Nasal Septal Perforation Closure by “Sandwich Grafts”: Technique, Initial Results

Nasal septal perforation closure represents a considerable surgical challenge. Many techniques rely on the implantation of foreign materials that pose a persisting threat of infection. The authors have identified a reliable technique closing septal perforations by an autologous “sandwich graft.” It is layered around a piece of auricular cartilage, covered with temporal fascia, thus emulating the physiological layers of the nasal septum. Finally, the prepared graft is then sewn into the perforation in an underlay technique and kept in place by septal splints for 4 weeks. The technique is easily feasible and strives to reconstruct the nasal as physiological as possible. The data obtained from a case series of 11 patients highlights the efficacy of the technique.

“Sandwich technique” enables preservation of hearing and antivertiginous effect in cholesteatomatous labyrinthine fistula

Purpose The aim of the study was to assess hearing, surgical and clinical results of the treatment in patients with cholesteatomatous labyrinthine fistula (LF) focusing on the different techniques and materials used in the management. Methods Study group included 465 patients. Cases with LFs discovered or confirmed during surgical procedure were thoroughly analyzed. Results LFs were noted in 11.4% of all cases. Thirty-eight patients, with all follow-up data available, were included into the further analysis. Most LFs were located in the lateral semicircular canal (87%). LFs were assessed as small in 2 cases, as medium in 24 patients while 12 were described as large. Based on Dornhoffer and Milewski classification, 50% of LFs were classified as IIa, 24% as IIb, 6 LFs were very deep (type III), while 4—superficial (type I). The size and type of LF did not influence postsurgical complaints (p = 0.1070, p = 0.3187, respectively). Vertigo was less frequent in LFs treated by “sandwich technique”, especially those with opened endosteum. In 30 (79%) patients, hearing improved or did not change after surgery. Hearing outcomes were significantly better in the ears operated by means of CWU technique (p = 0.0339), in LFs with intact membranous labyrinth (p = 0.0139) and when “sandwich technique” was performed (p = 0.0159). Postsurgical bone conduction thresholds levels were significantly better in LFs covered by “sandwich method” (p = 0.0440). Conclusion “Sandwich technique” (temporal fascia–bone pate–temporal fascia) enables preservation of hearing as well as antivertiginous effect in patients with cholesteatomatous labyrinthine fistula.

Tenderness of the Skin after Chemical Stimulation of Underlying Temporal and Thoracolumbar Fasciae Reveals Somatosensory Crosstalk between Superficial and Deep Tissues

Musculoskeletal pain is often associated with pain referred to adjacent areas or skin. So far, no study has analyzed the somatosensory changes of the skin after the stimulation of different underlying fasciae. The current study aimed to investigate heterotopic somatosensory crosstalk between deep tissue (muscle or fascia) and superficial tissue (skin) using two established models of deep tissue pain (namely focal high frequency electrical stimulation (HFS) (100 pulses of constant current electrical stimulation at 10× detection threshold) or the injection of hypertonic saline in stimulus locations as verified using ultrasound). In a methodological pilot experiment in the TLF, different injection volumes of hypertonic saline (50–800 µL) revealed that small injection volumes were most suitable, as they elicited sufficient pain but avoided the complication of the numbing pinprick sensitivity encountered after the injection of a very large volume (800 µL), particularly following muscle injections. The testing of fascia at different body sites revealed that 100 µL of hypertonic saline in the temporal fascia and TLF elicited significant pinprick hyperalgesia in the overlying skin (–26.2% and –23.5% adjusted threshold reduction, p < 0.001 and p < 0.05, respectively), but not the trapezius fascia or iliotibial band. Notably, both estimates of hyperalgesia were significantly correlated (r = 0.61, p < 0.005). Comprehensive somatosensory testing (DFNS standard) revealed that no test parameter was changed significantly following electrical HFS. The experiments demonstrated that fascia stimulation at a sufficient stimulus intensity elicited significant across-tissue facilitation to pinprick stimulation (referred hyperalgesia), a hallmark sign of nociceptive central sensitization.

