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.     

Correction of the pinched nasal tip with alar spreader grafts.

A pinched nasal tip is caused by collapsed alar rims secondary to weak lateral crura. The resulting deformity can be corrected with alar spreader grafts--autogenous grafts of septal or auricular cartilage that are inserted between and deep to the remaining lateral crura to force them apart, propping up the caved-in segment. We describe the surgical technique, indications, and variations in design of alar spreader grafts and present representative results from our series of 38 patients.     

The boxy nasal tip: classification and management based on alar cartilage suturing techniques

The boxy nasal tip is characterized by a broad, rectangular appearance of the tip lobule on basal view. This manifests anatomically as one of three types: type I, which features an increased intercrural angle of divergence (greater than 30 degrees) and normal domal arc (4 mm or less) manifesting as the tip-defining points; type II, which features an increased angulation of the domes of the lower lateral segments of cartilage, creating a widened domal arc (greater than 4 mm) and normal angle of divergence (30 degrees or less); and type III, which features a combination of increased angle of divergence (greater than 30 degrees) and widened crural domal arc (4 mm or greater). In this article, the available techniques for correction of the boxy tip are reviewed and an algorithmic approach for the management of this problem is demonstrated using the open approach to rhinoplasty. Using an individualized algorithmic approach with intraoperative nasal tip analysis and three nasal tip suture reshaping techniques, consistent aesthetic results can be obtained in the correction of the boxy nasal tip.     

Correction of the secondary nasal tip and of alar and/or columellar collapse

The authors present their surgical technique for the correction of the secondary nasal tip with alar and/or columellar collapse. They employ a cartilage autograft in the form of an anchor or half an anchor which is taken from the auricular concha and is designed according to the requirements of the pathology to be corrected. In their experience, they have observed neither complications with the use of these grafts nor unacceptable scars in the columellar incision.     

The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem.Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.     

Individual modifications in body contour surgery: the "limited" abdominoplasty

Stretching of the abdominal wall and skin following pregnancy or excessive weight gain may be limited to the infraumbilical area. In these patients, abdominal repair may be accomplished with a shorter incision and without the necessity for relocating the umbilicus with its attendant visible scar. Forty patients are presented in whom excellent aesthetic repairs were effected through short curvilinear, low abdominal incisions with removal of a modest amount of excess skin. Fascial plication from pubis to umbilicus or above is facilitated by buried figure-of-eight sutures. Suction-assisted lipectomy may be employed as an adjunct. Recovery is facilitated by the reduced incision line length, reduced undermined area, and absence of tension in the midline skin incision, such as may occur in a standard abdominoplasty in which large amounts of panniculus and skin are removed with a complete repair of the abdominal wall. The limited abdominoplasty may be safely performed with ketamine-diazepam anesthesia in an office surgical center. Major complications are few and generally reflect the unpredictable nature of the elasticity of the abdominal skin.     

"Cap" on the tip of Salmonella flagella

Flagellar filaments isolated intact from a Salmonella short-flagella mutant are unable to serve as nuclei for flagellin polymerization in vitro, whereas the filaments reconstructed in vitro from the mutant flagellin are able to do so. The inability of intact flagella to nucleate flagellin polymerization appears to be common to wild-type bacteria and thus suggests that the tip of intact flagella are generally inactivated or capped in vivo. Careful observations of the tips of intact flagella and reconstructed flagellar filaments of a wild-type species have revealed marked difference between them: the intact flagella usually have blunt ends, whereas reconstructed filaments have concave, "fish-tail" ends. Moreover, a thin structure is often observed attaching to the very end of the intact flagella. We suspect that this "capping" structure is essential to the elongation mechanism of flagellar filaments.     

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.     

Range retractions and extinction in the face of climate warming

Until recently, published evidence for the responses of species to climate change had revealed more examples of species expanding than retracting their distributions. However, recent papers on butterflies and frogs now show that population-level and species-level extinctions are occurring. The relative lack of previous information about range retractions and extinctions appears to stem, at least partly, from a failure to survey the distributions of species at sufficiently fine resolution to detect declines, and from a failure to attribute such declines to climate change. The new evidence suggests that climate-driven extinctions and range retractions are already widespread.     

Crucial ignored parameters on nanotoxicology: the importance of toxicity assay modifications and "cell vision"

Until now, the results of nanotoxicology research have shown that the interactions between nanoparticles (NPs) and cells are remarkably complex. In order to get a deep understanding of the NP-cell interactions, scientists have focused on the physicochemical effects. However, there are still considerable debates about the regulation of nanomaterials and the reported results are usually in contradictions. Here, we are going to introduce the potential key reasons for these conflicts. In this case, modification of conventional in vitro toxicity assays, is one of the crucial ignored matter in nanotoxicological sciences. More specifically, the conventional methods neglect important factors such as the sedimentation of NPs and absorption of proteins and other essential biomolecules onto the surface of NPs. Another ignored matter in nanotoxicological sciences is the effect of cell "vision" (i.e., cell type). In order to show the effects of these ignored subjects, we probed the effect of superparamagnetic iron oxide NPs (SPIONs), with various surface chemistries, on various cell lines. We found thatthe modification of conventional toxicity assays and the consideration of the "cell vision" concept are crucial matters to obtain reliable, and reproducible nanotoxicology data. These new concepts offer a suitable way to obtain a deep understanding on the cell-NP interactions. In addition, by consideration of these ignored factors, the conflict of future toxicological reports would be significantly decreased.