Craig L. Cupp

The septum in rhinoplasty.

Recognition and correction of septal abnormalities in rhinoplastic surgery has been a constant evolution aided by the development of an in depth anatomic understanding of the nose and the refinement of techniques based on the pertinent anatomy. Whether the deformity presents a functional, aesthetic, or combined problem, the authors prefer a single stage technique that separates the structural components of the nose, isolating the deformities present, and then reconstructing the components to effect a desirable result in terms of airway and appearance. Although no two nasal surgeries are identical, there are characteristic deformities that are noted to be generally more problematic. We briefly review normal septal anatomy as it pertains to the septorhinoplasty operation and then discuss our approach to specific septal variations that we have found to have a significant impact with regard to achieving satisfactory functional and aesthetic results.

The percutaneous columellar strut.

Background Understanding tip support mechanisms is essential for nasal surgery, especially for preservation or augmentation of tip projection. Methods Support of the nasal tip often is improved by the use of struts placed between the medial crura. The percutaneous columellar strut is a technique that provides additional tip support during septoplasty and closed rhinoplasty. The strut is placed via a small vertical columellar incision. Results The advantage of easy and simple insertion outweighs the minor potential disadvantage of a small, visible vertical columellar scar. It is useful in addressing tip ptosis when trauma, surgery, or aging has reduced the contribution of the septum to tip support. Conclusion A detailed description of the percutaneous columellar strut technique and results of its application are presented.

Effects of activated macrophages and fibroblast growth factor on random skin flap survival in swine

Objective: To examine the effect of application of activated autologous macrophages and basic fibro‐blast growth factor (FGF) on random skin flap survival in swine. Design: A randomized nonblinded controlled trial. According to a standard design, six dorsally based, random‐pattern skin flaps were raised in each of 12 Yorkshire pigs. Methods: Twenty‐five milliliters of blood is harvested from each animal 20 to 24 hours prior to flap creation. Monocytes are isolated, placed in culture medium, and then activated by the addition of platelet‐derived growth factor (PDGF) and tissue growth factor beta (TGF‐β). Following an 18‐hour incubation period, the monocytes are decanted and quantified, and their viability confirmed. These cells are then infused into the wound bed of the treatment flaps immediately following flap creation, and FGF is added prior to flap closure. The position of treatment and control flaps is systematically varied with regard to anterior‐to‐posterior and side‐to‐side flap positions within each animal. The area of superficial flap necrosis is evaluated on postoperative day 7, digitally scanned, and analyzed using graphics software. Control flaps are elevated similarly, but receive no placebo treatment. Results: Two‐way analysis of variance (ANOVA) demonstrated nonsignificant differences between pig side and anterior, middle, and posterior flap positions within treatment and control flap groups. Using side and position pooled data, a one‐way ANOVA showed no statistically significant differences between treatment and control flaps. Conclusions: The cellular and biochemical events following creation of a surgical wound are complex and incompletely understood. Our attempt to augment the natural role of the macrophage in wound healing by employing cytokines to activate these cells and to accelerate their arrival by implanting them into the wound bed failed to enhance flap survival. Further study is warranted to ascertain the details of wound healing, particularly with respect to cytokine concentrations and the timing of their roles, if we are to find a clinically applicable means of enhancing flap survival.

Utilizing topical therapies and mitomycin to reduce scars.

Minimizing scar size, width, and contour of elevation is a common goal for the facial plastic surgeon. Various standard techniques are employed to reduce tension and enhance the rapid and uneventful healing of incisions. In some cases, these routine measures are not judged to be adequate, and additional intraoperative and postsurgical measures are employed to control the bodys innate healing processes. Mitomycin C and self-drying silicone gel have been particularity useful in our practice.

The Effects of Macrophages on the Survival of Random Skin Flaps in Swine

Tissue macrophages play a critical role in neovascularization by releasing angiogenic cytokines. Macrophages normally arrive into a wound bed 48 to 96 hours following an injury. 1 Introducing macrophages into a wound bed at the time of closure would theoretically stimulate neovascularization in the traumatized tissue prior to what is normally observed. The ability to promote early angiogenesis could be an important factor in the survival of an extended skin flap.

Tonsillectomy in the anticoagulated patient.

Objectives: The objectives of this study were to review perioperative bridging strategies for anticoagulated patients and to describe a novel bridging strategy for tonsillectomy in an anticoagulated patient that addresses both primary and secondary hemorrhage risks. Methods: A literature review and a case report are presented. PubMed was reviewed for evidence-based recommendations on perioperative management of anticoagulated patients. A case report is detailed of a 28-year-old woman with antiphospholipid syndrome on warfarin for high risk of venous thrombosis who underwent tonsillectomy. A perioperative bridging strategy incorporating outpatient low–molecular weight heparin and inpatient unfractionated heparin was implemented to minimize risks of thrombosis and primary and secondary posttonsillectomy hemorrhage. Results: Limited evidence supports a consensus on the best perioperative management of anticoagulated patients. Tonsillectomy in an anticoagulated patient has not been described previously. The patient in this case underwent successful tonsillectomy with no thrombosis or bleeding after 1 month of follow-up. Conclusions: Tonsillectomy can be done relatively safely in an anticoagulated patient at high risk for thrombosis. The perioperative bridging strategy should account for its unique risk of primary and secondary postoperative hemorrhage. A proposed algorithm for managing these competing risks is presented.