Mini-forum: rhinoplasty by external approach. Collumello-trans-alar approach of open rhinoplasty: advantages]

For several years, the authors have been using a columellar transalar incision through the medial crus along the nasal septum, reaching the vault and continued laterally by a transalar cartilaginous incision. The nasal tip is thus opened like a car-hood, leaving the alar cartilage attached to the skin and exposing the triangular cartilage and the nasal septum. This approach allows septoplasty to be performed with excellent exposure. The tip is easily revised backwards allowing anomalies to be viewed directly. The advantages of this external approach compared with the classical external Rethi's approach are multiple: simplicity and rapidity of the technique, excellent access to triangular cartilages and the triangular-septum junction; possibility of always going from an endonasal approach to an external one and excellent access to the tip. Moreover, there is no long term swelling of the tip. The indications of this external approach are asymmetry of the tip, excessive tip projection, saddle nose deformities and secondary rhinoplasties. No complication has been observed in a series of 32 patients with a follow-up of 6 to 48 months. There is no disturbance of the tip position and the skin scar is imperceptible.     

Mini-forum: rhinoplasty by external approach. External or endonasal approach for rhinoplasty?]

There appears to be a renewed interests in the external approach to rhinoplasty, first described 60 years ago, despite the external columellar incision, due to the excellent exposure of the cartilaginous structures provided by this approach. Progress has been made in rhinoplasty. Cartilage grafts are much more widely used than in the past and surgeons try to reconstruct a normal anatomy of the skeleton, which has become easier with this approach. However, the closed approach has demonstrated its efficacy for a long time and allows correction of a large range of deformities. The open rhinoplasty should not be the standard procedure and its indications should only be based on limitations of the closed approach. The external procedure is particularly indicated in some difficult cases of nasal tip surgery and secondary rhinoplasty.     

Technical aspects of appendectomy]

The author suggests a guiding plate for appendectomy that enables a surgeon to make incisions of the anterior abdominal wall in adults strictly in accordance with the demands of the Volkovich-D'yakonov access. Moreover, he suggests a wound spreader for appendectomy, supplied with a grip mechanism, that helps avoiding peritoneal traumas and facilitates suturing of muscles.     

Methods of burn treatment. Part II: Technical aspects]

The best treatment for burns and scalds depends on the depth of the skin necrosis. Epidermal and superficial dermal burn injuries (IIa) can heal spontaneously with conservative treatment without scar development, but deep dermal or full-thickness burns constitute an absolute indication for surgery. Full-thickness or split-thickness skin grafts are used for wound closure. In the case of extensive burn injuries allografts are used for temporary wound closure. In certain licensed laboratories autologous keratinocytes can be cultured for transplantation. In circumferential burn injuries affecting the extremities or the trunk the rigid eschar has to be incised to relieve the pressure behind it. Following a debridement conservative treatment of superficial dermal burns involving wound coverage with biosynthetic dressings or nanocristalline silver gauze dressings or use of special disinfecting ointments can be implemented.     

Psychologic aspects of revision rhinoplasty

This article is designed to provide some utility in identifying favorable prospective patients for revision rhinoplasty having balanced yet slightly divergent views, expectations, and more importantly, unfavorable candidates who are best left unrevised. The management after-the-fact of the few patients who meet with and unsatisfactory outcome is also discussed.     

Technical note: "look-ahead" navigation method for K-wire fixation in rhinoplasty.

OBJECTIVE: The Kirschner wire (K-wire) technique for fixation of rib cartilage grafts to the maxilla is a powerful tool in rhinoplasty. It gives the nose unparalleled anterior projection. However, the technique is challenging because of poor maxillary visualization through the open rhinoplasty approach. Inaccurate K-wire placement can cause dental injury or violation of the nasal/palatal mucosa. This study evaluates the efficacy of a surgical navigation system to guide K-wire placement. STUDY DESIGN: K-wires were placed, through an open rhinoplasty approach, into the maxilla of 12 fresh cadaver heads by a single surgeon. Six control specimens had K-wires placed without navigation. Six treatment specimens had K-wires placed with the "look-ahead navigation method," in which a surgical navigation device was attached to the K-wire gun. All maxillae were then sectioned to determine the final location of the K-wires. RESULTS: Four out of five (80%) of the K-wires were successfully placed in the treatment group, although only 3 out of 6 (50%) of the K-wires were successfully placed in the control group. One treatment K-wire was dislodged during the sectioning process and had to be excluded. The average K-wire deviation in the axial plane was less for the treatment group (0.2 +/- 0.4 mm) than for the control group (1.8 +/- 1.5 mm; P < .05). CONCLUSION: When surgical navigation is used in K-wired cartilage strut graft placement to maxilla, it can improve the accuracy of K-wire placement. This may result in reduced complications due to errant K-wire placement.     

