Temporalis fascia grafts for facial and nasal contour augmentation

Immediate Reconstruction With Autologous Temporoparietal Fascia After Enucleation of Infected or Extruded Alloplastic Nasal Implants

Simultaneous reconstruction after removal of nasal silicone implants was published as diced, autologous rib and ear auricular cartilages, and each had their shortcomings. Temporoparietal fascial grafts were used for facial and nasal contouring, vascularized tissue coverage, and augmentation the nose, lip. The temporoparietal fascia graft may be considered for in-time replacement of allografts and remaining bulkiness. From 2006 until 2008, the temporoparietal fascial graft was used in 20 referred patients with nasal allografts in a medical center. The female-to-male ratio is 17:3. The mean age is around 32.6 years old. All the patients refused disfigurement after the removal of the implants for at least 3 months. All the patients were followed up for 5 years. All patients recovered within 1 to 2 weeks. The nasal skin envelop was preserved or healed. There was neither graft exposure, nor recurred infection. The procedure is a useful method of eliminating inflammatory squeals. The temporoparietal fascial graft used, was able to bridge the 3-month gap without the implant. The smooth nasal dorsum skin was regained with adequate nasal projection. All patients were followed up in plastic surgery clinics without recurrence. There are no reports in the English literature of the use of temporoparietal fascial grafts to treat nasal implant infection. The temporoparietal fascial graft is a simple and reliable method to provide thin, broad, pliable, easy neovascularized, adequate coverage, contour, and bulk on the cartilage dorsum of the nose, an inconspicuous donor site, consistency, and minimal resorption.

Secondary rhinoplasty for unilateral cleft lip nasal deformity using the complex of autologous costal cartilage and fascia grafts

BACKGROUND

Secondary unilateral cleft lip nasal deformity is a prevalent condition in the world, and surgical repair remains a formidable challenge. The objective of the study is to investigate functionally and aesthetically outcomes of a new technique using a complex of autologous costal cartilage and fascia grafts to repair the secondary unilateral cleft lip nasal deformity.

METHODS

First, the autologous costal cartilage and fascia were harvested from a total of 34 patients with secondary unilateral cleft lip nasal deformity, who were undergoing treatments at the First Affiliated Hospital of Xi'an Jiaotong University from April 2020 to June 2023. Then, the cartilage was sub-divided into 6 pieces and placed on the depressed alar base, nasal columella, lower lateral cartilage, and nasal tip. At the same time, the fascia was trimmed to cover the nasal tip cap graft and augment the dorsum of the nose. Patient outcomes were assessed through subjective evaluation and objective anthropometric measurements. In addition, associated complications were also examined.

RESULTS

All were primary healing incisions, and no patients were encountered with any clinical complications. We found that the overall mean score of the Independent Rhinoplasty Outcome Score (IROS) was very good during the subjective assessment. Also, the objective measurements indicated an excellent nasal symmetry. Furthermore, both functionally and aesthetically satisfactory outcomes were obtained in all the patients during long-time follow-up.

CONCLUSIONS

Secondary rhinoplasty using the complex of autologous costal cartilage and fascia grafts is a safe and effective approach for unilateral cleft lip nasal deformity repair.

Closure of Nasal Septal Perforations Using a Diced Cartilage in Fascia Graft

The spectrum of surgical techniques in the repair of nasal septal defects is wide. The objective of this study was to assess the feasibility of using a diced cartilage in fascia (DC-F) graft for successful closure of nasal septal perforations and to evaluate symptom reduction. This was a retrospective study of 18 patients undergoing surgical repair of symptomatic nasoseptal perforations of different etiologies using a DC-F graft from 2020 until 2021. The procedure was feasible in all of the 18 patients. Reconstruction of septal defects with a DC-F graft led to reduction of crust formation, reduction of epistaxis, and improvement of nasal breathing in 13 out of the 18 patients when seen for their 2-month follow-up. Reperforation occurred in three cases, leaving defects of 1, 7, and 5 mm in diameter. In one case, the reperforation was symptomatic. A DC-F graft proved to be a reliable and reproducible method for the closure of nasoseptal perforations of variable sizes, of different locations, and of different etiologies.

Revisiting the Use of Deep Temporalis Fascia Grafts in Ophthalmology

PURPOSE

To report new indications for deep temporalis fascia (DTF) grafts in the ophthalmic field.

METHODS

Monocentric retrospective interventional case series study. All the patients who underwent a DTF graft in an unpublished new indication over the study period (May 2020-October 2023) were included. For each patient, gender, age, graft indication, outcomes, complications, and follow-up duration were collected. In most cases, the DTF graft was covered by a vascularized flap.

RESULTS

Eight patients underwent a DTF graft over the study period. The indications were: radiotherapy-induced scleral necrosis in three cases, tendinoplasty to replace the inferior rectus muscle tendon invaded by a locally advanced conjunctival carcinoma in one case, Ahmed glaucoma valve tube exposure in one case, intraocular lens with scleral fixation exposure in one case, orbital cerebrospinal fluid fistula (orbitorrhea) in one case, and post-traumatic complete corneal graft loss in one case. The DTF graft was successful in 87.5% of cases after a mean follow-up of 11.4 months. No complications were observed.

CONCLUSIONS

DTF graft is a highly versatile graft that can be easily harvested. New indications for DTF grafts may include the repair of radiotherapy-induced scleral necrosis, the creation of oculomotor tendon and the temporary packing of large ocular tissue loss in an emergency context. Further studies with a longer follow-up are needed to confirm our preliminary results.

Current Practices in Dorsal Augmentation Rhinoplasty

BACKGROUND

Dorsal augmentation rhinoplasty addresses the aesthetic and functional impairments caused by a deficient nasal dorsum. Augmentation rhinoplasty can be performed using a variety of different surgical techniques and grafting materials that all have distinct advantages and disadvantages.

