Simultaneous open rhinoplasty and alar base excision: is there a problem with the blood supply of the nasal tip and columellar skin?

In a prospective study, 15 consecutive patients who underwent simultaneous open rhinoplasty and alar base excision were included to investigate whether there is a problem with the blood supply of the nasal tip and columellar skin. During the surgical procedure in these patients, there was transection of the columellar arteries and external nasal arteries, and frequently of the alar branches of the angular artery. Yet, none of the patients had any evidence of ischemia of the nasal tip or columellar skin, and there was primary wound healing with a thin-line transcolumellar scar in all patients. Techniques to avoid injury to the lateral nasal artery and nasal tip plexus are discussed. It was concluded that simultaneous open rhinoplasty and alar base excision is safe as long as certain surgical principles are applied.     

The "iatrogenic-hanging columella": preserving columellar contour after tip retroprojection

This article discusses a method for treating the ultraprojecting tip by the resection of columellar skin in open rhinoplasty. Lack of postoperative contraction of columellar skin and soft tissue may result in an "iatrogenic-hanging columella." Columellar skin resection frequently produces its own deformities because of a discrepancy in the width of the columellar base side and the infralobular flap side. The ultraprojecting tip was present in 56 of 660 consecutive rhinoplasty patients (8 percent) over 8 years (1991 to 1998). Of these 56 patients, 48 underwent partial resection of the infralobular skin flap. Of these 48 patients, eight (17 percent) required secondary skin revision of the columellar resection area. The technique was then modified since 1998. Over 2 years, 13 of 129 consecutive rhinoplasty patients (10 percent) were judged to have an ultraprojecting tip. Of these, eight patients were treated with a modification in the technique by resecting skin on the posterior columellar base. No resection areas were revised in the second series. Of the 789 patients in both series, 647 (82 percent) underwent primary rhinoplasties, 126 (16 percent) had secondary rhinoplasties, and 16 (2 percent) had tertiary rhinoplasties. The treatment of excess columella skin adds a subtle aesthetic improvement to the postoperative nasal contour. By resecting skin on the posterior columellar base or the posterior columellar base and, rarely, the anterior flap, an iatrogenic-hanging columella can be avoided.     

Hispanic rhinoplasty in the United States,with emphasis on the Mexican American nose

Because an increasing number of Hispanic patients are seeking nasal surgical treatment, a critical analysis of 25 consecutive Hispanic rhinoplasties was performed. After a review of the patient data and preoperative photographs, a new classification was developed, based on the type of deformity rather than geographical origins (as previously used). A treatment paradigm is offered for each type of deformity. Type I involves a high radix, a high dorsum, and a nearly normal tip and is often referred to as a Castilian nose. Treatment consists of a closed functional reduction rhinoplasty, with dorsal reduction and minor tip changes. Type II involves a low radix, a normal dorsum, and a dependent tip and is a new designation. Treatment consists of a finesse rhinoplasty with a radix graft, minimal dorsal changes, use of a columellar strut for support, and open tip suturing. Type III involves a broad base, thick skin, and a wide tip deformity, with its worst expression in the mestizo nose. Treatment consists of a balanced rhinoplasty with minimal dorsal alteration but maximal lobular reduction and an open-structure tip graft. The following conclusions with respect to Hispanic rhinoplasty in the United States are important: (1) an enormous anatomical diversity of deformities is present, in contrast to Asian and black noses; (2) three distinct types of deformities have been identified, each of which requires a different surgical approach; (3) a wide variety of surgical techniques are necessary, in contrast to other ethnic noses; (4) conservative dorsal reduction is essential for type II and III noses; and (5) limitations imposed by the skin envelope are far less than presupposed, and the results are better than generally recognized. As the Hispanic population grows and becomes more prosperous, plastic surgeons in the United States can expect to encounter an increasing number of Hispanic patients requesting rhinoplasty.     

Secondary rhinoplasty using flying-bird and vestibular tornado incisions for unilateral cleft lip patients

To correct the nasal deformity in cleft lip patients, a new procedure of open rhinoplasty using a "flying-bird" incision in the nostril tip with a vestibule "tornado"-shaped incision in the cleft side is presented. The newly designed vestibular incision produces effective vestibular advancement with the freed lower lateral cartilage. The flying-bird incision makes it possible to produce a suitable nostril tip appearance with symmetrical external nostril vestibules. If the vestibular defect after flap advancement is wide, a full-thickness skin graft is used to give priority for making a good external nostril shape. This procedure is useful for most cleft lip noses, particularly in cases of moderate to severe deformity.     