Surgical therapy of varicocele. Technical note on the inguinal approach]

BACKGROUND: There are several therapeutic proposals for idiopathic varicocele treatment, but all of them present a certain number of relapses. The technique proposed consists, through an inguinal approach, in a systematic ligation and section of all veins potentially responsible of a venous reflux. METHODS: During a period from 1990-1995 a total of 73 patients were surgically treated for idiopathic varicocele with this technique. All patients underwent preoperative spermiogram, hormonal assay and Doppler velocimetry. Through an inguinal approach, under selective spinal anaesthesia, a ligature and section of the internal spermatic vein at the internal inguinal ring is performed, followed by searching, ligature and section, of other veins responsible of venous reflux (external spermatic vein, anastomosis with sapheno-femoral veins, arteriovenous micro-anastomosis, pubic veins). The patient is discharged within twenty-four hours. RESULTS: An external dilated spermatic vein was discovered in 30.1%, pubic veins in 49.3%, anastomosis with safeno-femoral veins in 10.9% and arteriovenous micro-anastomosis in 43.8%. There were no mortality or serious postoperative morbidity; only in five cases there were complications consistent in two orchitis and three hydrocele. No relapse at follow-up (12-36 months), performed with palpation and a Doppler study, was found, while there was a spermiogram improvement in 61.6% of cases. CONCLUSIONS: This surgical approach is a safe and radical treatment without any relapse, of all types of varicocele.     

The transvestibular approach: a new horizon in rhinoplasty

The lower lateral cartilage has intricate anatomical elements that define shape, projection, and relations with other nasal tip structures. Good exposure of the lower lateral cartilages is an essential step in rhinoplasty. Conservative surgical techniques are essential to get natural long-term results. Different endonasal techniques have limitations in visualizing the lateral and intermediate crura, predisposing patients to asymmetries in reduction and rearrangement. In this article, a new endonasal rhinoplasty approach is described. Using a marginal incision, the vestibular skin is elevated and the endonasal surface of the lower lateral cartilage is exposed, permitting precise reduction, rearrangement, and placement of interdomal suspension sutures and lateral crural spanning sutures. This article discusses the surgical steps and results of my experience using this approach. This transvestibular approach is a new, dependable, and simple method that should allow rhinoplastic surgeons to perform this operation with predictable results and limited variables.     

Postero-lateral surgical approach to soft cervical herniated discs. Technical note]

Most ruptured cervical discs are operated on by an anterolateral approach. The posterior approach is an older procedure, nowadays underused because it was associated with a high morbidity, especially in terms of medullary complications. However, posterior approach has evolved in posterolateral route, which is not so devastating and has a very low morbidity rate. It gives excellent functional results when surgery is dedicated to monoradiculopathy from soft posterolateral cervical hernias. It seems appropriate to consider this surgical route as an alternative to anterolateral surgery in these very selected cases. The authors describe and comment the technique.     

Repair of cartilage defects. Technical aspects

Efficacious treatment of chondral and osteochondral defects of the weight bearing surfaces represents a real challenge for the orthopaedic surgeon. Treatment options for full thickness cartilage defects are discussed in this paper. Poor biomechanical characteristics of the reparative fibrocartilage promoted by "traditional resurfacing techniques" provide only moderate clinical outcome in the treatment of such lesions. During the last decade several new efforts have been expressed to provide a hyaline or hyaline-like gliding surface for a full thickness defected area on the weight bearing surface. Among several surgical procedures, autologous osteochondral transplantation methods, including osteochondral mosaicplasty, chondrocyte transplantation, periosteal and perichondrial resurfacement and allograft transplantation are the favoured "new methods". Experimental background, operative techniques and clinical results of these new procedures are detailed in this overview. According to the early and medium term experiences of these methods it seems that a hyaline or hyaline-like resurfacement of the defected area can provide a more durable gliding surface and a better clinical outcome than the so called "traditional resurfacing techniques". Autologous osteochondral mosaicplasty--as an easy, one-step procedure, providing a relatively quick rehabilitation--can be an alternative in the treatment of small and medium sized lesions. Excellent clinical outcome, low costs of the treatment and short rehabilitation time represent the main advantages of this method. Autologous chondrocyte transplantation seems to be a promising option in the treatment of larger full thickness defects but requires relatively expensive two-step procedure and longer rehabilitation period. Both of the above mentioned techniques have femoral, tibial, patellofemoral and talar applications as well. According to the present recommendations transplantation of osteochondral allografts can be indicated at massive osteochondral lesions. There are less experiences with the clinical use of periosteal and perichondrial resurfacing techniques and biomaterials. Beside the promising early and medium term results of these methods the authors express that a successful treatment of the full-thickness cartilage damages of the weight bearing surfaces depends not only the way of the cartilage repair but on the treatment of the underlying cause as well. According to this statement for an effective treatment of full thickness defects on the weight bearing surfaces requires careful patient selection, complex operative plan and well organized treatment course.     

