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     

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.     

The Pif1 Helicase,a Negative Regulator of Telomerase,Acts Preferentially at Long Telomeres

Telomerase, the enzyme that maintains telomeres, preferentially lengthens short telomeres. The S. cerevisiae Pif1 DNA helicase inhibits both telomerase-mediated telomere lengthening and de novo telomere addition at double strand breaks (DSB). Here, we report that the association of the telomerase subunits Est2 and Est1 at a DSB was increased in the absence of Pif1, as it is at telomeres, suggesting that Pif1 suppresses de novo telomere addition by removing telomerase from the break. To determine how the absence of Pif1 results in telomere lengthening, we used the single telomere extension assay (STEX), which monitors lengthening of individual telomeres in a single cell cycle. In the absence of Pif1, telomerase added significantly more telomeric DNA, an average of 72 nucleotides per telomere compared to the 45 nucleotides in wild type cells, and the fraction of telomeres lengthened increased almost four-fold. Using an inducible short telomere assay, Est2 and Est1 no longer bound preferentially to a short telomere in pif1 mutant cells while binding of Yku80, a telomere structural protein, was unaffected by the status of the PIF1 locus. Two experiments demonstrate that Pif1 binding is affected by telomere length: Pif1 (but not Yku80) -associated telomeres were 70 bps longer than bulk telomeres, and in the inducible short telomere assay, Pif1 bound better to wild type length telomeres than to short telomeres. Thus, preferential lengthening of short yeast telomeres is achieved in part by targeting the negative regulator Pif1 to long telomeres.     

An analysis, from photographs, of the results of four approaches to elongating the columella after repair of bilateral cleft lip.

A system for subjective and objective clinical analysis of the lower third of the nose before and after lengthening the columella was devised, and used the study of photographs of 77 patients who had had lengthening done by one of 4 approaches. It was found that each method was equally effective in lengthening the columella and in restoring a normal relationship between the structures in the tip of triangle (the basal view of the nose). However, there were certain peculiar advantages and disadvantages of each surgical technique, and these are discussed.     

Finite element modeling reveals complex strain mechanics in the aponeuroses of contracting skeletal muscle

A finite element model was used to investigate the counter-intuitive experimental observation that some regions of the aponeuroses of a loaded and contracting muscle may shorten rather than undergo an expected lengthening. The model confirms the experimental findings and suggests that pennation angle plays a significant role in determining whether regions of the aponeuroses stretch or shorten. A smaller pennation angles (25°) was accompanied by aponeurosis lengthening whereas a larger pennation angle (47°) was accompanied by mixed strain effects depending upon location along the length of the aponeurosis. This can be explained by the Poisson effect during muscle contraction and a Mohr’s circle analogy. Constant volume constraint requires that fiber cross sectional dimensions increase when a fiber shortens. The opposing influences of these two strains upon the aponeurosis combine in proportion to the pennation angle. Lower pennation angles emphasize the influence of fiber shortening upon the aponeurosis and thus favor aponeurosis compression, whereas higher pennation angles increase the influence of cross sectional changes and therefore favor aponeurosis stretch. The distance separating the aponeuroses was also found to depend upon pennation angle during simulated contractions. Smaller pennation angles favored increased aponeurosis separation larger pennation angles favored decreased separation. These findings caution that measures of the mechanical properties of aponeuroses in intact muscle may be affected by contributions from adjacent muscle fibers and that the influence of muscle fibers on aponeurosis strain will depend upon the fiber pennation angle.     

"Secondary stem lengthening" in the palm Iriartea deltoidea (Arecaceae) provides an efficient and novel method for height growth in a tree form

? Premise of the study: Although traditionally assumed that all height growth in trees occurs at apical meristems, sequential measurement of internode lengths in the palm Iriartea deltoidea suggested that stems were lengthening long after the differentiation of tissues and far below the apical meristem. This observation is difficult to reconcile with the fact that neither the water-conducting vessels nor the sugar-transporting sieve tube cells are capable of lengthening after differentiation. However, the vascular bundles in palms form a spiral within the stem and could theoretically lengthen if the spiral "straightened". ? Methods: We marked stretches of internodes on small and medium-sized palms and measured their lengths over 2 years. Additionally, we collected material from small palms with short internodes and large palms with long internodes and made cross sections to determine the angle of vascular bundles within stems. ? Key results: We found that stems lengthened (up to 12% over 2 years) below the apical meristem in small and medium-sized palms and that the spiral angle in vascular bundles of small palms was significantly larger than at the base of large palms indicating a straightening of the spiral. ? Conclusions: These results represent the first determination of "secondary lengthening" in tree stems as well as the most efficient method for height growth in terms of carbon investment. Likewise, elongation of stems allows palms to exhibit plasticity in height growth rates for more rapid growth when short-lived canopy gaps are present than they would have with apical growth alone.     

