Saturday, August 28, 2010

Regenerative Medicine: Re-Growing Body Parts

This may seem futuristic, but it is happening today. Now imagine if we could apply this technology to those who suffer from empty nose syndrome, because of surgically removed turbinates, to burn victims, to cancer patients who are missing parts of their nose, if not most, to those like me suffering with nerve pain due to excessive removal of tissue in and around my nose tip and nostril area, even for those who need major reconstruction of the nose with grafts could benefit from this technology, since the surgeon wouldn't have to harvest the grafts from your own body which adds a lot of time to your surgery once shaped and put in place. You also wouldn't have to worry about warping, absorption, infection, or any of those downsides with grafting as performed today. It's an area that i hope some Plastic Surgeon or E.N.T. will explore. I think this is the future for nose reconstruction surgery/treatment as well as it is for all the other medical fields. One won't have to depend on donor body parts for transplants any longer. It's truly a transformational breakthrough.

Wednesday, August 4, 2010

More concerns when harvesting costal cartilage for use in nose surgery.

The human rib cage. (Source: Gray's Anatomy of...Image via Wikipedia
Two major concerns about, harvesting rib cartilage are: 1. the risk of  pneumothorax, a release of air from the lungs and 2. the concern about as we age rib cartilage tends to calcify therefore the cartilage becomes more like bone. 

According to Dr. Barry Eppley, a plastic surgeon in Indianapolis, his preference is the 7th, 8th, and free floater 9th rib for harvesting.  He claims it " is easier and provides plentiful options of shape and configurations. A small subcostal incision can be moved around to provide good visibiity and the underlying rectus muscle is split vertically for access rather than transecting it." See link below (exploreplasticsurgery).

He continues,  "One of the major concerns about rib harvesting is the risk of pneumothorax as the lung pleura  is close by underneath. But at the level of the 7th ribs and lower, the lower apex of the lung is higher so this is not going to happen. In over 65 cases of rib harvest at this chest wall level, the pleura has never been violated. It becomes evident at the level of the 7th and most certainly at the 6th rib."  So for those seeking revision rhinoplasty and need rib grafts, don't forget to ask the surgeon at time of consult which rib he uses, how many has he done like that, and has he/she had any complications with it. 

Another nose revision surgeon , Dr. Anil Shah in Chicago prefers to use the 5th, and 6th rib. He says "either the 5th or 6th rib are most commonly used.  The 5th rib has the advantage of being straighter and not really connected to any of the other ribs.  The disadvantage is it tends to be smaller.  The 6th rib tends to be longer but more curved than the 5th rib.  In addition, it tends to connect to other ribs." See link below (shahfacial plastics).

How about calcification of the ribs as we age?

According to Dr. Shah,  "as we age, the cartilage portion of the rib cage becomes calcified and eventually actually turns to bone. This process is typically complete at age 55, but I operated on patients well over fifty who have had substantial cartilage remaining in their ribs".  When your over the age of 40 there is normally more calcification which makes the costal graft harder to shape, however the upside to this is there is less chance of warping over the years. 

Dr. Eppley mentions "one can always find enough cartilage to use. I have done rib grafts up to age 65 and adequate cartilage has always been found".

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Irradiated cartilage (cadaver) grafts in nose surgery

So you need to have your nose built up but you don't have enough septal, or ear cartilage for support and you don't want synthetic implants in your nose, and your concerned about having your rib section operated on in order to harvest rib cartilage for nose grafting. Your option, Cadaver cartilage grafts. This is a controversial area, some nose surgeons say its much inferior to your own rib cartilage because of absorption problems, while others like Dr. Russell Kridel,  a facial plastics e.n.t. feels its a great option which shouldn't be overlooked and has shown studies (see medpagetoday link below) that support his view. Maybe it's a e.n.t. perspective vs the plastic surgeon's perspective. Most e.n.t.'s don't harvest rib cartilage for nose surgery (although this trend is changing) so it makes perfect sense they would be in favor of another option. But that's what makes things so interesting. The more options the better for the nose patient, however the debate between which is better can cause the patient to freeze in their tracks wondering who to believe and trust. Every surgeon has their own unique and favorite approach and so you have to consider what is best for you the patient and see if the surgeon has a lot of experience in the approach your seeking. What's right for one patient isn't right for another. Our general health, age, previous surgery's puts us all at a different place in time and has to be taken into consideration by the surgeon. It would be in the best interest of the surgeon to let the prospective patient know what options they provide and feel is appropriate. However they should not be afraid to also recommend another colleague to the patient, if that colleague does a procedure that they don't offer or specialize in yet is what  the patient is seeking. The surgeon will gain more respect from the patient this way, (meaning more referrals and positive internet forum comments) and therefore should not be afraid of losing the patient to someone else, since the patient will at the end go with who they feel is not only most qualified but with who can  offer what they want, making them feel more comfortable knowing they're on the same page with that particular surgeons view.

