Evaluation of Lyophilised, Gamma-Irradiated Amnion as a Biological Dressing

Burns, non-healing wounds and pressure sores cause extensive damage to the skin leading to infection and loss of precious body fluids. Despite advances in burn management the mortality rate continues to be high and the search for an economical and easily available dressing to control burn wound infection continues. Autologous skin has limited availability and is associated with additional scarring. Conventional dressings require frequent changes which can be painful and may even require anaesthesia.Amnion is an excellent biological dressing and its use in the treatment of burns has special appeal in India as there are religious barriers to the acceptance of bovine and porcine skin.Lyophilised, irradiated amnion provided for the first time in the country by the Tata Memorial Hospital Tissue Bank was evaluated as a temporary biological dressing. It was used to treat 35 patients with burns, 21 patients with bedsores and non-healing ulcers and the skin graft donor sites of 11 patients.The amnion was easy to handle and stuck well to the raw wound bed. An open dressing was used in most of the second degree burns which healed with hyperemia and early pigmentation. In patients with third degree burns, ulcers or skin graft donor sites, closed dressings were used. The exudate and induration were reduced and patients were more comfortable and experienced less pain. There was healthy granulation with good re-epithelialisation. Amnion was not used in patients with infected third degree burns.     

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty

Augmentation rhinoplasty of the Asian nose may be effectively accomplished with alloplastic materials. However, certain circumstances mandate the use of autologous grafts (e.g., dorsal augmentation that exceeds 8 mm and patient intolerance of alloplastic implants). Septal and auricular cartilages are inadequate for dorsal augmentation of the Asian nose. The use of costal cartilage for autologous augmentation in select Asian patients has proven to be a reliable method in more than 500 operative cases during a 10-year period. This study was designed to evaluate the ideal costal cartilage graft for augmentation rhinoplasty. Forty-two preserved cadavers were studied for the relationship of the individual rib cartilages to the surrounding tissue and for the length and caliber of each costal cartilage. The seventh rib was found to be the ideal rib graft by virtue of its safe location and overall size for grafting. The seventh rib is situated over the abdominal cavity, so the risk of pneumothorax is insignificant. The internal thoracic artery and vein descend in close apposition behind the first to sixth ribs but begin a course medial to the ribs inferior to this point, and therefore vascular injury during seventh-rib harvesting is unknown. The seventh rib also provides the greatest overall available length (90.7 mm, right; 89.6 mm, left) and thickness (17.6 mm, right; 17.5 mm, left). Despite the more conspicuous location of the incision required to harvest the seventh rib, the limited 3-cm incision that is used has healed favorably in almost all cases. The other major drawback for seventh-rib harvesting is the dissection required through the overlying rectus abdominis muscle, but little technical difficulty or postoperative morbidity is added with muscle dissection. The seventh rib is advocated as the ideal choice for augmentation rhinoplasty and potentially other recipient sites.     

The use of alloderm for the correction of nasal contour deformities

What rhinoplasty surgeon has not been frustrated by unmet expectations from unreliable graft materials? The quest for an ideal graft continues. Septal cartilage is not always adequate in amount or substance. Ear cartilage may cause unsightly irregularities over time. Cranial bone or rib harvest sites add to the complexity of the procedure and can be intimidating for many operators. This article describes the authors' successful experience with AlloDerm onlay grafts for the correction of nasal contour deformities in 58 primary and secondary rhinoplasty cases by means of the open and endonasal approaches. Forty-two patients received an open-approach procedure; the remaining 16 received grafting through an endonasal or closed approach. Thirty-seven of the patients were secondary rhinoplasty patients, and some underwent multiple nasal corrections. The indications, intraoperative surgical technique of graft placement, and representative results will be discussed. Long-term follow-up showed good results, though partial graft resorption occurred in some patients. Overall, this experience with AlloDerm for nasal augmentation was encouraging.     

Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty

Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain, but frequently the alar cartilages are missing--unilaterally, bilaterally, completely, or incompletely--with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised, or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columellar retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance, or malposition have been noted. Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear, and rib cartilage, fixed to the residual medial crura and/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair. Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to the surgeon's advantage. A rigidly supported framework with a nasal shape can mold a covering forehead flap or the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal. Anatomic alar cartilage reconstructions were used in eight reconstructive and eight secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized.     

Augmentation rhinoplasty with dermal graft and review of the literature

Nasal augmentation required following a trauma or a rhinoplasty operation poses a challenging problem to many plastic surgeons. Currently, allografts and autologous tissues are used for nasal augmentation; however, an ideal technique has not yet been described. Although preferred for augmentation of different parts of the body, pure dermal graft use has not been described for nasal augmentation. The authors performed nasal augmentation using a dermal graft in 90 patients in their hospital between 1994 and 2000, and they followed up the patients for 6 months to 8 years. In this article, the early and late results of dermal grafts for nasal augmentation are presented, and their advantages and disadvantages are discussed with a review of the literature. It was concluded that the easily obtained dermal graft could be an appropriate alternative in nasal augmentation, though it has not been used widely for this purpose.     

Nasal augmentation with Surgicel-wrapped diced cartilage: a review of 67 consecutive cases

Cartilage grafting has been used extensively to correct both the functional and aesthetic aspects of the nasal framework. The technique described by Erol ( 105: 2229, 2000) uses Surgicel-wrapped diced cartilage grafts in rhinoplasties. The advantages include its ease of preparation, the large volume of graft substrate available for use, and the avoidance of contour irregularities in the areas of placement. A retrospective case review of 67 consecutive patients who were treated with a Surgicel-wrapped diced cartilage graft as part of an aesthetic and/or functional rhinoplasty, in a 5-year period between 1995 and 2000, was performed in this study. All cases of congenital nasal deformities or deformities caused by trauma or tumors in which the technique was used were excluded. The charts were reviewed to determine demographic variables, the surgical procedures performed, prior operations, the rhinoplasty approach used, and the graft donor and recipient sites. Preoperative and postoperative photographs were examined, and the results were assessed. Data on the donor and recipient sites, complications, and the necessity for revisionary procedures were tabulated. There were two complications, namely, an infection, which resolved with aspiration and oral antibiotic therapy, and a recurrence of a dorsal depression, which necessitated repeated augmentation within 6 months. The technique of using Surgicel-wrapped diced cartilage proved to be effective for the augmentation of various areas of the nose. The complication and revision rates were acceptable and comparable to those of other techniques. Patient satisfaction with the aesthetic results was rated highly, with no reports of graft extrusion or contour irregularities. This technique is recommended for nasal augmentation and contouring for selected rhinoplasty patients.     

Nasal reconstruction with full-thickness cranial bone grafts and rigid internal skeleton fixation through a coronal incision

The use of iliac and rib bone as onlay grafts to the nasal dorsum often fails because endochondral grafts resorb unpredictably. Membranous cranial bone grafts are less likely to resorb, especially when used with rigid internal fixation techniques. However, when split, they are often too thin and can be difficult to contour. Full-thickness cranial bone grafts were used to achieve nasal augmentation in 26 patients with end-stage nasal skeleton deficiency. All procedures were carried out using only a coronal incision. Grafts were harvested through a craniotomy, carved meticulously, and secured rigidly with miniplates or bicortical screws. Donor sites were reconstructed with split cranial grafts, leaving an intact cranial vault. No graft was lost to infection, and there was no significant donor-site morbidity. In carefully selected patients this method of full-thickness cranial bone graft reconstruction yields good results.     