Management of the bulbous nose

"Bulbous nose" is a term patients often use to describe a "ball" on the end of their nose. This ball can be caused by the abnormal anatomy of alar cartilage or by the overlying soft-tissue coverage. The purpose of this article is to analyze the different causes of bulbous noses and their treatment options. An analysis was done based on four decades of experience and long-term follow-up. We included 10 patients for our discussion. The relationship of the tip to the vault must be analyzed, because it can create optical illusions. For instance, a low bridge makes the tip appear larger; therefore, a bulbous nose may be relative. Similarly, excessive narrowing of the nasal base by alar wedges makes the tip appear wider. Intrinsic causes of a bulbous nose include skin, subcutaneous tissue (including the nasal superficial musculoaponeurotic system, ligaments, and fat), and the shape and direction of the individual crus. Nasal skin varies as to volume and ability to contract; therefore, the shape, direction, or divergence of the individual crura cannot undergo unlimited modifications. There are several surgical possibilities for a given problem. Making the diagnosis of the underlying abnormal anatomy is the most important step; then the most appropriate operation can be selected. Struts, sutures, resection, dome division, and/or dorsal augmentation are all viable options for the management of the bulbous nose.     

Leave the fat, skip the bolster: thinking outside the box in lower third nasal reconstruction

Defects of the lower third of the nose often present especially challenging reconstructive dilemmas. The surrounding skin to match is often thick, sebaceous, and sun damaged, none of which characterizes the historically ideal periauricular donor skin for grafting. The surrounding nasal skin is quite stiff, precluding very small local flaps. To avoid the "misplaced patch" appearance of most classic full-thickness grafts to this area or the depressed scar of an elliptical excision, many surgeons turn to larger local or regional flaps. These provide not only skin color and texture match but also the necessary several millimeters of subcutaneous fat necessary for proper tip aesthetics. Many defects of the lower third are small, making many surgeons reluctant to employ these larger flaps with their long scars and potential to twist or distort delicate tip or ala anatomy. The author has sought a means to transport skin and subcutaneous fat for lower third nasal defects outside of flaps. On the basis of the superiority of nasolabial fold scars and a vast positive experience in the literature utilizing skin and fat composite grafts with no bolsters, the author applied these techniques to 33 lower third nasal defects in 29 patients. Of 33 grafts varying in size from 4 mm circular to 17 mm x 16 mm and retaining 1 to 5 mm of fat, no grafts were lost. Four grafts developed a 30 percent area or less of central necrosis resulting in localized depression. Three of these four grafts were in active smokers and the fourth graft was in a former smoker. Aside from these four grafts and one with considerable excess fat early in the series, contour was good to excellent. Hypopigmentation is still common but improves with time. Easily performed composite grafts effectively carry the necessary fat for aesthetic reconstruction and do not risk long scars on the nose and twisting of the tip and ala that can result from flaps. Revisions are infrequent and extremely simple when indicated.     

V-Y advancement flaps in the reconstruction of skin defects of the posterior heel and ankle

A V-Y advancement pedicle flap including fascia has been used for reconstruction of soft-tissue defects of the posterior heel and ankle region. This flap has been used to cover 17 defects in 16 patients ranging in age from 4 to 58 years, and results have been good. We limited this application to patients without systemic disease and under 60 years of age and did not apply it to the elderly, debilitated, or systemic vascular damaged patients. There were no complications or loss of overlying skin, with the exception of one superficial tip necrosis of the flap. The results indicate the reliability and usefulness of this procedure in coverage of the posterior heel and ankle regions. It is a relatively quick and simple procedure that is without a free skin graft, and it involves only one stage that adequately corrects the skin defect at the posterior heel and ankle without prolonged splintings and results in negligible deformity of the donor site.     

