A rotational method of bilateral cleft lip nose repair

Repairs of the bilateral cleft lip nasal deformity have focused on lengthening the lower columella by adding lip, nasal structure, or a piece of ear. In these methods, the raised true columella worsens the dorsal dislocation of the lateral crura of the alar cartilages and the lateral and dorsal displacement of the alar domes. We believe that lengthening the upper columella from above is more anatomic and reasonable than lengthening the lower columella. A method for reconstructing the upper columella by medial and ventral rotation of the dislocated alar domes is described. Figi's "flying bird" incision was extended to the columellar base along the nostril margin. Through this incision, the lower one-third of the nose, including the alae and nostril floors, was undermined widely. The inner layers, the nostrils, were freed from the surrounding tissues, except in the region of the columella and the septum, and rotated medially in the opposite direction of Cronin's technique. The resulting nasal shape, involving the columellar length and the concavity between the nasal tip and lateral ala, improved in 11 patients.     

Lengthening the nose with a tongue-and-groove technique

Lengthening the short nose is often a major task. The ability to maintain proper alignment between the nasal base and dorsum may prove difficult without sacrificing the suppleness of the former. In this article, the authors introduce a technique of nose lengthening that ensures alignment of the tip with the rest of the nose yet avoids tip rigidity, unless a significant increase in tip projection is also planned. Two spreader grafts are placed, one on either side of the septum, and are extended beyond the caudal septal angle proportional to the planned nasal lengthening. A columella strut, with the cephalocaudal dimension equaling the combination of the width of the existing medial crura plus the amount of planned nasal lengthening, is placed between the medial crura in continuity with the caudal septum and is fixed to the medial crura using 5-0 clear nylon or polydioxanone suture. If additional projection beyond what is achievable by mere placement of a columella strut is required, the strut is fixed to the spreader grafts in a more projected position. Otherwise, the columella strut is simply positioned between the extensions of the spreader grafts. It is necessary to mobilize the lower lateral cartilages to prevent excessive columella show. This procedure has been performed on 23 patients over the past 12.5 years, with 20 patients enjoying good-to-excellent results. The advantages of this technique include its predictability and reproducibility, and the ability to elongate the nose with a mobile nasal base that is in line with the rest of the nose. If suture fixation is used to gain more projection, the technique proves dependable but the nose will become more rigid than is optimal. The requirement of three pieces of properly shaped septal cartilage, which might not be available when a secondary rhinoplasty is performed, is the major disadvantage of this operation. Furthermore, the procedure is, to some degree, labor-intensive.     

Results of surgical lengthening of the short nose in the bilateral cleft lip patient

Some children with bilateral cleft lips do not grow a long enough nose and require surgical lengthening of the nose. We review our 12-year experience with a one-stage slide operation to achieve this. Seven males and 5 females had this operation at ages 7 through 13 years, and we have followed them from 6 months to 12 years. The results, and the subsequent growth effects are described. In general, good long-term improvement has been achieved and the external scars have not proved to be a major drawback. Subsequent procedures upon the columella, alae, and upper lip are often required to establish an unobtrusive nasal appearance.     

Columellar elongation in bilateral cleft lip repair: early results.

Flattening of the nasal tip and shortness of the columella are two of the deformities that remain following successful repair of a bilateral cleft of the lip. Until now, correction has not been possible without producing undesirable scars on the surface of the nose or lip. A three-dimensional Z-plasty on the alar rim achieves columellar lengthening and forward projection of the tip, but it does not have these disadvantages.     

Congenital isolated absence of the nasal columella: reconstruction with an internal nasal vestibular skin flap and bilateral labial mucosa flaps

Congenital aplasia of the nasal columella is a very rare anomaly. The deformity is characterized by the isolated absence of the columella from the nasal tip to the root of the philtrum, including the medial crura of the alar cartilages; surrounding structures such as the septum, nose, and upper lip are normal. To the best of our knowledge, only four such cases have been described to date. The embryopathogenesis for this uncommon disease is presently unknown. Our report describes a 14-year-old girl with congenital agenesis of the columella as an isolated anomaly. Her family history was positive for the presence of the same congenital deformity, which also affected her older brother; there was, however, no consanguinity between the parents. The columella defect was reconstructed with an internal nasal vestibular skin flap and bilateral upper labial mucosa flaps. There are many techniques available to repair columella defects, including free grafts from the ear, local flaps from the forehead, face, upper lip, and nose, distant flaps such as tube pedicle flaps, and free flaps from the ear. Each of these techniques has advantages and disadvantages. Because of this, the treatment of columella defects should be individualized.     