METHODS

Grafting materials have unique characteristics, uses, and safety profiles. A detailed overview of various grafting materials and their uses, risks, and benefits is provided.

RESULTS

Autologous grafting materials include septal cartilage, auricular cartilage, and costal cartilage. These donor sites can provide various amounts of en bloc or diced cartilage. Alternatively, bone may be used when strong structural stability is required, and soft tissue may be used to fill mild to moderate defects. Homologous grafts (e.g., irradiated and nonirradiated rib) and acellular dermal matrices are alternatives to autologous graft with many similar advantages and no need for an additional surgical site. Lastly, alloplastic implants may be successfully used for dorsal augmentation if both patient and surgeon understand their associated risks.

CONCLUSION

To perform successful dorsal augmentation, surgeons should be familiar with the wide variety of operative approaches and augmentation materials that are currently available and understand their risks, benefits, and uses.

Application of a bilateral temporal fascia free graft in a dog with multifragmented frontal sinus and nasal bone fracture

OBJECTIVE

To describe the use of temporal fascia free grafts to treat dorsal open comminuted frontal sinus and nasal fractures.

ANIMAL

One Belgian shepherd dog.

STUDY DESIGN

Case report METHODS: A 5-year-old spayed female Belgian shepherd was admitted with severe facial deformation due to trauma. A deep, 3 cm wide wound was present between the nose and the frontal sinus. No abnormalities were detected on neurological examination. On computed tomographic examination, comminuted open fractures of the frontal and nasal bones were associated with a severe depression of the dorsal wall and presence of bone fragments in the sinus cavities. Bone fragments were apposed with polydioxanone monofilament suture. Bilateral temporal fascia grafts were placed over the bone fragments.

RESULTS

The integrity of the frontal and nasal cavities, and the facial profile of the dog were restored. No short-term or long-term complications were observed after 4 months follow up.

CONCLUSION

The innovative combination of suture apposition of bone fragments and a temporal fascia free graft resulted in very satisfying long-term outcomes in a dog with open sinus and nasal bone fractures.

Destructive Frontonasal Mucocele Following Facial Trauma and Surgery

ABSTRACT

Mucoceles are fluid filled cysts with numerous etiologies that can erode bone and if left untreated, can lead to infraorbital and intracranial complications. With limited cases published in the medical literature, our patient with a frontonasal mucocele expanding from the frontal sinus to the nasal dorsum with erosion of the nasal bones and upper lateral cartilages, provides an opportunity for evidence-based diagnosis and treatment. We present a 24-year-old female with a nasal mass destroying numerous nasal structures. Three surgical approaches were considered: open rhinoplasty, bicoronal approach, and Lynch excision; the latter executed with subsequent total nasal reconstruction. Bone, septal cartilage, and temporalis fascia were utilized to provide structural support and a posterior nasal septal flap was incorporated to maintain a blood supply. Integrity of nasal structure and cosmesis as well as recurrence of disease were monitored during postoperative visits.

Rhinoplasty: Aesthetic Augmentation With Improvement of Dorsal Aesthetic Lines

BACKGROUND

Camouflage of nasal dorsum, aesthetic augmentation, and highlighting the dorsal aesthetic lines are essential elements in modern rhinoplasty. Numerous techniques have been utilized, including deep temporal fascia, rectus abdominis fascia, and diced cartilage in fascia (DC-F). Despite their widespread adoption, technical challenges remain, especially when utilized for aesthetic purposes.

OBJECTIVES

This paper details the utilization of fascia and DC-F for aesthetic dorsal refinement in primary and secondary cases. One of the main goals was to achieve ideal dorsal aesthetic dorsal lines rather than just volume augmentation.

METHODS

The authors employed grafts from the deep temporalis fascia and rectus abdominis fascia in 4 configurations: (1) single layer, (2) double layer, (3) full-length DC-F, and (4) partially filled segmental DC-F grafts. Technical refinements included careful determination of dimensions and meticulously suturing to the dorsum at appropriately 10 points to prevent graft displacement.

RESULTS

The authors report their experience with 146 clinical cases over 35 months from January 2017 to December 2019. The patients were divided for 4 groups depending on which type of graft was utilized.

CONCLUSIONS

Autogenous deep temporal fascia, rectus abdominis fascia, and DC-F were utilized to camouflage dorsal irregularities, highlight dorsal aesthetic lines, and aesthetically augment either the entire nasal dorsum or its individual parts. Optimization of cutting, stitching, filling the graft, and careful fixation of these grafts on the nasal dorsum significantly increases the predictability of these techniques and minimizes problems.

Tubed Temporalis Fascia for Nasal Dorsal Contouring: A Novel Technique

INTRODUCTION

Nasal dorsum irregularities may occur after nasal trauma or as a postrhinoplasty complication. Here, we present a novel technique using temporalis fascia (TF) grafting for primary and revision rhinoplasty to repair the nasal dorsum, hide nasal irregularities, and improve nasal contouring.

METHODS

This prospective cohort study was conducted from January 2019 to June 2019 and evaluated nasal dorsal contouring using the TF in a tubed form. The outcome variables were patient satisfaction, dorsal irregularity, and contour definition. The predictor variable was the use of tubed TF for dorsal augmentation. Other associated variables were age, sex, indication for surgery, surgery type, and graft size. Patient satisfaction was evaluated using the Rhinoplasty Outcome Evaluation questionnaire. A rhinoplasty specialist other than the surgeon who performed the procedure evaluated the dorsal augmentation outcomes by inspection and palpation of the dorsum. All statistical analyses were performed using the SPSS software.

