Septal crossbar graft for the correction of the crooked nose

Surgical management of the crooked nose still constitutes a problem that is difficult to solve because of the possibility of recurrence and the risk of weakening the supporting structures. The authors propose an innovative surgical technique for the correction of this deformity that takes into account both aspects of the problem. The technique combines septoplasty by means of staggered intracartilaginous incisions with the original positioning of a unilateral spreader graft. Once realignment of the deviated cartilages is achieved, this cartilaginous stent, referred to as a "crossbar graft," makes it possible to keep the mobilized axis firmly in the correct position over time. This graft is also quite effective from a functional point of view in restoring the correct angle of the internal nasal valve. Moreover, the technique allows for the harmonization of the aesthetic line from the eyebrow to the tip-defining point on the concave side with the same line on the other side.     

Surgical correction of burn deformities of the nose.

We present a method for reconstruction of the everted nostrils of the burned nose. Through a "ram's horn" incision, the everted vestibular lining and lower lateral cartilages are mobilized and repositioned, and the resultant defect is covered with a full-thickness skin graft. The linear scar is created as part of a circle, so that the postoperative contracture will improve the alar contour.     

Secondary correction of the unilateral cleft lip nose using a conchal composite graft

The secondary deformity of the unilateral cleft lip nose has many components. One is the dorsal dislocation of the lateral crus of the alar cartilage. We used a conchal composite graft positioned between the piriform aperture and the lateral crus and the upper lateral cartilage to correct this dislocation in nine patients. We believe that this graft is effective because it elevates the lateral crus of the alar cartilage off the depressed piriform aperture. This technique is very simple to perform, and it is easy to achieve nasal symmetry. Our results have been quite satisfactory, with no recurrence of dorsal dislocation. The donor site was covered by a subcutaneous pedicled flap from the cephaloauricular sulcus, leaving an inconspicuous deformity.     

Surgical correction of the inverted nipple with a tendon graft: hammock procedure

Our procedure, in which the inverted nipple was suspended using autogenous tendon grafts, was easy to perform, and it was not necessary to cut the lactiferous ducts. There was no deformity of the nipple or areola after this procedure, and the surgical scars were inconspicuous. Three patients who were followed up for over 1 year after surgery were presented in this paper. In eight patients (13 corrected inverted nipples), good results were obtained and there have been no complications to date.     

Surgical correction of the nose and midface in maxillonasal dysplasia (Binder's syndrome)

In 48 patients with maxillonasal dysplasia the retruded nasal base was corrected with onlay cancellous bone grafts after subperiosteal dissection using an oral vestibular approach. Support for the nasal dorsum was achieved in 39 patients with an L-shaped bone graft from the iliac crest introduced through the same approach. The advancement of the nose was found stable on lateral cephalograms; i.e., resorption did not occur. However, the grafts showed considerable remodeling. Half the patients found the stiffness of the nose to be disturbing. In nine patients, the cartilaginous septum was used instead as a support for the nasal dorsum and tip. At operation, the entire cartilaginous septum was mobilized after subperichondrial dissection and rotated forward either pedicled at the nasal dorsum or completely released. Cartilage regenerated in the periochondrial pocket left behind the advanced septum. The anterior transfer of the nose was 6 to 10 mm. The use of septal advancement is preferred over bone implants in the correction of maxillonasal dysplasia in patients in whom the bony nasal dorsum is of adequate height because it results in a soft and flexible nose and the risk of traumatic fracture and resorption is eliminated. The technique has been used in adolescents with promising results.     

Primary correction of the unilateral cleft lip nose: a 15-year experience

This paper reviews a 15-year personal experience based on 400 unilateral cleft nasal deformities that were reconstructed using a method that repositions the alar cartilage by freeing it from the skin and lining and shifts it to a new position. The rotation-advancement lip procedure facilitates the exposure and approach to the nasal reconstruction. The nasal soft tissues are transected from the skeletal base, reshaped, repositioned, and secured by using temporary stent sutures that readapt the alar cartilage, skin, and lining. The nasal floor is closed and the ala base is positioned to match the normal side. Good subsequent growth with maintenance of the reconstruction has been noted in this series. The repair does not directly expose or suture the alar cartilage. Improvement in the cleft nasal deformity is noted in 80 percent of the cases. Twenty percent require additional techniques to achieve the desired symmetry. This method has been used by the author as his primary unilateral cleft nasal repair and has been taught to residents and fellows under his direction with good results. This technique eliminates the severe cleft nasal deformity seen in many secondary cases.     

The free tongue graft for correction of secondary deformities of the vermilion in patients with cleft lip

From January of 1985 to January of 1990, 31 patients with repaired cleft lip and secondary vermilion defects underwent 45 revisional procedures. A free tongue graft was utilized seven times in six patients (19 percent). Indications for its use were a V-shaped vermilion deficit or a "whistling" deformity associated with a sagittal vermilion deficiency and normal or insufficient lateral vermilion bulk. Of the seven free tongue grafts, none was lost. Three patients have required revisions, including repeat free tongue graft in one. Proper positioning of the graft along the free vermilion border has made color and texture match satisfactory. The free tongue graft is a simple and reliable means of transferring both vermilion bulk and surface mucosa. Introduction of the free tongue graft has eliminated the need for more cumbersome procedures, such as the Abbé flap or the tongue flap, in properly selected patients.     

