Craig S. Murakami

Clinical consensus statement: Diagnosis and management of nasal valve compromise

Objective: To create a clinical consensus statement to address ambiguities and disparities in the diagnosis and management of nasal valve compromise (NVC). Subjects and Methods: An updated systematic review of the literature was conducted. In addition, a Modified Delphi Method was used to refine expert opinion and facilitate a consensus position. Results: After two rounds of surveys and conference calls, 36 items reached consensus, six items reached near consensus, and 10 items reached no consensus. The categories that had the greatest percentage of consensus or near consensus items were as follows: definition, history and physical examination, outcome measures, and management. Conversely, the categories with greater percentage of no consensus items were adjunctive tests and coding. Conclusion: The consensus panel agreed that NVC is a distinct clinical entity that is best evaluated with history and physical examination findings. Endoscopy and photography are useful but not routinely indicated, whereas radiographic studies are not useful in evaluating NVC. Other objective nasal outcome measures may not be useful or accepted for NVC. Nasal steroid medication is not useful for treatment of NVC in the absence of rhinitis, and mechanical treatments may be useful in selected patients. Surgical treatment is the primary mode of treatment of NVC, but bill coding remains ambiguous and confusing.

Necrotizing fasciitis of the eyelids

Necrotizing fasciitis is a destructive soft tissue infection that rarely involves the eyelids. Three cases of necrotizing fasciitis of the eyelids are described. Necrotizing fasciitis was preceded by minor forehead soft tissue trauma in two cases and occurred spontaneously in one. In two patients necrotizing fasciitis was bilateral and involved both the upper and lower eyelids. Review of these cases, in addition to 18 cases previously reported in the English literature, reveals a predominance in females, preceding minor local soft tissue trauma, frequent bilateral involvement, and an association with alcohol abuse and diabetes. In all of the patients, group A β-hemolytic streptococci were cultured from the wound. Early recognition of the disease process, prompt surgical debridement of the necrotic tissue, aggressive antimicrobial therapy, and delayed skin grafting combine to minimize morbidity.

Preserving Structural Integrity of the Alar Cartilage in Aesthetic Rhinoplasty Using a Cephalic Turn-in Flap

Resection of the alar cartilage has long been a mainstay of aesthetic rhinoplasty. One drawback of this technique is the destabilization of the ala/lateral nasal wall complex. Herein we describe the cephalic turn-in flap, a technique for reinforcement of the alar cartilage after removal of its cephalic portion.

Mandibular reconstruction with transforming growth factor-β1

Hypothesis: Transforming growth factor‐β1 (TGF‐β1) plus demineralized bone matrix (DBM) will reconstruct a critical mandibular defect devoid of periosteum in a canine model.

Pediatric nasal injuries and management.

Although serious trauma injuries are uncommon in the pediatric population, nasal injuries are a more common problem. In this population, many physicians are uncomfortable managing these injuries. The evaluation and treatment of nasal trauma differ considerably in children compared with adult nasal fractures. Poor patient cooperation during the physical exam coupled with significant anatomic differences can present the nasal surgeon with a difficult diagnostic dilemma. The surgical management of pediatric nasoseptal injuries is not without controversy, as disturbing the nasal growth centers can have significant effect on future nasal and midfacial development. This article reviews the diagnostic and therapeutic challenges presented by these injuries for children and provides recommendations to successfully manage nasal injuries in this population.

Treatment of Prominent Ears and Otoplasty: A Contemporary Review

Prominent ears affect approximately 5% of the population and can have a significant psychological impact on patients. A wide variety of otoplasty techniques have been described, all sharing the goal of re-creating the normal appearance of the ear and achieving symmetry between the 2 sides. Recent trends in otoplasty techniques have consistently moved toward less invasive options, ranging from nonsurgical newborn ear molding to cartilage-sparing surgical techniques and even incisionless, office-based procedures. Herein, we review anatomy of the external ear, patient evaluation, the evolution of nonsurgical and surgical otoplasty techniques, otoplasty outcomes, and future trends for treatment of prominent ears.