RESULTS

Seventy-four patients (21.6% men and 78.4% women) were treated with the tubed TF. The mean age was 28.97 years. Thin skin was the most common indication (48.6%) for using TF. The graft size was 2-5 cm; inspection and palpation revealed no irregularities. No reception site complications occurred. One patient had a mild hematoma at the donor site. The mean patient satisfaction score was 10.14 preoperatively and 19.95 postoperatively (p = 0.001).

DISCUSSION/CONCLUSIONS

Our novel technique of using the TF graft in a tubed form was easy to perform. Furthermore, the tubed TF covers all irregularities, is good for dorsal augmentation, and improves dorsal contouring and definition.

Cadaveric study of deep temporal fascia for autologous rhinoplasty grafts: Dimensions of the temporal compartment in Asians

Background

Due to the anatomical complexity of the deep temporal fascia (DTF), practical guidelines for its safe harvest are lacking. However, since the upper temporal compartment (UTC) contains no vital structures, it may provide safe access for DTF harvest. This study aimed to identify the anatomical structures of the temporal compartment in Asian cadavers and to measure their dimensions to enable safe DTF harvest.

Methods

The anatomical structures surrounding the temporal compartment were identified in 27 hemifaces from 15 Korean cadavers. After dissection, digital images were acquired and craniometric landmarks were placed upon them to identify the boundaries of the temporal compartment. The horizontal and vertical lengths of the temporal compartment were measured and their surface areas were computationally assessed. Subsequently, differences in the results by sex were evaluated.

Results

The five-layer anatomical structure of the UTC was clearly visualized. The UTC was bounded by the temporal septa superiorly and inferiorly, the innominate fascia laterally, and the DTF medially. No vital structures were present within the UTC. The vertical and horizontal lengths of the UTC were 6.41±0.67 cm and 10.44±0.83 cm, respectively, and the surface area of the UTC was 48.52±5.65 cm². No statistically significant differences were observed in any dimensions between male and female patients.

Conclusions

During rhinoplasty, DTF can be harvested as an autologous graft material from the UTC. An anatomical understanding of the UTC will aid in the safe and simple harvest of a sufficient amount of DTF.

Use of an Augmentation Spreader Graft for Management of Nasofacial Angle in Patients With Pseudo-Hump

BACKGROUND

Correction of the hump nose entails more than just simple elimination of the dorsal hump. Recent trend is toward conservative reduction of the hump and appropriate adjustment of the radix height. East Asians often present with pseudo-hump due to underprojected radix or tip, which accentuates the height of the hump. This study introduces our method of pseudo-hump correction and achieving a balanced nasal profile with minimal reduction of the hump and augmentation of the dorsum and tip with a modified augmentation spreader graft.

METHODS

A retrospective review was conducted of 97 consecutive cases of Korean patients undergoing hump reduction with simultaneous augmentation of the radix with resected hump fragments and augmentation of the nasal dorsum with augmentation spreader graft. No implants were used in any of the patients. Anthropometric analysis was performed, and patient satisfaction was evaluated at postoperative 1 year.

RESULTS

Postoperatively, hump was eliminated, and the dorsum and tip were successfully elevated using only autologous septal cartilage. The radix was augmented without surface irregularity or graft visibility. Nasal dorsum, tip, and radix projection increased significantly after surgery. Subjective evaluation revealed a high level of satisfaction in 84%.

CONCLUSIONS

Our multipurpose bilateral augmentation spreader graft positioned above the septal plane was effective in dorsal and tip augmentation without the need for alloplastic material. Conservative hump reduction combined with augmentation of the relatively deficient areas of the nose produces a balanced nasal profile.

Height Changes of Tutoplast-Processed Fascia Lata Over Time After Dorsal Augmentation During Rhinoplasty

PURPOSE

Tutoplast (Tutogen Medical, Neunkirchen am Brand, Germany)-processed fascia lata (TPFL) has been used for dorsal augmentation in rhinoplasty in the Republic of Korea for approximately 10 years, but few studies have described changes in TPFL in terms of dorsal height over time. We investigated changes in dorsal height after TPFL use as a dorsal implant material during rhinoplasty.

MATERIALS AND METHODS

The records of 18 rhinoplasty patients who had undergone dorsal augmentation with TPFL were examined retrospectively. The patients had undergone rhinoplasty from March 2008 to June 2012. Two different ear, nose, and throat doctors analyzed the first follow-up photographs (2 lateral views and 2 oblique views) taken at approximately 1 month postoperatively and the last follow-up photographs taken from 18 to 75 months after surgery. The last follow-up photographs were classified as showing no nasal dorsal height change, slight change, and marked change compared with the first follow-up photographs.

RESULTS

Of the 18 patients enrolled, 50% (n = 9) showed no change in the nasal dorsum whereas 33% (n = 6) showed mild depression and 17% (n = 3) showed marked depression of the nasal dorsum at last follow-up.

CONCLUSIONS

About half of the patients who had undergone dorsal augmentation using TPFL during rhinoplasty showed mild or marked dorsal depression over time. It is recommended that TPFL be used with another implant during augmentation rhinoplasty or TPFL be used only for a slightly depressed nose. In addition, patients should be informed that TPFL could be resorbed over time.

Platelet-Rich Fibrin Improves the Viability of Diced Cartilage Grafts in a Rabbit Model

BACKGROUND

Diced cartilage may be wrapped with synthetic or biological materials before grafting to a recipient site. These materials have unique advantages and disadvantages, and a gold standard is not available.

OBJECTIVES

The authors investigated the effects of platelet-rich fibrin (PRF) on the survival of cartilage grafts in a rabbit model.

METHODS

In this experimental study, diced cartilage pieces from the ears of 9 male rabbits were left unwrapped or were wrapped with PRF, oxidized regenerated cellulose, or fascia. Specimens then were placed into subcutaneous pockets prepared on the backs of the rabbits. The animals were sacrificed 2 months after the procedure, and the grafts were excised for macroscopic and histopathologic examination.