Lengthening of the postoperative short nose: combined use of a gull-wing concha composite graft and a rib costochondral dorsal onlay graft

Several causes of short nose are known: congenital anomaly, developmental problem, trauma, and various types of rhinoplasty-the postoperative short nose being one of the most difficult problems to correct in plastic surgery. Contracted skin envelope, tissue deficiency of cartilage and mucosal lining, and poor circulation make postoperative short nose difficult to lengthen and susceptible to recurrence. Thus, for effective lengthening and long-term maintenance of it, specific grafts should be used to supplement the missing lining and cartilage and a mechanical support also is needed to withstand the skin contraction. The nose consists of three structural layers: the outer skin envelope, middle osteocartilaginous framework, and inner mucosal lining. Many methods have been proposed to correct short nose deformity. Those procedures lengthen the nose slightly, but none of them take into account the unique characteristics of postoperative causes and the structural concept of the nose. The procedures have resulted in only limited success. On the basis of the above clinical findings and the structural concept, we developed a surgical technique to correct postoperative short nose according to the structural layers. Our method consists of three main surgical maneuvers: (1) a gull-wing concha chondrocutaneous composite graft to supplement the deficient middle and inner layers, (2) a rib costochondral onlay graft on the dorsum to reinforce the framework, and (3) wide dissection of the outer skin envelope to cover the lengthened framework without tension. We prefer a closed surgical approach rather than an open approach to avoid too much tension on the columellar incision site and to allay patients' fear of an additional scar. From 1988 to 1998, we performed our lengthening technique on six female patients. All six patients demonstrated a significant lengthening and improved appearance postoperatively. After the lengthening procedure, the average nasolabial angle improved from 116 degrees to 104 degrees. The mean follow-up period was 8.7 months, with a range of 3 to 17 months. Sometimes, epidermal sloughing in the vertical strut of the gull-wing     

Repairing defects of the lower eyelid with a free chondromucosal graft.

A method is presented for the repair of full-thickness defects of the eyelid. The lining and tarsal plate are replaced by a free chondromucosal graft from the nasal septum, in which the cartilage is thinned and perforated. Cover is provided by a compound, bipedicled flap of skin and muscle from the opposite lid.     

Surgical correction of entropion and ectropion in the same lid

A patient with medial ectropion and lateral entropion of the same lower lid is presented, and the surgical management of this unusual condition utilizing a horizontal lid-shortening, orbicularis sling procedure, fixation of the posterior and anterior lamellae of the lid, and resection of the tarsal conjunctival layer is described. We believe that the key to the successful management of this condition lies in treating each component surgically as if it were a separate entity, and by using a combination of surgical techniques, both eyelid malpositions can be corrected.     

Thermostabilization of recombinant human and bovine CuZn superoxide dismutases by replacement of free cysteines

Human CuZn superoxide dismutase (HSOD) has two free cysteines: a buried cysteine (Cys6) located in a beta-strand, and a solvent accessible cysteine (Cys111) located in a loop region. The highly homologous bovine enzyme (BSOD) has a single buried Cys6 residue. Cys6 residues in HSOD and BSOD were replaced by alanine and Cys111 residues in HSOD by serine. The mutant enzymes were expressed and purified from yeast and had normal specific activities. The relative resistance of the purified proteins to irreversible inactivation of enzymatic activity by heating at 70 degrees C was HSOD Ala6 Ser111 greater than BSOD Ala6 Ser109 greater than BSOD Cys6 Ser109 (wild type) greater than HSOD Ala6 Cys111 greater than HSOD Cys6 Ser111 greater than HSOD Cys111 (wild type). In all cases, removal of a free cysteine residue increased thermostability.     

Ultrastructure of free nerve endings in respiratory and squamous epithelium on the rat nasal septum

The distribution of nerve fibres in the mucosa of the nasal septum of the rat was investigated by means of transmission electron microscopy on transverse and tangential ultrathin sections. Near the basement membrane of respiratory and squamous epithelium, a rather dense network of unmyelinated nerve fibres occurs. Some fibres in the respiratory epithelium ascend between the epithelial cells to reach up to the tight junctions. These fibres appeared in transverse sections to end as hooks or boutons, sometimes with branches. These shapes resemble the free nerve endings that are considered to act as nociceptors. The small intraepithelial fibres, with diameters of about 0.5–1 m, contain both dense granules and clear vesicles comparable to synaptic vesicles. Substance P was found in dense granules in basal fibres; vasoactive intestinal peptide was absent throughout the epithelium. Acetylcholinesterase activity was observed closely associated with the basal fibres; the apical fibres showed little if any activity. Membrane specializations pointing to an efferent function as well as structures usually associated with mechanoreceptive functions were lacking in both respiratory and squamous epithelium.Part of this work was presented at the Annual Conference of the Netherlands Society for Electron Microscopy, 28–29 Nov 1985, Wageningen, The Netherlands. See Spit BJ and Hendriksen EGJ (1986) Ultramicroscopy 19:102–103     

Surgical correction of Stahl's ear using the cartilage turnover and rotation method

Various operative methods for the correction of Stahl's ear exist. We, however, have devised an alternative "turnover and rotation" procedure. In this procedure, the deformed cartilage itself is used in its original contour to form a new scaphoid fossa, thus simplifying the corrective procedure and establishing a reliable operative method in which reversion to the original state is thought to be highly unlikely.