Dean M. Toriumi

Use of octyl-2-cyanoacrylate for skin closure in facial plastic surgery

Octyl-2-cyanoacrylate is a long carbon chain cyanoacrylate derivative that is stronger and more pliable than its shorter chain derivatives. One hundred and eleven patients underwent elective surgical procedures by the same surgeon using either octyl-2-cyanoacrylate or sutures for skin closure at the University of Illinois at Chicago. Most patients underwent excision of benign skin lesions with a mean wound size of 112 mm3. Patients were randomized into either control (vertical mattress suture closure) or test groups (closure with octyl-2-cyanoacrylate). Surgical judgment was used to determine which wounds in each group required application of subcutaneous sutures to relieve tension and aid in skin edge eversion. Generally, full-thickness (through dermis) wounds larger than 1 cm3 required the use of subcutaneous sutures. The time required to close the epidermis with suture (mean, 3 minutes and 47 seconds) was about four times that of octyl-2-cyanoacrylate (mean, 55 seconds). Wounds were evaluated at 5 to 7 days for infection, wound dehiscence, or tissue reaction, and at 90 days using the modified Hollander wound evaluation scale. At 1 year, photographs of the wounds were evaluated by two facial plastic surgeons that graded the cosmetic outcome using a previously validated visual analog scale. There were no instances of wound dehiscence, hematoma, or infection in either group. Results of wound evaluation at 90 days determined by the modified Hollander scal revealed equivalent cosmetic results in both groups. Results of the visual analog scale ratings showed scores of 21.7 +/- 16.3 for the 49 patients treated with octyl-2-cyanoacrylate and 29.2 +/- 17.7 for the 51 control patients treated with sutures. The lower visual analog scale score represented a superior cosmetic outcome at 1 year with the octyl-2-cyanoacrylate as compared with sutures. This difference is statistically significant at p = 0.03. Additionally, patient satisfaction was very high in the group treated with octyl-2-cyanoacrylate.

Vascular Anatomy of the Nose and the External Rhinoplasty Approach

OBJECTIVE To characterize the venous, lymphatic, and arterial blood supply of the nose and determine the effect of the external rhinoplasty approach on this vasculature. We hypothesized that dissection in the areolar tissue plane below the musculoaponeurotic layer of the nose will preserve the nasal vasculature and minimize postoperative nasal tip edema. DESIGN The study included preoperative and postoperative clinical evaluation, cadaver dissection, and histologic examination. In the clinical section, lymphoscintigraphy was performed before and after rhinoplasty using the endonasal (transnostril) or external (open) approach. Additionally, nasal tip edema was subjectively quantified at specified interval after surgery. In the cadaver dissection section, 15 fresh cadavers were dissected to identify the venous and arterial vasculature. In the histology section, fresh nasal tissue was examined by light microscopy to verify the anatomy of arteries, veins, and lymphatic vessels. SETTING Subjects for the clinical section of the study were volunteers undergoing primary rhinoplasty surgery at the University of Illinois College of Medicine at Chicago. PATIENTS Lymphoscintigraphy was performed on nine patients who underwent rhinoplasty surgery. Seven of these patients underwent postoperative lymphoscintigraphy. INTERVENTIONS The rhinoplasty procedures included three different methods of exposure of the nasal structures. Two patients underwent an endonasal (transnostril) nondelivery approach using a transcartilaginous incision. Five patients underwent the external approach with three receiving dissection in the areolar tissue plane below the musculoaponeurotic layer (preserving major nasal vasculature) and two undergoing dissection above the musculoaponeurotic layer (disrupting nasal vasculature). MAIN OUTCOME MEASURES In the clinical section of the study, the outcome measures were tracer flow as seen on lymphoscintigraphy and tip edema scores subjectively quantitated on a scale from 1 (none) to 4 (maximal). RESULTS Clinical Section: Lymphoscintigraphy revealed flow of tracer along the lateral aspect of the nose (cephalic to lateral crura) to the preparotid lymph nodes. Postoperative scans revealed preservation of flow of tracer with the endonasal (transnostril) approach and the external approach with submusculoaponeurotic areolar tissue plane dissection. There was loss of normal flow of tracer with the external approach using dissection that disrupted the musculoaponeurotic layer with supratip debulking. The nasal tip edema scores for the transnostril and external approach using areolar plane dissection were significantly lower than the external approach with disruption of the musculoaponeurotic layer. Cadaver Dissection Section: Other than the lateral nasal veins, the major arteries, veins, and lymphatic vessels ran superficial to the musculoaponeurotic layer of the nose. The lateral and dorsal nasal and the columellar arteries comprise an alar arcade that provides the major blood supply to the flap elevated in the external rhinoplasty approach. Histologic Section: Light microscopy of plastic resin sections verified the lymphoscintigraphic and cadaver dissection findings. The lymphatic vessels were located primarily in the reticular dermis above the muscle layer. CONCLUSIONS The major arterial, venous, and lymphatic vasculature courses in or above the musculoaponeurotic layer of the nose. In the external rhinoplasty approach, dissection in the areolar tissue plane below the musculoaponeurotic layer will minimize tip edema and protect against skin necrosis by preserving the major vascular supply to the nasal tip.

