[Tip sutures]

Suture techniques are widely used and can be very useful and efficient to support the nasal tip and correct its deformities. Nevertheless, they are so powerful that they have to be performed very precisely if the surgeon does not want to create cosmetics as well as functional problems. The authors describe the main tip sutures and their effects, expected or not.

[Osteotomies in rhinoplasty]

Osteotomies are performed to modify the shape of the bony part of the nose, therefore they should not be done systematically. Main indications are correction of deviated nose, narrowing of bony vault and roofing of an open roof after important hump resection. The nose should be very precisely analyzed before osteotomies if the surgeon doesn't want to create deformities such as step, inverted V, pinched nose or saddle nose. When too narrowed, bones can also block the airway and lead to functional problems.

[Standard rhinoplasty]

Most patients who consult a surgeon for rhinoplasty do not want a radical change in their nose. They seek a reduction in the volume of the nasal pyramid and correction of a precise element that they judge to be ungainly--most often an osteocartilaginous hump. The procedure that we qualify as "standard" will eliminate the osteocartilaginous hump, decrease the dimensions of the septum and reduce the size of the alar crus of the alar cartilage. Although the required technical maneuvers are simple, their sequence must be coherent with a few basic rules that are simple but rarely explained in order to avoid defects linked to excessive, or on the contrary, insufficient corrections.

[Correction of the broad nasal tip]

AIM OF STUDY

The multiple techniques, the accurate examination and the checking of the various anatomic components (skin, cartilage resistance) could explain the difficulty for the surgeon to choose a main line, achieving the purpose of perfect and permanent results. Facing this complexity, the goal of this study is to plan step by step, using a simple and original technique in order to correct a broad nose.

METHODS

The modification of the nasal tip includes resection techniques, currently the most used, the cartilaginous reshaping with sutures or onlay grafts and more recently the reinforcement structures approach by inlay grafts. Basically, there are 3 important stages in the performing of a new nose tip: projection and rotation control of the tip, nasal base stability and reshaping of the tip. The author reports an original technique for the control of the tip projection and reshaping the middle crus with two cartilaginous grafts disposed on the external side of the medial crus. These two grafts permit both improving naturally the support of the tip and stabilizing the columella, avoiding the classical median columellar strut.

RESULTS

Through a ten-year experience with 203 cases, every patient result was analyzed and criticized. All the cases were reviewed after 2 years at least, and the unwanted effects were noted. Nineteen patients have had a secondary rhinoplasty (11%), 4 for a revision tip surgery (2%). There is no respiratory dysfunction and more than 90% of patients are satisfied for their aesthetic result. We think that the main problems as resection techniques with skin or mucosa retraction, unpredictable long-term effect on the tip, unknown future of the grafts, especially onlay grafts responsible sometimes for unpleasant irregularities, could be minimized with this procedure. The more the nasal tip is stabilized, the more the results are better and longer lasting.

CONCLUSION

The surgery of the nose tip is focused not only with shaping procedures of the middle or lateral crus. The technique reported is very simple and safety for the nasal tip surgery through a modification and/or a reinforcement of the initial structure, maximizing the contact between skin and anatomical component and economizing the interposition of a cartilage graft as far as possible. It is a new concept including respect of the anatomy, and stability, which are the best guarantee for a durable result.

[Middle third of the nose and internal valve. Alar wall and external valve]

To many surgeons, nasal airway obstruction is synonymous with either septal deviation or inferior turbinate hypertrophy. The role of internal and external nasal valves is often less known by surgeons even if it is crucial in nasal breathing and strongly interrelated with esthetic of the middle third of the nose and alar wall. Therefore, precise examination of the two valves and conservative surgery should help to avoid many functional and esthetic problems.

[Two cases of lymphoma in an implant capsule: A difficult diagnosis, an unknown pathology]

The anaplastic large cell lymphoma (ALCL) is a rare disease, its incidence in the United States is one case per 500,000 women and three for 100 million patients for breast single location. Forty-six cases have been reported in the literature. They can grow on any type of implant: expander prosthesis silicone and saline, smooth or textured envelope. Currently, the consensus process includes capsulectomy, removal of the implant, chemotherapy and radiotherapy. However, some authors classify under indolent disease, but we believe that some cases may escape any therapeutic and become very aggressive forms. It is therefore important to make an early diagnosis and start treatment urgently. Severity and suspicion of iatrogenic nature of ALCL have an obligation to inform future with implants.

[Mandibular reconstruction using an iliac crest free flap vascularized by the deep circumflex iliac vessels. A clinical study apropos of 30 cases]

Thirty cases of mandibular defects were reconstructed with a free iliac flap vascularised by the deep circumflex iliac vessels. Twenty five of these cases involved soft tissue damage with a defect of the mandible. The surgical procedure described by I. Taylor was used. Three anatomical variations of the pedicle were found. The features of the iliac bone are particularly suitable for mandibular reconstruction. The natural shape of the iliac bone does not require complex osteotomies and its healing capacity allows simple osteosynthesis. The thickness of the muscular pedicle, and thus the flap, is determined by the position of the lower edge of the skin components with respect to the iliac crest. This type of flap currently remains very useful in reconstruction of major mandibular and adjacent soft tissue destruction because of the very low incidence of failure (2 cases) and complications.