Ali Teoman Tellioglu

Temporoparietal fascia : An anatomic and histologic reinvestigation with new potential clinical applications

Temporoparietal fascia constitutes a very important structural unit from both an aesthetic and a reconstructive surgical point of view. A histologically supported anatomic study was conducted for the reappraisal of the anatomic relationships and clinical application potentials of the data obtained. Anatomy of the temporoparietal fascia was investigated on 20 sides from 10 cadavers. After dissections, necropsies were obtained to demonstrate histologic features of the temporoparietal fascia. The outer part of the temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) in the inferior border and with orbicularis oculi and frontalis muscles in the anterior border. Therefore, plication of the temporoparietal fascia can increase tightness of the SMAS, orbicularis oculi, and frontalis muscle in rhytidectomy. The frontal branches of facial nerve were noted to course parallel to the frontal branch of the superficial temporal artery, lying deeper to the temporoparietal fascia within the innominate fascia. In the view of these findings, conventional subfascial dissection, which is performed to protect frontal branches of the facial nerve, is not reasonable during the temporal part of rhytidectomy. Careful subcutaneous dissection just under the hair follicles is more appropriate to avoid nerve injury and also provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy with protection of the auriculotemporal nerve and the superficial temporal vessels. Furthermore, two layered structures of the temporoparietal fascia are very suitable to insert a framework into the temporoparietal fascia for ear reconstruction to eliminate some of the shortcomings of Brents technique. A thin muscle layer was also noted within the outer part of the temporoparietal fascia below the temporal line; the term “temporoparietal myofascial flap” would, therefore, be more accurate than “temporoparietal fascial flap.” Finally, the innominate fascia and the deep temporal fascia can be elevated with the two layers of the temporoparietal myofascial flap to obtain a well‐vascularized, four‐layered myofascial flap based on the superficial temporal vessels. This multilayered flap can be used to reconstruct all defects when fine, pliable, thin, multilayered flaps are required. (Plast. Reconstr. Surg. 105: 40, 2000.)

Turn-in Folding of the Cephalic Portion of the Lateral Crus to Support the Alar Rim in Rhinoplasty

BackgroundsThe hypoplastic, weak lateral crus of the nose may cause concave alar rim deformity, and in severe cases, even alar rim collapse. These deformities may lead to both aesthetic disfigurement and functional impairment of the nose.MethodsThe cephalic part of the lateral crus was folded and fixed to reinforce the lateral crus. The study included 17 women and 15 men with a median age of 24 years. The average follow-up period was 12 months. For 23 patients, the described technique was used to treat concave alar rim deformity, whereas for 5 patients, who had thick and sebaceous skin, it was used to prevent weakness of the alar rim. The remaining 4 patients underwent surgery for correction of a collapsed alar valve.ResultsSatisfactory results were achieved without any complications.ConclusionsTurn-in folding of the cephalic portion of lateral crus not only functionally supports the lateral crus, but also provides aesthetic improvement of the nasal tip as successfully as cephalic excision of the lateral crura.

The effect of carnitine on random-pattern flap survival in rats.

Carnitine is an endogenous cofactor involved in the transport of long-chain fatty acids into the mitochondria where they undergo beta-oxidation. Through another reaction, carnitine produces free coenzyme A and reduces the ratio of acetyl-coenzyme A to coenzyme A, thereby enhancing oxidative use of glucose, augmenting adenosine triphosphate synthesis, and reducing lactate production and acidosis. Because of its regulatory action on the energy flow from the different oxidative sources, especially under ischemic conditions, carnitine has been used in cardiovascular diseases such as coronary heart disease, congestive heart failure, peripheral vascular disease, dyslipidemia, diabetes, and chronic renal diseases with satisfactory results. A flap is also a relatively ischemic tissue and may obtain benefit from carnitine. To investigate this, 30 rats were divided into three groups of 10 animals: a control group and two carnitine-treated groups. Random dorsal skin flaps were elevated on the rats. In the control group, no pharmacologic agents were used. Of the two treated groups, group 1 was treated with 50 mg/kg/day carnitine for 1 week and group 2 was treated with 100 mg/kg/day carnitine for 1 week. The areas of flap necrosis were measured in each group. The median areas of flap necrosis of the groups were 12.55, 9.23, and 4.9 cm2, respectively. There was a statistically significant improvement of flap necrosis in carnitine-treated groups compared with the control group (group 2, p = 0.001; group 3, p = 0.000). Furthermore, there was less necrosis in the high-dose carnitine-treated group than the low-dose carnitine-treated group. As a conclusion, carnitine may have a dose-dependent effect to increase flap survival in random skin flaps.

