of fistulas as well as selected cases of primary pharyngeal reconstruction. The use of this flap is described in five patients. Two patients underwent laryngectomy with partial pharyngectomy that left inadequate mucosa for primary closure. A sternocleidomastoid myoperiosteal flap was used to add width to the remaining mucosa. Both patients healed within 3 weeks and remained stricture free. Three other patients who underwent radiation followed by tumor resection and standard primary closure of the pharynx developed fistulas. Two fistulas were repaired successfully with the sternocleidomastoid myoperiosteal flap, and both patients were able to eat a general diet on the eighth postoperative day. Reconstruction was also performed in dogs to histologically evaluate the epithelialization capacity of the periosteum. There was total epithelialization of the flap at 4 weeks after reconstruction.