Cleft lip nose correction with onlay calvarial bone graft and suture suspension in Oriental patients

To correct the secondary cleft lip nose deformity in Oriental patients, many alar cartilage mobilization and suspension techniques have been developed. However, these techniques have critical limitations. One of the limitations is the suspension vector, and another is suspension power. The suspension vector is from inferior to superior and from the deformed alar cartilage to the normal alar cartilage. Thus, the vector is not suitable for normal nasal tip projection. The suspension power is not satisfactory because Oriental people have underdeveloped, thin alar cartilages and thick skin. So, the suspended, deformed alar cartilage may relapse and pull the normal alar cartilage to the deformed side. To overcome these limitations, the authors use the cantilever calvarial bone graft for tip projection; it also serves as a strong, rigid framework for cartilage and soft-tissue suspension. Using these techniques, the authors can create normal nasal tip projection and a normal looking nasal aperture.     

Functional reconstruction of swallowing and articulation after total glossectomy without laryngectomy: money pouch-like reconstruction method using rectus abdominis myocutaneous flap

When a total glossectomy is performed without a laryngectomy, the functional recovery of swallowing and articulation is extremely important in maintaining the patient's quality of life. The authors established a money pouch-like reconstruction method in which a round and raised tongue is rebuilt using a rectus abdominis myocutaneous flap. In this method, the skin island of the rectus abdominis myocutaneous flap is created about 20 percent larger than the defect in both width and length. The skin island is sutured to the defect such that the excess skin folds into the shape of a money pouch. This allows the tongue to be reconstructed with its tip and dorsum touching the hard palate and its base bulging in the dorsal and posterior directions. Misswallowing was not detected in the three patients who had this surgery, and each of them had improved articulation sufficient to carry out daily conversations.     

Molecular Comparison of Bacterial Communities on Peripheral Intravenous Catheters and Matched Skin Swabs

Skin bacteria at peripheral intravenous catheter (PIVC) insertion sites pose a serious risk of microbial migration and subsequent colonisation of PIVCs, and the development of catheter related bloodstream infections (CRBSIs). Common skin bacteria are often associated with CRBSIs, therefore the bacterial communities at PIVC skin sites are likely to have major implications for PIVC colonisation. This study aimed to determine the bacterial community structures on skin at PIVC insertion sites and to compare the diversity with associated PIVCs. A total of 10 PIVC skin site swabs and matching PIVC tips were collected by a research nurse from 10 hospitalised medical/surgical patients at catheter removal. All swabs and PIVCs underwent traditional culture and high-throughput sequencing. The bacterial communities on PIVC skin swabs and matching PIVCs were diverse and significantly associated (correlation coefficient = 0.7, p<0.001). Methylobacterium spp. was the dominant genus in all PIVC tip samples, but not so for skin swabs. Sixty-one percent of all reads from the PIVC tips and 36% of all reads from the skin swabs belonged to this genus. Staphylococcus spp., (26%), Pseudomonas spp., (10%) and Acinetobacter spp. (10%) were detected from skin swabs but not from PIVC tips. Most skin associated bacteria commonly associated with CRBSIs were observed on skin sites, but not on PIVCs. Diverse bacterial communities were observed at skin sites despite skin decolonization at PIVC insertion. The positive association of skin and PIVC tip communities provides further evidence that skin is a major source of PIVC colonisation via bacterial migration but microbes present may be different to those traditionally identified via culture methods. The results provide new insights into the colonisation of catheters and potential pathogenesis of bacteria associated with CRBSI, and may assist in developing new strategies designed to reduce the risk of CRBSI.     

Measurement and Prediction of Insertion Force for the Mosquito Fascicle Penetrating into Human Skin

Mosquitoes are exceptional in their ability to pierce into human skin with a natural ultimate painless microneedle, namedfascicle. Here the structure of the Aedes albopictus mosquito fascicle is obtained using a Scanning Electron Microscope (SEM),and the whole process of the fascicle inserting into human skin is observed using a high-speed video imaging technique. Directmeasurements of the insertion force for mosquito fascicle to penetrate into human skin are reported. Results show that themosquito uses a very low force (average 18 μN) to penetrate into the skin. This force is at least three orders of magnitude smallerthan the reported lowest insertion force for an artificial microneedle with an ultra sharp tip to insert into the human skin. In orderto understand the piercing mechanism of mosquito fascicle tip into human multilayer skin tissue, a numerical simulation isconducted to analyze the insertion process using a nonlinear finite element method. A good agreement occurs between thenumerical results and the experimental measurements.     

