Radial bone graft usage for nasal septal reconstruction

Radial bone graft usage for nasal septal reconstruction

Yakup Cil1, Atacan Emre Kocman1, Abdul Kerim Yapici1, Serdar Ozturk2
1 Department of Plastic Surgery, Eskisehir Military Hospital, 26020, Eskisehir, Turkey
2 Department of Plastic Surgery and Burn Center, Gulhane Military Medical Academy, Ankara, Turkey

Correspondence Address:
Yakup Cil
Eskisehir Military Hospital, Department of Plastic Surgery, 26020, Eskisehir
Turkey

DOI: 10.4103/0970-0358.81446

Background: Although various techniques have been described for correction of crooked and saddle nose deformities, these problems are challenging with high recurrence and revision rates. Conventional septal surgery may not be adequate for nose reconstruction in crooked and saddle nose deformities. Materials and Methods: Between December 2005 and October 2009, six patients with crooked nose and five patients with saddle nose deformities underwent corrective surgery in our clinic. All patients were male, and the mean age was 21 years (range, 19-23 years). We used rigid radial bone graft to prevent redeviation and recurrence following corrective nasal septal surgery. Results: The mean follow-up period was 28 months, ranging from 18 to 46 months. Mean operation time was 4 hours (3-4.5). All patients healed uneventfully. None of the patients required secondary surgery. Conclusions: We believe that radial bone grafts offer a long lasting support in treatment of challenging cases with crooked and saddle nose deformities.

Keywords: Crooked nose; nose reconstruction; radial bone; saddle nose

How to cite this article:
Cil Y, Kocman AE, Yapici AK, Ozturk S. Radial bone graft usage for nasal septal reconstruction. Indian J Plast Surg 2011;44:36-40
How to cite this URL:
Cil Y, Kocman AE, Yapici AK, Ozturk S. Radial bone graft usage for nasal septal reconstruction. Indian J Plast Surg [serial online] 2011 [cited 2011 May 23];44:36-40. Available from: http://www.ijps.org/text.asp?2011/44/1/36/81446

Conventional septal surgery may not be adequate to prevent recurrences in the management of severely deviated nose with crooked and saddle nose deformities. [1],[2] In order to correct the crooked nose deformity, dorsal hump resections, [2] a variety of modified osteotomies, [3] septal cartilage manipulations, [4] suture correction technique, [5] and spreader grafts [6] have been recommended in the literature

In a true septal saddle nose deformity, dorsal grafts alone cannot restore dorsal nasal height. Dorsal improvement in such patients could be achieved by dorsal onlay grafts combined with columellar strut [7] or L-shaped dorso-caudal frame. [1]

Although; various techniques have been described for correction of the crooked and saddle nose deformities, these problems still have high recurrence and revision rates. We used rigid radial bone graft to prevent redeviation and recurrence following corrective nasal septal surgery.

Between December 2005 and October 2009, six patients with crooked nose and five patients with saddle nose deformities underwent corrective surgery. All patients were male and the mean age was 21 years (range, 19-23 years). Patients had both functional and cosmetic nasal problems. In all patients, the deformity was secondary to past nasal trauma. Patient-related assessments were performed before operation and follow-up. [8]

Surgical technique

All surgeries were performed under general anaesthesia. After local anaesthetic infiltration the nasal structures were exposed through an open rhinoplasty approach. Following hump resection, the septum was dissected subperichondrially and resected leaving a 0.8 to 1-cm dorsal and caudal L-strut. Deviated caudal segment of the septal cartilage was straightened medialized and secured to the periosteum of the anterior nasal spine. Radial bone graft was accessed from the lateral antecubital region, and bone graft was harvested from the lateral side of radial bone [Figure 1]. Radial bone is triangular in cross section. The anterior and posterior surfaces of the radius are generally smooth, whereas an oval roughening for the attachment of pronator teres marks approximatelly the middle of the lateral surface of the radius. Bone graft was harvested a segment (about 5?1 cm) located between the insertion of the pronator teres and the brachioradialis muscles. Lateral antecubital nerve, flexor and extensor muscles were protected during bone graft harvesting procedure. Bone graft was thinned by bone filing and shaped in the form of a L-strut as "key in the keyhole pattern" [Figure 2], [Figure 3]. The dorsal strut was placed by tongue in groove technique on the anterior nasal spine. L-strut frame was sutured under the upper lateral cartilage remnants and between the domes of two lower lateral cartilages to hide palpable edges and secure it in place. Lateral and median osteotomies were also performed if bony pyramid was also deviated. Any residual irregularities on the dorsum were camouflaged with Erol's Turkish delight. [9] Tipplasty was performed if necessary. Following closure, nasal packing and plaster cast were applied. A plaster cast was also applied on the forearm and removed 1 week later. The packing and the nasal splint were removed at 4 th and 7 th days, respectively. Figure 1: Intraoperative view of the radial bone graft taking side, L-strut bone graft is taken from the lateral side of radial bone.
Abbrevations: MN: Median nerve, RA: Radial arter, BR: Brachioradial muscle.