Surgical techniques for management of the crooked nose.

Correction of the crooked or deviated nose can be very complex and requires use of a wide range of surgical techniques to straighten the nose and maximize nasal function. The cosmetic deformity may be difficult to correct due to the memory of the bone and cartilage. Despite the best attempts at correction of the deformity through the use of osteotomies, cartilage resection, and grafting, and precise suture techniques, the nose may remain slightly deviated. The subtle concavities and convexities that remain on the dorsum may be camouflaged with appropriate tissue grafting techniques. As light casts shadows over these regions, the viewer will have the perception of a persistent nasal deviation. Preoperative discussion with the patient is important to explain to the patient that it is very difficult to get the nose perfectly straight. If the patient has unrealistic expectations, the surgeon should consider not operating on the patient.

Contemporary Review of Rhinoplasty

We conducted a contemporary review covering advances and trends in primary and functional rhinoplasty as published during the past decade. Specifically, we reviewed studies supporting the evidence for functional rhinoplasty, nasal valve surgery, and septal reconstruction. In addition, key articles discussing cephalic malpositioning of the lower lateral cartilages and tip contouring are reviewed. We also report studies involving lateral osteotomy techniques, computer imaging, and the use of homologous, alloplastic, and absorbable implants. When appropriate, we review outcomes data from key studies because these data are becoming increasingly important for evidence-based medicine, physician grading, and procedure reimbursement. Using evidence-based approaches whenever possible will help to ensure predictable patient outcomes.

The Effect of Polydioxanone Absorbable Plates in Septorhinoplasty for Stabilizing Caudal Septal Extension Grafts

IMPORTANCE Caudal septal extension grafts (CSEGs) can be used to alter and secure nasal projection and length. Graft position and thickness play an important role in terms of both function and aesthetics. The limitations of harvesting cartilage from additional sites necessitate development of a more efficient method for securing CSEGs. OBJECTIVE To assess the efficacy and safety of polydioxanone absorbable plates used in primary and revision septorhinoplasty. DESIGN, SETTING, AND PARTICIPANTS We investigated all patients who underwent primary or revision septorhinoplasty with the use of absorbable plates to secure CSEGs at a tertiary academic medical center from 2010 to 2014. To standardize and objectify the symptoms of nasal obstruction, a validated quality-of-life instrument called the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, with 5 questions on a scale of 0 to 4, was implemented preoperatively and postoperatively. Preoperative and multiple successive postoperative measurements of nasal length and projection were taken using 3dMDvultus imaging software. MAIN OUTCOMES AND MEASURES Change in NOSE questionnaire score, change in nasal length and projection, and complications. RESULTS There were no absorbable plate-related complications in the 95 included patients. Comparing preoperative and postoperative NOSE questionnaire scores, there was a statistically significant improvement in all 5 categories: mean (SD) change of -1.42 (1.59) in congestion, -1.56 (1.53) in blockage or obstruction, -1.60 (1.54) in breathing through nose, -0.90 (1.54) in trouble sleeping, and -1.28 (1.46) in breathing during exercise (P < .001 for all) in the 50 patients with available data. In the 24 patients with greater than 180 days of follow-up, follow-up ranged from 183 to 717 days, and mean (SD) change in nasal length and projection was 0.64 (2.19) and 0.26 (0.96) mm, respectively, showing no statistically significant change over time (P = .17 and .21, respectively). CONCLUSIONS AND RELEVANCE In our study population, nasal length and projection maintained position over time when absorbable plates were used to secure CSEGs. Absorbable plates appear safe and effective when used to secure CSEGs and limit the requirement of harvesting additional cartilage. Nasal airway improvement can be obtained when absorbable plates are used to secure CSEGs. LEVEL OF EVIDENCE 4.