Maximizing the use of the abdominoplasty incision

Candidates for abdominoplasty often request multiple procedures at the time of consultation. Some of these patients have the potential opportunity to have ancillary procedures performed through the abdominoplasty incision, such as breast augmentation or suction-assisted lipectomy. Access via the abdominoplasty incision can also limit the need for distant donor sites, for instance, when autologous fillers or rib graft are necessary. The techniques described are straightforward and are based on standard principles that should be considered when ancillary procedures are performed in conjunction with abdominal contouring procedures. In a review of 70 consecutive patients undergoing abdominoplasty, 91 ancillary procedures were performed in conjunction with the abdominoplasty. Of the total number of patients undergoing abdominoplasty, 29 patients underwent 30 procedures facilitated through their abdominoplasty incision, including 23 suction-assisted lipectomies of the flanks, six breast augmentations, and one rib cartilage harvesting for rhinoplasty. A review of the author's experience and discussion for potential options afforded by this exposure are presented.     

Temporalis fascia grafts for facial and nasal contour augmentation

For the past 70 years, fascial grafts have been used in reconstructive surgery mainly because of their tensile strength. Although the thigh (fasciae latae) has been the principal donor site, fascia taken from the temporalis muscle has the advantages of (1) ease of harvest under local anesthesia, (2) usually being in the same operative field, (3) minimal postoperative discomfort, and (4) negligible residual scar deformity. These grafts can be effectively used as the sole source of contour augmentation of facial depressions in primary as well as secondary rhinoplasty. Such grafts undergo an initial uniform shrinkage (approximately 20 percent) during the first 4 to 6 weeks postoperatively due to compaction and condensation of the fibrous tissue of the fascia, after which the grafts stabilize and become firm. Concavities should be overcorrected accordingly. No inflammation or encapsulation has been seen clinically or histologically in 18 patients followed for periods ranging from 6 to 18 months.     

The use of irradiated allograft in a paediatric population: an Indian experience

Lyophilised, irradiated bone allografts available for the first time in the country from the Tata Memorial Hospital Tissue Bank were used in 30 paediatric patients from January 2001 to August 2004. They included 20 patients of scoliosis of various origin and ten with assorted orthopaedic conditions including one congenital kyphosis, two Pott’s spine, one Perthes disease, one developmental dysplasia of the hip (DDH), one infective non-union, one fibrous dysplasia and three with bone defects either due to trauma, a cyst or removal of hardware. Morsellised allograft was used in 28 patients. In those␣cases of scoliosis in which ribs were resected out during costectomy, the morsellised allograft was␣mixed with morsellised rib autograft. Non-morsellised femoral head grafts were used in two patients, one a case of varus open derotation osteotomy in Perthes disease and the other an acetabuloplasty in DDH. Patients were followed at intervals of 8–12 weeks and radiological evaluation was done periodically. The follow up period ranged from 1 to 4 years post surgery. All patients with scoliosis showed excellent union at the grafting site with non-progression of curve and no signs of loosening at implant site. The two patients, in whom non-morsellised femoral head grafts were used, both showed incorporation of the graft with good fusion within a 4 month period. None of the patient had infection, non-union, pseudoarthrosis, fracture at the graft site, or any other complication.     

Indications and use of composite grafts in 100 consecutive secondary and tertiary rhinoplasty patients: introduction of the axial orientation

