Dorsal Graft Research Articles

Use of Mastoid Periosteum Graft in Primary and Revision Rhinoplasty.

The authors initiated the use of a mastoid periosteum graft to augment or camouflage the dorsum and radix. This report describes the techniques and treatment outcomes of mastoid periosteum grafts in primary and revision rhinoplasty. Medical records of 62 patients who underwent rhinoplasty with mastoid periosteum were reviewed retrospectively. Of these, 21 patients who participated in follow-up for more than 6months were analyzed through a comparison of pre- and postoperative photographs. Aesthetic results were scored on a scale of 0 to 4 (0 = poor, 1 = fair, 2 = moderate, 3 = good, 4 = excellent) with photographic evaluation by two independent surgeons. A mastoid periosteum graft was used in 32 primary and 30 revision cases. The graft was used to augment the radix (28 cases), dorsum (15 cases), and both radix and dorsum (19 cases). Cartilage underlay was combined with mastoid periosteum grafts in 38 patients (61.3%, 17 in radix graft, 8 in dorsal graft, and 13 in both). The aesthetic outcome score assessed in 21 patients was 2.8 on average (3.2 in primary and 2.4 in revision cases). Cartilage combined cases showed better aesthetic outcome than free graft cases (3.1 vs. 2.5, respectively). Three cases of partial graft resorption were found, but there were no major complications. Mastoid periosteum grafting is a safe and effective method to augment the radix or dorsum in primary and revision rhinoplasty. Long-term partial resorption cannot be completely excluded, which necessitates further study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lateral osteotomy plus hump resection vs hump re-modeling without lateral osteotomy: impact on frontal nasal view.

SUMMARYThis article reviews the personal experience and evolution of osteotomy approach in the last years of practice to obtain a natural appearance of the nasal pyramid in the frontal view. The aim is to analyse the long-term results after rhinoplasty on nasal width in two different cohorts of patients subjected to lateral osteotomy plus hump resection vs. hump re-modeling without lateral osteotomy considering the impact on frontal nasal view and how this relates to changes observed over time in the nasal width and contour. The study was carried out between January 2010 and December 2013, considering 42 patients undergoing primary rhinoplasty. Comparisons were made between the change in the dorsal width of the nasal pyramid at the level of the medial canthi, at the level of the inferior margin of the orbital rim, of ventral width of the nasal pyramid at the level of the medial canthi and at the level of the inferior margin of the orbital rim. In the first group, we found significant postoperative mean widening of the intercanthal dorsal width and narrowing of the ventral, while in the second group there was significant postoperative mean narrowing of the dorsal width both at level of the medial canthi and the anterior junction of the nasal bones. Our analysis seems to point out that dorsal grafting is useful for re-shaping the nasal profile with a persistent and harmonious correction of the dorsal frontal dimension of the nose. Simple hump removal/repositioning may be considered in selected instances to avoid lateral osteotomies. It also seems of paramount importance to tailor osteotomies according to nasal bone anatomy: large, strong and curved bones deserve aggressive narrowing by lateral and medial continuous osteotomies without periosteal elevation, although this approach may be insufficient to narrow the upper dorsal aspect of the nose.

EDITORIAL COMMENT

In recent decades, oral mucosa grafts have increasingly replaced flaps and other grafts in the reconstructive urologists’ armamentarium for repair of urethral strictures by substitution urethroplasty. With the rise in oral mucosa graft use, there has also been a greater consideration of the potential limitations and morbidity of oral mucosa graft harvesting. 1 Wood DN Allen SE Andrich DE Greenwell TJ Mundy AR The morbidity of buccal mucosal graft harvest for urethroplasty and the effect of nonclosure of the graft harvest site on postoperative pain. J Urol. 2004; 172: 580-583 Crossref PubMed Scopus (151) Google Scholar As a result, further alternative graft sources have been investigated. Tunica vaginalis has been proposed as a potential alternate graft source for substitution urethroplasty, with several animal model studies and a small series of patients showing promising results in the short term. 2 Calado AA Macedo Jr, A Delcelo R de Figueiredo LF Ortiz V Srougi M The tunica vaginalis dorsal graft urethroplasty: experimental study in rabbits. J Urol. 2005; 174: 765-770 Crossref PubMed Scopus (25) Google Scholar , 3 Foinquinos RC Calado AA Janio R Griz A Macedo Jr, A Ortiz V The tunica vaginalis dorsal graft urethroplasty: initial experience. Int Braz J Urol. 2007; 33 (discussion 529-531): 523-539 Crossref PubMed Scopus (25) Google Scholar Tunica vaginalis may present some advantages over oral mucosa grafts, including its ease of harvest, lack of morbidity, and larger surface area.