Use of the nasal SMAS to reconstruct defects of the tip, alae, columella, or septum.

Reconstruction using traditional methods for small and medium-sized losses of the soft tissues of the lower third of the nose, including the tip, the columella, alae, or the cartilaginous septum, has meant leaving cicatricial stigmata surrounding the region and has required at least two operational stages. A comprehensive study of the local anatomy was completed, and a specific technique (presented herein) was used to transfer and distribute the well-vascularized layer of superficial muscle and aponeurotic tissue (SMAS) from the dorsum of the nose to the needed site, which provided bulk and a well-nourished surface that could be covered by a distant skin graft, using a one-step flap. The surgical approach to the SMAS was carried out through the scar over the site of tissue loss or through the site of regional ablation or the traumatic wound. Several representative cases are presented.     

Lengthening the aesthetically short nose

An aesthetically short nose is defined as a developmental deformity in which the nose appears foreshortened. It is characterized by a decreased distance from the nasofrontal angle (NFA) to the tip-defining points (TDP) and an increased nasolabial angle with increased nostril show. A method is described and illustrated for lengthening the aesthetically short nose by rotating the nasal tip in an inferior direction. This rotation results in an actual lengthening, as well as an illusion of lengthening of the nose.     

Reconstruction of the tip of the nose and ala by load cycling of the nasal skin and harnessing of extra skin

Reconstruction for loss of the nasal tip, adjoining columella, and left ala was largely accomplished by means of load cycling of the skin of the nose. The harnessing of the skin's viscoelastic properties can yield a fairly significant amount of extra skin, thus enabling a rather complicated problem to be dealt with by a relatively simple maneuver.     

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     

Primary repair of the bilateral cleft lip nose: a 15-year review and a new treatment plan

For 15 years a forked flap has been used for columella reconstruction in primary repair of the bilateral cleft lip nose. With the adolescent growth spurt, three unfavorable features have become apparent: (1) the columella may grow too long and the nostrils too large, (2) often the nasal tip remains broad, and (3) there is a drift of the columellar base and the lip-columellar angle is transgressed by scar. This procedure has therefore been discontinued. A new treatment plan is presented in which the columella is reconstructed from tissues in the splayed-out nasal tip.     

Alar rim raising.

The relationship of the alar rim to columella visibility and nostril proportion is crucial to a good aesthetic result. The alar rim has been a neglected part of the nose in primary and secondary rhinoplasty procedures for want of a natural contouring operation. Results of directly excising the alar rim and its indications are presented with adequate follow-up. Indications for the procedure include (1) recontouring of the cleft lip nose with anterior webbing, (2) equalizing asymmetrical nostrils, (3) enlarging small nostrils, (4) correcting a hanging (sigmoid) ala, and (5) converting round to oval nostrils.     

Aspects of the maintenance of the life cycle of Fasciola hepatica in Lymnaea columella in Minas Gerais,Brazil

Fascioliasis is a parasitic disease of domestic ruminants that occurs worldwide. The lymnaeid intermediate hosts of Fasciola hepatica include Lymnaea columella, which is widely distributed in Brazil. A colony of L. columella from Belo Horizonte, MG, was reared in our laboratory to be used in studies of the F. hepatica life cycle, the intermediate host-parasite relationship and development of an anti-helminthic vaccine. In the first experiment 1,180 snails were exposed to miracidia of F. hepatica eggs removed from the biliary tracts of cattle from the State of Rio Grande do Sul. In the second and third experiments the snails were exposed to miracidia that had emerged from F. hepatica eggs from Uruguay, maintained in rabbits. The rates of infection in the first, second and third experiments were 0, 42.1 and 0% respectively. Over 15,806 metacercariae were obtained and stored at 4 degrees C. Four rabbits weighing 1.5 kg each were infected with 32-44 metacercariae and two with 200. Three rabbits begin to eliminate eggs of the parasite in the feces from 84 days after infection onwards. The biological cycle of F. hepatica in L. columella and the rabbit was completed within 124 days.     

