The Effect of Skeletal Remodeling on the Nasal Profile: Considerations for Rhinoplasty in the Older Patient

The effect of continued differential growth of the adult male craniofacial skeleton on the nasal profile is examined in the present study. Two groups of individuals (N= 20) were compared, young (ages 16–23) and old (49–64). A three-dimensional CT scan was created for each individual in a standardized view. The change in position of four skeletal reference points with soft tissue correlates was analyzed. Changes were evaluated in both the vertical and the horizontal dimensions relative to the sella-nasion and to a perpendicular from the sella-nasion. Results show that the area of the maxilla at the pyriform remodels posteriorly with age (p= 0.017), while the position of the other three points does not change in a significant fashion. This suggests that differential growth continues to occur in the aging craniofacial skeleton. Differential growth is further documented by calculating the percentage change in the position of any of the four points: the pyriform changed 80.2% from young to old, while the other points changed only from −9.3 to +22.1%. The craniofacial skeleton is the scaffold for the overlying soft tissues. Because the pyriform aperture represents the skeletal platform for the nasal pyramid, pyriform remodeling in a posterior direction retrudes the nasal profile with age. In addition, loss of pyriform height may distort the normal relationship of the alar base to the columella. These changes require assessment for the optimal result from aesthetic rhinoplasty.     

Helical Advancement with a Posterior Auricular Pull-Through Flap: A Technique for Reconstruction of Combined Helical and Scaphal Defects

Ear reconstruction after skin cancer resection has traditionally challenged the reconstructive surgeon and many techniques of reconstruction have been published as a testiment to this. With the widespread use of Moh's technique for resection, more tissues are now available after resection, and this has created a new challenge for the reconstructive surgeon—to use creatively all the remaining tissues and maximize the aesthetics of the ear reconstruction. This paper demonstrates a one-stage technique for reconstruction of a combined helical and scaphal Moh's defect which utilizes helical advancement with a posterior auricular skin flap.     

Reconstruction of Saddle Nose Deformities Using Porous Polyethylene Implant

Various materials have been employed for nasal contour restoration. We used porous polyethylene implants in reconstruction of saddle nose deformity in 36 cases. Only one complication occurred in the 8–18 months follow-up period. No implant was removed. Both cosmetic and functional results were accepted as pleasing by the patients.     

Reconstruction of Extensive Long-Bone Defects in Sheep Using Porous Hydroxyapatite Sponges

The capacity of hydroxyapatite (HA) implants to support large defect repair in weight-bearing long bones of large size animals was investigated. Diaphyseal resections 3.5 cm of the tibia were performed in five adult sheep. They were substituted with HA macroporous ceramic cylinders anatomically shaped, and an external fixator was assembled. The sheep were sacrificed at 20, 40, 60, 120, and 270 days after surgery, respectively. Histology and micro X-ray study of resected implants and adjacent tissues showed proper integration of ceramic with newly formed periosteal bone as early as 20 days after surgery. In one sheep, the external fixator was removed 5 months after surgery. The animal gained the ability to walk with no functional impairment until it was sacrificed 4 months later. At this time, extensive integration of ceramic with bone was detected radiographically and confirmed by a morphological study of the resected sample. Our data indicate that large defects in a weight-bearing long bone can be repaired to the extent necessary for full functional recovery in large animals. These data set the stage for further intervention on material properties as well as for preliminary attempts to use ceramic prostheses for reconstruction of large bone defects in humans. Received: 15 July 1997 / Accepted: 9 July 1998     

Body Dysmorphic Disorder and Aesthetic Surgery: Case Report

The appearance of psychiatric disorders among plastic surgery patients is well-known, and its frequency is higher than in other surgical branches. There is evidence that these patients may suffer from body dysmorphic disorder (BDD), a mental disorder characterized by excessive concern about some imaginary or slight physical defect, causing significant clinical discomfort, social deterioration, and losses in other important areas of the individuals' activity. We present a typical case of BDD and discuss diagnostic criteria and the proper attitude the plastic surgeon should adopt toward this kind of patient.     