Extended L-Framework: An Innovative Technique for Reconstruction of Low Nasal Dorsum by Autogenous Costal Cartilage Graft.

Background:Congenital, iatrogenic, and traumatic etiologies can produce a deficient nasal dorsum requiring dorsal augmentation. Traditional techniques for dorsal augmentation as onlay dorsal graft, cantilever graft, or conventional L-framework usually have less stability and produce a rigid lobule if the single unit framework extends to the tip. Because of abundant volume and relative ease of harvest and carving, the autogenous rib cartilage has been considered the graft of choice for dorsal nasal augmentation when structural support is necessary and sufficient septal cartilage is not available.Methods:Eighteen patients with congenital, iatrogenic, and posttraumatic low nasal dorsum were reconstructed with the extended L-cartilage framework over the past 3 years with an average postoperative follow-up of 15 months. The framework was reconstructed from 3 carved cartilaginous pieces. If needed, columellar strut, spreader, and tip grafts were also provided.Results:All the 18 patients were generally satisfied with the cosmetic and functional outcomes at around 1-year follow-up. The nasal projection and dorsal aesthetic lines were pleasing and maintained over a prolonged postoperative follow-up period. There was free natural movement of the lobular part of the nose. No major complications were encountered.Conclusions:Consistent, reproducible results were achieved with using the extended L-framework in primary and secondary rhinoplasty and in posttraumatic dorsal nasal deformities as well. This technique has different advantages over the conventional techniques as the extended framework is more anatomical, preserves pliability of the lobule, maintains stability without any means of fixation, and offers good control of aesthetic needs.

Buccal One-Stage Mucosal Graft Urethroplasty for Urethral Stricture. Results of 10 Years of Experience.

Aim: Representing our data regarding use of buccal mucosa for treatment of recurrent urethral stricture. Evaluating effectiveness of buccal graft for reconstruction of urethral segment both penile and bulbar urethra.
 Materials and methods: We repaired 95 urethral strictures with buccal mucosa grafts from 2004 to 2015. Mean patient age was 39 years. The etiology of stricture was unknown in 54% of cases in other cases ischemia, trauma, instrumentation was the reason. 96% had undergone previous urethrotomy or dilation. The buccal mucosa graft was harvested from lower lip mostly. Mean graft length was 3.8 cm. The graft was placed on the ventral and dorsal bulbar urethral surface in 61 and 34 cases, respectively. In pendulous urethra we routinely use the dorsal graft the Asopa inlay graft or Barbagli onlay graft. Clinical outcome was considered a success or failure at the time that any postoperative procedure was needed, including dilation. Mean follow-up was 36 months (range 16 to 62).
 Results: We had a success rate of 77% with dorsal inlay or onlay flap for pendulous urethra inferior than ventral graft used for bulbar urethra which was 81% success rate.
 Conclusions: In our experience the placement of buccal mucosa grafts into the ventral or dorsal surface of the bulbar urethra showed an acceptable success rates 81% and 77% respectively. Longer times of follow up is need to see if the results deteriorated more.

Dorsal Vaginal Graft Urethroplasty as a Treatment for Female Urethral Stricture: Case Reports of Four Patients

Female urethral stricture is uncommon and difficult to diagnose. Currently, only a small amount of literature has reported the successful treatment of female urethral stricture using a reconstruction approach. In this study we describe our results with the management of female urethral stricture using a dorsal vaginal graft. Four patients were diagnosed with female urethral stricture and were treated with urethral reconstruction using a dorsal vaginal graft. Primary urethroplasty using dorsal vaginal graft can be considered as a first-line option in the management of female urethral stricture, especially in centers with experience in graft-based reconstruction.