RESULTS

The cartilage graft wrapped with PRF showed superior viability compared with the cartilage graft wrapped with oxidized regenerated cellulose. No significant differences were found among the other groups. The groups were not significantly different in terms of rates of inflammation, fibrosis, or vascularization.

CONCLUSIONS

PRF enhances the viability of diced cartilage grafts and should be considered an appropriate biological wrapping material for cartilage grafting.

Rhinoplasty: panel discussion

Should one use an open or closed rhinoplasty approach? How appropriate is the endonasal approach in modern-day rhinoplasty? Should the tip lobule be divided or preserved? Are alloplastic implants inferior to autologous implants? Does release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid one-third nasal pinching in reduction rhinoplasty? Over past 5 years, how have rhinoplasty techniques and approaches evolved?

Subciliary augmentation of the lower eyelid in Asians using a deep temporal fascia graft: a preliminary report

BACKGROUND

Pretarsal fullness of the lower eyelid has recently gained popularity in the Asian population. Hyaluronic acid injection is a simple, nonsurgical method for creating pretarsal fullness of the lower eyelid, but the effects last only 6-12 months. A need exists for a surgical procedure with long-term effects. We describe the use of a deep temporal fascia graft for subciliary augmentation of the lower eyelid.

METHODS

Between September 2009 and October 2011, seven Japanese patients underwent subciliary augmentation of the lower eyelid. This retrospective study was conducted on four of the seven patients who were followed for more than 1 year. A skin incision of approximately 1 cm was made at the lateral canthus along the subciliary crease of the lower eyelid and the skin was undermined to create a subcutaneous tunnel. A stab incision was then made 2 mm below the ciliary margin near the level of the lower lacrimal punctum. The orbicularis oculi muscle was incised under the skin incision at the lateral canthus, and the stump of the incised muscle was suspended to the periosteum of the lateral orbital rim. A deep temporal fascia graft was placed in the undermined subcutaneous plane of the lower eyelid.

RESULTS

Lower-eyelid pretarsal fullness was maintained at more than 1 year after surgery. The eyelids regained a natural appearance, and the patients were highly satisfied. Morphometric measurements demonstrated increased projection and width of the lower-eyelid pretarsal fullness.

CONCLUSIONS

Deep temporal fascia grafting is safe and reliable for subciliary augmentation of the lower eyelid.

LEVEL OF EVIDENCE V

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 .

[Techniques for correction of the nasal dorsum]

Correction of the nasal dorsum ranks among the most common surgical procedures in rhinoplasty. Due to the involvement of nasal support structures such as septolateral cartilage and the K and scroll areas, these procedures have both aesthetic and functional impacts. In addition to spreader grafts and spreader flaps, the most important surgical methods currently include the split hump reduction technique, cartilage-fascia transplants and cartilage grafts from rib and ear. In addition to serving to correct deformities, the techniques described here help prevent complications such as inverted V, hourglass and saddle nose deformities, as well as nasal valve stenosis. The basic operative principle calls for reinforcement and reconstruction of the anatomical support structures, while avoiding overresection and mucosal lacerations.

Mastoid fascia tissue as a graft for restoration of nasal contour deformities

A wide variety of autologous grafts have been used for the coverage of contour deformities in rhinoplasty. Mastoid fascia tissue (MFT) grafts are easy to harvest and very versatile, and the resulting donor site scar is not visible. Natural looking results can be obtained with MFT grafts when used for the coverage of dorsal irregularities, for dorsal augmentation, for camouflaging abnormalities related to skin atrophy, and even for tip-of-nose coverage and tip augmentation. Mastoid fascia tissue was used as a graft in 8 primary and 22 secondary cases for various purposes. All patients had satisfactory cosmetic results. Used in conjunction with a rigid graft such as cartilage, MFT grafts, which are ideal fillers, can be successfully used in rhinoplasty.

Augmentation of the upper lip with temporalis fascia: a quantitative analysis

BACKGROUND

Lip augmentation is a very common cosmetic procedure. A wide variety of materials have been used to enhance and contour the lips, including alloplastic and autogenous substances.

OBJECTIVES

The authors describe their experience with augmentation of the upper lip using an autologous graft from the temporalis fascia.

METHODS

Patients were enrolled prospectively. Upper-lip projection and vermilion show were measured preoperatively and 6 months postoperatively for 19 patients who were candidates for lip augmentation with temporalis fascia.

RESULTS

Six months postoperatively, the mean values for upper-lip projection and lip vermilion were significantly greater than preoperative measurements.

CONCLUSIONS

Augmentation of the upper lip with temporalis fascia appears to be safe and effective. Larger patient series, longer follow-up, and comparative studies are needed to corroborate these preliminary results.

LEVEL OF EVIDENCE

4.

Dorsal nasal augmentation with "open sandwich" graft consisting of conchal cartilage and retroauricular fascia

BACKGROUND

Augmenting the nasal dorsum with conchal grafts can cause visible irregularities over time due to the morphological qualities of that material.

OBJECTIVES

This study describes the senior authors' technique of dorsal nasal augmentation with chondrofascial "open sandwich" grafts consisting of pieces of conchal cartilage and retroauricular fascia. The authors assess the efficiency and reliability of this graft in nasal dorsal augmentation.

METHODS

The authors retrospectively reviewed the cases of 19 patients who underwent dorsal augmentation rhinoplasty with chondrofascial grafts. Both cartilage and fascia were harvested through the same incision in the retroauricular sulcus. The conchal graft was cut in 2 to 4 pieces and slightly crushed with tissue forceps. The pieces of cartilage were arranged and fixed to the fascia in different patterns according to the nasal dorsum contour.

