Ronald P. Gruber

The spreader flap in primary rhinoplasty.

Background: In a primary rhinoplasty that requires a humpectomy, the dorsal aspect of the upper lateral cartilages is commonly discarded. Many of these patients need spreader grafts to reconstruct the middle third of the nose. However, it is possible to reconstruct the upper lateral cartilages into “spreader flaps” that act much like spreader grafts. Methods: A tunnel is created on the underside of the upper lateral cartilage, which is released from the cartilaginous septum and also from its attachment to the nasal bone (medially). It is then rolled on itself to make a spreader flap, which is secured with sutures. Scoring along the dorsal edge of the upper lateral cartilage may be necessary. The flap is then secured to the dorsal edge of the reduced dorsal septum. Results: In 21 patients who underwent an open approach (and four patients who underwent the closed approach), the spreader flap almost always reconstructed the middle third of the nose. It was easy to execute in the open approach but difficult in the closed approach. At surgery, two patients undergoing the open approach and one patient undergoing the closed approach needed spreader grafts because the flaps were too narrow. Postoperatively, only one patient (operated on by the open approach) exhibited inadequate nasal width. Conclusions: Spreader grafts are the standard for reconstructing the middle third of the nose. However, the spreader flap avoids harvesting and carving cartilage for those grafts. In the open approach, the technique is easy to execute. Conclusions could not be drawn regarding the long-term success with the closed approach.

Breast reconstruction following mastectomy: a comparison of submuscular and subcutaneous techniques.

An analysis of the benefits of submuscular versus subcutaneous implantation was made on mastectomy patients. Ninety-one breast were reconstructed following mastectomy. In 30 breasts, the implants were placed subcutaneously; in 19, subpectorally, and in 42, beneath both the pectoralis and the serratus. The follow-up averaged 2 to 3 years, and recent cases included postoperative tonometry measurements to quantitate the degree of capsular contraction. In addition, 12 cadaver dissections were done to delineate muscle insertion and origins. Results indicate that (1) submuscular implants are clearly superior to subcutaneous ones; (2) subpectoral implantation requires complete detachment of the muscular origin from the ribs; (3) subserratus implantation provides extra muscular coverage, but dissection is more difficult owing to its firm rib attachment; and (4) the subserratus technique provided the lowest incidence of capsular contracture, although the breast was slightly flatter initially, but improved with time.

The effect of commonly used antiseptics on wound healing.

Acetic acid, hydrogen peroxide, and povidone-iodine solutions were applied to experimental wounds in rats and to human donor sites to test their effects on wound healing. Control donor sites were treated with saline or dry Owens gauze. The acetic acid and povidone-iodine solutions had no significant gross or microscopic effect on the wounds. The hydrogen peroxide solution seemed to hasten the separation of the scab and to shorten the healing time, though characteristic bullae and ulceration appeared if the hydrogen peroxide treatment was applied after the crust had separated, when new epithelium was visible. We believe that the use of hydrogen peroxide should be avoided after crust separation. When only dry Owens gauze was used to treat split-skin graft donor areas, the result was a 3-day prolongation of the scab separation (compared to the saline controls) and greater subepidermal reactive and inflammatory changes.

Changing the convexity and concavity of nasal cartilages and cartilage grafts with horizontal mattress sutures: part I. Experimental results.

Prior studies indicated that horizontal mattress sutures can control the curvature of a convex lateral crus. This study undertook to ascertain the ideal spacing for mattress sutures, determine what effect they have on the subsequent strength of the cartilage, and compare that to the resultant strength after scoring procedures used to control curvature. Curved fresh cadaver septa of various thicknesses (0.5, 1, and 1.5 mm) were used. The ideal spacing (gap between suture purchases) for the mattress suture was sought in 15 specimens. The consequent change in stiffness (modulus) of the cartilage was measured in nine other specimens before and after suture placement and after scoring. If the spacing was too large, instability resulted. If it was too small, curvature correction could not be obtained. An ideal mattress spacing (6 to 8 mm for 0.5-mm specimens and 8 to 10 mm for 1.5-mm specimens) removed most curvature and provided stability. The mattress suture increased the stiffness (modulus) above normal and far above that when the curvature was removed by scoring. The mean composite modulus before suturing was 4.6 MPa. After ideally spaced sutures, it was 6.2 MPa, a 35 percent increase in stiffness. After scoring to improve curvature, it was 2.4 MPa, a 48 percent reduction in stiffness (p = 0.02, Wilcoxon signed rank test). The horizontal mattress suture technique corrects cartilage curvature if the appropriate spacing is used. The corrected cartilage is stiffer/stronger than normal cartilage and much stiffer/stronger than if scored.

Suture algorithm for the broad or bulbous nasal tip.

