External approach for secondary rhinoplasty

A systematic approach, using the external rhinoplasty technique, is presented to aid the plastic surgeon in obtaining improved aesthetic and functional results in patients with postoperative nasal deformities. In over 100 external rhinoplasties, there were no problems with the stairstep transcolumellar incision used to provide complete visualization of the underlying nasal framework. The external approach allows for a more accurate intraoperative anatomic diagnosis and subsequent complete correction of the nasal deformity. Three case reports are presented to demonstrate the indications and versatility of the external approach in secondary rhinoplasty.     

Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution

To achieve success in rhinoplasty, the plastic surgeon takes advantage of numerous intraoperative techniques designed to manipulate nasal soft tissue and the osseocartilaginous framework. Although the postoperative result may meet preoperative aesthetic goals, an element of nasal airway obstruction can persist from failure to acknowledge the role of inferior turbinates. Surgically responsive inferior turbinate hypertrophy is frequently not addressed secondary to inadequate history taking, incomplete physical examination, and/or surgeon reluctance to handle these sensitive structures.The goal of this article is to discuss the anatomy and physiology of the inferior turbinates, to present the role for inferior turbinate surgery during rhinoplasty, and to delineate the evolution of the current technique of submucosal resection of the inferior turbinates. Over the past 14 years, the senior author (R.J.R.) has performed inferior turbinates surgery on 648 patients as part of a rhinoplasty.     

两种手术方式治疗Krouse分级T2、T3上颌窦内翻性乳头状瘤的疗效及对炎性应激指标的影响

目的:对比鼻内镜下经泪前隐窝入路、鼻内镜下中下鼻窦道开窗术两种手术方式治疗Krouse分级T2、T3的上颌窦内翻性乳头状瘤的疗效及对炎性应激指标的影响。方法:回顾性分析50例上颌窦内翻性乳头状瘤患者的临床资料。根据手术方式分成A组(n=26,鼻内镜下中下鼻窦道开窗术)和B组(n=24,鼻内镜下经泪前隐窝入路)。考察两组围术期指标、炎性应激指标[白介素-8(IL-8)、白介素-10(IL-10)、降钙素原(PCT)]、并发症、复发率。结果:与A组相比,B组的术中出血量更少,手术时间、术后鼻腔内创面愈合时间、住院时间更短,术后疼痛程度更轻,组间对比差异有统计学意义(P<0.05)。两组术前、术后1 d、术后10 d的IL-8、PCT水平呈先升高后降低趋势,IL-10呈先降低后升高趋势(P<0.025),B组术后1 d的IL-8、PCT水平低于A组,IL-10水平高于A组(P<0.05)。两组并发症发生率、术后复发率组间对比均无统计学意义(P>0.05)。结论:以鼻内镜下经泪前隐窝入路治疗Krouse分级为T2、T3的上颌窦内翻性乳头状瘤患者,创伤小,术后恢复快,可减轻患者炎性应激,术后并发症少,是治疗上颌窦内翻性乳头状瘤疗效较好的手术方式之一。     

Immediate versus delayed midface distraction in a primate model using a new intraoral internal device

The theoretic advantage of distraction osteogenesis of the craniofacial skeleton, especially in cases of severe midface retrusion and in the presence of maxillary scarring, is prevention of relapse following significant advancements. The purpose of this study is to demonstrate the utility of a new low-profile, intraoral, internal device for midface distraction at the conventional or high Le Fort I level. In addition, the present study compares the efficacy of immediate versus delayed distraction on subsequent maxillary relapse. Four adult rhesus Macaca mulatta monkeys were divided into two groups. Group 1 underwent immediate midface distraction; group 2 underwent delayed distraction. All four monkeys underwent a modified Le Fort I osteotomy through an upper buccal sulcus incision and bilateral application of the intraoral midface distraction devices. No other osteotomies or incisions were necessary. Immediate distraction, performed in group 1, entailed intraoperative activation of the devices and distraction of 10 mm followed by a 5-day lag period before postoperative activation and distraction of an additional 10 mm at the rate of 1 mm/day. Delayed distraction, performed in group 2, entailed a 5-day postoperative lag period before device activation and distraction of 20 mm at the rate of 1 mm/day. Both groups thus underwent 20 mm of midface distraction. All devices were removed 6 weeks after completion of distraction. All monkeys tolerated the devices and daily distraction uneventfully. On the basis of serial cephalograms and dental models obtained throughout the experimental period, there was no evidence of relapse in either the immediate or delayed groups 6 months after distraction. In addition, on the basis of histologic, ultrastructural, and dry skull analysis, no significant differences were observed in the quality of regenerate bone obtained when comparing the immediate and delayed distraction groups. Significant midface advancement is thus feasible using this new internal, intraoral distraction device, which presents several advantages over other internal devices that require coronal incisions and additional osteotomies to achieve midface advancement. In addition, immediate distraction may abbreviate the distraction period without adverse sequelae.     