Variation of hamstrings lengths and velocities with walking speed

Crouch gait, one of the most prevalent movement abnormalities among children with cerebral palsy, is frequently treated with surgical lengthening of the hamstrings. To assist in surgical planning many clinical centers use musculoskeletal modeling to help determine if a patient’s hamstrings are shorter or lengthen more slowly than during unimpaired gait. However, some subjects with crouch gait walk slowly, and gait speed may affect peak hamstring lengths and lengthening velocities. The purpose of this study was to evaluate the effects of walking speed on hamstrings lengths and velocities in a group of unimpaired subjects over a large range of speeds and to determine if evaluating subjects with crouch gait using speed matched controls alters subjects’ characterization as having “short” or “slow” hamstrings. We examined 39 unimpaired subjects who walked at five different speeds. These subjects served as speed-matched controls for comparison to 74 subjects with cerebral palsy who walked in crouch gait. Our analysis revealed that peak hamstrings length and peak lengthening velocity in unimpaired subjects increased significantly with increasing walking speed. Fewer subjects with cerebral palsy were categorized as having hamstrings that were “short” (31/74) or “slow” (38/74) using a speed-matched control protocol compared to a non-speed-matched protocol (35/74 “short”, 47/74 “slow”). Evaluation of patients with cerebral palsy using speed-matched controls alters and may improve selection of patients for hamstrings lengthening procedures.     

Improvement of the "young" fatty neck

The properly selected relatively young patient with good skin tone and an obtuse cervicomental angle can be aesthetically improved through just a submental incision, combined with an extensive submandibular defatting and medial platysmoplasty.     

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.     

Short range stiffness elastic limit depends on joint velocity

Muscles behave as elastic springs during the initial strain phase, indicated as short range stiffness (SRS). Beyond a certain amount of strain the muscle demonstrates a more viscous behavior. The strain at which the muscle transits from elastic- to viscous-like behavior is called the elastic limit and is believed to be the result of breakage of cross-bridges between the contractile filaments. The aim of this study was to test whether the elastic limit, measured in vivo at the wrist joint, depended on the speed of lengthening. Brief extension rotations were imposed to the wrist joint (n=8) at four different speeds and at three different levels of voluntary torque using a servo controlled electrical motor. Using a recently published identification scheme, we quantified the elastic limit from measured joint angle and torque. The results showed that the elastic limit significantly increased with speed in a linear way, indicating to a constant time of approximately 30 ms before cross-bridges break. The implications for movement control of the joint are discussed.     

The lip lift

Attention is brought to a seldom-considered sign of aging--the lengthening of the upper lip. It is easily corrected by excising a wavy ellipse of lip skin and hiding the scar up under the nose. A vertical midline component may be added. The scars are minimal, and the results have been excellent in 83 patients.     

The telomere lengthening conundrum—artifact or biology?

Recent longitudinal studies of age-dependent leukocyte telomere length (LTL) attrition have reported that variable proportions of individuals experience LTL lengthening. Often, LTL lengthening has been taken at face value, and authors have speculated about the biological causation of this finding. Based on empirical data and theoretical considerations, we show that regardless of the method used to measure telomere length (Southern blot or quantitative polymerase chain reaction-based methods), measurement error of telomere length and duration of follow-up explain almost entirely the absence of age-dependent LTL attrition in longitudinal studies. We find that LTL lengthening is far less frequent in studies with long follow-up periods and those that used a high-precision Southern blot method (as compared with quantitative polymerase chain reaction determination, which is associated with larger laboratory error). We conclude that the LTL lengthening observed in longitudinal studies is predominantly, if not entirely, an artifact of measurement error, which is exacerbated by short follow-up periods. We offer specific suggestions for design of longitudinal studies of LTL attrition to diminish this artifact.     