Prevalence and surgical management of concurrent adult acquired buried penis and urethral stricture disease.

To describe the prevalence and surgical management of coexistent adult acquired buried penis (AABP) and urethral stricture disease. AABP patients often have urinary dribbling with resultant chronic local moisture, infection, and inflammation that combine to cause urethral stricture disease. To date, no screening or surgical management algorithms have been described. A multi-institutional retrospective study was conducted of the surgical management strategies for patients with concurrent AABP and urethral stricture disease from 2010 to 2017. AABP patient demographics, physical exam findings, and comorbidities were compared between those with and without stricture disease to suggest those that would selectively benefit from screening for stricture disease. Of the 42 patients surgically managed for AABP, 13 had urethral stricture disease (31.0%). Stricture location was universal in the anterior urethra. Sixty-one percent (n = 8) of strictures were 6cm or longer and managed prior to AABP repair with Kulkarni urethroplasty. Patients with urethral stricture disease were significantly more likely to have clinically diagnosed lichen sclerosus (p = 0.00019). There was no significant difference in BMI, age, or comorbidities between patients with and without urethral stricture disease. Extensive anterior urethral stricture is common in patients with AABP. Clinical characteristics cannot predict stricture presence except possibly the presence of lichen sclerosus. Definitive stricture surgical options include extensive Johanson Urethroplasty or Kulkarni Urethroplasty. Kulkarni Urethroplasty prior to AABP repair has the benefits of a single-stage repair, good cosmetic outcome with meatal voiding, and dorsal graft placement to allow safe degloving of the penis in the subsequent AABP repair.

Analysis of the donor site complications after long-strip lingual mucosal graft for the treatment of long-segment anterior urethral strictures in males

Objective To analyze the donor site complications of male patients with long segment anterior urethral strictures that underwent urethroplasty by using a long-strip lingual mucosal grafts (LMG) six months later. Methods Between August 2006 and December 2014, a total of 81 patients with long segment anterior urethral stricture underwent a procedure of urethroplasty using a long-strip LMG. The mean patients’ age was 41.2 years (range 18-74) and the mean urethral stricture length was 12.1 cm (range, 8-20 cm), a single LMG was more than 9 cm. Two techniques of urethroplasty were performed: One-sided dorsal graft augmentation urethroplasty was performed in 70 patients, 12 of the 70 patients underwent urethroplasty by using a LMG in addition to a BMG, owing to the presence of very long strictures; Dorsal patch graft urethroplasty was performed in 11 patients. Results Of the 81 patients a single long-strip LMG with length of 9-11 cm was used in 52 patients, LMG measured ≥12 cm in 17, and LMG combined with buccal mucosal graft (BMG) in 12. The mean follow-up period was 41 months (range, 15-86 months) postoperatively. The overall urethroplasty success rate was 82.7%. Six months after the operation, 28 patients (34.6%) reported a minimal to moderate difficulty in fine motor movement of the tongue (difficulty with spitting tiny fish bones). Among these 28, 22 patients (27.2 %) had associated numbness over the donor site, 10 patients (12.3%) had parageusia, and 11 patients (13.6%) reported slurring of speech. The donor site complications occurred higher in patients with LMG length≥12 cm (14/29) than those patients with LMG length<12 cm (14/52)(χ2=19.049, P<0.01). At 12 months, 5 patients (6.2%) reported minimal difficulty in fine motor movement of the tongue, and reduced to 1 patient at 24 months. Conclusions The donor side complications after long-strip lingual mucosal graft for the treatment of long-segment anterior urethral strictures are primarily limited to the first postoperative year, the incidence of complications appeared to be related to the length of the harvested graft. Key words: Lingual mucosa; Complication; Urethral stricture; Urethroplasty

Comparative study between tubularized incised plate urethroplasty with and without dorsal inlay graft