Subtotal Septal Reconstruction: An Update

Subtotal septal reconstruction is a surgical technique used to reconstruct severe septal deviations that are not easily repaired using less invasive methods. Patients with identifiable septal fractures across the caudal or dorsal segments of the L-strut are good candidates. These patients may present with deformities such as the deviated nose or saddle nose. Adequate autologous cartilage is needed to reconstruct the septum. The deviated segments of the nasal septum are removed and then reconstructed by replacing the caudal septum with a straight piece of septal cartilage fixated to the nasal spine. The bilateral extended spreader grafts fixated to the remnant dorsal strut is then fixed to the caudal septal replacement graft to reconstitute the L-strut. In some cases, the dorsal strut may overlap the caudal portion of the L-strut to complete the repair. Care must be taken in setting nasal length, projection, rotation, and supratip break. If these parameters are not set very carefully deformity may ensue. Other potential complications include change in the upper lip smile or a crease forming in the upper lip when the patient smiles. This is a complex technique and must be performed with special care to avoid deformity.

Rhinobase: A Comprehensive Database, Facial Analysis, and Picture-Archiving Software for Rhinoplasty

Correspondence: Dr Hamilton, Department of Otolaryngology–Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242 (grant-hamilton@uiowa.edu). Financial Disclosure: None reported. Additional Contributions: Norman Koren, MA, of Imatest provided his insights on camera testing and image analysis, and M. Bridget Zimmerman, PhD, provided statistical consultation.

Three-dimensional evaluation of unilateral cleft rhinoplasty results.

Three-dimensional (3D) imaging is a relatively new method of objectively evaluating surgical results, allowing the surgeon to accurately measure postsurgical changes with little inconvenience to the patient. Its accuracy and reliability has been consistently demonstrated in the literature. This article describes updated methods that we use with 3D imaging software to assess rhinoplasty results at our institution. The measurements described include the assessment of symmetry, tip projection, rotation, volume, width, and topographic width. We also apply these techniques to assess the surgical changes of patients with unilateral clefts who underwent secondary rhinoplasty performed by the senior author.

Discussion: Use of autologous costal cartilage in Asian rhinoplasty.

I the article entitled “Use of Autologous Costal Cartilage in Asian Rhinoplasty,” Jin et al. presented their experience in 83 patients undergoing augmentation rhinoplasty. The authors emphasize that most Asian rhinoplasty patients do not need reduction, but benefit most from augmentation. They are making an effort to move away from the standard in Asia, which is alloplastic augmentation. The authors should be commended for this effort, as use of costal cartilage has a very steep learning curve and requires great skill and attention to detail to avoid warping or other related deformity. Jin et al. noted warping of the dorsal graft in five of 66 patients, for an incidence of 7.6 percent. However, they point out that the incidence is likely higher and may approach 10 percent, as many patients may have subtle degrees of warping that are not bothersome (to the patients). The problem is that autologous costal cartilage is a dynamic living piece of tissue that can change after it is carved. If placed onto the nasal dorsum and not fixed rigidly into position, the chance of some degree of bending is high. The key to avoiding warping is to fixate the dorsal graft to the underlying dorsum in as rigid a manner as possible. Jin et al. discuss the methods that we have used to fixate dorsal grafts.1 Placement of perichondrium on the undersurface of the distal end of the dorsal graft over a rasped or perforated bone surface will permit the upper aspect of the graft to rigidly fix to the bone.2 Additional fixation to the upper lateral cartilages will assist in fixation of the lower aspect of the graft. Another important factor is to limit dissection of the subperiosteal pocket over the nasal dorsum so the dorsal graft can be forced into a tight pocket that limits movement. These factors decrease movement of the graft and aid in rapid fixation that will help prevent warping. Jin et al. also discuss the harvesting of the costal cartilage. It is important to understand that the incision is made small to minimize the visible scar and minimize morbidity to the patient. However, surgeons should not use a small incision until they are comfortable with the dissection and do not feel they are increasing morbidity by going to a small incision. The objective is to harvest an appropriately sized segment of cartilage without damaging the pleura and creating a pneumothorax. Surgeons should begin with a larger incision measuring 4 cm or larger to allow excellent exposure and dissect the costal cartilage without damaging the deep perichondrial layer and underlying pleura. The other key issue with major dorsal augmentation is to ensure a natural transition from dorsal graft to underlying nasal dorsum. If this is not achieved, the dorsal graft can become visible as the skin contracts around it and reveals the lateral margins of the dorsal graft. We minimize graft visibility by carefully carving the dorsal graft so it transitions to the base it will lie on. This is easier to accomplish if the platform is wider and flatter. We avoid performing osteotomies in patients undergoing major dorsal augmentation, as this will narrow the bridge and make the dorsal graft more difficult to camouflage.2 We also frequently apply a sheet of costal perichondrium to the lateral margins of the dorsal graft to tent across the transition from dorsal graft to nasal dorsum.2 A natural appearing dorsum will demonstrate an A-frame appearance that is narrower anteriorly and wider along the base of the dorsum along the ascending process of the maxilla. Jin et al. discussed the option of laminating pieces of costal cartilage to prevent warping of the dorsal grafts. We have used this method in the past and in theory it creates a laminated block similar to plywood. The problem is that each layer is inFrom the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago. Received for publication August 9, 2012; accepted September 25, 2012. Copyright ©2012 by the American Society of Plastic Surgeons