Rupture of Trilucent-Type Breast Implants: A Clinical Case

We present the case of a patient who underwent cosmetic breast augmentation in 1996, with Trilucent-type implants. Four years later, there were delayed complications inherent in the implants, which caused serious clinical problems.     

Primary Reconstruction of the Ala Nasi in Cleft Lip

Displacement of the lateral crus of the alar cartilage of the nose in cleft lip is demonstrable in diagrams showing the pathological anatomy of this deformity. An account is given of our method used for several years, whereby the lateral limb is returned to a more natural position, alar convexity is restored, and the angle between the limbs is corrected. Two flaps taken from the inside surface of the nostril are alternated. The caudal one is a full-thickness flap composed of vestibular skin, while the cranial flap comprises the cartilage and the vestibular mucosa; the lateral limb is left attached to the mucosa. Alternation does not require any interruption of cartilage continuity, so there is no risk of surgical damage to the perichondrium and cartilage in young subjects. The two limbs (particularly the lateral one) are positioned in such a way that their normal growth can be expected, as shown by the aesthetic results on follow-up after a period of many years. This method is a primary reconstruction technique of the ala nasi, applied at the same time as the lip repair and compatible with current methods.     

Use of Porous High-Density Polyethylene in Revision Rhinoplasty and in the Platyrrhine Nose

Nasal reconstruction presents a significant challenge to the facial plastic surgeon. Reestablishment of the desired aesthetic nasal contour and restoration of respiratory function are the dual goals of this endeavor. While autologous cartilage or bone is considered optimal grafting material, the supply is often limited and harvesting entails additional morbidity. Many synthetic materials have been introduced for use in nasal reconstruction, but high infection and extrusion rates have left most surgeons dissatisfied with conventional implants. Porous polyethylene (Medpor) implants were used for nasal reconstruction in 187 patients; 66 (35.3%) patients underwent primary rhinoplasty, while revision surgery was performed in 121 (64.7%) patients. Most patients required multiple implants, including columella struts, plumper grafts, dorsal tip implants, and nasal valve battens. Postoperative follow-up ranged from 6 months to 3.5 years. Complications occurred in five (2.6%) patients. Three early and two delayed infections necessitated implant removal in five patients, all of whom had compromised skin–soft tissue envelopes secondary to heavy smoking, cocaine abuse, or prior surgery. One case of an overly augmented nasal dorsum and tip required implant removal, reduction, and reinsertion. All implants were easily removed. No other complications including implant extrusion or skin erosion have been noted. Porous polyethylene (Medpor) implants allow for fibrovascular ingrowth, which lends stability to the implant. Porous polyethylene implants are well tolerated and provide an ideal material for nasal reconstruction.     

Evaluation of the Median Forehead Flap and the Nasolabial Flap in Nasal Reconstruction

Basal cell carcinoma, which accounts for 70%–80% of all cutaneous malignancies in the United States, has increased recently in Japan. We compared methods for reconstruction after surgery for basal cell carcinoma, which is expected to increase further in the future. Thus patients who underwent reconstruction after surgery for basal cell carcinoma of the nose using medial forehead flaps and nasolabial flaps were selected, and the effectiveness of these flaps was compared by taking the size and location of the tissue defect into consideration. As a result, possibly because of anatomical and histological differences of the face between Caucasians and Asians, better results were obtained with nasolabial flaps than with median forehead flaps.     

