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BACKGROUND When reducing the broad nasal base, there is a limit to the amount of soft tissue that can be resected, beyond which the anatomy distorts and the nostrils become stenotic (if resection enters the nostril). Alar mobilization by freeing soft-tissue attachments helps. This study purported to examine the nature of those attachments and the extent of medialization. METHODS The supporting tissues of the ala were sequentially divided in 16 fresh hemifacial cadavers. Key structures included the following: (1) the soft tissues and pyriform ligament of the anterior maxilla, (2) the periosteum posterior to the pyriform rim (in the bony nasal vault), and (3) the soft tissues along the horizontal pyriform rim. After release of each tethering region, the ala-pyriform distance was measured. RESULTS After releasing the anterior maxillary periosteum and pyriform ligament along the vertical pyriform rim, the ala-pyriform distance was reduced by a mean of 1.9 mm. After releasing the periosteum posterior to the pyriform rim (in the nasal vault), it was reduced by a mean of 1.7 mm. Releasing the soft tissues (which were thick medially) of the horizontal pyriform rim reduced the mean distance 1.0 mm for a total of 4.6 mm. Medialization resulting from anterior and posterior releases was significantly greater than that from the horizontal pyriform rim (p < 0.0006 and p < 0.015, respectively), but they were not significantly different from one another. CONCLUSIONS This cadaver study confirmed the role of the stabilizing effect of the pyriform ligament and the periosteum lateral and posterior to the pyriform rim. The total release was substantial, suggesting a clinical means of achieving tension-free alar medialization.

Background The broad nasal base is occasionally not correctable by excisional procedures alone because nostril distortion or stenosis may result (if resection enters the vestibule). Moreover, recurrence is a common problem when alar mobilization and suture approximation techniques are used. The authors developed an algorithm for nasal base reduction to prevent these complications. Methods A new classification of the broad nasal base was utilized that included patients with general nasal base enlargement and patients with a vertically oriented alar axis (traditionally difficult to correct without distortion). Both groups received an alar release including the following: (1) the soft tissues and pyriform ligament of the anterior maxilla; (2) the periosteum posterior to the pyriform rim (in the bony nasal vault); and (3) when necessary, soft tissues along the horizontal pyriform rim. Interalar sutures maintained the alae in their new medialized position. Twelve patients who only underwent alar release were evaluated. Results Nasal base reduction was achieved in all cases without distortion. Three patients required release of the horizontal tissues of the pyriform rim (including a condensation of the pyriform ligament). After a follow-up period of 11 months to 3(3/4) years, there were two cases of partial recurrence and one partial airway obstruction. Conclusions Not all causes of a broad nasal base are amenable to resection procedures, especially the generally broad nasal base such as that due to thick skin or a vertically oriented alar axis. However, a tension-free alar release with medialization by suture fixation is effective. The incidence of recurrence can be expected to be reduced.

Background: Failure of palatal shelf fusion at the precise gestational time point when shelf elevation and migration normally occur results in clefting. The present study defined the mechanism of clefting in the congenital caprine model by evaluating the temporal sequence of palatal shelf fusion. Methods: Six Spanish-type goats pregnant with twins were gavaged for 10 days (gestational days 32 to 41) with anabasine. Goats were examined with ultrasound throughout this period to assess fetal movement and evaluated histologically. Twelve untreated, unclefted fetuses served as controls. Results: After anabasine induction, real-time ultrasound confirmed a dramatic decrease in fetal movement. Hyperflexion of the neck occurred throughout the experimental period compared with control fetuses, in which spontaneous neck movements occurred. Histologic evaluation of the induced fetuses demonstrated the tongue wedged between the palatal shelves throughout the period of fusion. The shelves remained vertically oriented without elevation, ultimately resulting in clefting. The unclefted, control group demonstrated progressive elevation and migration of the palatal shelves between gestational days 38 and 40, with contact and fusion of the medial edge epithelia in the midline. Conclusions: Palatal clefting in the congenital caprine model occurred concomitant with reduced fetal movement. Resultant neck hyperflexion causes the tongue to obstruct medial migration of the palatal shelves and fusion, whereas the shelves themselves are either directly prevented from elevation secondary to anabasine impairment or indirectly secondary to the obstructing tongue. Although the molecular mechanism for the teratogenic effects of anabasine remains elusive, the authors have demonstrated an association between reduced fetal movement and palatal clefting in their congenital caprine model.

Submandibular gland suspension, a procedure designed to complement surgical rejuvenation of the aging neck, uses largely blunt dissection and suspension to the mandibular periosteum to elevate the gland, improving neck contour without excision of submandibular gland tissue. Although there is an increase in operative time, the risk of intraoperative and postoperative bleeding problems is very low, and the authors report high patient satisfaction.