The fragile alar rims are complex structures whose specialized and supportive skin ensures the competence of the external valves and the patency of the inlets to the nasal airways. A chart review was performed of 100 consecutive secondary or tertiary rhinoplasty patients in whom the author had placed composite grafts before February 1999. Follow-up continued for at least 12 months. In 94 percent of the patients, composite grafts were harvested from the cymba conchae by removing the cartilage with its adherent anterior skin. In 6 percent of the patients, independently indicated alar wedges supplied the grafts. Six patients required secondary procedures to thin the alar rims, but such revisions have not been necessary since primary contouring of the cartilaginous graft component was instituted. Three auricular donor-site complications (one keloid, two thickened graft contours) were successfully revised through office procedures. Prior cosmetic rhinoplasty in a patient with normal alar cartilage anatomy exceeded all other etiologies as the cause of the deformity for which composite grafts were indicated (50 percent). The second most common etiology was deformity from prior rhinoplasty in a patient with alar cartilage malposition (33 percent of patients). Congenital deformities (7 percent of patients), trauma (6 percent), and prior tumor ablation (4 percent) comprised the remaining etiologies. Composite grafts were used most frequently to correct alar notching or asymmetry in rim height (43 percent of patients) or to provide an increase in apparent or real nasal length (28 percent). External valvular incompetence (14 percent of patients), nostril or vestibular stenosis (11 percent), or combined vestibular stenosis and lateral alar wall collapse (4 percent) were less common indications. Most composite grafts were oriented in the coronal plane (parallel to the alar rims). However, nostril or vestibular stenosis was corrected by sagittally placed composite grafts, and a third orientation (axial plane), to the author's knowledge not described previously, was used in patients with combined nostril stenoses and flattening of the alar walls. In this secondary rhinoplasty series, iatrogenic alar rim deformities or stenoses following cosmetic rhinoplasty dominated other causes requiring composite graft reconstruction (83 percent of patients). Of these 83 patients, 39.7 percent had preexisting alar cartilage malpositions, further supporting the importance of making accurate anatomical diagnosis part of every preoperative rhinoplasty plan.     

Unpredictable growth pattern of costochondral graft.

Costochondral grafts have gained increasing popularity in reconstruction of the temporomandibular joint and condyle in children. This is a report on the long-term follow-up of eight adolescent patients who underwent reconstruction of the temporomandibular joint and ramus for correction of hemifacial microsomia or trauma-related temporomandibular joint ankylosis during varying periods of growth. Six patients had hemifacial microsomia, and two suffered from posttraumatic temporomandibular joint ankylosis. Average follow-up was 80.4 months. Four patients had excessive growth of the graft, one patient had suboptimal growth, and three patients had no growth. In addition, one patient had undergone four procedures for significant graft overgrowth. Based on this study and review of the literature, we have concluded that the growth pattern of the costochondral graft is extremely unpredictable, ankylosis is a common problem following a temporomandibular joint reconstruction with costochondral graft, and mandibular overgrowth on the grafted site can actually be more troublesome than the lack of growth. Furthermore, maxillary growth is proportionately influenced by vertical mandibular growth of the graft, while the horizontal maxillary growth is not altered. Ankylosis is a result of ossification of the cartilaginous portion and the three-dimensional graft overgrowth, aggressively extending beyond the cartilage graft boundary. Based on this study, we recommend that this procedure be performed only on severe deficiencies. Adequate amounts of soft tissue should be retained between the skull base and the graft, and we further recommend harvesting the graft from the fourth or fifth rib, which may reduce the potential for overgrowth.(ABSTRACT TRUNCATED AT 250 WORDS)     

Chin augmentation with nasal osteocartilaginous graft

The use of the nasal hump removed during rhinoplasty was described by Aufricht in 1934 and 1958. In the past 10 years, the author has been using a similar technique but with significant variations. Before beginning the rhinoplasty surgery, the author dissects, through a submental incision, a subperiosteal mental pocket. Then, the osteocartilaginous nasal hump is removed; once the mucoperiosteum/mucoperichondrium is meticulously dissected, the nasal hump is tailored to achieve a mental form and the removed alar cartilage, nasal spine, or septal cartilage is used to fill or supplement the concavities of the hump. This report includes a total of 36 cases, 10 of which were controlled after 3 to 8 years of implantation by tridimensional computed tomography, from which the author observed an osteointegration with the mandibular bone and no reabsorption of the grafts or alteration of the structure of this bone. The patients revealed a high degree of satisfaction, and during the clinical examination, the author could not observe or palpate any distortion of the shape or projection of the chin. None of the grafts needed review or removal. This simple, fast procedure is a very good alternative for patients with some form of microgenia or when patients and surgeons are not likely to use alloplastic implants.     