Frontalis sling operation with deep temporal fascial graft in blepharoptosis repair.

Of the many techniques for the treatment of blepharoptosis, the decision regarding the proper technique depends on the functional capacity of the levator muscle and the severity of ptosis. For poor-to-absent levator muscle function and severe ptosis, the frontalis sling technique is suitable for treatment. The frontalis muscle is used to achieve sufficient opening for palpebral fissure. The many materials used for the frontalis sling include catgut, collagen, fascia lata, Prolene, silicone, stainless steel, sclera, tantalum, Supramid, and tendons.1 The deep temporal fascia has been successfully used as a graft material in plastic and reconstructive surgery with minimal donor-site morbidity. We present our experience with the deep temporal fascia for the frontalis sling in ptosis repair.

Computed Tomographic Evaluation Before Cranial Bone Harvesting to Avoid Unexpected Hazards During Aesthetic Procedures

Abstract. Nowadays, cranium is the preferred bone-graft donor site for facial aesthetic operations. Preoperative information about the quality of cranial bone, such as bone thickness or presence of the diplopic space, can be useful to minimize intracranial complications. This fact is neglected in reconstructive and aesthetic surgery. The aim of this study is to assess the reliability of Computed Tomography (CT) to determine cranial bone quality. Sixty-four cadaver parietal bones, the preferred site for bone-graft harvesting, were used in this study. In the first stage, posterior parietal bone thickness, which is accepted as the thickest part of cranium, was measured at specially determined points using a micrometer and the results were recorded. Bone thickness was then measured again in the same points with CT. The two methods were compared statistically. The measurements were not found to be statistically different. The similar values obtained with CT and micrometers suggest that CT can accurately and reliably determine cranial thickness. Preoperative CT can be a significant guide for the harvest of cranial bone grafts without any intracranial complications in aesthetic surgery.

Cartilage Z plasty on lateral crus for treatment of alar cartilage malposition

BACKGROUND Alar cartilage malposition is an anatomical variation. Axis of the lateral crus lies cephalically and can be parallel to the cephalic septum. The characterised findings of the malposition are broad and bulbous nasal tip, abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities and associated external valvular incompetence. This article presents a new technique for the repositioning of the lateral crus in this article. METHODS Open rhinoplasty was conducted. A cartilage Z plasty was performed on the lateral crus of the alar cartilage to treat for malposition. The 14 women and 8 men included in the study had an average age of 27 years (range, 18-46 years). The average follow-up period was 12 months (range, 4-20 months). RESULTS Alar cartilage malposition was successfully corrected in patients with aesthetic and functional improvements. CONCLUSIONS Cartilage Z plasty can effectively correct alar cartilage malposition. Advantages of this technique can be listed as follows: it does not require extra graft material and protects the lateral crural complex; it does not disrupt movements of the alar muscles and can also serve to adjust projection of the nasal tip.

Training model for microvascular anastomosis.