Objectives The aim of this study was to compare the results of two single-stage hypospadias repairs, namely, tubularized incised plate (TIP) repair with and without dorsal inlay preputial skin graft urethroplasty as regards meatal stenosis, urethral stricture, and cosmetic outcome. Background The most commonly performed operation to repair distal hypospadias is the TIP repair. The key step is midline incision of the urethral plate, which widens a narrow plate and converts a flat groove into a deep plate groove, ensuring a vertical, slit neomeatus and a normal-caliber neourethra. At times in cases of distal hypospadias, the urethral plate is very narrow and needs to be augmented or substituted for further tubularization. We report our experience with primary single-stage dorsal inlay urethroplasty using inner preputial skin grafts. Patients and methods This study included 30 patients less than 10 years old who presented with primary distal types of hypospadias with narrow urethral plate at the Department of Plastic Surgery, Menoufia University Hospital and were divided into two groups: group A included 14 patients operated by TIP without dorsal inlay graft and group B included 16 patients operated by TIP with dorsal inlay graft. Patients who had undergone circumcision, previous hypospadias repair, or who had a deeply grooved urethral plate were excluded. Results A total of 16 children underwent primary dorsal inlay preputial graft urethroplasty, of whom one (6.2%) child had partial wound dehiscence, two (12.5%) of the children had meatal stenosis, and one (6.2%) of these children developed urethral stricture; 14 children underwent TIP urethroplasty, of whom two (14.3%) children had wound dehiscence, four (28.6%) of the children had meatal stenosis, and four (28.6%) of these children developed urethral stricture. Conclusion Primary dorsal inlay inner preputial graft urethroplasty successfully fulfills all traditional hypospadias repair criteria. It offers a viable, safe, rapid, and easy option in the management of proximal hypospadias with a narrow urethral plate.

Combined Dorsal and Ventral Onlay Buccal Graft Technique for Large and Complex Penile Strictures.

Purpose To present a modified technique of managing extensive penile urethral strictures with dorsal and ventral onlay buccal mucosa grafts. Patients and Methods From October 2014 to January 2016, a total of 12 patients underwent urethroplasty for penile urethral strictures, using dorsal and ventral onlay grafts from buccal mucosa. The mean age was 42.75 (17–71). All patients completed the IPSS and QoL questionnaire, and uroflowmetry was done preoperatively. After surgery, the follow-up included completion of IPSS and QoL questionnaire and measuring of uroflow at 1, 3, 6, and 12 months. Postoperative urethrography was performed in complex cases or in the event of deterioration of voiding symptoms. Results The mean length of the strictures was 5.45 (2, 2–16) cm. Mean Qmax changed from 3.45 ml/sec preoperatively to 18.33 postoperatively, and mean IPS score significantly decreased from 20.1 preoperatively to 8.98 postoperatively. All values were statistically significant (p < 0.001). No intraoperative or immediate postoperative complications were recorded. Overall, at 12 months, 11 out of 12 patients (91.6%) had a marked improvement in quality of life and uroflowmetry parameters. Conclusions In the properly selected patient, the combined use of double graft for penile urethral strictures can be successful with minimal morbidity, at short-term follow-up.

Application of proper digital artery island flaps of adjacent digit for repair of finger soft tissue defects and reconstruction of blood circulation

Objective To research the surgical procedure and clinical effects of proper digital artery island flaps of adjacent digit for repair of finger soft tissue defects and reconstruction of blood circulation. Methods From March 2010 to May 2015, 21 cases of finger soft tissue defects were treated with proper digital artery island flaps of adjacent digit. The artery or nerve defect ranged from 1.5 to 4.0 cm. The skin and soft tissue defects area ranged from 1.5 cm×1.0 cm to 4.0 cm×2.0 cm. During the operation, proper digital artery and its island flaps were obtained from adjacent side margin of adjacent digit, and transferred to repair skin and soft tissue defects and reconstruct blood circulation simultaneously. The nerve defect was bridged by forearm or foot dorsal cutaneous nerve graft. Results Vasospasm occurred in 2 cases during intraoperative dissection, which was relieved after local application of papaverine and hot warm saline. Vascular crisis occurred in one case 2 hours after the operation, which was relieved by operative exploration. The rest flaps survived uneventfully. The follow-up period ranged from 6 to 48 months with the average being 18 months. The appearance and texture of the flaps were good. Partial protective sensations were restored. The original appearance and function of the injured finger were recovered. No dysfunction occurred in donor fingers. According to the functional evaluation standards issued by Hand Surgery Society of the Chinese Medical Association, the results were excellent in 13 cases, good in 6 cases, fair in 2 cases. Conclusion Application of proper digital artery island flaps of adjacent digit for repair of finger soft tissue defects and reconstruction of blood circulation not only has the clinical effect of flow-through flap, but also has the advantages of simplicity, safety and reliability, which is worth promoting. Key words: Finger injuries; Surgical flaps; Flow-through flaps; Transfer repair

