Grafts and Implants

Repetitive reconstructive rhinoplasty

Plastic surgeons have the appropriate knowledge and clinical experience to perform a rhinoplasty. In the past 8 years, the authors have received for consultation some patients who had already undergone more than one rhinoplasty. As this shows, the specialist must be familiarized with the surgical technique specific for each case and its respective terminology. The authors propose the use of "repetitive reconstructive rhinoplasty" in referring to all the patients who for different reasons come to the specialist for a new rhinoplasty after a minimum of three surgeries performed previously. It must be emphasized that the plastic surgeon assumes the responsibility for choosing to perform repetitive reconstructive rhinoplasty, incurring the legal risk that the aesthetic or functional results may not satisfy the patient's expectations. One of the principal reasons for introducing repetitive reconstructive rhinoplasty emphasizes the "reconstructive" rather than the "aesthetic" role, whereas the legislation in many countries interprets the word "aesthetic" to imply an obligation for results that approximate perfection.

Epidural application of ionomeric cement implants. Experimental and clinical results

During setting and hardening, the hybrid bone substitute ionomeric cement (Ionocem) achieves a stable and durable bond with the apatite of the adjacent bone without interpository soft tissue. Fluid contact during setting results in the release of aluminium ions which may reach critical levels as high as 3000 micrograms/l. On epidural application it is, therefore, essential to prevent cement constituents from gaining access to the intradural space. After the cement has hardened, the presence of aluminium is demonstrable in the adjacent bone to a maximum depth of 20 microns (EDX microanalysis). In rabbits, epidural placement of freshly mixed cement causes slight thickening of the dura. There is reason to believe that human dura, with a thickness 10 times greater, is impermeable to components of the cement. After epidural application of the freshly mixed cement in the frontobasal and laterobasal regions and at the skull cap and petrous apex, 76 patients in all have been followed for up to 6.5 years. During this period no complications have arisen and functional (and cosmetic) results are promising. The availability of preformed implants (Ionoroc, Ionocast) permitted the peridural placement of minimal quantities of freshly mixed cement. These implants were fixed to localized sites on the adjacent calvarial bone by use of Ionocem. Notwithstanding the stringent manufacturer guidelines, there have been reports in the literature that during the vulnerable stage of setting neurotoxic aluminium ions were released into the dural space with a fatal outcome in two cases. In view of potential intradural complications, such as may occur in case of dural leaks, it was considered that further application of the material adjacent to the dura was no longer warranted. The production of Ionocem was discontinued in May 1995.

Epiglottis in reconstruction of the larynx and trachea

Many methods have been proposed for reconstruction of the larynx and trachea. An ideal method would utilize tissue which is native to the area, highly viable, convenient to the surgeon, and expendable to the patient. This tissue should be composite, that is, containing both epithelium and skeletal support. This paper describes the use of epiglottis in repair of laryngeal and tracheal defects due to cancer or trauma. The methods of repair include 1) pedicled composite epiglottic flap, 2) free composite epiglottic graft, and 3) pedicled epiglottic mucosal flap. Results in 15 patients are discussed and indicate that use of the epiglottis is an effective method for one-stage laryngotracheal reconstruction.