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Figure 2: Two pieces of L-strut bone graft (above). An interlocked design (key in the keyhole pattern) of L-strut is introduced (center). L-strut bone graft was placed the nose (below)

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Figure 3: Late view of radial bone graft donor site (above), radiological appearance of radial bone graft donor site (center), three-dimensional CT imaging of L-strut bone graft (below).

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The mean follow-up period was 28 months, ranging from 18 to 46 months. Mean operation time was 4 hours (3-4.5). Intraoperatively, it was found that septal cartilage was thickened and distorted in all cases. All patients healed uneventfully [Figure 4],[Figure 5] and [Figure 6]. None of the patients required secondary surgery. The graft did not get displaced in any case, and did not develop unsightly irregularities over time. No absorption or extrusions of the grafts or infection were seen in follow-up period. Radial bone fractures were not seen in follow-up [Figure 3]. None of the cases had further neurovascular complications in follow-up. We have satisfactory results in our series of septal reconstruction using radial bone graft in 11 patients according to patient-related assessments. [8] Figure 4: Preoperative anterior view of the patient with saddle nose deformity (above, and below; left). Postoperative 26 months later (above, and below; right).

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Figure 5: Preoperative anterior view and inferior view of the patient with crooked nose deformity (above; right and left). Postoperative 24 later (below; right and left).

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Figure 6: Preoperative anterior view of the patient with crooked nose deformity (above, and below; left). Postoperative 20 months later (above and below; right).

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Septum is the key for operative management of complicated nose reconstruction. [1],[2] Besides straigtening the septum, maintaining its support is also crucial for long-lasting results. [2] The most popular method is reinforcement of corrected septum with spreader grafts. [1],[2],[10] The spreader grafts restore the integrity of septal L-struts [11] and resist the memory of the septal cartilage. [12] Byrd et al. [13] used unilateral spreader-extension grafts by placing them unilaterally on the concave side of the deformity. Rohrich et al. [2] placed asymmetric spreader grafts to camouflage any residual deformity and to restore dorsal aesthetic lines. Unilateral spreader graft known as the "crossbar graft" has also been described to keep the realigned septum in correct position over time. [6] However, in case of severely deviated cartilaginous septum, relatively weak cartilage grafts (obtained from septum itself or from ear concha) can not maintain adequate support. It is also technically difficult to harvest long and straight pieces of spreader grafts from a severely distorted osseocartilaginous septum. Additionally, flexible cartilage has unpredictable tendency to retain its curvature attributed to its memory. A more rigid framework is necessary against the deforming forces during the healing period. Some authors preferred using alloplastic materials as spreader grafts for more rigid stabilisation. [14],[15] However, there is concern about using alloplastic materials in the literature. [16]

Saddle nose is one of the difficult nasal deformities as crooked nose. Onlay grafts were used in mild to moderate dorsal depression treatment. [17] Using only dorsal struts can not maintain adequate support for severe saddle nose deformity. Columellar support is also necessary to prevent downward tilting of distal end of the dorsal strut. [1] Ribs are carved and shaped as pistol like spreader grafts and columellar struts, and most preferable method of saddle nose deformity correction. However, rib cartilage has an unpredictable tendency to bend and thus gives the nose a twisted appearance. [18] The boney component too is plagued with the problem of bone resorption with time. Other disadvantages of rib harvest are of pneumothorax and conspicuous contour deformity.