RESULTS

The follow-up period ranged from 12 to 35 months in 16 patients who qualified for inclusion in the final data. The maximal thickness of the chondrofascial graft was 4.5 mm. There were no major complications in the recipient area, except 1 case of undercorrection. There were 2 complications in the donor area. In 1 case, a hematoma was treated conservatively. In another case, a strip of skin necrosis in the conchal area occurred and was treated by excision and direct suture with satisfactory resolution.

CONCLUSIONS

The autologous chondrofascial graft is appropriate for slight to mild dorsal nasal augmentation. The method, as with most rhinoplasty techniques, requires careful and judicious preoperative examination, planning, and execution. The postoperative scar is inconspicuous and the donor site morbidity is minimal.

Histomorphological Changes of Tutoplast-Processed Fascia Lata Grafts in a Rabbit Rhinoplasty Model

Objectives

Tutoplast-processed fascia lata (TPFL) is a commercially available homograft that has been successfully used as graft tissue for rhinoplasty. The present study evaluates the histomorphological changes of TPFL in a rabbit rhinoplasty model.

Study Design

Prospective study using a rabbit model.

Setting

Animal laboratory of the Asan Medical Center.

Subjects and Methods

The study used 15 New Zealand White rabbits. Each rabbit was implanted with a TPFL (experimental group) and autologous fascia lata (control group) graft of equal size into the nasal dorsum. Rabbits were killed at 1, 3, and 6 months, and the grafts were removed and microscopically assessed for fibroblast proliferation, neovascularization, inflammation, and thickness.

Results

For TPFL grafts, the degree of inflammation significantly decreased between 1 and 3 months ( P = .041). The degree of fibroblast proliferation continually increased over time. There was a mild degree of neovascularization for the TPFL graft at 1 month. The degree of neovascularization increased between 3 and 6 months ( P = .041). For the degree of inflammation, fibroblast proliferation, and neovascularization, there was no significant difference between TPFL and autologous fascia lata at 6 months. Mean thickness analysis showed that there was no significant thickness reduction in both TPFL and autologous fascia lata grafts at 6 months.

Conclusion

The TPFL grafts showed negligible resorption rates and favorable tissue reactions in the rabbit rhinoplasty model.

Superficial mastoid fascia as an accessible donor for various augmentations in Asian rhinoplasty

This study was designed to assess the anatomic characteristics and clinical versatility of superficial mastoid fascia as a soft-tissue donor for augmentation in Asian rhinoplasty. Dissections were performed on four fresh cadavers (eight ears) for histologic study. A 3×10 mm2-sized full layer of skin and underlying soft tissue was harvested from the postauricular area, transversely and longitudinally (cephalic and caudal directions), 5 mm apart from the midpoint of the auriculocephalic sulcus. The average fascial thickness and nerve distribution were assessed using digital microscopic images after haematoxylin and eosin (H&E) staining. In the histologic study, the average measured thickness of the superficial mastoid fascia was between 3.8 and 4.5 mm in various directions. Clinically, 33 subjects who underwent rhinoplasty using superficial mastoid fascia were assessed prospectively. When soft tissue was needed in various types of augmentations, a longitudinal incision was made on the posterior auriculocephalic sulcus and the maximum thickness of superficial mastoid fascia was harvested. The sizes of the superficial mastoid fascia used in the 33 subjects ranged from 0.4×2.5 cm2 to 1.2×4.2 cm2. The superficial mastoid fascia was grafted regionally for the nasion, tip and nasal dorsum. In two cases, hypertrophic scars developed at the donor site. Four subjects experienced transient dysaesthesia and hypoaesthesia at the donor area postoperatively. Superficial mastoid fascia may be a useful resource in rhinoplasty as a donor for various types of augmentations, allowing easy access without prominent scarring or permanent sensory nerve damage when a low-to-moderate volume of soft tissue is required.

A novel autologous scaffold for diced-cartilage grafts in dorsal augmentation rhinoplasty

BACKGROUND

Diced-cartilage grafts have been used for dorsal nasal augmentation for several years with good results. However, compounds such as Surgicel and temporalis fascia used as a wrap have inherent problems associated with them, predominantly inflammation and graft resorption. An autologous carrier could provide stabilization of cartilage grafts while avoiding the complications seen with earlier techniques.

METHODS

In our patients, a malleable construct was used for dorsal nasal augmentation in which autologous diced-cartilage grafts were stabilized with autologous tissue glue (ATG) created from platelet-rich plasma (platelet gel) and platelet-poor plasma (fibrin glue).

RESULTS

A prospective analysis of 68 patients, who underwent dorsal nasal augmentation utilizing ATG and diced-cartilage grafts between 2005 and 2008, were included in the study. Although there was notable maintenance of the dorsal height, no complications occurred that required explantation over a mean follow-up of 15 months.

CONCLUSION

The use of ATG to stabilize diced-cartilage grafts is a safe, reliable technique for dorsal nasal augmentation. The platelet gel provides growth factors while the fibrin glue creates a scaffold that allows stabilization and diffusion of nutrients to the cartilage graft.

Structural grafts and suture techniques in functional and aesthetic rhinoplasty

Rhinoplasty has undergone important changes. With the advent of the open structure approach, requirements for structural grafting and direct manipulation of the cartilaginous skeleton through suture techniques have increased substantially. The present review analyzes the current literature on frequently referenced structural grafts and suture techniques. Individual techniques are described and their utility is discussed in light of available studies and data.

Use of Tutoplast-Processed Fascia Lata as an Onlay Graft Material for Tip Surgery in Rhinoplasty

Objectives. Tutoplast-processed fascia lata (TPFL) is a commercially available homograft that has been successfully used as human graft tissue for dorsal augmentation in rhinoplasty. The present study evaluated the use of TPFL as an onlay tip graft material in rhinoplasty.

Study Design. Case series with chart review.

