Emrah Arslan

Diced cartilage grafts have long been used in rhinoplasty. Along with their various reported advantages, they also have some disadvantages. The irregular resorption rate of the engrafted mass is one of the major issues noted with diced cartilage grafts. An explanation for the unpredictable resorption rate has not yet been elucidated. This study aimed to determine the role of traumatized versus nontraumatized cartilage as the source of diced cartilage grafts. This study included the noses of 32 patients (19 traumatized noses and 13 nontraumatized noses) who underwent surgery using Surgicel-wrapped diced cartilage grafts. The most remarkable result noted in this study was that a Surgicel-wrapped diced cartilage graft, if prepared from traumatized cartilage (in 19 patients), failed to maintain a stable long-term volume. Partial volume loss was noted in 100% of these patients. However, the rate of this partial resorption was different for every individual and could not be predicted. The highest retention of cartilage graft volume was seen primarily over the nasal osseocartilaginous junction. In nontraumatized patients, however, the engrafted mass maintained long-term volume stability. These patients evidenced no visible external irregularities, and only a few very slight imperfections were noted with finger palpation. Diced cartilage of traumatic origin is not recommended for any purpose. In such cases, the authors’ engrafting algorithm consists of autobone or ear conchal cartilage grafts for dorsal augmentation, columellar struts from the nontraumatized part of the septum, and spreader grafts from the nontraumatized part of the septum or ear concha.

Background: Dorsal hump reduction is a critical step in rhinoplasty. Most of the reasons behind revisional procedures are related to incorrect hump reduction.Methods: The authors used a modified dorsal hump reduction method in their primary cases, the steps of which are as follows: 1) dissection of the nasal vault; 2) bilateral submucoperichondrial dissections to free the cartilaginous septum; 3) separation of the upper lateral cartilages from the cartilaginous septum; 4) partial dissection of the upper lateral cartilages from the inner surfaces of the nasal bones bilaterally; 5) separation of the bony septum from the nasal bones bilaterally; 6) reduction of the partially isolated nasal bones; 7) en bloc cartilaginous and bony septum removal. The authors have operated on 68 primary cases over a 2 year period (30 mo).Results: In the great majority of cases, the results were satisfactory. No revisions were performed in this patient group.Conclusions: This method is a good alternative to traditional techniques in noses with a high and narrow roof, thin skin, and weak middle nasal vault. Revision could be performed more easily when required. Initially, wide noses may not seem good candidates for this procedure; however, careful case‐based preoperative planning may overcome this difficulty.

The authors compared a single fascicle nerve (SFN) repair technique to the traditional nerve trunk autograft. A rat sciatic nerve model was used to determine if a thinner SFN autograft would provide adequate nerve regeneration for a nerve gap repair and result in more rapid nerve regeneration than the conventional nerve trunk grafting technique. The hypothesis was that a pure sensorial graft would allow return of both sensory and motor function as well as a mixed graft. Thirty-six male Lewis rats were randomized into six experimental groups. The sciatic nerve of the animals was exposed and transected proximally and distally. The rats received one of six nerve repair techniques including: a control group with no repair; conventional nerve trunk autograft; tibial SFN repair; peroneal SFN repair; sural SFN repair; and a three SFN repair. Functional nerve recovery was assessed by three separate tests. Sensory and motor recovery were assessed weekly via the Mantel-Haenszel pin prick and toe spread tests. Electrophysiological studies were performed at the 6th and 12th postoperative week using SomatoSensory Evoked Potential (SSEP) testing. Sensory and motor function evaluation demonstrated better recovery in the SFN autograft recipients, compared to the traditional nerve trunk autograft group. SSEP testing at the 6th and 12th weeks confirmed these results, and generated 4.32 milliseconds of P1/N2 latency values for the sural nerve group, which was similar to the non-operated control side. This was not observed in the conventional nerve trunk group in which P1/N2 latency values were within 7.65 milliseconds. All of the rats that received an SFN graft had regained complete sensory recovery by the 4th postoperative week; nerve trunk group recovery at 4 weeks regained 38% of sensory return and full recovery was seen at 8 weeks. In addition to demonstrating full sensory recovery, the sural SFN group exhibited complete motor recovery as early as 8 weeks, whereas the remaining groups including the traditional nerve repair group regained only 77% of their normal motor function. This study introduced the concept that thin SFN autografts demonstrate better functional recovery, compared to traditional nerve autograft techniques. Among the three SFN grafting methods used (tibial, peroneal, and sural), the sural SFN autograft led to the best functional recovery. The advantages of utilizing an SFN graft over the traditional nerve grafting technique include less nerve graft needed for reconstruction of a nerve gap, reduced morbidity at the donor site, and significantly more rapid return of function.

Because of physiologic changes with advancing age as well as previously traumatized and then healed tissues, secondary rhinoplasty for a middle-aged patient is a challenging procedure. Depending on both factors, changes in the midvault can cause a functional airway disorder, and the nose also may need a complete correction for cosmetic purposes. To achieve aesthetic and functional outcomes, augmentation rhinoplasty using a combination of triple cartilage grafts, namely, spreader, columellar, and dorsal onlays, was performed for 12 patients. Sufficient nasal airways with satisfactory appearance were achieved for 11 of 12 patients. Only one patient had improved but still insufficient nasal function with a good aesthetic result. Augmentation rhinoplasty using a combination of triple cartilage grafts for middle-aged patients could be considered an effective procedure for improving the patient’s nasal airway and appearance.

The article describes an enhanced frontalis sling procedure in the management of blepharoptosis with poor or no levator function. This modified method were used in the care of three patients and based on the principal of two-point fixation of the graft material that was prepared from solvent-dehydrated cadaveric fascia lata onto the frontalis muscle. After more than 1 year of follow-up, no recurrence was noted. With no extra incision over the skin, this surgical approach could be useful in the correction of difficult ptosis cases.