Preputial mucosal graft for urethral repair

Urethral stricture disease is the commonest cause of morbidity in urology practice in sub-Saharan Africa. In contrast, prostate disease is commonly cited as the leading cause of urological disease in most urology practices in developed countries. In Africa, the aetiology of urethral stricture disease is compounded by a high prevalence of sexually transmitted infections (STIs), increasing levels of urethral trauma and over-stretched urological services. Thus, patients with prostate disease are treated with long-stay urethral catheters for periods often up to two years. This increases the risk of urethral stricture. The predominant aetiological factor is sexually transmitted infection due to gonococcus or chlamydia. This frequently leads to long severe strictures with spongiofibrosis, especially in the anterior urethra where the periurethral glands are located. These strictures respond poorly to urethral dilatation, optical urethrotomy or primary anastomosis. The majority of strictures in Africa are best treated by open substitution urethroplasty. The gold standard has been the use of buccal mucosa graft for this substitution procedure. This procedure poses a great challenge in most centres with limited resources. In these settings, we have found that the use of a dorsal onlay free preputial graft is easy to perform and gives good results.

Geometric Modeling of the Nasal Valve.

AbstractWe have used a simple geometric model to examine forces affecting the nasal valve after dorsal reduction and spreader graft placement. The study was designed on the geometric modeling of the internal nasal valve (INV). Published measurements of the leptorrhine nose were used to construct a geometric model of the INV. The changes in the cross-sectional area (CSA) occurring after reduction rhinoplasty were calculated algebraically, as was the effect of these changes on the tendency of the lateral wall of the INV to collapse. The effect of spreader grafting on the CSA was determined, and the total change in CSA of the INV in various scenarios was determined and compared with the reported normal CSA. Relative to published norms, the gain in CSA from spreader grafting can be significant if thick grafts are used. When the lateral wall of the INV is conceptualized as a cantilevered beam fixed medially, the reduction of length reduction of the lateral segment of the INV can significantly reduce the tendency for the inward collapse of the lateral wall. The reduction in CSA of the INV associated with dorsal nasal reduction can be ameliorated through the placement of spreader grafts. Moreover, the reduction in length of the INV sidewall also limits inward collapse, assuming it is firmly reattached to the dorsal septum. An enhanced appreciation of the physical properties of the INV anticipated through a simplified geometric analysis will be invaluable to the rhinological surgeon interested in enhancing nasal function.

Dorsal Augmentation Using Autologous Costal Cartilage or Microfat-Infused Soft Tissue Augmentation

Costal cartilage grafting is increasing in popularity with increased demand for augmentation rhinoplasty and increased need for grafting material for structure rhinoplasty techniques. Use of costal cartilage for dorsal grafting is both art and science. The art is demonstrated in the act of carving a dorsal graft that will reflect the actual contour of the nasal dorsum. The science is linked to the methodology of how the grafts are contoured to match the patient's desires and how the graft is fixed to the bony dorsum to minimize the risk of warping and displacement. Variations in dorsal graft design and methods of fixation are described. Use of the perichondrial interface between dorsal graft and perforated/rasped nasal dorsum acts to ossify the dorsal graft to the underlying bone, creating an immobile and natural appearing nasal dorsum. The fixation of the dorsal graft limits movement and hence decreases the likelihood of warping or deformity. Use of microfat in rhinoplasty has tremendous potential for camouflage and to promote healing of compromised tissues. Using microfat-infused soft tissue augmentation (MISTA), the surgeon is able to deliver microfat to an open surgical field, promote healing, and provide soft tissue augmentation. In this technique, microfat is injected into soft tissue carriers (perichondrium, temporalis fascia, etc.) and then implanted into the surgical field. MISTA has tremendous potential utility in many areas of cosmetic and reconstructive surgery.

