O. Onur Erol

The Turkish delight: a pliable graft for rhinoplasty.

In nose surgery, carved or crushed cartilage used as a graft has some disadvantages, chiefly that it may be perceptible through the nasal skin after tissue resolution is complete. To overcome these problems and to obtain a smoother surface, the authors initiated the use of Surgicel-wrapped diced cartilage. This innovative technique has been used by the authors on 2365 patients over the past 10 years: in 165 patients with traumatic nasal deformity, in 350 patients with postrhinoplasty deformity, and in 1850 patients during primary rhinoplasty. The highlights of the surgical procedure include harvested cartilage (septal, alar, conchal, and sometimes costal) cut in pieces of 0.5 to 1 mm using a no. 11 blade. The fine-textured cartilage mass is then wrapped in one layer of Surgicel and moistened with an antibiotic (rifamycin). The graft is then molded into a cylindrical form and inserted under the dorsal nasal skin. In the lateral wall and tip of the nose, some overcorrection is performed depending on the type of deformity. When the mucosal stitching is complete, this graft can be externally molded, like plasticine, under the dorsal skin. In cases of mild-to-moderate nasal depression, septal and conchal cartilages are used in the same manner to augment the nasal dorsum with consistently effective and durable results. In cases with more severe defects of the nose, costal cartilage is necessary to correct both the length of the nose and the projection of the columella. In patients with recurrent deviation of the nasal bridge, this technique provided a simple solution to the problem. After overexcision of the dorsal part of deviated septal cartilage and insertion of Surgicel-wrapped diced cartilage, a straight nose was obtained in all patients with no recurrence (follow-up of 1 to 10 years). The technique also proved to be highly effective in primary rhinoplasties to camouflage bone irregularities after hump removal in patients with thin nasal skin and/or in cases when excessive hump removal was performed. As a complication, in six patients early postoperative swelling was more than usual. In 16 patients, overcorrection was persistent owing to fibrosis, and in 11 patients resorption was excessive beyond the expected amount. A histologic evaluation was possible in 16 patients, 3, 6, and 12 months postoperatively, by removing thin slices of excess cartilage from the dorsum of the nose during touch-up surgery. This graft showed a mosaic-type alignment of graft cartilage with fibrous tissue connection among the fragments. In conclusion, this type of graft is very easy to apply, because a plasticine-like material is obtained that can be molded with the fingers, giving a smooth surface with desirable form and long-lasting results in all cases. The favorable results obtained by this technique have led the authors to use Surgicel-wrapped diced cartilage routinely in all types of rhinoplasty.

New Capillary Bed Formation with a Surgically Constructed Arteriovenous Fistula

This study on 24 rats has demonstrated that neovascularization of the skin through an arteriovenous fistula is possible. A vascular bed can be created by the use of long interpositional vein grafts. An arteriovenous fistula in the shape of a loop could not only provide vascularity to create a skin flap of unlimited size but could possibly vascularize a digital replantation with severely damaged vessels and provide enough additional vascularity to facilitate the take of bone grafts and tissue composites.

A mastopexy technique for mild to moderate ptosis.

A surgical technique for mastopexy, done through a circumareolar incision and leaving no noticeable scar, is described. The skin brassiere is undermined and a rotation-invagination and suture maneuver are performed which simultaneously augments the projection of the breast and elevates the nipple-areola complex. The overlying skin contours itself to the reshaped breast. The favorable results obtained in six patients with this new method are encouraging and further use in selected patients is planned.

Reconstructing the breast mound employing a secondary Island omental skin flap

We have shown in an initial animal study that omentum will adequately vascularize a skin flap and allow transfer of this tissue composite for use in surgical reconstruction of the breast. Based on this experimental procedure, a technique employing a two-stage operation has been developed and used in 21 female patients in reconstruction of the breast after radical mastectomy. In the first stage, the omentum, attached to one gastroepiploic artery and vein, is exteriorized to the subcutaneous tissue of the lower abdominal wall. In the second stage, the distal omentum, now vascularizing the overlying skin and soft tissue, is moved as a secondary island flap to the anterior chest wall to complete the breast reconstruction. In all but 1 of our 21 patients who have been followed for 1 to 8 years, reconstruction of large defects, including the chest wall, breast mound, and infraclavicular axillary fold depression, was performed without use of a prosthesis. In one patient, there was complete necrosis of the flap due to vascular impairment; there were three instances of delayed healing and a significant but partial loss of the flap in one patient. All complications were encountered in the first 10 patients of the series during the time the technique was being refined.

The treatment of burn scar hypopigmentation and surface irregularity by dermabrasion and thin skin grafting.

Scar tissue and leukoderma-type discoloration of the skin due to deep burns are treated by dermabrasion and thin split-thickness skin-graft application. This method was applied to 18 patients on whom the treated lesion sites were located as follows: 8 in the facial area, 9 on the extremities, and 1 on the neck. Adequate repigmentation and flat surfaces were obtained in all patients at the end of 6 months, and results persist at the end of a considerable follow-up period (1 to 4 years). The technique, advantages, disadvantages, and results are discussed.