Setting. Academic tertiary care medical center.

Subjects and Methods. The study involved a retrospective analysis of rhinoplasty cases using TPFL as a tip onlay graft. The study included 82 patients (46 men and 36 women) who underwent tip surgery using TPFL from February 2006 to June 2008. By comparing facial photographs before and after the operation, 2 independent rhinoplastic surgeons assessed outcomes of 8 months postoperative time as being excellent, fair, or poor. Using the pre- and postoperative profile view, anthropometric measurements were also made.

Results. The 82 subjects included 71 primary and 11 revision patients. TPFL was used as a tip onlay graft in final tip modification. Postoperative assessment found that only 6 (7%) patients had excellent results, 51 (62%) had fair results, and 25 (31%) had poor results. Pre- and postoperative anthropometric measurements showed the technique resulted in an overall increased nasal tip projection postoperatively (0.56 ± 0.09 vs 0.60 ± 0.08; P < .05). However, the overall nasolabial angle was not changed after surgery (91.35 ± 10.36° vs 93.05 ± 8.3°; P = .08). No patient experienced infection, visible graft contour, or migration.

Conclusion. TPFL was not that satisfactory in terms of aesthetic outcome when used as a tip onlay graft material in rhinoplasty patients.

Resolution of posttraumatic recurrent nasal fistula using temporoparietal fascia

Temporoparietal fascial grafts have been used for both nasal and facial contouring, for vascularized tissue coverage, and to augment the nose and lip. The temporoparietal fascial graft provides thin, broad, pliable, easily neovascularized, adequate coverage, contour, and bulk on the cartilage dorsum of the nose, as well as an inconspicuous donor site. A 23-year-old female motorcyclist had an accident with 1 angular laceration wound on the dorsum of the nose in 2006. There was intermittent discharge in the dorsal nose 2 weeks after primary repair. Six months later, the open-tip rhinoplasty was applied to the recurrent fistula of the nose dorsum. There were 2 fistulous orifices and 1 fibrotic cavity with hair ingrowth. After replacement of the rolled temporoparietal fascia, external nasal splinting was applied to mold the shape for 1 week. There was neither graft exposure nor recurrent infection. The procedure is a useful method to eliminate inflammatory squeals. The smooth nasal dorsum skin was regained with adequate nasal projection.

Treatment of recurrent intractable periauricular fistula using temporoparietal fascia

The temporoparietal fascia has been used extensively for vascularized tissue coverage, augmentation, and facial contouring. The temporoparietal fascial graft provides thin, broad, pliable, easily neovascularized, adequate coverage, contour, and bulk, as well as a hidden donor site.A 19-year-old woman had periauricular fistulae since she was 2 years. Her condition was diagnosed as left preauricular fistula, and she has been operated on by otolaryngologists 8 times and by plastic surgeons 2 times. The temporoparietal fascia was tunneled through a postauricular pocket to fulfill the cavity under her left earlobe and preauricular area.Facial fistulae were resolved without wound dehiscence, graft exposure, and recurred infection. Local preoperative tenderness was minimal.The temporoparietal fascial graft offers the following advantages as a 1-stage procedure: ease of neovascularization, being in the same operative field, being soft and compliant to the pocket, having a minimal graft resorption, and having a minimal donor site discomfort and disfiguration.

Rhinoplasty: dorsal grafts and the designer dorsum

Over the last 2 decades, many of the difficulties in shaping primary tips and rebuilding destroyed secondary tips have been solved through the use of tip sutures and grafts. Dorsal grafts, which are a highly visible determinant of the nasal profile and contour, have become the greatest challenge in rhinoplasty surgery. This article reviews the author's different approaches to dorsal grafts using fascia and diced cartilage, either separately or in combination.

Bilateral temporoparietal fascial free flaps for reconstruction of bilateral hand defects: a report of two cases

Bilateral temporoparietal fascial free flaps were used for reconstruction of bilateral hand defects in two male patients. A 42-year-old man sustained crushed injury to both hands with avulsion defects and exposed bones and tendons. The two separate procedures were performed under general anesthesia. The temporoparietal fascial free flap was skin grafted on the ward on the following day after the operation. The other patient was a 61-year-old leprosy patient who had bilateral high ulnar nerve palsy for 28 years. One simultaneous procedure was performed under local anesthesia for harvesting the temporoparietal fascial free flaps and under brachial block for preparation of the recipient sites. The free flaps were used for augmentation of the atrophic first web spaces. The postoperative results of the two cases were satisfactory. The functions of both hands were restored with normal gliding mechanism of the tendons in the first case, and permanent correction of the atrophic web spaces was demonstrated in the second case. The temporoparietal fascial free flap is an ideal flap for coverage of hand defects as well as augmentation of first web space atrophy.

Temporoparietal fascial free flap for correction of first web space atrophy

Fourteen temporoparietal fascial free flaps were used for correction of first web space atrophy from ulnar nerve palsy in 13 patients. Ten sustained ulnar nerve injuries and three suffered from leprosy. The procedures were performed under general anesthesia except one leprosy patient with bilateral ulnar nerve palsy in which local anesthesia and brachial block were employed to harvest bilateral free flaps and recipient site preparations, respectively. The follow-up time varied from 4 to 64 months. The postoperative results were satisfactory and there was no resorption of the free flaps. The consistency of the augmented first web space was soft and compressible like natural feel. The size of the flap was more than enough for augmentation of first web space and donor site morbidity was minimal and accepted by all patients. We conclude that temporoparietal fascial free flap is an ideal autogenous tissue for correction of first web space atrophy.

Saddle nose deformity reconstruction with a split calvarial bone L-shaped strut

OBJECTIVE

To describe a technique for creation of a split calvarial bone L-shaped strut that provides dorsal support while increasing tip projection in patients with substantial septal saddle nose deformities from various underlying inflammatory conditions and surgical resection.