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 wide spread adoption, technical challenges remained, especially when utilized for aesthetic purposes. Objectives The paper details the use of fascia (F) and diced cartilage in fascia grafts (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 We used grafts from the deep temporalis fascia (F) and rectus abdominis fascia (RF) in 4 configurations: 1) single layer, 2) double layer, 3) full length diced cartilage in fascia grafts (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 We report our experience: 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 used. Conclusions Use of autogenous deep temporal fascia, rectus abdominis fascia, and diced cartilage in fascia (DC-F) to camouflage dorsal irregularities, to highlight dorsal aesthetic lines, and to aesthetically augment either the entire nasal dorsum or its individual parts. Optimization of cutting, stitching, filling the graft, careful fixation of these grafts on the nasal dorsum, significantly increases the predictability of these techniques and minimizes problems.

A New Target for Temple Volumization? An Anatomical and Ultrasound Guided Study of the Intermediate Temporal Fat Pad

Background Current techniques for temple volumization primarily focus on deep or superficial targets. Further anatomical exploration of intermediate injection targets is warranted. Objectives The purpose of this study was to examine the anatomy of the intermediate temporal fat pad (ITFP) as it relates to filler injection procedures and to explore the utilization of ultrasound technology for clinical localization. Methods Ultrasound technology was utilized to identify and inject red dyed hyaluronic acid filler into the ITFP in 20 hemifacial fresh cadavers. Cross-sectional dissection was performed to confirm injection accuracy and document pertinent anatomical relationships. The same technique was performed in a single clinical patient case employing ultrasound guidance and injectable saline. Results The ITFP is a quadrangular structure located in the anterior-inferior bony trough. The ITFP is supplied by a middle temporal artery branch and encased between the superficial and deep layers of deep temporal fascia. In 18 of 20 (90%) injections performed under ultrasound guidance, the injected product was accurately delivered to the substance of the ITFP, and in 2 of 20 (10%), the product was found immediately below the deep layer of deep temporal fascia within the temporalis muscle. In the single clinical case, saline was successfully injected in the ITFP under ultrasound guidance. Conclusions The ITFP is a consistent anatomical structure in the anterior-inferior trough of the temporal fossa. Ultrasound technology can be utilized to identify and inject the fat pad. Further clinical evaluation will determine the role of this fat pad as a potential intermediate injection target for temple volumization procedures.

Blood clots affect the response of tympanic membrane perforations to gelfoam grafting after ventilation tube insertion

Chronic tympanic membrane (TM) perforation associated with ventilation tube (VT) insertion was commonly encountered in pediatric patients with chronic otitis media with effusion (COME) treatment and eustachian tube dysfunction. The persistent perforation require surgical closure by myringoplasty. Song JS et al. recently a paper entitled: “Evaluating short and long term outcomes following pediatric myringoplasty with gelfoam graft for tympanic membrane perforation following ventilation tube insertion.” In their study, the authors performed gelfoam myringoplasty to repair the perforations following VT insertion in children and compare the successful TM closure rate among different graft materials. The authors believed that gelfoam alone was superior to hyaluronic acid (HA), tragal cartilage (TC), and gelfoam-plus-temporal fascia (TF). The sample size is unbalanced and incommensurable between gelfoam and other graft materials. In addition, a confounding factor was added in the gelfoam group, thereby affected the assessment of TM closure. Thus, the conclusion is not rigorous and scientific.

Lipoma of the temporal region: a rare case series

Lipomas are common benign tumours that can occur in most parts of the body. Lipomas arising from the deep temporal fat pad, found between the two layers of the deep temporal fascia, are rare, however; there has been only one documented case report to our knowledge. We describe a second case arising from the temporal fat pad in a patient treated at our unit, having previously reported the first one, and discuss the relevant anatomy and management.