Different bone graft sources were described for nasal reconstruction. [19],[20] Radius is a longutidinal bone, and it is not curved as olecranon [20] and calvarial harvesting. [19] Lateral aspect of radial bone provides a source of straight framework when shaped properly. The dorsal strut was placed as tongue in groove technique, and it was interlocked with caudal strut as "key in the keyhole" pattern. L-strut-shaped bone graft supports the realigned caudal-dorsal septum despite the cartilaginous memory of the previous position. Also, it does not obstruct airway because of its delicate shape.

Recently, mastoid bone graft was described in rhinoplasty. [21] Although mastoid bone graft may be useful for augmentation of nasal dorsum, this technique has some limitations including difficulty in working with the inherent curvature of the mastoid bone and also unavailability of adequate nasal septal support for reconstruction of crooked nose. Mastoid bone is provided only 30-40 mm autologous bone graft. Injury of the facial nerve is a potential complication in donor site. Radius provides enough bone graft source for straight bone frame preparation (5 cm length). In addition; radial bone graft can be shaped for L-strut frame easily.

Successful rhinoplasty is best achieved through careful analysis of the problem and clear communication with the patient regarding expectations of surgery. Our experience with these patients of using bone grafts was that they were not disturbed by the rigid L-shaped bony strut. They were happy about a straight nose with a natural appearance.

Radial bone fractures were not seen in our cases. The radius must be carefully split during harvest in order to prevent postoperative fracture at the donor site. Length is generally enough to a segment located between the insertion of the pronator teres and the brachioradialis muscles (about 5 cm). The split radius is adequate to prepare L-strut frame. Unsightly scar formations at the doner site were not seen in our series.

We believe that radial bone grafts offer long-lasting results in treatment of challenging crooked and saddle nose deformities. More clinical studies with more patients are necessary to highlight the real impact of this technique.

 
Daniel RK. Rhinoplasty: Septal saddle nose deformity and composite reconstruction. Plast Reconstr Surg 2007;119:1029-43.  
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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A modified technique for nipple-areola complex reconstruction

A modified technique for nipple-areola complex reconstruction

Shoeib A Mohamed1, Peir Camillo Parodi2
1 Department of Plastic Surgery, Sohag University, Egypt,
2 Department of Plastic Surgery, Udine University, Italy,

Correspondence Address:
Shoeib A Mohamed
Department of Plastic Surgery, Sohag University, Egypt

DOI: 10.4103/0970-0358.81450

Background: From a historical perspective, many techniques of nipple reconstruction have been performed, including a graft from the contralateral nipple, composite grafts such as toe pulp or earlobe tissue and even an intra-dermal tattoo alone. This is the final stage of breast reconstruction, and is carried out only when the surgeon is confident that acceptable symmetry and shape of the reconstructed breast has been achieved. The technical challenges of nipple reconstruction include correcting position, maintaining adequate projection and creating an inconspicuous scar. An alternative to a surgically reconstructed nipple is the use of silicone prosthetic nipples. Materials and Methods: From August 2006 until September 2007, 80 cases of nipple/areola reconstruction were performed in our department (UDINE UNIV.) following mammary reconstruction or conservative breast surgery. Forty cases were carried out with the classical technique and another 40 cases with the introduction of our modification in the form of deepithelization of a semicircular area of the adjacent skin at the base of the flap. Postoperative follow-up as regards the nipple size, site, projection, symmetry and donnar scar were assessed. Patient satisfaction was also addressed and evaluated. Results: There were good to excellent results as regards nipple size, symmetry and projection. The technique is suitable for different autologous and implant reconstruction. The technique is an outpatient procedure, is easy and is not consuming time. Areolar graft from the contra-lateral areola is colouur matching and shows nearly no deference from the opposite one. Conclusions: Simple technique and not time consuming. Maintains the consistency and projection of the new nipple. Patient satisfaction. Minimal complication.