Impaired neuromuscular function during isometric, shortening, and lengthening contractions after exercise-induced damage to elbow flexor muscles

The purpose of this study was to examine the effect of exercise-induced damage of the elbow flexor muscles on steady motor performance during isometric, shortening, and lengthening contractions. Ten healthy individuals (age 22+/-4 yr) performed four tasks with the elbow flexor muscles: a maximum voluntary contraction, a one repetition maximum (1 RM), an isometric task at three joint angles (short, intermediate, and long muscle lengths), and a constant-load task during slow (approximately 7 degrees/s) shortening and lengthening contractions. Task performance was quantified as the fluctuations in wrist acceleration (steadiness), and electromyography was obtained from the biceps and triceps brachii muscles at loads of 10, 20, and 40% of 1 RM. Tasks were performed before, immediately after, and 24 h after eccentric exercise that resulted in indicators of muscle damage. Maximum voluntary contraction force and 1-RM load declined by approximately 45% immediately after exercise and remained lower at 24 h ( approximately 30% decrease). Eccentric exercise resulted in reduced steadiness and increased biceps and triceps brachii electromyography for all tasks. For the isometric task, steadiness was impaired at the short compared with the long muscle length immediately after exercise (P<0.01). Furthermore, despite no differences before exercise, there was reduced steadiness for the shortening compared with the lengthening contractions after exercise (P=0.01), and steadiness remained impaired for shortening contractions 24 h later (P=0.01). These findings suggest that there are profound effects for the performance of these types of fine motor tasks when recovering from a bout of eccentric exercise.     

Cephalometric and anthropomorphic observations of Binder's syndrome: a study of 19 patients

Binder's syndrome (maxillonasal dysplasia) is a disorder characterized by nasomaxillary hypoplasia. To ascertain the extent of underdevelopment of the midfacial skeleton and soft tissues, 19 of 29 patients with Binder's syndrome were retrospectively evaluated, both with cephalometry and anthropometry. Ten females and nine males were placed collectively into three age groups: 6 years, 10 years, and 16 to 17 years. Cephalometric measurements disclosed a short anterior cranial base (S-N), a normal length of the vertical maxilla (SE-PNS), a decreased horizontal maxilla (PNS-A, Co-A), a recessed orbitale (SNO), and a high-normal mandibular length (Co-Gn). Anthropometry revealed a large nasofrontal angle, acute nasal inclination and nasolabial angle, decreased nasal prominence (Sn-Prn), a decreased columellar length (C-Sn), and a normal vertical nose (N-Sn) and upper lip (Sn-Sto) length.     

Conflicting effects of exercise on the establishment of a short-photoperiod phenotype in Syrian hamster

In the Syrian hamster, winter seasonal inhibition of reproduction occurs in response to decreasing day length. This inhibitory response is modulated by nonphotic cues. In particular, access to a running wheel has been shown to produce incomplete gonadal regression. The present study sought to determine whether this occurs as a consequence of wheel effect on adaptation of the circadian system to short days or whether downstream physiological responses are involved. Short-day adaptation of the circadian clock, which is located in the suprachiasmatic nucleus (SCN) of the hypothalamus, was tested by lengthening the photosensitive phase of the SCN (assayed by light-induced c-Fos expression in the SCN) as a parameter. We found that wheel-running activity does not inhibit the integration of the photoperiodic change by the SCN even if complete testicular regression is prevented. Moreover, this exercise was even capable of accelerating the lengthening of the photosensitive phase after the transfer to short day length. Thus, although wheel-running activity inhibits the short photoperiod-induced gonadal regression, it acts on the SCN to accelerate the integration of the photoperiodic change by the biological clock.     

Activation and aponeurosis morphology affect in vivo muscle tissue strains near the myotendinous junction

Hamstring strain injury is one of the most common injuries in athletes, particularly for sports that involve high speed running. The aims of this study were to determine whether muscle activation and internal morphology influence in vivo muscle behavior and strain injury susceptibility. We measured tissue displacement and strains in the hamstring muscle injured most often, the biceps femoris long head muscle (BFLH), using cine DENSE dynamic magnetic resonance imaging. Strain measurements were used to test whether strain magnitudes are (i) larger during active lengthening than during passive lengthening and (ii) larger for subjects with a relatively narrow proximal aponeurosis than a wide proximal aponeurosis. Displacement color maps showed higher tissue displacement with increasing lateral distance from the proximal aponeurosis for both active lengthening and passive lengthening, and higher tissue displacement for active lengthening than passive lengthening. First principal strain magnitudes were averaged in a 1cm region near the myotendinous junction, where injury is most frequently observed. It was found that strains are significantly larger during active lengthening (0.19 SD 0.09) than passive lengthening (0.13 SD 0.06) (p<0.05), which suggests that elevated localized strains may be a mechanism for increased injury risk during active as opposed to passive lengthening. First principal strains were higher for subjects with a relatively narrow aponeurosis width (0.26 SD 0.15) than wide (0.14 SD 0.04) (p<0.05). This result suggests that athletes who have BFLH muscles with narrow proximal aponeuroses may have an increased risk for BFLH strain injuries.     