METHODS

Case series and review of the literature.

RESULTS

Fifteen patients underwent nasal reconstruction at our institution using the split calvarial bone L-shaped strut technique with postoperative follow-up to 36 months (range, 9-36 months). The causes of septal perforation leading to saddle nose deformity included cocaine use, infection, sarcoidosis, malignant lesion, iatrogenic causes, and Wegener granulomatosis. All cases resulted in an augmented, straightened nasal dorsum and increased tip projection. Results were maintained throughout follow-up with no evidence of graft infection, resorption, or migration.

CONCLUSIONS

The split calvarial bone L-shaped strut provides dual benefits of dorsal support and increased tip projection. Numerous techniques have been discussed for dorsal augmentation with varied success; however, the long-term maintenance of this graft in patients with severely compromised vascularity owing to underlying inflammatory conditions such as Wegener granulomatosis highlights its presumed advantages. The procedure can be performed using the external rhinoplasty approach, obviating the need for radix incisions for plating or intranasal mucosal incisions. These advantages make the L-shaped strut technique excellent for nasal reconstruction in patients with substantial septal saddle nose deformities regardless of cause and duration of defect.

Comparison of AlloDerm, fat, fascia, cartilage, and dermal grafts in rabbits

OBJECTIVE

To compare various graft materials in the rabbit model, including autologous cartilage, dermal tissue, fat, and AlloDerm (a cadaver-derived material).

METHODS

Twenty-five New Zealand white rabbits were used. Equally sized autogenous (fat, fascia, cartilage, and dermal) grafts and AlloDerm were implanted into subcutaneous dorsal pockets on the rabbits. Animals were killed 1, 2, 3, and 4 months after surgery. The grafts were examined microscopically for thickness, resorption, fibrosis, neovascularization, inflammation, eosinophilia, and the presence of multinucleated giant cells or microcysts.

RESULTS

The cartilage grafts revealed excellent viability with no resorption. The fascial grafts showed negligible volume loss. The dermal grafts developed epidermoid cysts. The AlloDerm grafts demonstrated graft thickening at 1 month and total resorption at 3 and 4 months. The fat grafts demonstrated 30% to 60% partial resorption.

CONCLUSIONS

The major disadvantage of using an autogenous fat graft was partial resorption, whereas cyst formation was observed with dermal grafts. AlloDerm caused tissue reaction and resorption. The best graft material was cartilage, with a low absorption rate, good biocompatibility, and minimal tissue reaction or fibrosis, followed by fascia, with a minimal shrinkage capacity and tissue reaction.

In vivo study to assess the viability and mass effect of fascia injection in comparison with block fascia graft

Recently, fat injection has gained favor among plastic surgeons for soft tissue augmentation. However, fat injections lose 50% of their volume after 1 year. The profession is in need of an injectable bulking material that gives a long-lasting improvement. Using 30 male rats, this study investigated the stability of the size and structure of the injected fascia autograft and compared it with surgically transplanted fascia. The fascia graft was harvested from the back of the rat, big, and divided into two equal pieces. The first piece was minced into a paste and injected subcutaneously on the anterior surface of the right ear. The other piece was transplanted subcutaneously on the anterior surface of the left ear. The grafts were observed for any sign of resorption over 1 to 6 months.Grossly, injection and transplantation sites were palpable at the end of the observation periods. Microscopic examination showed that injected fascia maintains its histomorphologic structure. These findings indicate that the injected fascia graft is well tolerated, and the size of the graft remained stable. According to this study, fascia injection can result in bulking material that gives a long-lasting improvement, and can be a viable alternative to other methods.

The new reconstruction technique in the treatment of the skin cancers located on the eyelid: Posterior temporalis fascia composite graft

Background

Difficulty of reconstruction of the eyelids arises from the need to reconstruct different supporting and covering structures in a single operation. Defects in the anterior lamella of the eyelids can be readily repaired with skin grafts or flaps but posterior lamellar reconstruction needs more complex applications.

Methods

We performed posterior lamellar eyelid reconstruction with posterior parts of the temporalis fascia, since their anatomical and histological features are very similar to the defects. Nine patients with skin tumors located on the periorbital region were treated with local skin flaps and deep layer of the temporalis fascia.

Results

Grafts were harvested very easily. There was no complication related with graft or donor site. Biopsy was performed in three cases and normal conjunctival elements were seen. Functional and acceptable aesthetically results were achieved in all patients.

Conclusion

Ideal reconstructive material for replacement of the posterior lamina is still lacking. Tarsal reconstruction can be made with deep temporalis fascia with success since the thickness of the both tissues are very similar and also since the loose areolar layer of the temporalis fascia is very thin and highly vascularized, this layer can be used in reconstruction of the conjunctiva. According to our knowledge this is the first report of using of the posterior part of temporalis fascia as a composite graft in the literature.

Rhinoplasty and the nasal SMAS augmentation graft: advantages and indications

We evaluated the nasal superficial musculoaponeurotic system (SMAS) as an autologous augmentation graft material in the thick-skinned patient undergoing cosmetic rhinoplasty using a retrospective review. Representative case reports demonstrated preliminary long-term results after augmentation with the nasal SMAS graft in an academic rhinoplasty practice. En bloc excision of the nasal SMAS in thick-skinned patients produced uniformly favorable improvements in nasal tip definition without adverse sequelae. Moreover, in 10 patients, the harvested material was also used for volume augmentation at various adjacent nasal sites, including the radix, nasal sidewall, and nasal dorsum. Long-term follow-up ranging from 1 to 3 years suggests stable volume augmentation in this initial patient series. No donor morbidity was observed in properly selected patients, and enhancements in nasal tip definition were uniformly favorable. Additional studies are needed to more accurately characterize long-term nasal SMAS graft survival in all patients.