The history and current status of suture techniques to correct a broad or bulbous nasal tip are reviewed. General principles for suture techniques to control tip shape are discussed; they include leaving an approximately 6-mm-wide lateral crus. The algorithm presented includes four sutures, all of which are not necessary in every case. These sutures include (1) the transdomal suture (to narrow the individual domes), (2) the interdomal suture (to provide symmetry and tip strength and sometimes to narrow the tip complex), (3) the lateral crural mattress suture (to reduce lateral crural convexity), and (4) the columella-septal suture (to prevent tip drop and adjust tip projection). The lateral crural mattress suture is the newest of these sutures. It specifically controls undesirable convexity of the lateral crus. The four-suture algorithm is principally designed for primary open rhinoplasties. However, it is also recommended for secondary rhinoplasties. A minor modification is suggested for use in closed rhinoplasties. The algorithm is intended to reduce the difficulty of determining which of the currently available rhinoplasty sutures are useful and in what order they should be used. Illustrative cases are provided. The advantages and disadvantages of this particular algorithm, compared with others that have been proposed, are also reviewed.

Periareolar subpectoral augmentation mammaplasty.

A modification of an established technique to augment the breast is described. Thirty patients underwent subpectoral augmentation though a periareolar incision with a follow-up period of 10 to 16 months. The purpose was to combine the benefit of subpectoral placement (to minimize capsular contracture) with an inconspicuous scar, which usually results from the periareolar approach. Under general anesthesia a periareolar incision was used. Dissection proceeded straight down to the pectoralis muscle, which was split between its fibers to enter the areolar subpectoral plane. The origin of the muscle from the ribs and part of the sternum was detached and the pocket was subcutaneously extended lateral to the muscle. Thus a larger than otherwise expected implant could be inserted without the problem of displacement by the muscle, Postoperative tonometry was done to quantitate the degree of breast softness. Initial results suggested that (1) the incidence of capsular contracture can be reduced by virtue of using th subpectoral plane; (2) breast tonometry measurements of brest softness or firmness correlate well with the clinical impression; (3) the periareolar scar is superior to the inframammary scar; and (4) the periareolar approach allows easy access to the subpectoral plane and allows for better visualization of the muscular detachment.

The intercartilaginous graft for actual and potential alar retraction.

Background: Alar retraction deformities occasionally require significant soft-tissue release and relatively large cartilage grafts. In addition, correction of the short nose by only lengthening the septum can result in potential postoperative alar retraction. Consequently, both types of cases, true and potential alar retraction (in short noses), would benefit from a technique that lengthens the sidewall of the nose. Methods: The intercartilaginous graft technique is a modification of the lateral crural strut graft technique. An intercartilaginous graft is inserted between the upper lateral cartilage and what remains of the lateral crus (lateral crus element). The technique emphasizes maximum soft-tissue release to insert a cartilaginous graft that spans the gap between the upper lateral cartilage and the lateral crus element. The graft is inserted under slight tension to maintain maximum lengthening of the sidewall of the nose. Results: Thirteen patients had intercartilaginous grafts placed. Seven patients had actual alar retraction and six patients had short noses with potential alar retraction. There was no postoperative alar retraction in 10 patients. Two patients with actual alar retraction were not completely corrected, and one required surgical revision. One patient with a short nose exhibited postoperative alar retraction, but it was not significant enough to warrant reoperation. Conclusions: The intercartilaginous graft technique, a modification of the lateral crural strut graft technique, corrects moderate to severe alar retraction and prevents alar retraction after lengthening of very short noses. Its success depends on substantial soft-tissue release and insertion of a maximal sized graft between the upper lateral cartilage and the lateral crus element under slight tension.

Ketamine-assisted intravenous sedation with midazolam: benefits and potential problems.

A review of 134 cases of ketamine-induced intravenous sedation was undertaken. It was concluded that (1) whereas properly titrated midazolam with low-dose ketamine (0.5 mg/kg) can provide almost complete absence of behavioral problems and complete analgesia, transient oxygen desaturation may be seen, and (2) the induction phase of ketamine is an opportunity for the surgeon to rehearse mask ventilation.

Grafting the nasal dorsum with tandem ear cartilage.

A technique for autogenous grafting of the nasal dorsum with ear cartilage is suggested based on the results of 25 consecutive cases. The technique involves (1) harvesting the entire cymba conchae and cavum conchae of the ear; (2) separating them and suturing them to each other in tandem fashion; (3) filling the underside concavity of the cymba conchae part of the graft with scraps of cartilage; (4) avoiding any bruising or crushing of the graft; and (5) filling any minor residual irregularities of the dorsum with soft tissue or cartilage from the cephalic trim of the lateral crus. The results suggest a consistent augmentation of the nasal dorsum for deficiencies from 3 to 6 mm in size. Four of the 25 cases did require secondary correction for dorsal convexity, inadequate augmentation, and surface irregularities. The technique, however, has been helpful in that ear cartilage is invariably available, allowing septum to be used for more important grafts. The procedure is easily performed under local anesthesia with no significant distortion to the donor site.

Lengthening the short nose.

Lengthening short nose is one of the most difficult rhinoplasty problems. Two suggestions are made. First, substantial release of soft tissues is mandatory to lengthen the short nose. Second, the technique espoused involves: (1) releasing the septal mucoperichondrium bilaterally, (2) releasing the septal upper from the lower lateral cartilage, and (3) using a baton graft attached to the septum, which in turn holds the tip cartilages in a more caudal position. Thirteen surgeries were performed with satisfactory results and few complications.