Augmentation rhinoplasty: dorsal onlay grafting using shaped autogenous septal cartilage

We describe our experience with autogenous septal cartilage onlay grafts for augmentation of the nasal dorsum in primary and secondary rhinoplasty cases. After careful nasofacial analysis, the grafts are custom-shaped into inverted-V-frame, A-frame, or inverted-U-frame grafts, depending on the type and degree of augmentation desired. The dorsal elevation is thus tailored to fit the imperfection at hand, resulting in a smooth, natural-looking nasal contour. The indications for each type of graft are reviewed, and the surgical technique of graft harvesting and carving is detailed and illustrated.     

Segmental bone and cartilage reconstruction of major nasal dorsal defects

This article describes the results of segmental bone and cartilage reconstruction of significant nasal dorsal defects. Solid bone graft reconstructions frequently lead to an unnatural hardness of the nasal tip. Rib cartilage reconstructions are pliable and soft but are a problem because they easily undergo warpage. The operation is performed using the open approach. Outer cranial bone graft is used for the bone component and extends at least two-thirds of the length of the dorsum. It is secured in place with a compression screw and a Kirschner wire. The cartilage component consists of an abbreviated L strut constructed of septal or conchal cartilage. It is slotted into the cranial bone in a tongue-in-groove manner and is sutured to it through a drill hole in the bone. The dorsal profile is completed with a single cartilage onlay graft or multiple sagittal cartilage grafts secured to the sides of the L strut. Twelve patients underwent segmental reconstruction of nasal deformities. Within this group, five patients underwent secondary rhinoplasty, five underwent posttraumatic rhinoplasty, and two underwent nose augmentation for Oriental features. There were seven men and five women. In all cases, good nasal tip mobility was maintained, and the nasal tips were soft. The interface between the bone graft and cartilage graftwas well camouflaged. The two did not separate. This procedure follows the principle of replacing lost tissue with like materials.     

Full-thickness grafting of acute eyelid burns should not be considered taboo.

Split-thickness skin grafts are commonly used for the treatment of acute eyelid burns; in fact, this is dogma for the upper lid. Ectropion, corneal exposure, and repeated grafting are common sequelae, almost the rule. It was hypothesized that for acute eyelid burns, the use of full-thickness skin grafts, which contract less than split-thickness skin grafts, would result in a lower incidence of ectropion with less corneal exposure and fewer recurrences. The records of all patients (n = 18) who underwent primary skin grafting of acutely burned eyelids (n = 50) between 1985 and 1995 were analyzed retrospectively. There were 10 patients who received full-thickness skin grafts (12 upper lids, 8 lower lids) and 8 patients who received split-thickness skin grafts (15 upper lids, 15 lower lids). Three of 10 patients (30 percent) who received full-thickness skin grafts and 7 of 8 patients (88 percent) who received split-thickness skin grafts developed ectropion and required reconstruction of the lids (p = 0.02). No articles were found substantiating the concept that only split-thickness grafts be used for acute eyelid burns. The treatment of acute eyelid burns with full-thickness rather than split-thickness skin grafts results in less ectropion and fewer reconstructive procedures. It should no longer be considered taboo and should be carried out whenever possible and appropriate.     

Chin augmentation with conchal cartilage

Profile enhancement most frequently involves mentoplasty. For this purpose, the author performs conchal grafts to the chin. A total of 28 women aged 15 to 76 years (mean age, 38.11 +/- 15.11 years) requested mentoplasty by itself or combined with rhinoplasty, rhytidoplasty, or submental lipoplasty. The conchal cartilage was harvested subperichondrally through a posterior 3-cm incision. The specimen measured 3 x 1 cm, which was sufficient to project the chin 2 to 3 mm. For 4 to 5 mm of projection, both cartilages were used. The graft was positioned under the periosteum and held with two 5-0 nylon sutures. In these cases, the conchal cartilage graft was a suitable option for chin augmentations up to 5 mm.     