Maximizing the use of the abdominoplasty incision

Candidates for abdominoplasty often request multiple procedures at the time of consultation. Some of these patients have the potential opportunity to have ancillary procedures performed through the abdominoplasty incision, such as breast augmentation or suction-assisted lipectomy. Access via the abdominoplasty incision can also limit the need for distant donor sites, for instance, when autologous fillers or rib graft are necessary. The techniques described are straightforward and are based on standard principles that should be considered when ancillary procedures are performed in conjunction with abdominal contouring procedures. In a review of 70 consecutive patients undergoing abdominoplasty, 91 ancillary procedures were performed in conjunction with the abdominoplasty. Of the total number of patients undergoing abdominoplasty, 29 patients underwent 30 procedures facilitated through their abdominoplasty incision, including 23 suction-assisted lipectomies of the flanks, six breast augmentations, and one rib cartilage harvesting for rhinoplasty. A review of the author's experience and discussion for potential options afforded by this exposure are presented.

Processing of fascia for vocal fold injection. A study in vitro and in paralyzed canine vocal folds

To evaluate the simplest and safest method to mince fascia for autologous vocal fold injection, we performed an in vitro study applying porcine fascia and a prospective study using a canine model. Six different surfaces were tested in the laboratory for mincing fascia. The ease of handling of tissue on each surface was noted. Minced fascia was studied by microscope under polarized illumination, and the number and nature of foreign particles were recorded. After the safest method to mince fascia was established, 2 dogs were operated on. The recurrent nerve was sectioned, and a piece of fascia lata was harvested and cut with scissors on a steel surface. Fascia injection deep into the thyroarytenoid muscle was performed. The dogs were painlessly sacrificed 6 months later, and the larynges were removed for histomorphological study. On cutting, all polymer surfaces released small amounts of particles. These were not evident when we used glass or steel plates, but their hard surfaces were difficult to work on. Cutting a piece of fascia with scissors was found to be effective and safe in terms of microscopic foreign particles. The two dogs suffered no perioperative or late complications. Six months later, a well-preserved, vascularized, collagen-rich tissue was in its place without any evidence of acute or chronic inflammation. The histomorphological findings were identical to those of our previous study, with the exception that this time, no foreign particles from the mincing surface were present. An autologous fascia graft proves to be well preserved and well tolerated in the augmentation of a paralyzed vocal fold, and scissors are simple and effective in mincing it for injection.

Results of fascial augmentation in unilateral vocal fold paralysis

The objective of this study was to evaluate the effects on voice quality of augmentation by injection of minced fascia in patients with unilateral vocal fold paralysis. Preoperative and postoperative voice samples from 14 patients (6 men and 8 women; mean age, 59 years) were analyzed by computerized acoustic analysis and blinded perceptual evaluation. Statistically significant improvements were seen in perturbation measurements (jitter and shimmer), noise-to-harmonics ratio, and maximum phonation time. A panel of evaluators rated 10 of the 14 postoperative voices as normal or near-normal. Injection laryngoplasty with minced fascia offers a new, effective, well-tolerated, and inexpensive method to medialize a paralyzed vocal fold. The graft seems to survive well, as indicated by good vocal results with a follow-up ranging from 5 to 32 months.

[The temporal periosteum: anatomical study and surgical implications]

The periosteum of the temporal area is mentioned at different places in the literature: either against the osseous plane like everywhere in the human body, or between the deep and the superficial temporal fascia. The subperiosteal subtemporal approach in craniofacial surgery in children is in favour of a juxta-osseous localization of the periosteum. Ten premature still-born neonates and two adults cadavers have been dissected for this study and, permit anatomical and histological (with HES coloration) studies. With every specimen, the authors concluded that the temporal periosteum is against the outer table of the calvarium. It became thinner in adults because of direct insertions of the temporalis muscle in the calvaria. An anatomical description of the layers of the temporal area is realised and discussed with an extensive review of the literature. The authors have proposed a subperiosteal subtemporal approach in craniostenosis surgery.

Histology of injected autologous fascia in the paralyzed canine vocal fold

OBJECTIVE

To evaluate the histology of minced and injected autologous fascia graft in the augmentation of unilateral vocal fold paralysis.

STUDY DESIGN

Prospective study using a canine model.

METHODS

Nine dogs were operated. At first, a piece of fascia was harvested from fascia lata and minced into tiny chips with a scalpel. Cutting off a section of the recurrent nerve paralyzed the right vocal fold. The minced fascia-paste (0.1 mL) was injected using a pressure syringe into the paralyzed thyroarytenoid muscle under direct laryngoscopy. Two animals were killed at 3 days, one at 10 days, three at 6 months, and three at 12 months postinjection. Each dog underwent laryngectomy and serial coronal sections of paraffin blocks from the posterior part of the vocal folds were made.

RESULTS

The dogs experienced no complications perioperatively or during follow-up. Under microscopy, muscle of the paralyzed vocal fold was atrophied in comparison to the contralateral control. There was an acute inflammatory reaction induced by the graft. This did not exist in the specimens taken at 6 and 12 months. No extensive edema, areas of necrosis, or formation of granulomas was seen at any time. Maturation of the graft was characterized by active collagen remodeling up to 12 months. At that time the graft consisted of firm, condensed fibrous tissue. Scar formation around the graft was moderate, and the subepithelial layer of the vocal fold remained undisturbed. Each graft consisted of singular foreign bodies from the polyamide mincing plate. We cannot exclude that their presence would have had an impact on the final architecture of the graft.

CONCLUSION

In a canine vocal fold, the free fascia graft is well tolerated and after 12 months a well-organized, collagen rich tissue is seen on histological sections. The findings are in accordance with clinical studies applying free fascia grafts.