Effect of Polyethylene on Osteocalcin, Alkaline Phosphatase and Procollagen Secretion by Human Osteoblastic Cells

We have studied the direct effects of polyethylene particles on osteoblastic function in primary human bone cell cultures. The cells were obtained from trabecular bone fragments of patients undergoing knee reconstructive surgery. When the cells reached confluency, they were subcultured into two flasks, one untreated (control culture) and the other treated with polyethylene particles, and incubated until confluency. Osteoblastic function was evaluated by assaying osteocalcin, alkaline phosphatase, and C-terminal procollagen type I, with and without 1,25(OH)₂D stimulation, in the cell-conditioned medium. We found that addition of polyethylene to these osteoblastic cell cultures induced higher levels of secreted osteocalcin after 1,25(OH)₂D stimulation. Alkaline phosphatase levels increased whereas C-terminal procollagen type I levels decreased in the cell conditioned medium after polyethylene was added to the cultures. Treatment of the control cultures with 1,25(OH)₂D stimulated alkaline phosphatase levels and decreased C-terminal procollagen type I. However, these osteoblastic markers in 1,25(OH)₂D-treated cells did not change in cultures with polyethylene. This study demonstrates that polyethylene particles have a direct effect on osteoblastic markers in human bone cells in culture. Received: 2 May 1996 / Accepted: 17 June 1997     

Equivalence of Nasal Spray and Subcutaneous Formulations of Salmon Calcitonin

The aim of this study was to assess the efficacy and safety of nasal spray and subcutaneous formulations of salmon calcitonin. Two-hundred-four patients, 27 males and 177 females, aged 72 years on average, with a recent, painful, vertebral crush fracture were given either 50 IU/day of subcutaneous salmon calcitonin (SCSCT, 102 patients) or 200 IU/day of intranasal salmon calcitonin (INSCT, 102 patients) for 30 consecutive days, according to a double-blind, double-placebo design. The two-sided 95% confidence interval of the difference between the two formulations for the pain on D30 assessed by Huskisson's Visual Analogue Scale (VAS) [−5.3 mm, 7.9 mm] was included in the [−10 mm, 10 mm] reference interval. Equivalence of the two formulations, was demonstrated. At the end of the study, the 95% confidence intervals of VAS of both treatment groups were included in the [0 mm, 30 mm] interval, which is considered to be clinically pertinent. Relief was obtained in less than 10 days for more than 50% of patients. The urinary hydroxyproline/creatinine and calcium/creatinine ratios remained constant between D1 and D30 with both formulations. General safety was comparable between the two formulations. Local safety of INSCT was similar to that of its placebo. Received: 13 August 1996 / Accepted: 31 December 1996     

Open Rhinoplasty Through a Forked Flap Incision

Surgical elongation of the short columella is a challenging problem for the surgeon. Although some flaps from the upper lip are successfully used to correct this deformity on cleft lip patients with a scarred upper lip, these methods cannot be applied to noncleft patients with a smooth upper lip. Distant flaps and composite grafts do not give the best aesthetic results. The use of an external approach for rhinoplasty is preferred by many surgeons, especially for difficult or secondary cases. Most incisions for open rhinoplasty are placed on the columella. This report describes a new incision for open rhinoplasty to be used on patients with a short columella. The incision is a standard forked flap with a columellar base but the legs of the flap extend to the nostril bases instead of to the upper lip. This method was used on eight aesthetic rhinoplasty patients with a short columella between March 1995 and March 1998. The results of the method are discussed.     

Unilateral Osmotic Swelling in Textured,Single-Lumen,Saline-Filled Mammary Implants: Clinical and MRI Findings

An odd complication following routine breast augmentations was observed in two patients. Single-lumen, textured, high-profile, saline-filled mammary implants were placed in the submuscular plane and postoperative course was uneventful in the presented cases. Unilateral, gradual, and spontaneous swelling in one of the operated breasts was observed 6–14 months after surgery that prompted patients for examination. MRI showed regular external contours of the mammary implants without any evidence of rupture or extracapsular leakage. However, a substantially volumetric increase in the auto-inflated implant was noted since transverse diameter of the right breast implant was twice the left normal implant. All cases had to be re-operated and implants were explanted. Auto-inflated implants were checked and were found to be intact. Intraoperative findings included swelling of the implant and brown discoloration of the previously-transparent saline solution. Furthermore, composition of the fluid inside the expanded implant was found to have changed, possibly through an osmotic gradient. Several mechanisms such as osmotic swelling, defect at the valvular system of the implant, and inorganic salts yielded from texturization process in the shell are suggested but further research with more refined techniques should be done. The present study provides supplementary MRI and confirmatory clinical findings on this bizarre phenomenon and other factors apart from the disruption of the implant integrity may play a role.     

