Anil R. Shah

Quantitative Comparison Between Microperforating Osteotomies and Continuous Lateral Osteotomies in Rhinoplasty

OBJECTIVE To determine the difference in nasal bone narrowing between 2 techniques: the low lateral intranasal perforating osteotomy technique and the low lateral continuous osteotomy technique. METHODS A retrospective analysis of preoperative and postoperative photographs to determine the changes of the dorsal width of the nose (width of plateau of the nose, or dorsal nasal highlight) and the ventral width (junction of the flattened surface of the maxilla and the ascending nasal process of the maxilla). RESULTS Twenty patients underwent continuous osteotomies, and 40 underwent intranasal perforating osteotomies. The continuous osteotomy technique had a preoperative to postoperative decrease in the ventral width of 7.0% (P < .01). The perforating osteotomy technique had a decrease in the ventral width of 3.6% (P < .001). Neither technique resulted in a statistically significant change in dorsal width (P < .25). There was no significant difference in ventral and dorsal narrowing when comparing continuous osteotomies to perforating. CONCLUSIONS Both the continuous and perforating osteotomy technique resulted in a decrease in the ventral nasal bone width. No statistical difference was found between continuous and perforating osteotomy techniques in the amount of nasal bone narrowing (P < .25).

Defining the facial extent of the platysma muscle: a review of 71 consecutive face-lifts.

OBJECTIVE To delineate the superior (facial) extent of the platysma muscle. METHODS A total of 142 facial halves were examined from 71 consecutive deep-plane rhytidectomies performed over a period of 3 months. The platysma muscle was identified and isolated during the procedure. The superior extent of the platysma was measured along the line created by the angle of the mandible to the malar eminence, also known as the malar mandibular line. RESULTS On average, the platysma extended 3.98 cm along the malar mandibular line, superiorly from the inferior border of the mandible. The platysma was located 3.09 cm inferiorly from the malar eminence along the malar mandibular line. On average, the platysma muscle occupied 56% of the malar mandibular line. CONCLUSION The platysma muscle may have a more significant facial extension than previously described.

Alar Retraction Etiology, Treatment, and Prevention

IMPORTANCE The effect of different rhinoplasty maneuvers on alar retraction remains to be elucidated. OBJECTIVE To determine the etiology and treatment of alar retraction based on a series of specific rhinoplasty maneuvers. DESIGN Retrospective review of a single surgeons rhinoplasty digital photo database, examining preoperative alar retraction from January 1, 2002, to December 31, 2005, in 520 patients. Patients with more than 1 mm of alar retraction on preoperative photographs were identified. Postoperative photographs were examined to determine the effect of specific rhinoplasty maneuvers on the position of the alar margin; these maneuvers included cephalic trim, cephalic positioning of the lower lateral cartilage, composite grafts, alar rim grafts, alar batten grafts, and overlay of the lower lateral cartilage. SETTING Tertiary care academic health center. PARTICIPANTS Forty-five patients with alar retraction met inclusion criteria, resulting in 63 nasal halves with alar retraction. MAIN OUTCOMES AND MEASURES Intraoperative findings, postoperative results. RESULTS Forty-seven percent of the patients (n = 21) had prior surgery; 47% also had cephalically positioned lower lateral cartilages. Among patients with less than 4 mm of cartilage width at the outset, 46% of those who received supportive grafts achieved target correction vs only 7% for patients who did not undergo supportive cartilage grafting. In patients who underwent more than 4 mm of cephalic trim, those who received supportive grafts achieved 46% of target correction vs 11% among those who did not. Ninety-five percent of composite grafts, 69% of alar strut grafts, 47% of alar rim grafts, 43% of vertical lobule division, and 12% of alar batten grafts achieved their target correction values. CONCLUSIONS AND RELEVANCE Alar retraction is a highly complex problem. It can be seen de novo and is associated with cephalically positioned lower lateral cartilages. Structurally supportive grafting-including composite grafts, alar strut grafts, alar rim grafts, vertical lobule division, and alar batten grafts-can improve alar retraction. LEVEL OF EVIDENCE 4.

Analysis of Vector Alignment With the Zitelli Bilobed Flap for Nasal Defect Repair A Comparison of Flap Dynamics in Human Cadavers

OBJECTIVE To determine whether differences of angles between the alar rim and the long axis of the secondary defect in a Zitelli bilobed flap affect alar displacement in a fresh cadaver model. METHODS In fresh cadaver heads, identical, unilateral 1-cm circular defects were created at the superior alar margin. Three different laterally based bilobed flap templates for reconstruction were used. One template, used on 3 cadavers, had an angle of 60 degrees between the alar rim and the long axis of the secondary defect. Another template, used on 3 cadavers, had an angle of 90 degrees . The last template had an angle of 135 degrees and was used on 2 cadavers. Photographs were taken before the repair and after with the camera and cadaver heads in the same spatial relationship to each other. RESULTS In the 3 cadavers that had repair using an angle of 60 degrees , all cadavers experienced alar retraction, with a mean displacement of 1.3 mm. This was not a statistically significant change (P = .07). In the defects that had repair using an angle of 90 degrees , there was also no significant alar displacement (P = .72). In the 2 cadavers that underwent repair using an angle of 135 degrees , both ala underwent depression by 1.0 mm. When the differences achieved between the different angles were compared, there was a significant difference in measured distortion between the cadavers that had 90 degrees and 60 degrees vector placement (P = .02). There were no measurable changes to the contralateral maximal nostril distance. CONCLUSIONS Vector alignment can have an impact on nostril displacement. In bilobed flaps, the axis of the secondary defect may play an important role. This study suggests that secondary defects aligned perpendicular to the nostril have the least amount of alar distortion.

Cervical lipoblastoma: an uncommon diagnosis of neck mass.

ASE REPORTS ase 1 A 1-year-old girl presented with a 2-week istory of an enlarging left neck mass. The atient had no history of fever, hoarseness, dyshagia, or airway compromise. Her past medical istory was unremarkable with the exception of grade 2/6 functional systolic murmur. Physical xamination demonstrated a soft and compressble mass in the left posterior triangle measuring pproximately 6 5 cm (Fig 1). The mass was ontender to palpation and mobile, and the overying skin was not cellulitic. Computed tomogaphy (CT) scan with contrast revealed a nonnhancing mass with a radiolucent density in upraclavicular region extending toward the meiastinum. The mass was excised through a trancervical approach. The actual mass, when exised, measured 7 10 cm. It was adherent to he subclavian vessels but was successfully disected free with preservation of the sternocleiomastoid muscle, the internal jugular vein, and he accessory nerve. The mass was a cystic but ultilobulated soft tissue tumor.