Use of human amnion for microvascular interpositional grafts

A major problem associated with vascular grafting employing an artificial graft is the inflammatory response provoked by the graft and subsequent complications of classical acute rejection phenomena when the graft is implanted subcutaneously into human volunteers. The favorable results obtained by a preliminary study of subcutaneous implantation of amnion in our laboratory have led us to a prospective study to determine its value as a vascular graft. Tubed conduits of glutaraldehyde-treated amnion were hand constructed of varying diameters and lengths. They were employed as segmental interpositional grafts in experimentally created femoral and aortic arterial defects in Sprague-Dawley rats. Patency rates varied from 60 to 90 percent, with all grafts showing remarkable reendothelialization within 3 to 4 weeks postoperatively. Morphology, antigenic reaction, blood flow, and patency of the different experimental amnion grafts were evaluated and compared to appropriate controls.     

Distraction osteogenesis of costochondral bone grafts in the mandible

Costochondral grafting for reconstruction of the Pruzansky type III mandible has given variable results. Lengthening of the rib graft by means of distraction had been advocated when subsequent growth of the grafted mandible is inadequate. This retrospective study reviews a series of patients with mandibular costochondral grafts who underwent subsequent distraction osteogenesis of the graft. A retrospective review identified two patient groups: group 1 consisted of individuals (n = 9) who underwent costochondral rib grafting of the mandible followed by distraction osteogenesis several months later at a rate of 1 mm/day. Group 2 consisted of patients with Pruzansky type II mandibles who had distraction osteogenesis without prior rib grafting (n = 9). The biomechanical parameters, orthodontic treatment regimens, and complications were examined versus patient age and quality of the rib graft. Distraction osteogenesis was successfully performed in six of the rib graft patients (group 1) and in all of the group 2 individuals. On the basis of the Haminishi scale, the computed tomographic scan appearance of the regenerate was classified as "standard or external" in six of the group 1 patients and as either "agenetic" or "pillar" (fibrous union) in the remaining three patients. In group 1, the average device was expanded 23 mm (range, 20 to 30 mm). Group 2 mandibular distraction results were all classified as either standard or external, and there was an average device expansion of 22.4 mm (range, 16 to 30 mm). The length of consolidation averaged 12.6 weeks in group 1, compared with 8.5 weeks in the traditional mandibular distraction patients (group 2). The mean shift of the dental midline to the contralateral side was 2.5 mm in group 1 versus 4.0 mm in group 2. Complex multiplanar and transport distractions were successfully performed on grafts of adequate bony volume. All four patients in group 1 with tracheostomies were successfully decannulated after consolidation. Rib graft distraction complications included pin tract infections in two patients, hardware failure with premature pin pullout in one patient, and evidence of fibrous nonunions in three young patients with single, diminutive rib grafts. In group 2, there were no distraction failures. Distraction osteogenesis can be successfully performed on costochondral rib grafts of the mandible; however, the complication rate is higher than in non-rib-graft patients. Performing the technique on older, more cooperative individuals seems to reduce this risk. In addition, placement of a double rib graft or an iliac bone graft of sufficient volume to create a neomandible with greater bone stock is an absolute requirement to decrease the risk of fibrous nonunion and provide a bone base of sufficient size for retention of the distraction device and manipulation of the regenerate.     

Surgical correction of the vertically deficient chin

Surgical correction of the vertically deficient chin has received relatively little attention. This paucity of information is most likely related to the failure to diagnose vertical microgenia and the questionable stability of its surgical correction utilizing autogenous bone grafts. This paper reports on eight patients who have undergone vertical augmentation genioplasty utilizing a transverse symphyseal osteotomy and interpositional implantation of porous, block hydroxyapatite. All patients had preoperative measured decreases in lower face height. Mean vertical lengthening of the chin was 5.3 mm. Seven of the eight patients had class II occlusions and underwent simultaneous sagittal advancement of the chin. Follow-up at a mean time of 11.1 months revealed complete stability of the vertically repositioned symphyseal segment. Mean ratio of the vertical soft to hard tissue augmentation was 0.89:1. There were no instances of operative complications. Vertical facial aesthetics and their application in the evaluation and treatment of patients with vertically deficient lower faces and chins are reviewed.