Reconstruction of the Eye Socket

Ten cases of irradiated and exenterated orbits in retinoblastoma patients were treated for reconstruction of the eye socket. The follow-up was from 1 to 5 years, with no retraction of the treated area and without sequels of the donor site. The author finds that this pathology is a new and precise indication for the grafted temporofascial island flap described by Dr. O. Erol.     

Umbilical restoration in abdominal dermolipectomy: A simple double-Y, double-M technique

The authors present a simple technique for restoration of the umbilicus in abdominal dermolipectomy. This procedure is represented by a double-Y cutaneous incision on the abdominal skin and by a double-M cutaneous incision on the umbilical skin. This technique restores a neoumbilicus with multiple small skin flaps and conceals the periumbilical scar at the bottom of the umbilicus. Different designs and figures are proposed to explain the procedure.     

Calcium-Induced Natriuresis: Physiologic and Clinical Implications

Assessment of the tubular reabsorption of calcium (Ca) by infusion is complicated by suppression of parathyroid hormone (PTH) secretion, and by activation of the serpentine Ca sensing receptor in the renal tubule, which inhibits Ca and sodium reabsorption, but little is known about the magnitude of the natriuretic effect of Ca in human subjects. Accordingly, we reanalyzed the relationship between serum Ca and urine Ca and sodium excretion expressed per unit of creatinine clearance (CaE and NaE), and per unit of time (UCa and UNa), during a standard Ca infusion, in 14 healthy volunteers and in 8 primary hyperparathyroid patients. In healthy subjects we observed a large effect of Ca infusion on NaE, which rose as high as 8 mmol/liter GFR. In patients with primary hyperparathyroidism both CaE and NaE during Ca infusion were significantly lower overall than in healthy subjects for comparable values of serum Ca (P < 0.05 by covariance analysis), due mainly to a decline or reversal of the slopes at the highest serum Ca levels. In both controls and primary hyperparathyroid subjects the variance of CaE as dependent variable was explained by both serum Ca and by NaE as independent variables (P < 0.001). We conclude that (1) The natriuretic effect of hypercalcemia was unexpected large and if maintained would lead to substantial depletion of extracellular fluid. (2) Patients with chronic hypercalcemia, including primary hyperparathyroidism, probably have mild sodium depletion, and are more susceptible to volume depletion. (3) Calcium reabsorption during Ca infusion is reduced by suppression of PTH secretion and increased by volume contraction due to sodium depletion. Discrimination between different basal levels of parathyroid function is successful because these effects usually cancel out. (4) The increase in tubular reabsorption of Ca due to volume contraction can initiate a vicious circle, of importance to the pathogenesis and treatment of severe hypercalcemia. Received: 11 May 1999 / Accepted: 13 January 2000     

Ultrastructural and Electron Diffraction of the Bone-Ceramic Interfacial Zone in Coral and Biphasic CaP Implants