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.     

Postrhinoplasty nasal cysts and the use of petroleum-based ointments and nasal packing

Nasal cysts are rare complications of rhinoplasty, and numerous theories exist regarding their cause. The term "paraffinoma" has been used to describe cyst formation observed after topical antibiotic ointment application with nasal packing in the immediate postoperative period. Such complications are rare but may occur because of the inherent properties of the agent used or a lack of meticulous technique (in the placement of incisions and nasal packing). Three cases of postrhinoplasty cysts with a variety of presentations, including incidental intraoperative findings, bilateral medial canthal masses, and a draining dorsal cyst, are described. Although such cysts are uncommon, techniques to prevent these unwanted sequelae should routinely be used, with the judicious application of non-petroleum-based topical antibiotic preparations.     

Repair of bilateral complete cleft lip: intraoperative nasolabial anthropometry

Synchronous repair of bilateral complete cleft lip and nasal deformity requires conception of three-dimensional form and fourth-dimensional changes with growth, as distorted by the malformation. The aim is to obviate typical postoperative nasolabial stigmata. The strategy is to construct fast-growing features on a smaller scale and slow-growing features on a normal or slightly larger scale. In this study, intraoperative alterations in nasolabial dimensions were documented by anthropometry in 46 consecutive infants with bilateral complete cleft lip. These values were averaged and compared with measures from normal Caucasian infants at ages 0 to 5 months and 6 to 12 months. Nasal height (n-sn) and nasal width (al-al), both fast-growing features, were set smaller (88 percent and 96 percent, respectively) than those of age-matched normal infants. In contrast, the slow-growing features, nasal protrusion (sn-prn) and columellar length, were constructed longer than normal (130 percent and 167 percent, respectively). Because all labial features grow rapidly, they were made diminutive in this study, with the exception of central vermilion-mucosal height (median tubercle), which was purposively made full. These maneuvers resulted in a normal, average overall upper-lip height (sn-sto). Two technical refinements also are described: (1) construction of deepithelialized bands flanking the philtral flap to improve surface contour; and (2) positioning and fixation of the dislocated alar cartilages, performed entirely through superiomedial nostril rim incisions.     

鼻内镜动力切削术对鼻前庭囊肿患者CRP、TNF-alpha、IL-6 及IL-8 的影响

目的：探讨鼻内镜下动力切削系统治疗对鼻前庭囊肿患者CRP、TNF-alpha、IL-6 和IL-8 的影响。方法：选取2012 年6 月至2013 年1 月我院收治的鼻前庭囊肿患者163 例,随机分为两组。实验组（80 例）行鼻内镜下动力切削系统行囊肿切除术,对照组（83 例）给予微波治疗。观察并比较两组患者手术前后血清CRP、TNF-alpha、IL-6 和IL-8 水平的变化情况,并比较两组患者手术情况、术 后并发症及远期疗效。结果：与对照组比较,实验组手术时间较长,术中出血量较多,差异具有统计学意义（P＜0.05）,实验组术后 感染率较低,术后复发率较低;术后CRP、TNF-alpha、IL-6 和IL-8水平升高,与对照组相比,实验组各项指标较高（P<0.05）。结论：鼻内 镜下动力切削系统治疗鼻前庭囊肿具有较好的临床治疗效果,且复发率低,值得临床推广。     

Intraoperative coagulation activity--a defined group of trauma surgery patients

Analyses of blood coagulation in a defined group of patients before, during, and after trauma-surgery confirms an intraoperative trigger-mechanism, that causes postoperative thromboembolic complications. They also proof the correlation between extent of tissue-lesion and extent of triggering, this was previously presumed from the postoperative incidence of thromboembolic complications. Apart from the usual blood coagulation tests the following parameters where analysed: Factor VIII: C, Ristocetin-Co-factor, Factor Xa, AT III, TAT, Reptilase-time, tPA, D-dimers, and FPA. Simultaneously, it was shown, that a preoperative prophylaxis of thrombosis can prevent an intraoperative increase of Factor Xa, that plays a key role in postoperative thromboembolic complication. The increased intraoperative turnover of coagulation factors, which is necessary for physiologic blood coagulation, is not prevented.     

