Fei Fan

Tissue engineering of human nasal alar cartilage precisely by using three-dimensional printing.

Background: Tissue engineering strategies hold promise for the restoration of damaged cartilage. However, the results of most studies report irregularly shaped beads of cartilage, which are not precise enough. Thus, a precise shape of cartilage graft must be taken into consideration. The goal of this study was to develop a simple method of creating a precisely predetermined nasal alar shape with the aid of three-dimensional printing. Methods: Lower lateral cartilage from cadavers was observed and scanned by computed tomography. Molds of the lower lateral cartilage were achieved by using three-dimensional printing. Human nasal cartilage was obtained and chondrocytes were harvested. Then, the mixture of cells and poly(glycolic acid)/poly-L-lactic acid was cultured in vitro and implanted into the subcutaneous tissue of nude mice. Results: After subcutaneous implantation, the length and width of the samples were measured, and the results were not statistically significantly different from the native lower lateral cartilage (p > 0.05). Their thickness was measured and the results were statistically different from the native lower lateral cartilage (p < 0.05). Histologic examination of the engineered constructs revealed that both the cell and tissue morphologic features of engineered cartilage were similar to those of native lower lateral cartilage. The biomechanical properties of the engineered cartilage exceeded those of native cartilage. Conclusions: This study demonstrates that three-dimensional printing–aided tissue engineering can achieve precise three-dimensional shapes of human nasal alar cartilage. To our knowledge, this is the first reported creation of a precise nasal alar cartilage with a tissue-engineering strategy and three-dimensional printing technique.

Correction of unilateral cleft lip nose deformity using nasal alar rim flap.

Objective The objective of this study was to show the use and effectiveness of nasal alar rim flap on the correction of unilateral cleft lip nasal deformity. Methods Thirty-one patients (age range, 10–29 years; mean, 15.1 years; 14 male and 17 female patients) with unilateral cleft lip underwent rhinoplasty surgery using alar rim flap. The excessive skin of nasal alar was marked, then a skin flap was raised. This flap can be transferred medially (type 1) or laterally (type 2) to narrow the nostril or to augment the nasal sill and, of course, to correct the alar web deformity. Preoperative and postoperative photographs were measured for photogrammetric analysis in 16 patients. Result The alar rim flap used in patients with unilateral cleft lip made the nostrils more symmetrical. The nostril sill was augmented with flap type 1. The alar base width was narrowed with flap type 2 (P = 0.03). The alar web deformity was corrected. Conclusions The alar rim flap could be an ideal treatment option for correction of alar web deformity in patients of unilateral cleft lip.

Combined silicone implant and cartilage grafts for augmentation rhinoplasty.

AbstractSilicone implants are widely used in Asia for nasal dorsal augmentation. Meanwhile, autologous cartilage grafts are the most preferred materials for tip surgery. In order to minimize the drawbacks of silicone implants, combined silicone implant and cartilage grafts were introduced for augmentation rhinoplasty. In this work, augmentation rhinoplasty technique using combined silicone implant and cartilage grafts are reported. Forty-six patients underwent dorsal and tip augmentation using this technique. The outcomes were satisfactory in 45 patients. Bilateral marginal incisions were used without transcolumellar incision. By suturing the silicone nasal implant with a shield cartilage graft, a new complex was achieved. Assisted with a columellar strut either sutured to the complex or not, the new complex could provide improved dorsal height and tip projection with low complication rate in augmentation rhinoplasty.

Nasal Reconstruction and Repair of Secondary Nasal Deformities Following Treatment of Nasal Hemangiomas.

Background: Secondary nasal deformities and retardation of development due to treatment of nasal hemangioma during infancy are a challenge when it comes to nasal reconstruction. In order to evaluate nasal repair and reconstruction in these patients, the authors compared the ease and outcomes of using expanded forehead, nasolabial sulcus, and medial upper arm tube flaps. Methods: According to the deformities and patients’ wishes, flaps were selected; using autogeneic rib cartilage, auricle cartilage, or silica gel as a scaffold or without framework; the inner lining were made by the residual scar tissue or the distal end of transferred flap. The esthetical and functional scores were recorded by the Nasal Appearance and Function Evaluation Questionnaire score to evaluate the effectiveness of the methods. Results: From January 2010 to December 2015, 34 patients were included. Postoperative follow-up went for 12 to 36 months. The expanded forehead flap was used in 28 patients, the nasolabial sulcus flap in 5 patients, and the medial upper arm tube flap in 1 patient. Regarding framework, 20 patients used rib cartilage, 8 patients used auricle cartilage, 1 patient used silicone, and 5 patients did not use any framework. All patients reported the increasing nasal appearance and function evaluation. Conclusion: Repair of secondary nasal defects following treatment of hemangiomas in infants and young children using an expanded frontal flap and autogenous cartilage framework is a reliable method with great long-term esthetic results. The nasolabial sulcus flap is a relatively simple method, especially for patients with a unilateral nasal alar defect. Supporting structure is needed and appropriate overcorrection is necessary.

Comparison of Two Different Grafts in Nasal Framework Reconstruction of Binder Syndrome: Cartilage and Silicone

Background: Binder syndrome is a rare congenital malformation with a flat facial profile especially a depressed nose. Rhinoplasty plays an important part in the multidisciplinary surgical protocol. Different materials have been proposed to reconstruct nasal framework. But fewer evidence concerns which graft can achieve more stable and appreciated nasal contour. In this article, the authors reported surgical details and experience of nasal framework reconstruction of Binder syndrome, compare the esthetic outcomes of 2 grafts: autologous costal cartilage and L-shaped silicone covered with auricular cartilage. Methods: A retrospective study of 25 Binder syndrome patients (9 with silicone and 16 with costal cartilage) was managed. Anthropometric method was used to evaluate nasal profiles preoperatively and postoperatively. Surgical techniques, complications were reviewed. Statistics analysis was managed. Probability (P) of <0.05 was considered significant. Results: Tip proportions (angle of convexity of the face with nose, nose tip–length quotient, tip projection anterior glabellar line quotient) improved in silicone group, but cartilage group achieved superior esthetic outcomes than silicone in tip projection, subnasal protrusion, and nasal labial angle. Conclusion: Autologous costal cartilage is more favorable to reconstruct the nasal framework and regain nasal esthetics of Binder syndrome.