We investigated the influence of natural coral implants used as a bone substitute on the quality of bone ingrowth in rabbits 2, 3, and 6 weeks after implantation. Explants were characterized by transmission electron microscopy and electron diffraction. Bone ingrowth has been previously demonstrated by light microscopy, however, few have been performed in electron microscopy to compare mineralized tissue ingrowth in coral implants which occurs at the expense of calcium carbonate to that of calcium phosphate (CaP) implants. The interface between coral aragonite and mineralized tissue or bone was abrupt, with no invasion of the aragonite structure by newly formed crystals, as occurs in micropores when biphasic CaP (BCP) ceramics were used. The restoring process appears to be different from that induced by BCP implants. Precipitation of needle-like apatite crystals on the CaCO₃ implant surface was not observed. Instead, apatitic smooth-shaped crystals formed in aggregates. The coral dissolution process does not release phosphate and so precipitation of apatite does not occur in the micropores of the coral implant, thereby limiting the formation of an apatite layer and hence bone bonding to the outer surface of the implant. In addition, on the outer surface of the implant, close to bone and a phosphorus source, the CaP crystals that do form are in aggregates presumably due to the carbonate and mismatch between the aragonite and the apatite. This seems to result in a delayed bone attachment or weaker bone bonding than CaP implants which encourage an epitaxial biological crystal deposition. Received: 21 July 1995 / Accepted: 7 August 1997     

Estrogen,Progesterone and Testosterone Receptors in Human Fetal Cartilaginous Tissue: Immunohistochemical Studies

Computerized image analysis was used to study the distribution in cartilage of receptors to estrogen, progesterone, and testosterone during human fetal development. We have examined three histologically distinct cell groups (hypertrophic, proliferating, and reserve zones) in long bones, vertebrae, and trachea from 19 fetuses. Comparisons were made across gender and gestational age. Contrasting with controls, we examined the density of receptors, the size of the nuclear area in which the receptors were detected, the number of hormone receptor-bearing cells, and the total receptor quantity per sample. We found that estrogen, progesterone, and testosterone receptors were detected in the nuclei of all cell types, in both female and male embryonic cartilaginous tissue. Gender differences were small and inconsistent. Changes associated with gestational age depicted a pattern of hormone receptor manifestation, shifting from the immature cell types to more differentiated cells. This was evident from the receptor densities and from the cellular area in which receptors were sighted. These dynamics are accompanied by a general increase in receptor content per sample, brought about by the concomitant increase in receptor containing area size and cell number. The increase in receptor levels seems to reflect the maturation and growth of the fetal skeleton. Received: 9 October 1995 / Accepted: 22 November 1996     

Correction of a Posttraumatic Nasal Deformity Using a Hard Palate Mucosa Graft

We report corrected cases of posttraumatic nasal deformity using a hard palate mucosal graft as covering material of the inner-side defect. In all cases, the deformity was corrected satisfactorily. The nasal cavity was preserved, and because of the stiffness of the grafted mucosa, it did not collapse in the course of breathing. In all cases, the palate donor site healed in approximately 2 weeks, and after healing, none of the patients complained of irritation or ulceration. These results indicate that hard palate mucosa is also applicable in the correction of a traumatic deformity of the nose as an alternative to the auricular composite graft equally in the case of a nontraumatic deformity.     

Comparative Study of the Reconstruction of Articular Cartilage Defects with Free Costal Perichondrial Grafts and Free Tibial Periosteal Grafts: An Experimental Study on Rabbits

The purpose of this study was to compare the chondrogenic potential of free perichondrial with free periosteal grafts in the resurfacing of full-thickness defects of patellar articular cartilage in rabbits. We used adolescent New Zealand rabbits weighing between 2.4 and 3.6 kg. A 6-mm wide and 3-mm thick defect was created on the patellar articular surface. A total of 30 rabbits were randomly divided into a control group and two test groups. One test group received free perichondrial grafts (PC); the other received free periosteal grafts (PO). All the animals were killed 8 weeks after surgery. All the histological samples were scored from 0 to 17 according to a standard scoring system. Differences in the quality of the regenerated tissue were only found between the control and the test groups. There were no statistically significant histological differences between the grafted defects of the PC and the PO groups that there are not on any of the variables. The results of this study support that there are not significant differences in the quality of the repair tissue when using these two types of biological grafts. Received: 7 July 1998 / Accepted: 8 January 1999