Anthropometric study of synostotic frontal plagiocephaly: before and after fronto-orbital advancement with correction of nasal angulation

Surgical correction of synostotic frontal plagiocephaly (unilateral coronal synostosis) focuses on the asymmetry of the forehead and orbits. However, there is controversy regarding whether nasal angulation should be addressed during primary fronto-orbital advancement in infancy. This prospective study was undertaken to answer that question. Preoperative and postoperative anthropometric measurements were obtained for 19 infants with nonsyndromic synostotic frontal plagiocephaly. The measurements included nasal angulation, nasion-to-endocanthion distance, nasion-to-exocanthion distance, and exocanthion-to-tragion distance. All patients underwent bilateral parallelogrammatic fronto-orbital correction. Closing wedge nasal ostectomy was performed for group I (n = 14) and was not performed for group II (n = 5). The average age at the time of follow-up assessments was 3 years 8 months (range, 1 to 14 years) in group I and 5 years 5 months (range, 2 to 15 years) in group II. A statistically significant change was observed for patients who underwent primary correction of nasal angulation; the change correlated with improved naso-orbital symmetry, as judged with nasion-to-endocanthion and nasion-to-exocanthion measurements (p < 0.01 and p < 0.05, respectively). Group I patients exhibited an average preoperative nasal angulation of 9.15 +/- 0.8 degrees that decreased to 3.1 +/- 0.6 degrees postoperatively (p < 0.01). Group II patients exhibited an average preoperative nasal angulation of 6.4 +/- 0.7 degrees that was unchanged postoperatively at 7.2 +/- 1 degrees. The improvement in nasal angulation in group I was particularly striking because the patients in group II exhibited, on average, a lesser degree of preoperative nasal deviation (p < 0.01). This prospective comparison of fronto-orbital correction of synostotic frontal plagiocephaly with and without nasal correction confirmed an earlier study and demonstrated that angulation of the nasal pyramid does not self-correct within 5 years after traditional bilateral fronto-orbital repair. Closing wedge nasal ostectomy results in improved nasal angulation and naso-orbital symmetry, without evidence of distortion or inhibition of nasal growth.     

A model for planning rhinoplasty

A rhinoplasty model is detailed in which nasal shape is conceived as a dynamic system, the result of powerful expansive and contractile forces, of a skin sleeve in equilibrium with a dynamic skeleton, in which the alar cartilages are external to the remaining skeleton and support a large area of lower nasal skin. In this system, changes in one region have "global" effects. Consequently, one powerful way to control nasal shape is to maintain skin sleeve size and thus maintain the preoperative nasal equilibrium. The surgeon who controls the postoperative equilibrium controls the postoperative result.     

Detection and identification of oral anaerobes in intraoperative bronchial fluids of patients with pulmonary carcinoma

Postoperative pneumonia may occur when upper respiratory tract protective reflexes such as cough and/or swallowing reflexes are impaired; thus, silent aspiration of oral bacteria may be a causative factor in postoperative pneumonia. This study aimed to quantify and identify bacteria in intraoperative bronchial fluids and to evaluate the relationship between impairment of cough/swallowing reflexes and silent aspiration of oral bacteria in elderly patients. After obtaining informed consent, cough and swallowing reflexes were assessed using an ultrasonic nebulizer and a nasal catheter, respectively. Using a micro‐sampling probe, intraoperative bronchial fluids were collected from nine subjects with pulmonary carcinoma and cultured anaerobically on blood agar plates. After 7 days, CFUs were counted and isolated bacteria were identified by 16S rRNA gene sequencing. Four subjects (aged 71.0 ± 8.4 years) had impaired swallowing reflexes with normal cough reflexes, whereas five subjects (73.6 ± 6.5 years) had normal cough and swallowing reflexes. The bacterial counts (mean CFU ± SD) tended to be higher in intraoperative bronchial fluids of subjects with impaired swallowing reflexes ([5.1 ± 7.7] × 10⁵) than in those of subjects with normal reflexes ([1.2 ± 1.9] × 10⁵); however, this difference was not statistically significant. Predominant isolates from intraoperative bronchial fluids were Streptococcus (41.8%), Veillonella (11.4%), Gemella (8.9%), Porphyromonas (7.6%), Olsenella (6.3%) and Eikenella (6.3%). These findings indicate that intraoperative bronchial fluids contain bacteria, probably derived from the oral microbiota, and suggest that silent aspiration of oral bacteria occurs in elderly patients irrespective of impairment of swallowing reflex.     

Long-term outcome of autogenous rib graft nasal reconstruction.