Influence of microgravity on root-cap regeneration and the structure of columella cells in Zea mays

We launched imbibed seeds and seedlings of Zea mays into outer space aboard the space shuttle Columbia to determine the influence of microgravity on 1) root-cap regeneration, and 2) the distribution of amyloplasts and endoplasmic reticulum (ER) in the putative statocytes (i.e., columella cells) of roots. Decapped roots grown on Earth completely regenerated their caps within 4.8 days after decapping, while those grown in microgravity did not regenerate caps. In Earth-grown seedlings, the ER was localized primarily along the periphery of columella cells, and amyloplasts sedimented in response to gravity to the lower sides of the cells. Seeds germinated on Earth and subsequently launched into outer space had a distribution of ER in columella cells similar to that of Earth-grown controls, but amyloplasts were distributed throughout the cells. Seeds germinated in outer space were characterized by the presence of spherical and ellipsoidal masses of ER and randomly distributed amyloplasts in their columella cells. These results indicate that 1) gravity is necessary for regeneration of the root cap, 2) columella cells can maintain their characteristic distribution of ER in microgravity only if they are exposed previously to gravity, and 3) gravity is necessary to distribute the ER in columella cells of this cultivar of Z. mays.     

Bilateral cleft lip reconstruction

Over a period of 8 years 140 bilateral cleft lips were operated using a muscle-repositioning banked fork-flap cheiloplasty. The use of buccal mucosal flaps in the intercartilaginous incision is helpful to decrease scarring and contracture by facilitating alar cartilage repositioning and wound closure without tension. Adding mucosa from the inferior turbinate makes complete wound closure relatively easy without tension. A lateral lip orbicularis muscle flap with white skin roll and vermilion is recommended for reconstruction of the Cupid's bow. Muscle continuity by freeing the muscle in one sheet and repositioning in front of the premaxilla with creation of a buccal alveolar sulcus is stressed to prevent the necessity of reentering the lip in a second procedure. The elongation of the columella is done at 1 to 6 years of age by advancing nasal floor tissue onto the columella and repositioning the alar cartilages superiorly and medially. When nasal floor tissue is inadequate, columellar lengthening is done by the use of a composite free ear graft.     

Analysis of the African American female nose

The African American nose has been broadly classified as ethnic yet it differs significantly in morphology from that of other ethnic groups with which it is categorized. The objectives of this study were to (1) establish an objective protocol for analysis of the African American female nose using anthropometric measurements, and (2) determine whether subjective subcategorization schemes are a reliable replacement for anthropometry. African American women (n = 107) between the ages of 18 and 30 years consented to participate in this study. Photographs and 14 standard anthropometric measurements were taken of the face and nasal region, including nose length, nose width, special upper face height, intercanthal distance, mouth width, nasal bridge inclination, nasal tip protrusion, ala thickness, nasal root width, nasal bridge length, tangential length of ala, length of columella, nasofrontal angle, and nasolabial angle. Nasal indices including nose width-nose height index, nasal tip protrusion-nose height index, and nasal tip protrusion-nasal width index were calculated. In addition, photographic analysis was performed to evaluate nostril shape, nasal base shape, and nasal dorsal height. Proportional relationships and subcategorization schemes were evaluated. A new method of nasal analysis for the African American woman uses the proportional relationships of the anthropometric measurements. Proportional relationships included a columellar to lobule ratio of 1.5:1, a nasolabial angle of 86 degrees, and an alar width to intercanthal distance ratio of 5:4. The nasal dorsal height classification scheme was the most reliable for subjective analysis. The degree of variability found within this group of young African American women is illustrated by the following indices and their respective ranges: nose width-nose height index mean, 79.7 (range, 57 to 102); nasal tip protrusion-nose height index mean, 33.8 (range, 23 to 46); and nasal tip protrusion-nose width index mean, 42.8 (range, 32 to 61). The guidelines provided are a baseline from which to begin analysis and evaluation.     