Discussion: Frequency of the preoperative flaws and commonly required maneuvers to correct them: a guide to reducing the revision rhinoplasty rate.

777 I the article entitled “Frequency of the Flaws and Commonly Required Maneuvers to Correct Them: A Guide to Reduction of Secondary Rhinoplasties,” the authors performed a retrospective chart review of 100 consecutive secondary rhinoplasty patients. The authors found that the most common patient complaints were airway obstruction (65 percent), dorsal asymmetry (33 percent), nostril asymmetry (18 percent), and tip asymmetry (14 percent). The senior author found that the most common deformities were dorsal asymmetry (65 percent), wide dorsum (47 percent), and nostril asymmetry (41 percent). It is not unusual for the patient presenting for secondary rhinoplasty to have primary complaints that do not align with what the secondary rhinoplasty surgeon finds as the most offending problems. This may reflect differences in aesthetics or what I believe is a tendency for secondary rhinoplasty patients to focus on one or two particular issues with their nose. This does not diminish the significance of their deformity but only emphasizes that what the patient sees may not align with what the surgeon sees. It is imperative for the surgeon to recognize the patient’s primary concerns and make it a priority to correct the problems at the time of corrective surgery. Preoperative computer imaging is very helpful in assessing the goals and expectations of the secondary rhinoplasty patient. It is advisable to “underimage” or perform computer imaging that shows realistic outcomes to avoid setting patient expectations too high. Patients with realistic expectations are more likely to be satisfied with the surgical outcome. In the end, it is the satisfaction of the patient that is essential and not necessarily the satisfaction of the surgeon. It is disturbing that the patient’s most common primary complaint was nasal obstruction and was noted in 65 percent of patients seeking secondary rhinoplasty in this series. This problem is in part attributable to inadequate correction of septal deformities, as the authors performed septoplasty (not all for functional purposes) on 71 percent of patients. Many of these problems could be prevented if septal deformities were corrected at the time of primary surgery. However, Constantian and Clardy have shown that most cases of nasal obstruction after rhinoplasty are related to lateral wall insufficiency and can be corrected by increasing lateral wall support.1 Constantian and Clardy found that improving lateral wall support provides a more significant improvement in nasal function than septoplasty.1 Obviously, this depends on the degree of septal deviation experienced by the patient. In patients with a severe septal deviation, there is usually more significant blockage of one internal airway. When the patient inspires, most of the airflow passes through the opposite or unobstructed airway. When the patient inspires, the nostril opposite the severe septal deviation may collapse at the external nasal valve if there is weakness along the alar margin. If prior surgery weakens the lateral wall of the nose, this can further compromise nasal function by increasing collapse at the external nasal valve. Therefore, it is important to evaluate the septum and the patency of the airway at both the internal and external nasal valves. Guyuron et al. placed alar rim grafts in 71 percent of patients and lateral crural strut grafts in 10 percent of patients and repositioned the lateral crura in 12 percent of patients. The majority of patients required some form of lateral wall support. Lateral crural strut grafts will provide maximal support to the lateral wall, and alar rim