Urethroplasty with dorsal buccal mucosa graft. Is it still the method of choice in long term urethral stenosis?

The aim of our work was to evaluate the long-term changes in symptoms (median 42 months) and to analyze data for any negative predictive factors for the application of the procedure, in patients who underwent to urethroplasty with dorsal buccal mucosa graft. During the period from 2010 to 2015 27 patients were examined. Than they underwent urethroplasty using dorsal buccal mucosa graft (graft of 4 x 2.5 cm). The evaluation of symptoms has been addressed through the application of the IPSS Quality of Life Questionnaire (International Prostatic Symptoms Score) and the evaluation of urinary flow has been carried out by a comparative analysis between the pre- and post-operative uroflowmetry. As our study has shown, data obtained by the screening tests in the post-operative follow-up indicate that there is an increase in the maximum flow of urine until 1 month after surgery. The results in the long-term follow-up are different because they show a partial reduction of the maximum flow although it is maintained around an average value of 23 ml/s being still higher than the maximum flow in the pre-operative period. According to our results it follows that there is a low failure rate of the procedure after a median of 42 months. Only in patients with urethral stenosis longer than 2 cm, a lower long term success is achieved. From what we could observe, this length of the stenosis seems to be the only negative predictive factor for long-term maintenance of a good Quality of Life in patients undergoing the procedure. The results obtained from our study confirm literature data according to which, the gold standard for 2-cm long bulbar urethral stricture whose lumen is well preserved with circumferential spongiofibrosis limited to 1-2 mm is the dorsal graft urethroplasty with buccal mucosa that in our study showed success rates higher of 80% after a median follow up of 42 months and a percentage of relapse-free patients of 82.1% ( median 3.5 years).

Saddle nose deformity: pathological grading and anatomical reconstruction

ImportanceManagement of saddle nose deformity needs to be directed toward diagnosing its etiology and its treatment.ObjectiveThe aim of this study was to propose a simple classification system for saddle nose deformity that depends on pathologic grading and anatomic reconstruction.SettingThis study was conducted at a university-affiliated tertiary hospital.Study designThe study design was a retrospective chart review.Patients and methodsPatients with saddle nose deformity presenting from 2012 to 2014 were reviewed. The patients were classified according to the septal condition as follows: grade 1, saddle nose due to pathology other than septal collapse (dorsum over-resection, familial, or racial); grade 2, septum is collapsed but can be fixed by means of bone grafts or septal replacement grafts; and grade 3, patients need cartilaginous septum reconstruction.ResultsThe study included 32 patients, 20 female and 12 male, with a mean age of 27 years. Eleven cases were of grade 1 and were managed with dorsal grafts (septal cartilage in two, conchal cartilage in two, and diced cartilage in fascia in seven cases). Sixteen cases were of grade 2, and all were post-traumatic primary cases. Bone grafts to straighten and stabilize the broken septum were used in 13 cases, and septal replacement grafts were used in three cases. Five cases were of grade 3 and required replacement of septal L-strut that was concealed with diced cartilage in fascia. Columellar strut was used in all cases.ConclusionDiagnosis and management of saddle nose deformity should depend on identifying the etiology of each case and classifying them into cases due to correctable septal pathology that can be managed with straightening the septum, or those due to missing septum that need septal reconstruction, and those due to low dorsum without septal pathology that can be simply corrected with dorsal grafts. Using this anatomical approach we are trying to achieve a strong esthetic pleasing functioning nose.

Dorsal Onlay with Diced Homologous Processed Rib Cartilage Grafts.