Keywords: Areola; breast; niple; reconstruction

How to cite this article:
Mohamed SA, Parodi PC. A modified technique for nipple-areola complex reconstruction. Indian J Plast Surg 2011;44:76-80
How to cite this URL:
Mohamed SA, Parodi PC. A modified technique for nipple-areola complex reconstruction. Indian J Plast Surg [serial online] 2011 [cited 2011 May 23];44:76-80. Available from: http://www.ijps.org/text.asp?2011/44/1/76/81450

Reconstruction of the nipple-areola complex has been shown to have a positive influence on the overall recovery process of women undergoing postmastectomy breast re-construction. [1],[2] From a historical perspective, many techniques of nipple reconstruction have been performed, including a graft from the contra-lateral nipple, composite grafts such as toe pulp or earlobe tissue, local flaps and even an intra-dermal tattoo alone. [3],[4] An alternative to a surgically reconstructed nipple is the use of silicone prosthetic nipples. [5],[6] Common to virtually all of these techniques is a postoperative loss of volume that occurs in the reconstructed nipple. [2]

Nipple areola reconstruction is the final stage of breast reconstruction, and should be carried out only when the surgeon is confident that acceptable symmetry and shape of the reconstructed breast has been achieved. The technical challenges of nipple reconstruction include correcting position, maintaining adequate projection and creating an inconspicuous scar.

The problem of all these techniques is a postoperative loss of volume that occurs in the reconstructed nipple. For this reason, many authors have advised creating a nipple that is up to twice the size ultimately desired to take into account this expected loss of volume. [7],[8]

In techniques involving the use of local flaps from the apex of the reconstructed breast mound, transposing flaps to reconstruct such large nipples can create a sizable defect in the skin envelope of the reconstructed breast. Attempts to close these donor sites directly can constrict the shape of the breast and therefore detract from the overall result. [9]

Over the past 20 years, the state of the art for nipple reconstruction has been the use of a local skin flap that is elevated at the ideal site of the intended nipple or pulled out of the contour of the breast and assembled as a projecting tissue mound. These "pull-out" flaps are derivatives of the skate design. [5],[6],[10]

In an attempt to devise a technique for reconstruction of the nipple-areola complex that would provide for a nipple of adequate bulk and long-term projection, deepithelizaation of a semi-lunar part of the adjacent skin central to the flap was developed. This design provides the long-term projection and decreases the cicatertial resorption of the nipple volume thus preserving its long-term volume.

From August 2006 until September 2007, 80 cases of nipple/areola reconstruction were performed following mammary reconstruction or conservative breast surgery, 40 with the CV of Hartrampf (classical) technique and 40 with the introduction of our modification.

The patients were having either post mastectomy breast reconstruction by autologous tissue or implants or were those following conservative breast surgery. All the procedures were done secondarily after 3-6 months of breast reconstruction. Sometimes, the nipple-areola reconstruction was performed at the time of symmetrization operation for the contra-lateral breast; at that time, the areolar skin could be used for grafting of the new areola.

Forty cases were performed as the usual CV of Hartrampf without modification, and another 40 cases with the introduction of the modification. Follow-up of both groups was performed at 3, 6 and 12 months postoperatively to document the size, projection and symmetry and comparison with the opposite side.

The patient herself assessed the results, and each patient could choose three possible indices of satisfaction: bad, good and excellent. Another assessment performed by measuring the decrease in the nipple projection in millimeters at 3, 6 and 12 months, respectively. The decrease in nipple projection was divided into three categories: <1 mm, 1-2 mm and >2 mm in our study.

Surgical technique

From our experience and those from other centres, the most simple and versatile technique for reconstruction is the local CV of Hartrampf technique, which was the classical technique performed. The contra-lateral nipple is used for determining the new nipple position. The CV flap technique involves raising two V-shaped flaps of the skin in continuity with a C-shaped, subcutaneous flap, and then rearranging them to create the new nipple.

The flap is designed to to produce a nipple 1.5 to 2 times the size of the opposite normal nipple in anticipation of the postoperative cicatertial resorption of the nipple flap.

The classical technique

The flap is elevated as shown in [Figure 1] and the donnar is closed primary. There is a narrow base of the new nipple beside downward inclination of the nipple due to deficient support of its base. Figure 1: (a) The classical CV flap technique, (b) The classical technique
Figure 1c: The classical technique

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Modification

That is why we modify the technique as shown in [Figure 2], in the form of deepithelization of a semicircular area of the adjacent skin. This deepithelized area of skin gives a good support to the base of the new nipple and guards against the narrow base and provides a good platform to the nipple enhancing maintenance of its projection as in [Figure 3]. Closure of the flap is performed as usual. Figure 2: (a) Modified technique, (b) Modified technique, (c) Modified technique

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The areola is reconstructed either by a split skin graft or from the contra-lateral areolar graft if it was performed during the symmetrization of the opposite breast as shown in [Figure 4]. The inset of the graft is carried out after deepithelization of a semicircular area at the base either of the nipple if it was a split-thickness graft or from the contra-lateral areola in the modified group of patients.