Partial Costal Cartilage Harvest for Rhinoplasty

Partial Costal Cartilage Harvest for Rhinoplasty To the Editor We read the article titled “Technique to Reduce Time, Pain, and Risk in Costal Cartilage Harvest” by Nelson and Gaball1 in a recent issue of JAMA Facial Plastic Surgery, and we watched with great interest the corresponding video for the article. The authors did well to demonstrate the bent blade used for decreasing the risk of pleural tear and the use of liposomal preparation of bupivacaine for eliminating postoperative donor-site pain. In this Letter, we would like to relate our experience and share a lesson in these perspectives that could be conducive for further application of these techniques. Nelson and Gaball1 used a bent blade to reduce operational risk, but the calcification of costal cartilage, a dangerous but often ignored factor, should also be taken into account. On average, our operation team completes at least 20 cases of rib cartilage harvest per month. Some rarely applied orthopedic instruments, including a chisel, hammer, wire saw, and an electronic-driven system, are now used more and more frequently in plastic surgical procedures because of the increasing calcification of costal cartilage. In addition, peripheral calcification is usually more severe than central. Therefore, the subtotal harvest technique may be more difficult because of a larger contact area than a transverse section. Regarding the use of liposomal preparation to prolong the effects of bupivacaine, a different local anesthetic with a longer half-life that effects the sensory nerve more than the motor nerve could be a better choice, and it could be costeffective to skip a liposomal preparation. For example, for the same purpose—easing postoperative donor-site pain—we injected ropivacaine into the rectus abdominis muscle around the stump when we transversely or diagonally divided part of it to take out the whole rib cartilage. Because the “subtotal” approach is impractical for constructing an integrated framework for total nasal reconstruction, these patients did not experience greater pain than patients who merely underwent rectus abdominis muscle longitudinal separation. However, the irreversible damage of muscle tissue caused by both bupivacaine and ropivacaine is still a perplexing problem. In conclusion, we thank the authors1 for contributing these innovative ideas. Our hope is that these 2 tricky problems can be solved in the near future for the benefit of patients.

Flap Delay or Not? A Technical Detail for Nasal Reconstruction with a Forehead Flap

Wework in a tertiary referral hospital and perform hundreds of nasal reconstructive surgeries every year. From recent nasal reconstruction–related articles, we find that clinical doctors generallydonot paycloseattention toflapdelay, especially the physical method of flap delay. Sometimes, this step is even skipped, but it is essential to promote the neovascularization and ensure the survival of transferred flap. In the three-stage forehead flap techniques,Menick uses an intermediate operation, including sculpturing subcutaneous fat and adding delayed primary cartilage grafts, to cause a physiological flap delay. Besides facilitating the placement of cartilage framework, this stage has positive influence on flap vascularization. To achieve a similar purpose, we use another strategy, a physical method. Seven days after the forehead flap transplantation, flap exercises are performed to ensure blood supply (►Fig. 1). Technically, long pliers with rubber hoses in the front are used to clip the root of the pedicle to limit the bloodcirculation. Thedistalflap shouldbekeptwarmandpink until 2 hours, two to three times a day, which is the standard protocol for pedicle division. The required time for this period varies from individual to individual, from 2 to 6 weeks. In clinical practice, we find this kind of physical flap delay is indispensable. Patients who completed this procedure three times per day enjoyed more similar complexion between transferred flap and adjacent receiving areas after pedicle division. In comparison, the color of the transferred flap was relatively darker, if the patient performed this step only twice per day. But after 3 to 6 months, the difference gradually disappears. We believe this phenomenon is related to the degree of revascularization, especially the intravenousmicrocirculationwhich could impacthyperpigmentation.Additionally, for patientswith smoking history, local radiation therapy, or a large amount of tissue defect, we tend to perform a stricter standard (thrice per day), because these patients are more likely to suffer from flap distal exfoliation or insufficient blood supply after pedicle division. Meanwhile, there is another reason for our physical flap delay. Preexpanded foreheadflap isour preference, considering theneed for lining andAsianshave lowerhairline andareprone to scar hypertrophy compared with Caucasians. Although preexpansion itself is beneficial to neovascularization, the simultaneously placed cartilage framework with flap transfer is a potential factor responsible for adverse effect. In spite of this, as long as the physical flap delay is performed appropriately and meets the standard protocol for pedicle division, the flap could have a reliableblood supply. So, theflap canbeproperly refined in the meantime to build a relatively normal shape for reconstructive nose. And patients with financial difficulties can return to their normal work and social life earlier, although further revision is recommended. In conclusion, physical flap delay facilitates neovascularization and a chance to avoid surgery. Therefore, besides focusing on flap and lining design, flap delay should not be neglected.

Cranial bone deformity after forehead tissue expansion.

The expanded forehead flap is frequently used for nasal reconstruction. When expanding the forehead tissue, the underlying cranial bones are compressed by the inserted expander. Many effects of tissue expansion on the bone have been reported including bone remolding, erosion, displacement, and so forth. In this work, we report a peculiar patient of cranial bone deformity after forehead tissue expansion, which demanded a surgical revision.