Monitoring of intracranial pressure with intraparenchymal fiberoptic transducer. Technical aspects and clinical reliability]

A fiberoptic intracranial pressure transducer (Camino) was assessed prospectively in 100 patients. In all, 122 sensors were inserted intraparenchymally at the bedside, without the help of a neurosurgeon. Before the procedure, patients were given 2 to 4 mg of phenoperidine. The scalp was opened over a few millimeters in the frontal paramedian area. A burr holc was made with a 2 mm bit. The dura mater was opened and a hollow screw inserted in the diplo?. When the zero of the transducer had been obtained, a 5 cm length was inserted within the screw. The transducer was then about 5 mm deep within cerebral parenchyma. The procedure took an average of about 15 min. An intracerebral haematoma around the transducer occurred five times. One had to be drained surgically. There were no infectious complications. The daily baseline drift was about 0.3 mmHg. The system seemed to be reliable: there was close agreement between the intracranial pressure (ICP), neurological status and CT scan findings. In trauma cases, there was also good correlation between mean ICP and the basal cistern obliteration score, finally, ICP became equivalent to mean arterial blood pressure in all brain dead patients. It is concluded that this system may be used in all cases where ICP requires to be monitored, even when the lateral ventricles are no longer visible, or when craniotomy has been performed. This will most probably result in a more extended use of ICP monitoring in neurosurgical intensive care.     

Auditory aspects of congenital malformations of the external and middle ears]

Auricular malformations are frequently associated to malformations of the external, the middle, and the inner ear in variable degrees. Asystematic audiometry must be performed in case of unilateral facial microsomia. This test which can be performed in very young patients can detect bilateral ear malformations necessitating auditory rehabilitation by surgery or external hearing aids. In major ear aplasia, air conduction hearing aids can rarely be proposed. In this case, bone conduction hearing aids using a mastoid transducer of through a bone anchored device yield the best auditory results with an excellent local tolerance.     

Less is more: A conservative approach to male rhinoplasty

Rhinoplasty in men has caused more traumatic problems of dissatisfaction, as compared to women, ranging from higher rates of complaints to murder of the surgeon. After an evaluation of the special problems related to change, I chose to reduce the amount of hump resected and to restrict the elevation of the nasal tip—nasolabial angle to a minimum compatible with normal appearance. The purpose is to avoid the tag of operated nose. Some illustrative cases are shown. The goal is presented as precision, discretion, and satisfaction. Sometimes, doing less is more.     

Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach

Background. Cardiopulmonary bypass and cardioplegic arrest result in known physiologic inflammatory, coagulopathic, and embolic states that may result in end-organ damage. Interest in off-pump complete coronary revascularization using sternotomy exposure is therefore increasing.

Methods. Using specific surgical and anesthetic techniques, we have been able to achieve total revascularization using off-pump coronary artery bypass grafting procedures (OP-CAB) through a sternotomy approach. Exposure techniques and local stabilization are tailored to individual vessels and cardiac regions. Vascular control is achieved with silicone-elastomer loops, occluders, and shunts. Poor ventricular function, advanced age, and other comorbid conditions, in and of themselves, were not considered contraindications to OP-CAB. Cardiomegaly or situations of small, intramyocardial, or heavily calcified vessels were relative contraindications to OP-CAB.

Results. Of 141 sternotomy OP-CAB cases, 132 (93.6%) were completely off-pump. The mean number of OP-CAB grafts per patient in the cases that were completely off-pump was 3.3 (range, 1 to 6). The 30-day operative mortality was 0%. There were four instances of intraoperative cardiac arrest, precipitated by vascular occlusion of the right coronary artery or manipulating a cardiomegalic heart. Advanced age (≥ 80 years) or profound ventricular dysfunction (ejection fraction ≤ 0.25) was present in a considerable percentage of patients (10.6% and 9.9%, respectively).

Conclusions. Off-pump coronary artery bypass grafting is successful for total revascularization in large numbers of patients. Anatomic factors, including cardiomegaly and small, intramyocardial, or heavily calcified vessels are possible contraindications to OP-CAB. Patients at highest risk for undergoing cardiopulmonary bypass, including those of advanced age and having ventricular dysfunction, are precisely the ones in whom OP-CAB may be the most useful.