A cadaver model was used for microvascular training as nonviable biologic model. Twenty-four fixed and 2 fresh adult cadavers were used for microvascular training. The radial artery, ulnar artery, and cephalic vein of the forearm were preferred. Respectively, end-to-end, end-to-side, and end-on-side microanastomosis techniques were performed. A cadaver model has several advantages over other training models. There are numberless vessels to perform different techniques for microvascular anastomoses. Several students can simultaneously work on the same cadaver at the same time. In addition, there is the opportunity of working on vessels of different sizes and diameters. The same conditions on the cadaver can be created before operation, and effective presurgical microvascular practice can be performed. A free-flap dissection can be easily performed to get experience before clinical operations. Furthermore, it may be combined with live animal models.

Simultaneous Open Rhinoplasty and Alar Base Excision for Secondary Cases

Background: Simultaneous open rhinoplasty and alar base excision are a very safe procedure for protecting the vascular supply of the nasal dip and the columellar skin in primary cases when surgical dissection is performed below the musculoaponeurotic layer of the nose. Major arteries of the external nose lie above the musculoaponeurotic layer. However, secondary cases may pose increased risks to the blood supply of the nasal tip and columella skin because of the decreased vascular supply and increased scar tissue from the previous rhinoplasty. We studied our secondary cases of simultaneous open rhinoplasty and alar base excision, to assess the real risk for necrosis of the nasal tip and columellar skin.Methods: A total of 12 secondary patients (6 men and 6 women) underwent simultaneous open rhinoplasty and alar base excision in the past 3 years. Their average age was 27 years (range, 21–35 years). The average follow-up period was 15 months (range, 1–35 moths). A modified grading system, originally described by Bafaqeeh and Al-Qattan, was used for assessment of the blood supply in the nasal tip and the columellar skin.Results:Satisfactory results were obtained for our patients, with the exception of one case. Grade 3 vascular compromise to the nasal tip and the columella was observed in one case, but the patient healed well with wound care treatment.Conclusion:Simultaneous alar base excision and open rhinoplasty can be performed safely in secondary cases. However some surgical maneuvers such as subcutaneous pocket preparation for the tip graft in closed rhinoplasty and subdermal defatting in the first rhinoplasty as well as previous scarring on the nasal lobule can disrupt the vascular supply of the nasal tip and columella skin. Under these conditions, alar base excision should be deferred and then performed as an isolated excision procedure.

Treatment of hyperdynamic nasal tip ptosis in open rhinoplasty: using the anatomic relationship between the depressor septi nasi muscle and the dermocartilaginous ligament.

BackgroundSmiling causes a deformity in some rhinoplasty patients that includes drooping of the nasal tip, elevation and shortening of the upper lip, and increased maxillary gingival show. The depressor septi muscle leads this deformity. The dermocartilaginous ligament originates from the fascia of the upper third of the nose and extends down to the medial crus, merging into the depressor septi muscle.MethodsIn this study, 100 primary rhinoplasty patients were studied for hyperdynamic nasal tip ptosis. Of these patients, 36 had hyperdynamic nasal tip ptosis due to hyperactive depressor septi nasi muscle. The dermocartilaginous ligament was used as a guide to reach the depressor septi muscle in open rhinoplasty. Muscle excision was performed just below the footplates of the medial crura. A strong columellar strut graft was placed between the medial crura to avoid narrowing of the columellar width resulting from tissue excision and to withstand activation of depressor septi muscle remnants.ResultsNo complications such as infection or hematoma occurred in the early postoperative period. The technique corrected the hyperdynamic nasal tip ptosis, increased upper lip length, and decreased gingival show when patients smiled. There was no narrowing of the columellar width. No depression in the columellar–labial junction due to distal resection of the depressor septi muscle was observed.ConclusionThe dermocartilaginous ligament can be used as a reliable guide to reach the depressor septi muscle in open rhinoplasty. Therefore, the hyperactive depressor septi muscle can be definitively identified and treated without an intraoral approach.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

A case of syngnathia, cleft palate and hypospadias: An isolated case or syndromic syngnathism?

Syngnathia occurs when an ectopic membrane forms a fibrous or bony adhesion between the maxillary and mandibular alveolar processes. A case of congenital syngnathia is presented.