Residual force enhancement during submaximal and maximal effort contractions of the plantar flexors across knee angle

Following active muscle lengthening, steady-state isometric force is elevated compared with an isometric contraction without prior lengthening for the same muscle length and activation level. This property of muscle contraction is known as residual force enhancement (RFE). Here, we aimed to determine whether neural factors may mask some of the mechanical benefits of RFE on plantar flexion torque production. Inherent to lengthening contractions is an increase in cortical and spinal-mediated inhibition, while knee flexion places the medial gastrocnemius at a neuromechanical disadvantage. Neuromuscular properties of the plantar flexors were investigated with a Humac Norm dynamometer in 10 males (∼27 years) with a flexed (90°) and extended (180°) knee and with or without calcaneal tendon vibration (frequency range: 80–110 Hz). There was no effect for vibration (p > 0.05), but there was an effect for knee angle (p < 0.05) such that there was a 2 fold increase in RFE with the knee flexed compared with extended. During submaximal torque matching, following active lengthening there was an activation reduction (electromyography; EMG) of 7.2 and 4.7% with the knee flexed and extended, respectively for soleus as compared with the reference isometric contraction, but no difference for the medial gastrocnemius. Despite attempting to excite Ia input onto the plantar flexor motor neuron pool, vibration had no influence on RFE. Surprisingly, RFE was elevated more for the knee flexed than extended, which was possibly owing to the activation differences across the disparate muscles of the triceps surae during the plantar flexion task.     

CO bond angle changes in photolysis of carboxymyoglobin

Previous studies [Chance, B., Fischetti, B., & Powers, L. (1983) Biochemistry 22, 3820-3829] of the local structure changes around the iron in carboxymyoglobin on photolysis at 4 K revealed that the iron-carbon distance increased approximately 0.05 A but was accompanied by a lengthening of the iron-pyrrole nitrogen bonds of the heme (approximately 0.03 A) that was not as large as that found in the deoxy form. Further analysis of these data together with comparison to model compounds indicates that the Fe-C-O bond angle in carboxymyoglobin is bent (127 +/- 4 degrees), having a structure identical, within the error, with the "pocket" porphyrin model compound FePocPiv(1-MeIm)(CO) [Collman, J. P., Brauman, J. I., Collins, T. J., Iverson, B. L., Lang, G., Pettman, R., Sessler, J. L., & Walters, M. A. (1983) J. Am. Chem Soc. 105, 3038-3052]. On photolysis, this angle decreases by 5-10 degrees. In addition, correlation is observed between the increase in the length of the Fe-C bond and the decrease of the Fe-C-O angle. These results suggest that the rate-limiting step in recombination is the thermal motion of CO in the pocket to achieve an appropriate bonding angle with respect to the iron. These changes constitute the first molecular picture of the photolysis process, as well as the structure of the geminate state, and are important in clarifying nuclear tunneling parameters.     

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.     

Cortical and Spinal Excitability during and after Lengthening Contractions of the Human Plantar Flexor Muscles Performed with Maximal Voluntary Effort

This study was designed to investigate the sites of potential specific modulations in the neural control of lengthening and subsequent isometric maximal voluntary contractions (MVCs) versus purely isometric MVCs of the plantar flexor muscles, when there is enhanced torque during and following stretch. Ankle joint torque during maximum voluntary plantar flexion was measured by a dynamometer when subjects (n = 10) lay prone on a bench with the right ankle tightly strapped to a foot-plate. Neural control was analysed by comparing soleus motor responses to electrical nerve stimulation (M-wave, V-wave), electrical stimulation of the cervicomedullary junction (CMEP) and transcranial magnetic stimulation of the motor cortex (MEP). Enhanced torque of 17±8% and 9±8% was found during and 2.5–3 s after lengthening MVCs, respectively. Cortical and spinal responsiveness was similar to that in isometric conditions during the lengthening MVCs, as shown by unchanged MEPs, CMEPs and V-waves, suggesting that the major voluntary motor pathways are not subject to substantial inhibition. Following the lengthening MVCs, enhanced torque was accompanied by larger MEPs (p≤0.05) and a trend to greater V-waves (p≤0.1). In combination with stable CMEPs, increased MEPs suggest an increase in cortical excitability, and enlarged V-waves indicate greater motoneuronal output or increased stretch reflex excitability. The new results illustrate that neuromotor pathways are altered after lengthening MVCs suggesting that the underlying mechanisms of the enhanced torque are not purely mechanical in nature.