Whereas reconstruction of the hypoplastic nose with rib grafting is common, the long-term outcomes of nasal growth and aesthetics are unknown. This study assessed nasal morphometrics, patient satisfaction, and the perception of nasal appearance by others up to 15 years after nasal reconstruction using cantilevered autogenous chondro-osseous rib grafting with rigid internal fixation in children. Records of all patients who received nasal rib grafts between 1983 and 1998 by one senior surgeon were reviewed. Patients in this study were operated on before their late teens and had greater than 1-year follow-up including serial photographic documentation. Nasal growth was determined by comparing anthropometric measurements preoperatively, perioperatively, and postoperatively. Patient satisfaction was determined through a questionnaire that addressed memory, donor-site morbidity, and nasal perception. Independent, blinded skilled observers who reviewed frontal and lateral photographs of the preoperative, perioperative, and postoperative intervals assessed nasal aesthetics. Thirty-two patients who underwent 38 rib graft reconstructions of the nasal dorsum and tip at an average age of 8.8 years constitute the study population. Six patients underwent secondary augmentation. The average interval between initial nasal reconstruction and evaluation for this study was 7.9 years. Comparative anthropometric measurements before and after surgery documented increases in both tip projection (2.3 percent) and nasal length (3.0 percent) and a decrease in nasolabial angle (1.9 percent). Patient satisfaction interview response rate was 100 percent of those whom we were able to contact (28 of 32). The average age at interview was 17.2 years. Most patients recalled the operation and denied recollection of pain. Donor-site long-term morbidity was not an issue for 86 percent of patients. Sixty-four percent of patients remembered their preoperative nasal appearance and 89 percent of these preferred the postoperative change and were not concerned with nasal scars or texture. Almost two-thirds of the patients had fixation screws removed from the nasal dorsum because of skin erosion, easy palpability, or visibility. Although several patients expressed a desire to make minor additional changes to their nose, only one of these elected offered presurgical consultation and none have had such surgery. The postoperative nasal appearance compared with that preoperatively was rated as improved for 66.3 percent of responses, 26.5 percent as unchanged, and 7.2 percent as deteriorated. Cantilevered autogenous chondro-osseous rib graft reconstruction of the nasal dorsum is an effective means of reconstruction for the hypoplastic nose in childhood with respect to morphometric measurements, patient self-perception, and the assessment of nasal appearance by others.     

Reversal of hyposmia in laryngectomized patients

To assess the degree to which the olfactory deficit associatedwith laryngectomy is simply due to the loss of nasal airflow,17 laryngectomees were fitted with a device (larynx bypass)which allowed them to produce approximately normal sniffs. Detectionthresholds were determined for two odorants, vanillin (reportedlyexcites only the olfactory nerve) and ammonia (a strong trigeminalirritant). Without the bypass nine patients detected neitherodorant. The others, who could manoeuver somewhat more vigorousnasal airflows, detected the odorants but only half had ‘normal’thresholds. In this latter group there was a tendency for decreasingdetection thresholds with increasing postoperative years. Withthe bypass all 17 patients achieved ‘normal’ ammoniathresholds whereas 10 achieved ‘normal’ vanillinthresholds. Thus, the loss of nasal airflow is a major contributorto the olfactory deficit of laryngectomy, and it may be theonly contributor for trigeminal irritants like ammonia. On theother hand, for non-trigeminal stimuli like vanillin other factorsseem to be involved.     

改良式吸痰装置的设计与临床应用

目的探讨改良式吸痰装置在儿科吸痰的应用效果。方法利用纳入、排除标准的抽样方法选取我院儿科2014年3月~2015年3月收治的138例肺炎患儿为研究对象,随机分为对照组68例和观察组70例。对照组采用常规吸痰装置进行吸痰,观察组采用改良的吸痰装置吸痰,观察比较两组患儿吸痰时鼻腔黏膜的出血情况、吸痰所需时间和护士满意度。结果观察组鼻腔黏膜出血2例,对照组15例,两组比较差异有统计学意义(P0.05);观察组有效吸痰时间为51.3s,明显低于对照组的103.5s,差异具有统计学意义(P0.05)。观察组的护士满意度为92.8%显著高于对照组的50%,两组比较差异具有统计学意义(P0.05)。结论改良式吸痰装置能缩短操作时间,降低鼻腔黏膜损伤,有利于护士快速有效解除患儿痰液堵塞,提高护士及家属满意度。     

Cavernous nerve stimulation and interposition grafting: a critical assessment and future perspectives

The sexual dysfunction that results from radical prostatectomy for carcinoma of the prostate is well established, with the degree of macroscopic preservation of the cavernous nerves tied to the degree of postoperative recovery of erectile function that is possible. In addition to the use of preoperative neuroprotective drugs and postoperative erectogenic agents, intraoperative nerve stimulation and grafting offer promise. Nerve stimulation may serve as a predictor of postoperative potency, and nerve grafting offers a potential way to correct the damage that occurs during wide resection. This article reviews the current literature on these intraoperative measures and discusses the need for additional studies of their potential benefits in prostatectomy candidates.     

