Ronald M. Friedman

Lateral crural strut graft: technique and clinical applications in rhinoplasty.

&NA; The lateral crural strut graft is a new, versatile technique for reshaping, repositioning, or reconstructing the lateral crura. These grafts are strips of autogenous cartilage that are sutured to the deep surface of the lateral crura. Lateral crural struts are useful in the correction of the boxy nasal tip, malpositioned lateral crura, alar rim retraction, alar rim collapse, and concave lateral crura. We describe the surgical technique and demonstrate representative results of our experience with these grafts in 118 patients.

Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping.

Autogenous rib cartilage grafts have gained more widespread use in rhinoplasty as dorsal onlay grafts and columellar struts. However, the usefulness of rib as a donor site has been limited by difficulties with postoperative cartilage warping. We hypothesized that the internal stabilization of rib cartilage grafts with Kirschner wires would prevent warping. The costochondral cartilages of a fresh cadaver were harvested and carved into 4 x 10 x 40 nm blocks. A single 0.035-in K-wire was placed longitudinally into the center of each of the study specimens (n = 9), whereas no internal stabilization was utilized in the control group (n = 9). Over a 10-day study period, a mean of 2.2 degrees of warping was observed in the grafts with K-wires as compared to 8.9 degrees in the control group. This indicates that internal stabilization of rib grafts significantly reduces warping (p < 0.001). In a subsequent clinical study, 28 patients underwent placement of internally stabilized columellar struts (n = 19) and/or dorsal nasal grafts (n = 12) using autogenous rib cartilage. At a mean follow-up of 13.5 months (range 3 to 36 months), graft warping was not observed in any patient. Satisfactory aesthetic results were achieved in all but one patient, in whom mild displacement of a dorsal onlay graft occurred. Palatal extrusion of the K-wire occurred in 3 of the first 9 columellar struts. This prompted an alteration in technique with no subsequent extrusions. We conclude that the internal stabilization of autogenous rib cartilage grafts with K-wires effectively prevents graft warpage.

Classification and correction of alar-columellar discrepancies in rhinoplasty

Classification and Correction of Alar-Columellar Discrepancies in Rhinoplasty Jack Gunter;Rod Rohrich;Ronald Friedman; Plastic and Reconstructive Surgery

Nasal tip blood supply: An anatomic study validating the safety of the transcolumellar incision in rhinoplasty

The nasal tip blood supply was studied through anatomic dissections and microangiography in 31 fresh cadaver specimens. The lateral nasal artery was present in all specimens, bilaterally in 30 (97 percent) and unilaterally in one (3 percent) and was located in the subdermal plexus 2 to 3 mm superior to the alar groove. The columellar branch of the superior labial artery was visualized bilaterally in 3 specimens (9 percent) and unilaterally in 21 (68 percent), and was absent in 7 (23 percent). Transcolumellar (external rhinoplasty) incisions were performed in 11 of these cadavers prior to dye injection. A consistent crossover flow (100 percent) was seen from the lateral nasal artery arcades to the distal aspect of the transected columellar branches. We conclude that nasal tip blood supply is derived primarily from the lateral nasal arteries, with a variable contribution from the columellar arteries. Collateral flow to the nasal tip may be provided by branches of the ophthalmic artery. The external rhinoplasty transcolumellar incision does not compromise nasal tip blood supply unless extensive tip defatting or extended alar base resections (above the alar groove) are performed.

Patency of different arterial and venous end-to-side microanastomosis techniques in a rat model

Microvascular anastomotic patency is the most important factor in determining a successful outcome in freeflap transfers. End‐to‐end and end‐to‐side techniques have been shown to provide equivalent arterial patency rates in clinical and basic science studies, and end‐to‐side anastomoses have been used extensively in microsurgical reconstruction. Nevertheless, the effect of venotomy shape on the patency of venous end‐to‐side anastomoses has not been previously reported. The purpose of this study was to compare the patency rates of end‐to‐side anastomoses using different techniques in both arteries and veins. In total, 104 Sprague‐Dawley rats were subdivided into four groups. The rats were anesthetized, and anastomosis was performed on either the femoral artery or vein on the right with the left used as control. Vesselotomy was varied between an end‐to‐side hole and an end‐to‐side slit with patency measured immediately following surgery and at 2 weeks. No significant difference in patency or histology between these techniques was demonstrated in any group. We conclude there is no difference in patency rate between the two techniques in arterial or venous vesselotomies; however, in small vessels < 1.5 mm, the slit technique is technically easier, and clinical recommendations are given. (Plast. Reconstr. Surg. 105: 156, 2000.)

Recurrent digital ischemia due to thrombosis of the persistent median artery

A case of recurrent digital ischemia due to thrombosis of the persistent median artery is presented. Diagnosis and treatment are based on accepted principles of therapy for upper extremity vascular disorders.

Management of traumatic supraorbital neuroma

Traumatic neuromas represent proliferative overgrowth of axons, Schwann cells, and fibroblasts at the proximal end of nerve injury or transsection. Although common elsewhere, traumatic neuromas have rarely been noted in the orbits. All but one of these reported lesions occurred after orbital surgery. We present a patient with a painful traumatic neuroma of the supraorbital nerve due to application of a halo fixation device. Neuroma resection and microneural repair resulted in prompt resolution of symptoms without compromise of nerve function.

Comparison of otoplasty techniques in the rabbit model

The relative merit of cartilage scoring versus suturing in otoplasty remains a subject of debate among leading plastic surgeons. We compared a variety of otoplasty techniques in 42 rabbit ears using anterior or posterior scoring, horizontal or vertical mattress sutures, and combinations of scoring and suturing. The ears were splinted with a right-angle fold for 10 postoperative days, and the animals were killed after 8 weeks. Suturing techniques, alone or in combination with scoring, maintained an angulation significantly closer to the desired. 90 degrees than anterior or posterior cartilage scoring (p < 0.05). The greatest accuracy and consistency were seen with horizontal mattress suturing, which provided an average angle (± SD) of 86 ± 8.5 degrees. Histological analysis demonstrated a significant increase in cartilage hyperplasia with suturing alone, whereas the other techniques achieved only mild to moderate increases. Our findings support the usage of horizontal mattress sutures to create the antihelical fold in otoplasty.

Saline made viscous with polyethylene glycol: A new alternate breast implant filler material

&NA; Silicone shell implants filled with either saline or polyethylene glycol 20000 at 85 percent weight/volume were placed subcutaneously on the dorsal aspect of 20 rabbits, and after 2 weeks, selected implants were ruptured by subcutaneous insertion of a hypodermic needle. After 6 weeks and 6 months, histologic analyses of tissue samples from both groups showed no deviation in any organ from the norm. Further physical and chemical experiments on these devices showed no contradiction to their use as potential alternative filler material for breast implants in plastic surgery.

Iloprost enhances survival of axial-pattern skin flaps in an ischemia- reperfusion model

Iloprost, a stable prostacyclin analogue, significantly enhances the survival of an axial-pattern groin flap in rats after ischemia-reperfusion. Treated flaps showed viability over 90 percent of their area 7 days after an 8-hour ischemic episode, whereas the saline-treated controls were viable over only 20 percent of their area (p = 0.002). This effect was seen at a low (10 ng/kg) dosage, and no apparent side effects were noted.