A soft plastic splint is used for supporting the new nipple. This noncompressing protective appliance is needed for 3 months postoperatively. Meticulous massaging by use of local cortisone is advised.

Both the techniques were performed under local anesthesia. In both the groups the new nipple areola was assessed in terms of the size, projection, nipple circumference, invagination and symmetry in relation to the opposite normal side. In addition, the patient's self-satisfaction was evaluated by scoring as excellent, good and poor in both the groups.

The decrease in the neonipple projection in millimeters was measured in both groups. This decrease was divided into three categories: <1 mm, 1-2 mm and >2 mm. In the modified technique group, 12 cases were <1 mm decrease in the projection while 18 cases were 1-2 mm and 10 cases were >2 mm decrease in the nipple projection, while in the classical technique group the figures were 4, 14 and 22 cases, respectively. This denotes the difference between the two groups in terms of degree of nipple projection, with a significant P-value as shown in [Figure 5] [Figure 6], [Table 1]. {Table 1}

Patient self-satisfaction was scored to be poor, good and excellent in the two groups as shown in [Figure 6]. In the modified technique group, two cases were bad, 13 cases were good and 19 cases were excellent while in the other group, 12 cases were bad, 17 cases were good and 11 cases were excellent. This clearly demonstrates the difference between the two groups and indicates the advantages of the modification towards a better overall outcome as seen in [Figure 7] and [Figure 8].

Nipple reconstruction is an important part of breast reconstruction. [1] We share the opinion of others that creation of the nipple transforms the reconstructed breast mound into a breast. [10],[11],[12],[13] Several nipple reconstruction techniques that use grafts or flaps have been reported. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] They give comparable and satisfactory short-term results, but these worsen over time, with a loss of projection, invagination and a relative widening of the base. It should be noted that retraction of the skin, dermis and fat forming the nipple still occurs, and some loss of nipple projection must be anticipated. [2]

The optimal technique of nipple reconstruction must be simple, reliable and produce nipples that show stable projection. This requires a very stable platform on which the nipple should rest and this we have created by the deepithelized semicircular part of the adjacent skin. The goal of our technique was to minimize this nipple height loss by ensuring a stable base. The semicircular area of deepithelialized skin in the central portion provides this platform. Projection loss caused by scar contraction in this area is therefore limited due to the stable platform on which the nipple base rests.

Deepithelialization of the supportive base seems to be a significant factor for long-term stability of results and, in addition, prevents a secondary invagination again because of this stable base below the neo-nipple. So we can conclude with reasonable certainity that a stable base is necessary for the flap projection and a simple deepithelialization is reliable, and ensures flap support without any risk of secondary invagination [Figure 5].

The choice to carry out a flap with a height 1.5 to 2-times that of the natural nipple was judicious because, after a time gap, the neo-nipple was identical in height to the normal nipple.

The geometric principles of this flap make it easy to perform. The technique allows orienting the flap pedicle in any direction, depending on the available tissues.

Several authors have stressed that, after surgery, care is essential. [10],[11],[12] A bandage should not compress the neo-nipple because this contributes to its secondary height loss. A soft plastic splint ensures a provisional protection of the nipple for approximately 3 months postoperatively.

The most common point of dissatisfaction with nipple-areola reconstruction has been shown to be the lack of long-term nipple projection, followed in descending order by colour mismatch, unattractive shape, size and texture and, finally, nipple malposition. [15]

In our series, there have been no cases of nipple flap loss. Overall, the aesthetic appearance of these reconstructed nipples has been highly satisfactory in the group of modified technique compared with the classical one [Figure 6].

The modified technique is easy to apply to most of the nipple flaps, with a minimum of extra time and effort applying basic plastic and reconstructive surgical principles.

 
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

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