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.     

包皮切割缝合器、商环及传统包皮环切术的临床疗效比较

目的:比较包皮切割缝合器与商环及传统包皮环切术治疗包皮过长或包茎的手术疗效及安全性。方法:将240例包皮过长或包茎患者随机分为传统包皮环切术组、商环组及包皮切割缝合器组(PCSD)。对比分析三组手术时间、出血量、术中疼痛评分、术后疼痛评分、切口愈合时间、感染、切口裂开、术后水肿、术后出血等情况。结果:在手术时间、术中疼痛评分、术后疼痛评分、切口愈合时间、感染、切口裂开、术后水肿方面,PCSD组都明显优于传统包皮环切术组及商环组(P0.05);PCSD组术中出血量明显少于传统包皮环切术组(P0.05),而与商环组比较未见明显差别;在术后出血方面,三组比较未见明显的差异。结论:PCSD可以明显缩短包皮过长或包茎的手术时间,降低术中、术后疼痛,减少术后并发症。     

Rotation advancement of the midface by distraction osteogenesis

A wide variety of disease processes produce alteration of midfacial skeletal growth, resulting in moderate-to-severe midface deficiency presenting as retrusion associated with Angle's class III malocclusion. Le Fort III osteotomies with advancement can provide an excellent tool for correction of this deformity. Recently, the corrective procedure of choice for advancement of midfacial segments has been distraction osteogenesis after osteotomy. Straight linear advancement is the most common choice for corrective movement of the midfacial segment, whether accomplished through acute surgical advancement or through the progressive distraction technique. Unfortunately, linear advancement can produce abnormal configurations, both at the nasal root and lateral orbits, regardless of the technique used. Enophthalmos, caused by orbital enlargement, may limit the advancement necessary to achieve class I occlusion.The authors have extended the utility of the Le Fort III procedure and have improved the final outcome by creating a controlled rotation advancement of the midfacial segment using distraction. The application of an existing internal distraction device is modified to control the movement of the midfacial segment in a rotation advancement path. Included in the series were 10 patients with severe midface retrusion secondary to multiple congenital syndromes, along with cleft lip and palate. The ages of the patients ranged from 6 to 14 years. An internal distraction system was used in all cases. Application of the distractor was substantially modified to simplify both fixation and removal and to produce controlled rotation advancement. The team orthodontist determined the final occlusal relationship. Percutaneous distractor drive rods were removed 4 to 6 weeks after active distraction to increase patient comfort. The distractors and all associated hardware were removed after 12 to 16 weeks of consolidation; follow-up periods ranged from 1 to 3 years.By using the modified distractor application to produce rotation advancement, the contour abnormalities at the nasal root and lateral orbit and the enophthalmos produced by linear advancement were eliminated. Significant improvement in facial contour and class I occlusion was obtained in all cases. Complications consisted of near exposure of the device in one patient. Stability has been excellent, with no relapse reported by the orthodontist.Rotational advancement of facial segments by distraction allows successful early intervention in patients with significant midface retrusion. The abnormal nasal root and lateral orbital configurations produced by direct linear advancement are avoided, and a stable and normalized facial configuration is produced.     

宫腔镜与腹腔镜手术剔除子宫肌瘤临床疗效观察

目的探讨宫腔镜与腹腔镜手术剔除子宫肌瘤的临床疗效。方法将我院收治的118例子宫肌瘤患者随机分为对照组与观察组,对照组实施腹腔镜子宫肌瘤剔除术,观察组实施宫腔镜子宫肌瘤电切术治疗,比较两组围手术期指标、术后子宫肌层愈合情况以及术后妊娠情况。结果观察组的手术时间、术中出血量、术后肌层完全愈合率以及首次妊娠距手术时间均显著优于对照组,差异有统计学意义(P0.05);两组术中转开腹率、术后发热率、月经改善率以及术后妊娠率比较,差异无显著性意义(P0.05)。结论宫腔镜与腹腔镜手术治疗子宫肌瘤均安全可靠,但宫腔镜术中出血量更少、术后恢复更迅速,是有生育要求患者的首选术式。