Nasal tip sutures part II: the interplays

The achievement of consistently superior results in rhinoplasty is rendered difficult in part by a number of complex interplays between the anatomical structures of the nose and the techniques used for their alteration, such as tip sutures. The effects of sutures depend largely on the magnitude of suture tightening, the intrinsic forces on the cartilages, cartilage thickness, and the degree of soft-tissue undermining. The tip complex is perhaps the most intricate of the nasal structures, exhibiting subtle but evident responses to manipulations of the lower lateral cartilages. The three-dimensional effects of nine suture techniques that are frequently used in nasal tip surgical procedures are discussed and illustrated. (1) The medial crura suture approximates the medial crura and strengthens the support of the tip. The suture also has effects that are less conspicuous immediately. There is slight narrowing of the columella, caudal protrusion of the lobule, and minimal caudal rotation of the lateral crura. (2) The middle crura suture approximates the most anterior portion of the medial crura. There is greater strengthening of the tip and some approximation of the domes with this suture. (3) The interdomal suture approximates the domes and can equalize asymmetric domes. However, the entire tip may shift to the short side if there is a significant difference in the heights of the domes because of short lateral and medial crura. (4) Transdomal sutures narrow the domal arch while pulling the lateral crura medially. The net results are increased tip projection, alar rim concavity, and the potential need for an alar rim graft. In addition, depending on suture position, cephalic or caudal rotation of the lateral crura may be observed. (5) The lateral crura suture increases the concavity of the lateral crura, reduces the interdomal distance, and may retract the alar rims. Perhaps the most significant inadvertent results of this suture are caudal rotation of the tip and elongation of the nose. This is important because patients who undergo rhinoplasty would often benefit from cephalic, rather than caudal, rotation of the tip. (6) The medial crura-septal suture not only increases tip projection but also rotates the tip cephalically and retracts the columella. (7) The tip rotation suture shifts the tip cephalad while retracting the columella. (8) The medial crura footplate suture approximates the footplates, narrows the columella base, and improves undesirable nostril shape. (9) The lateral crura convexity control suture alters the degree of convexity of the lateral crura. The nuances of these sutures and their multiplanar effects on the nasal tip are discussed.     

The hanging ala

The relationship of the alar rim to the columella can be altered during rhinoplasty. This may be especially true when a long nose has been shortened. In thin-skinned individuals, elevation of the ala may be accomplished by resection of the caudal aspect of the lateral crus without trimming the lining. In thick-skinned individuals, elevation of the ala may be accomplished by resection of the nasal lining at the cephalad border of the alar cartilage.     

A radical method of correcting the nasal deformity in adult patients with repaired unilateral lip clefts

A method of rhinoseptoplasty is described, which combines principles of several well-known procedures, with innovations introduced by the author, for the purpose of eliminating the causes of complex distortions of the lip, maxilla, and nose in unilateral clefts. This method aims at creating a secure support for the atrophic alar cartilage with a pedicled cartilage flap taken from the normal alar cartilage. Elevation of the dome and elongation of the columella on the cleft side are achieved by interdigitating mucocutaneous flaps. To improve symmetry and relieve nasal obstruction, the ala on the normal side is also corrected, as well as the deflected septal cartilage and the anterosuperior margin of the vomer.     

Cytochemical Localization of Phenolic Compounds in Columella Cells of the Root Cap in Seeds of Brassica napus--Changes in the Localization of Phenolic Compounds during Germination

Changes in the localization of phenolic compounds were investigatedin columella cells of embryonic roots in 1-year-old Brassicanapus seeds during 48 h of imbibition and germination. In dry,dormant seeds, phenolic compounds were located in the apoplasticcompartment between the cell wall and plasmalemma in the outermostlayer of the columella. These apoplastic phenolic deposits disappearedduring the activation processes associated with imbibition andgermination, but new deposits appeared successively in the nucleus,ER cisternae, protein bodies and on the outer surface of theroot cap. A large number of phenolic deposits were observedin the outermost part of the columella, becoming less frequenttowards the initial centre. Their appearance coincided withrestoration of the ER and immediately preceded cytological activation.After the primary root had emerged from the seed coat, depositsof phenolic compounds disappeared from the cytoplasm, but simultaneouslyappeared in the vacuoles. Copyright 1999 Annals of Botany Company Brassica napus var. oleifera, root columella, germination, phenolic compounds localization.