Diced cartilage wrapped in fascia or modeled with tissue sealant has successfully been used as dorsal onlay grafts in rhinoplasty. The use of autologous material introduces the risk of donor site morbidity, and sometimes availability is limited. We present a series of nine cases that were performed using diced irradiated homologous rib cartilage as an onlay graft. Good functional and cosmetic outcomes were achieved in all nine patients, and no significant resorption was seen after a mean follow-up of 20months. Homologous diced cartilage grafts are an attractive and well-tolerated alternative. The use ofdiced homologousmaterial does not seem to lead to significant resorption. These results must bereproduced in larger series. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical efficacy of short nose lengthening by using autologous costal cartilage

Objective To explore the clinical efficacy of applying autologous costal cartilage in lengthening the short nose. Methods Bilateral extended spreader grafts (ESG) and columellar strut grafts were performed by using autologous costal cartilage in 253 patients with short nose, which increased nasal dorsal length and the support force of nasal tip; meanwhile, autologous costal cartilage was used for dorsal augmentation, alar rim retraction, and nasal tip modification. Results A total of 253 patients with short nose were satisfied with postoperative morphology, which presented elongated nasal dorsum, correction of nasal tip topspin, and normal nasal columella-lobular angle. 6 months to 17 months follow-up was conducted, and nasal length and morphology showed stable, while 2 cases presented slight nasal tip decreasing, 4 cases presented dorsal grafts warping; after revision surgery, the 6 patients had also got satisfactory results. Conclusions Correction of short nose using autologous costal cartilage can result in more stable nasal reconstruction structure, and can be used for the shape correction of other subunits of the nose, achieving at the comprehensive improvement of nasal morphology and functions. Key words: Short nose; Costal cartilage; Rhinoplasty

The Pi Graft for Correction of Severe Saddle Nose Deformity.

Saddle nose deformity is challenging because there is both aesthetic and functional compromise, and high rates of recurrence have been reported. Autologous costal cartilage is the widely preferred medium for reconstruction, but there may be room for improvement in the configuration of the cartilage struts. The pi graft is stabilized at two points, proximally and distally, distinguishing it from the traditional L-strut. Indications include severe (Types III and IV) saddle nose deformity with collapse of the mid-vault, and recurrence after prior reconstruction. Costal cartilage is harvested and three struts are crafted to make the foundation layer: a dorsal strut, caudal strut, and mid-vault strut. An aesthetic layer is composed of a carefully crafted dorsal graft and tip graft. Three men and 11 women were treated from 2013 to 2015 using this method for severe saddle nose deformity. Aesthetic and functional outcomes were evaluated. Patients were followed up for 12 months (range, 8-14 months). There was no recurrence of deformity or warping of the aesthetic or foundation layers. All patients were guided to anticipate refinement of the tip at 3 months to ease the burden on the skin envelope in stage I, but only five patients (35.7%) opted for it, as the remaining patients were satisfied with their appearance. The pi graft is a composite reconstructive method that is designed to minimize warping and recurrence of the saddle nose deformity. This method was successful in this series, although objective comparisons with traditional methods were not made.

Saddle Nose Reconstruction with Bone Graft in Multiple Facial Fracture Patients

Background: Saddle nose deformities mostly result from trauma. Most reports of saddle nose correction after trauma relate to isolated fractures, but in this article the experience of the authors is presented in relation to bone grafting for the correction of the saddle nose in multiple facial fracture patients. Objectives: The current study aimed to report the results of a protocol for choosing the source of bone graft for dorsal nasal bone grafting in acute trauma patients with multiple facial fractures. Patients and Methods: In a retrospective study, archived files of maxillofacial trauma patients who were treated between 2005 and 2012 at Mashhad Emdad hospital (a level one trauma center) were reviewed. Cases were selected in which a traumatic saddle nose deformity concomitant with other facial fractures had been corrected with dorsal nasal bone grafting. The donor site, type of fixation, access to the dorsum of the nose, associated facial fractures, shape of the graft (cantilever or L-shaped), and plane of dissection in the dorsum of the nose (subperiosteal or subcutaneous) were assessed. Results: There were 11 patients treated using this method. The male-to-female ratio was 7:5. One miniscrew with the lag technique was the preferred method for the fixation of the dorsal nasal bone graft. Splitcalvarial bone graft was the most commonly used type of bone graft. An open rhinoplasty approach and maxillary degloving were two commonly used incisions, and the most commonly associated fractures were maxillary Lefort fractures. The cantilever design was used in eight patients for the correction of the saddle nose deformity, and in four patients the bone graft was inserted into the nose in the subcutaneous plane. Conclusions: Saddle nose reconstruction with bone graft in multiple facial fracture patients is a predictable method if surgical accesses to the region are carefully designed, considering the accompanying fractures.