Dynamic rhinoplasty for the plunging nasal tip: functional unity of the inferior third of the nose

To achieve permanent results for the correction of a drooping nasal tip, it is important to understand the mechanism responsible for the caudal rotation of the tip when a person speaks or smiles. This mechanism can be considered to depend on a "functional unity" formed by three components: (1) the cartilaginous framework (alar cartilages and accessories acting as a single structure); (2) muscular motors (m. levator labii superioris alaeque nasi and depressor septi nasi); and (3) gliding areas (apertura piriformis, the valvular mechanism between the upper lateral cartilages and alar cartilages, the lax tissue of the nasal dorsum, and the membranous septum). We describe a new anatomical and functional concept responsible for the plunging of the nasal tip. When a person smiles, the functional unit is activated by a combination of two forces acting simultaneously in opposite directions that rotate the tip caudally and elevate the nasal base. The levator moves the alar base upward and the depressor pulls the tip caudally. To correct the drooping tip, the transcartilaginous incision is extended laterally, and the lateral portion of the alar arch is dissected free from the skin and the mucosa, thus exposing the accessory cartilages. The arch is then severed at the level of the accessories to allow the cephalad rotation of the domes. The muscle insertions are dissected free from the accessories and a section of the muscle and, if necessary, the accessory cartilages, is removed. From January of 1991 onward, 312 patients have had this ancillary procedure performed in addition to the basic rhinoplasty technique.     

Valvular obstruction of the nasal airway.

Valvular nasal obstruction may occur in the postoperative rhinoplasty patient. One may anticipate a dropping of the tip, from residual redundant or inelastic skin, in some older patients with long noses. Measures to correct (or avoid) this may be undertaken at the time of the primary rhinoplasty. However, an overcorrection may be necessary if there is much redundant skin. Discretion may indicate the need for a secondary procedure. Lateral wall valving is unusual-but it may occur in the long, high, thin nose (where a suggestion of this action may be observed preoperatively). Maintenance of continuous cartilage along the alar rim, at the time of alar cartilage resection, appears to be important in prevention of postoperative valvular obstruction in these few patients.     

Nasal tip blood supply: confirming the safety of the transcolumellar incision in rhinoplasty

The transcolumellar incision in rhinoplasty has proven to be a safe and effective technique, even with simultaneous alar base resections. A sound appreciation of the blood supply to the nasal tip and adherence to the guidelines presented above will prevent vascular compromise of the nasal tip skin.     

Spatial features of vibrotactile masking effects on airpuff-elicited sensations in the human hand

It was recently shown that the cutaneous sensitivity to airpuffs is decreased by a low-frequency vibrotactile masker in the hairy skin, and by a low-frequency but especially by a high-frequency masker in the glabrous skin. In the current study, the spatial features of this masking effect were determined in four healthy human subjects, using a reaction time paradigm. The masking effect decreased monotonically with increasing interstimulus distance, and identically in longitudinal and transverse (i.e., lateral) directions in the palm or dorsal surface of the hand. The masking effect was stronger in the glabrous than in the hairy skin, especially in the fingers. In the glabrous skin, the spread of masking effect produced by a high-frequency masker was more extensive than that produced by a low-frequency masker. The mechanical spread of high-frequency vibration was less extensive than that of low-frequency vibration in the skin. In the glabrous skin, a masker applied to the tip of the finger produced a stronger masking effect on sensations in the base of the finger than when the masker was located at the base and the test stimulus was located at the tip. It is concluded that mechanical spread of vibration in the skin is of minor importance in explaining the masking effects. Different peripheral neural mechanisms underlie the airpuff-elicited sensations in the hairy and glabrous skin. The afferent inhibitory mechanisms are stronger for signals coming from the glabrous skin of the fingers than for signals coming from the hairy skin. Furthermore, the peripheral innervation density and size of the cortical representational areas may be of importance in determining the magnitude of the masking effect.     

Spatial Features of Vibrotactile Masking Effects on Airpuff-Elicited Sensations in the Human Hand