Computer-Aided Design and 3D Printing to Produce a Costal Cartilage Model for Simulation of Auricular Reconstruction.

M icrotia, or underdevelopment of the auricle, affects approximately 0.03% of live births. Carving an auricular cartilage framework from autogenous cartilage—the most common technique for auricular reconstruction—is one of the most challenging skills for the reconstructive surgeon to learn. Given the potential morbidity associated with technical errors in framework carving, opportunities for acquisition of this skill are limited. It is critical for surgeons to be able to practice their carving skills. This presents an opportunity for surgical simulation. Materials previously used for simulation of auricular framework carving include carrots, potatoes, porcine/bovine/human cadaveric costal cartilage, and dental impression material. These materials poorly represent the geometry, texture, and size of the harvested costal cartilage presented to the reconstructive surgeon. There is a commercially available model (Medicon, Tuttlingen, Germany) that is based on adult rib and is costly. To better represent pediatric rib geometry and texture, techniques were developed to produce negative molds from harvested pediatric rib cartilage. While these methods are an improvement on the simulation of shape and size, questions remained on the similarity of the material to costal cartilage. In this report, we aim to use computer-aided design and 3dimensional (3D) printing to create a representative pediatric costal cartilage model for simulation of auricular framework reconstruction. Furthermore, with computed tomography scan data, the potential for patient-specific simulation is introduced, allowing for surgical planning.

The extended Abbe flap

Large upper lip defects that include the surrounding aesthetic subunits of the midface are difficult to reconstruct. Abbé flaps have been a popular method of dealing with small upper lip defects but, as classically described, they are insufficient for larger defects. We performed cadaver injections to evaluate the vascular territory supplied by the inferior labial artery with particular attention to the submental area. Extended Abbé flaps were then designed and used in combined upper lip and midfacial reconstruction. Three cases and guidelines for the use of the extended Abbé flap are presented.

Autologous Costochondral Microtia Reconstruction.

Reconstruction with autologous costochondral cartilage is one of the mainstays of surgical management of congenital microtia. We review the literature, present our current technique for microtia reconstruction with autologous costochondral graft, and discuss the evolution of our technique over the past 20 years. We aim to minimize donor site morbidity and create the most durable and natural appearing ear possible using a stacked framework to augment the antihelical fold and antitragal-tragal complex. Assessment of outcomes is challenging due to the paucity of available objective measures with which to evaluate aesthetic outcomes. Various instruments are used to assess outcomes, but none is universally accepted as the standard. The challenges we continue to face are humbling, but ongoing work on tissue engineering, application of 3D models, and use of validated questionnaires can help us get closer to achieving a maximal aesthetic outcome.

Nasal osteotomies: anatomy, planning, and technique

The human nose is believed to have developed characteristics that distinguish it from the anatomy of other hominids with the emergence of Homo erectus 1.6 million years ago. These distinguishing features include the projection of the external nose, the relationship of the piriform aperture to the nasal bones, and the prominence of the nasal spine [1]. It is proposed that these features developed in response to the need for moisture conservation as activity of the genus Homo shifted to more open and arid environments [1]. Of course, most patients care little about the history of nasal evolution when requesting a rhinoplasty; however, it is incumbent upon the surgeon to recognize and preserve the function that underlies the form of the contemporary human nose. The bony–cartilaginous nasal vault is a critical determinant of that function. A thorough understanding of the anatomy of the nose is paramount in rhinoplasty. Correction of deformities of the nasal vault presents a challenge to the facial plastic surgeon. Suboptimal esthetic results may occur when inadequate or excessive mobilization of the nasal bony – cartilaginous framework is performed. Furthermore, postoperative complications such as collapse of the nasal airway may occur. Several techniques are available to mobilize appropriately and reposition the bony nasal vault. This article reviews pertinent anatomy, technical considerations, and clinical perspectives on mobilization of the nasal bones.