Secondary Musculocutaneous Flap: An Experimental Study

SUMMARY In four dogs, eight secondary musculocutaneous flaps were created by the vascularization of skin flaps with transposed sartorius muscle. All skin flaps demonstrated excellent viability on clinical follow-up, with vascularity confirmed by fluorescein dye, microangiography, and histologic studies. Potential clinical uses of this method are discussed.

New modification in otoplasty: anterior approach.

After harvesting the conchal cartilage in a large series of secondary rhinoplasties using the anterior approach, there was a marked improvement in the shape of the auricle, with unnoticeable scarring hidden under the convolution of the antihelix. In this series of 250 cases, there were no hypertrophic scars or keloid formations. Based on these favorable results, a new modification of otoplasty was developed using only the anterior approach. Between 1992 and 2000, 108 otoplasties were performed on 55 patients to correct the prominent ear using only the anterior approach. All maneuvers used in modern otoplasty, such as conchal reduction, scaphal cartilage scoring and folding, placement of horizontal mattress buried sutures, conchal setback, and the positioning of the tail and upper pole, can be easily and effectively performed using only the anterior approach as described in this article. The use of an anterior approach does not disturb the neurovascular system of the ear because it is located on the ears posterior side. Overall, patient and physician satisfaction has continued to be very high during the 8 years that this technique has been used. Some patients experienced a few minor complications, such as postoperative pain (16.3 percent), late suture reaction (1.8 percent), hidden helix (3.6 percent), and partial relapse (3.6 percent), that were easily corrected by the application of a Kaye-type buried suture and that were not directly related to the technique.

Calf augmentation with autologous tissue injection.

Background: Lean or asymmetric calves may cause body image problems. These deformities can be corrected by inserting a silicone calf prosthesis or silicone injection, and also through the use of an autologous fat or tissue cocktail. Methods: Thin and asymmetric parts of the leg are marked while the patient is standing. Depressed areas are observed at the anteromedial part of the tibia from the knee to the ankle. Fat tissue harvested under general anesthesia, using a syringe and a 4-mm cannula, is centrifuged to eliminate blood and lipids, antibiotic is added, and small amounts of fat grafts are injected into different layers using a cannula 15 or 26 cm in length and 3 mm in diameter. For the preparation of the tissue cocktail, tissue (dermis, fascia, fat) was cut into very small pieces measuring 0.5 mm to be passed through 16-gauge needles. The amount injected depends on the severity of deformity and the size of the legs. Rather than overcorrecting, injections are repeated if necessary, two to four times at 3-month intervals. Results: Between 1992 and 2003, 77 patients underwent calf augmentations with autologous fat and tissue cocktail injections, with follow-up from 1 to 8 years. Outcome was satisfactory in most patients, with moderate improvement in 10 patients (13 percent) and good improvement in 67 (87 percent). In 12 patients, small irregularities or asymmetries were seen after the first injection and were corrected with a second injection. No infection was reported in any case. Conclusion: Autologous augmentation and shaping offers scar-free, long-lasting results, with no late complications, and with the possibility of touchup.

Utilization of a composite island flap employing omentum in organ reconstruction: an experimental investigation.

New methods for the reconstruction of the ear, nose, and breast using omentum to vascularize appropriate tissue composites of skin, bone, and cartilage are described. The initial investigation demonstrated that it is possible to obtain an island composite flap with omentum-costal cartilage-skin flap and preserve cartilage viability inside the omentum. The ear and nose were reconstructed in two stages. In the first stage, the appropriately carved cartilage and/or bony framework was covered with omentum and a skin graft, leaving the tissue composite buried subcutaneously. In the second stage, the newly reconstructed organ was exteriorized and diagnostic studies were done. The breast reconstruction was undertaken in two stages, first creating an omental island skin flap and subsequently either implanting a standard prosthesis under the flap or transferring the entire composite superiorly to better simulate the clinical reconstruction wherein the lower abdominal skin with omentum would be moved to the anterior chest. In each reconstruction a variety of diagnostic studies, including intravenous fluorescein dye, radioactive isotope uptake, and microangiography, were performed.

The Abbé island flap for the reconstruction of severe secondary cleft lip deformities.

Primary repair of the cleft lip is often associated with secondary deformities, which require revision and secondary reconstruction. Patients with one or all of the following, a tight lip restricting use of orthodontic appliances, absence of a Cupids bow, or absence of vermilion tubercle, were treated with the Abbé island flap. A triangular muco-musculo-cutaneous island flap was designed in the central segment of the lower lip. A full-thickness incision of skin, muscle, and mucosa was made in the midline of the upper lip, dividing the lip into two segments, and the island Abbé flap was inserted. One week after surgery, the pedicle of the island flap was divided and the inset of the flap completed. Sixty patients with severe secondary cleft lip deformities (36 males and 24 females) were treated. Good aesthetic and functional results were achieved during 1 to 17 years of follow-up. Insertion of the Abbé flap resulted in release of the tight upper lip and a new, inconspicuous scar. Use of orthodontic appliances was facilitated, and tightness of the tissue, which restricted the expansion of the alveolar process, was eliminated. Adequate tissue was transferred to the upper lip, which improved the bulk of the lip and vermilion tubercle. The retrusion of the midface and the projection of the upper lip were also improved, and the upper and lower lips became better balanced. Donor site morbidities were insignificant. Use of the Abbé flap in selected patients resulted in successful reconstruction of secondary cleft lip deformities.