It was recently shown that the cutaneous sensitivity to airpuffs is decreased by a low-frequency vibrotactile masker in the hairy skin, and by a low-frequency but especially by a high-frequency masker in the glabrous skin. In the current study, the spatial features of this masking effect were determined in four healthy human subjects, using a reaction time paradigm. The masking effect decreased monotonically with increasing interstimulus distance, and identically in longitudinal and transverse (i.e., lateral) directions in the palm or dorsal surface of the hand. The masking effect was stronger in the glabrous than in the hairy skin, especially in the fingers. In the glabrous skin, the spread of masking effect produced by a high-frequency masker was more extensive than that produced by a low-frequency masker. The mechanical spread of high-frequency vibration was less extensive than that of low-frequency vibration in the skin. In the glabrous skin, a masker applied to the tip of the finger produced a stronger masking effect on sensations in the base of the finger than when the masker was located at the base and the test stimulus was located at the tip. It is concluded that mechanical spread of vibration in the skin is of minor importance in explaining the masking effects. Different peripheral neural mechanisms underlie the airpuff-elicited sensations in the hairy and glabrous skin. The afferent inhibitory mechanisms are stronger for signals coming from the glabrous skin of the fingers than for signals coming from the hairy skin. Furthermore, the peripheral innervation density and size of the cortical representational areas may be of importance in determining the magnitude of the masking effect.     

A modified Goldman nasal tip procedure for the drooping nasal tip

A modification of Irving Goldman's nasal tip procedure that borrows from the lateral crus to augment the height of the medial crus is described. Goldman's procedure has been modified by not including the vestibular skin with the segment of the lateral crus that is rolled medially to increase nasal tip projection, by adding a nasal septal cartilage strut between the medial crura for support when the medial crura are weak, and by maintaining a small separation caudally of the repositioned lateral crura at the new nasal dome to simulate a double nasal dome. This modified Goldman nasal tip procedure allows the surgeon to reshape the lower lateral nasal cartilage to increase nasal tip projection as an alternative to the use of a shield-type nasal tip graft, and at the same time it narrows the nasal tip with minimal resection of the lateral crus of the lower lateral nasal cartilage.     

Management of the droopy tip: a comparison of three alar cartilage-modifying techniques

The droopy tip is a common nasal deformity in which the tip is inferiorly rotated. Five hundred consecutive rhinoplasty cases were studied to assess the incidence and causes of the droopy tip deformity and to evaluate the role of three alar cartilage-modifying techniques--lateral crural steal, lateral crural overlay, and tongue in groove--in correcting such a deformity. The external rhinoplasty approach was used in all cases. Only one of the three alar cartilage-modifying techniques was used in each case, and the degree of tip rotation and projection was measured both preoperatively and postoperatively. The incidence of droopy tip was 72 percent, and the use of an alar cartilage-modifying technique was required in 85 percent of these cases to achieve the desired degree of rotation. The main causes of droopy tip included inferiorly oriented alar cartilages (85 percent), overdeveloped scrolls of upper lateral cartilages (73 percent), high anterior septal angle (65 percent), and thick skin of the nasal lobule (56 percent). The lateral crural steal technique increased nasal tip rotation and projection, the lateral crural overlay technique increased tip rotation and decreased tip projection, and the tongue-in-groove technique increased tip rotation without significantly changing the amount of projection. The lateral crural overlay technique resulted in the highest degrees of rotation, followed by the lateral crural steal and finally the tongue-in-groove technique. According to these results, the lateral crural steal technique is best indicated in cases with droopy underprojected nasal tip, the lateral crural overlay technique in cases of droopy overprojected nasal tip, and the tongue-in-groove technique in cases where the droopy nasal tip is associated with an adequate amount of projection.     

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog-ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 x 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated.     

Insertion of microneedles into skin: measurement and prediction of insertion force and needle fracture force

As a hybrid between a hypodermic needle and transdermal patch, we have used microfabrication technology to make arrays of micron-scale needles that transport drugs and other compounds across the skin without causing pain. However, not all microneedle geometries are able to insert into skin at reasonable forces and without breaking. In this study, we experimentally measured and theoretically modeled two critical mechanical events associated with microneedles: the force required to insert microneedles into living skin and the force needles can withstand before fracturing. Over the range of microneedle geometries investigated, insertion force was found to vary linearly with the interfacial area of the needle tip. Measured insertion forces ranged from approximately 0.1-3N, which is sufficiently low to permit insertion by hand. The force required to fracture microneedles was found to increase with increasing wall thickness, wall angle, and possibly tip radius, in agreement with finite element simulations and a thin shell analytical model. For almost all geometries considered, the margin of safety, or the ratio of fracture force to insertion force, was much greater than one and was found to increase with increasing wall thickness and decreasing tip radius. Together, these results provide the ability to predict insertion and fracture forces, which facilitates rational design of microneedles with robust mechanical properties.