M. Eugene Tardy

Variable histotoxicity of histoacryl when used in a subcutaneous site : an experimental study

Histoacryl (butyl-2-cyanoacrylate) is one of the least histotoxic cyanoacrylate derivatives and is used as a tissue adhesive. Clinical applications primarily include skin closure (blepharoplasty incisions, etc.). In a recent study, we demonstrated that Histoacryl elicits minimal histotoxicity when used to glue bone grafts to rabbit-ear cartilage. Acute inflammation was limited to areas where Histoacryl escaped from between the bone graft and ear cartilage to contact well-vascularized soft tissue. In this study, Histoacryl was applied between bone graft and cartilage in one rabbit ear and adjacent to well-vascularized soft tissue with no graft in the opposite ear. Histologic analysis revealed minimal if any inflammation when small amounts of glue was used in the nonvascular region between bone graft and cartilage. However, subcutaneous implantation contacting well-vascularized soft tissue resulted in increased acute inflammation and prolonged foreign-body giant-cell response. Further studies are required to rule out any long-term problems associated with subcutaneous implantation of Histoacryl.

Sublabial mucosal flap: Repair of septal perforations

The majority of perforations of the nasal septum, regardless of etiology, create little more than an annoyance to the patient. Perf orations commonly may be totally asymptomatic, discovered only on careful nasal examination. It is reasonable to assume, therefore, that only those septal defects creating important symptoms are deserving of repair and correction. Heavy crusting, recalcitrant bleeding and impending or actual loss of dorsal support are justifications for perforation closure. Textbooks and journals abound with suggested varieties of techniques of repair, testifying to the non-effectiveness of any one suitable approach. Local mucosal flaps, turbinate flaps, pedicle skin flaps, and free grafts of skin, dermis, perichondrium, cartilage, and fascia have all been employed with variable results. An inadequate blood supply and unfavorable scarred host bed commonly lead to failure of the above reconstruction methods. In the past five years a horizontal mucosal flap derived from the under-surface of the upper lip has proved reliable and expedient in septal perforation re-epithelialization and closure. The reconstructive procedure is not technically difficult and leads to minimal patient discomfort.The majority of perforations of the nasal septum, regardless of etiology, create little more than an annoyance to the patient. Perf orations commonly may be totally asymptomatic, discovered only on careful nasal examination. It is reasonable to assume, therefore, that only those septal defects creating important symptoms are deserving of repair and correction. Heavy crusting, recalcitrant bleeding and impending or actual loss of dorsal support are justifications for perforation closure.

Inspiratory nasal obstruction secondary to alar and nasal valve collapse: Technique for repair using autogenous cartilage

Summary Inspiratory nasal obstruction secondary to alar and nasal valve collapse results because of inadequate support of the lateral nasal wall and ala. This support can be restored by using curved autogenous cartilage supporting grafts placed in precisely shaped recipient pockets.

Cartilage suturing techniques for correction of nasal tip deformities

Cartilage suturing techniques used to alter nasal tip shape are reliable and effective in patients who may be difficult to manage because of variant anatomy. Patients with thin nasal tip skin may present problems with visible deformity (edges, bossae, etc) after aggressive cartilage excision, dome division, or tip grafting. Cartilage suturing techniques (transdomal suture, domal suture, etc) are particularly effective in patients with strong cartilages and tip bulbosity. These techniques can also provide increased tip projection and rotation. Cartilage delivery or the external rhinoplasty approach provides the exposure necessary to place these sutures. This article describes several different techniques of suturing tip cartilages that will provide precise narrowing of the nasal tip as well as increase tip projection and rotation. Modifications of the suturing techniques are based primarily on the anatomy of the lower lateral cartilages and desired contour changes.

The overprojecting nose: Aesthetics, diagnosis, and management

Recognition of the aesthetic range of acceptability of nasal projection is crucial to sophisticated rhinoplastic surgery. Within this article, various methods are discussed that use measurements of ratios and angles between facial landmarks to assist the surgeon in assessment of nasal projection. Chin projection, skin thickness, and patient age are further considerations when deciding how to best approach an aesthetic ideal for a particular patients face. This article then discusses preoperative assessment and diagnosis and emphasizes steps taken to correct problems of projection that completely depend on the anatomic etiology of the deformity.

Alar rim retraction: Composite graft repair

Summary Cephalic retraction of the alar margin is one of the more unpleasant complications following rhinoplasty. Knowledge and avoidance of the surgical manuevers that lead to alar retraction at the time of primary procedure should prevent its development. Fortunately this complication, if encountered, is largely correctable. Using the described method of composite graft repair, immediate and permanent correction of alar retraction can be achieved (Fig 4A, B).