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Diagnosis and Treatment of Inhalation Injury

Introduction Inhalation injury is a nonspecific term that refers to damage to the respiratory tract or pulmonary parenchyma by heat or chemical irritants carried into the airways during respiration. Along with total body surface area (TBSA) burned and age, inhalation injury is one of the three features most associated with mortality following thermal insult. Issues related to diagnosis and management of inhalation injury have been most…

The Pathophysiology of Inhalation Injury

Introduction and Epidemiology It has been more than three decades since Herndon and colleagues' first manuscript on inhalation injury was published. It was initially reported in 1985 that inhalation injury was a major determinant of mortality in severely burned patients. . The standard of care has evolved over time, but inhalation injury still remains a major problem. . Although sepsis is reportedly the most frequent cause…

Skin Substitutes and ‘the next level’

Introduction Structure and Function of the Skin Skin, the body's largest organ, is incredibly complex. Functionally, there are two layers with a highly specialized and effective bonding mechanism. Numerous appendages traverse the skin, and a rich and reactive capillary network provides nutrient flow while controlling temperature. The epidermis, consisting of the strata basale, spinosum, granulosum, and corneum, provides a vapor and bacterial barrier. The dermis provides…

The Skin Bank

History The first skin autograft was described by Reverdin in 1871, and the use of allograft skin as a clinical method for wound coverage soon followed. In 1874, Thiersch published a report about a small series of patients on whom he had used partial-thickness skin grafts. This led to extensive trials of harvesting extremely thin grafts, leaving some of the surface epithelium behind to aid in…

Anesthesia for Burned Patients

Introduction Continuous improvement in burn care since World War II has resulted in a steady increase in the rate of survival after large burn injury. These improvements have been attributed to aggressive fluid resuscitation, early excision and grafting of burn wounds, more effective antimicrobials, advances in nutritional support, and development of burn centers. Today most patients with more than 80% total body surface area (TBSA) burned…

Diced Cartilage Glue Graft for Nasal Augmentation

The Problem Irregular and overresected dorsum Tip bulbosity The Background Excessive hump resections may cause a concave dorsal profile with or without palpable and visible irregularities. Correction of this iatrogenic deformity is challenging, as many patients are critical due to being disappointed with the previous procedure, the dorsal soft tissues are scarred, and a natural-appearing volume augmentation is needed. Augmentation with alloplastic materials is considered risky,…

Correction of Overresection With Diced Cartilage Injection

The Problem The saddle nose previously corrected with carved costal cartilage, after 4 years was bent and subtotally resorbed. After removal of the remaining costal cartilage graft, a severe saddleback dorsum was evident. The Background In 1996, Skoog reported using resected dorsal hump as an autograft to correct an overly resected hump. Potential autografts for dorsum augmentation include septal, conchal, or rib cartilage and calvarium or…

Correction of Overresection With Non-Rib Cartilage Wrapped in Fascia

The Problem Primary rhinoplasty typically has no grafting issues because grafting material is abundantly present. However, in secondary cases with overresection, providing adequate material for grafting has been an issue of concern. Sufficient cartilage is necessary to provide form and function. Cartilages are the most critical grafting materials in secondary rhinoplasty. A graft is considered ideal when it is available and biocompatible, and when it has…

Correcting the Overresected Nose

The Problem Overresection of the lower lateral cartilages occurring as sequalae of an effort to create decreased tip volume and improved tip contour is a common complication seen in patients seeking revision rhinoplasty. Deformities that arise from aggressive reductive techniques can affect all areas of the nose including the bony and cartilaginous dorsum, as well as the tip, and produce the characteristic stigma of rhinoplasty that…

Correction of the Pinch Deformity by Alar Batten Graft

The Problem Pinch deformity is one of the main sequelae of routine reductive rhinoplasty. Although the prevailing trend is to preserve the nasal cartilages as much as possible, pinch deformity is still quite common. Several primary rhinoplasty patients show some extent of pinch deformities, therefore an alar batten graft may be an ideal option in select cases. Introduction The correction of a pinched nose has been…

Alar Pinch Deformity

Alar pinch deformity (APD) is the concave deformity of the tip area or nose alar that makes a change in the shape of the tip or causes buckling in on one or both sides. It may occur with or without breathing dysfunction. The first step for analysis of APD is the past history of the patient that includes any accidents or trauma to the nose, previous…

Management of the Ischemic Nose

The Problem Vascular compromise after surgical rhinoplasty is a rare but devastating complication that can lead to negative functional and aesthetic outcomes. Proper pre- and postoperative evaluation and management is critical, and include patient selection, limiting pre- and intraoperative risk factors, and aggressive postoperative treatment of any signs of ischemia. Failure to correctly manage the ischemic nose will result in nasal skin necrosis with subsequent deformity.…

Simultaneous Orthognathic and Rhinoplasty Surgery

The Problem How to make simultaneous orthognathic and rhinoplasty surgery predictable. The Background Orthognathic surgery and rhinoplasty are both challenging procedures, each requires a lot of experience, skill, and knowledge such as having the clinical judgment to determine when to perform them; understanding the scope and limitations of each intervention; knowing the possible complications and how to deal with them. The two surgeries are not a…

Rhinoplasty in Cleft Lip and Palate Patients

Introduction Cleft lip and palate (CLP) is the second most common congenital defect in the United States—affecting approximately 7,000 infants annually. CLP is caused by a variety of environmental and genetic factors. Due to hypoplastic or absent tissues, as well as the accumulation of scar tissue from previous surgeries, patients with CLP are likely to have functional deficiencies and cosmetic abnormalities of the nose. CLP patients…

Rhinoplasty in the Aging Nose

The Problem Aging causes tremendous effects on skin and underlying structures of the nose. These changes may lead to nasal airway incompetencies and cosmetic deformities. Rhinoplasty in this group of patients needs specific evaluations and precise technique. The Background Age-related changes of the nose are extensively discussed in rhinoplasty literature. In general, the dermal layer of skin is attenuated and skin becomes relatively thinner. Nasal ligaments…

Rhinoplasty in Thick-Skinned Patients

The Problem The predominant characteristics in thick-skinned patients seeking rhinoplasty are a bulbous nasal tip, poor definition of the different nasal subunits, and persistence of postoperative swelling if compared with normal- or thin-skinned patients, leading to inferior esthetic outcomes. The Background There are four main anatomical findings with varying degrees of severity that are peculiar to these kinds of noses: 1. The skin is very thick…

Crooked Nose: Effective Treatment Strategies for Bony Contouring

Introduction Almost every osseocartilaginous vault is asymmetric. This emphasizes the importance of individualized osteotomy when performing rhinoplasty. Specific anatomical variations in the bony vault such as width, length and height should be considered when selecting specific osteotomies. Osteotomies should no longer be thought of as an automatic step in rhinoplasty. Instead, they should be completed in an individualized fashion based on the anatomy of each side…

The Mixed Race Nose (Mestizo Nose)

The Problem The mixed race nose, also called mestizo nose or Hispanic nose, is a term that refers to nasal characteristics that include thick skin, a bulbous tip, and weak and flimsy cartilaginous structure. Patients frequently exhibit Fitzpatrick skin types III to V. Mixed race noses are more likely to present dorsal humps, saddle deformities, and retracted columellae. The sebaceous and relatively inelastic skin associated with…