The Rate of Warping in Irradiated and Nonirradiated Homograft Rib Cartilage: A Controlled Comparison and Clinical Implication.      

In this study it was concluded that there was no difference in warping characteristics between irradiated and nonirradiated homograft (allograft) rib cartilage.  Make note:
The centrally cut pieces of cartilage in each group warped less than peripherally cut blocks in each group.

 Prevailing concerns with ICC and Costal AutoGrafts:
Homologous irradiated costal cartilage (ICC) has been shown to resorb on long-term follow-up and has the potential to warp but studies have shown contradictory results. In addition to problems with resorption, warping, and bacterial infection fear of viral transmission despite extensive sterilization has severely reduced its usage. However, irradiation of soft tissue allografts (ICC) with high dosage(>3Mrad) radiation can sterilize allograft tissue, destroying bacteria and viruses including HIV and hepatitis. [For more info. on risks of infection and transmitted diseases from allografts see my post Nov.25/10]  Costal cartilage autografts provides a large volume of graft material with excellent structural support.Autogenous rib grafts are known to warp,buckle and absorption can occur and be somewhat unpredictable, but there are techniques a well informed  or experienced surgeon will incorporate to limit warping capabilities in rib grafts. [See my post on techniques used to reduce warping - dated Nov 7/2010].  So the general disadvantages of Costal grafts are warping,  potential donor site morbidities, including pneumothorax, scar visibility, and chest wall deformity, but once again  keep in mind these can be avoided or be marginalized when performed by a surgeon who's well experienced in performing costal grafting.

Allograft vs. Autograft

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

Rib Cartilage Safe for Rhinoplasty

Irradiated costal cartilage in augmentation rhinoplasty
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Monday, August 2, 2010

Are synthetic nose implants a good idea?

Most nose revision nose experts would probably agree your own cartilage from your body is the preferred choice over synthetic implants to use when building up the nose. Here is a video by Dr. Naderi expressing his personal views on the subject. Cadaver cartilage is another option, i will discuss at a later time in another post.

Removing Rib Grafts from the nose

NoseImage via Wikipedia
If your considering a revision to remove rib grafts, you will have to consider the consequences. One of the consequences is that your nose grafts support your nose now, and some of your previous supporting structures may of been partially removed or reshaped.  A better solution if you feel your rib grafts are too large, is too have the grafts made smaller in thickness, however, warping can then become a problem.You will have to see your nose revision surgeon or a new surgeon if that isn't an option to discuss your options, and hopefully the operative report is complete and specific enough to guide the surgeon contemplating correcting this issue. Maybe a ct-scan of the nose would reveal more information before attempting to perform such a surgery.

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Sunday, August 1, 2010

Is revision rhinoplasty the most expensive cosmetic/plastic surgical procedure?

Rhinoplasty. Preparing for the metal splint. T...Image via Wikipedia
The top 5 most expensive plastic surgery procedures in the 

So there you have it, Revision rhinoplasty is in the top 5 (4th on above links list )  most expensive cosmetic/plastic surgical procedure out there.

   What's unfortunate is that the majority of the people needing revision rhinoplasty suffer from structural damage as a result of their primary or secondary surgery.  It is unique when compared to the other cosmetic procedures because it's a health issue for many in terms being able to breath normal.

For example, like what happened to me, as has happened with many others, the primary nose surgeon over-resected the bridge of the nose and by doing so removed too much of the supporting cartilage, leading to nasal valve collapse, which makes inspired (inward) breathing through the nostrils difficult to near impossible. Even more frustrating and disturbing, is that revision rhinoplasty is not normally covered by health care system in Canada, at least not in any significant or proportionate amounts. And the ent's and plastic surgeons don't even try to help their patients  with a out of province or out of Country referral , because they either don't understand the problem of nasal valve collapse &/or they figure its not worth the effort, since the government health care covers a nominal amount under Septoplasty. In the United States, some portion is recoverable if you have company or private insurance. The highest amount I read online was 50% of the surgery was covered. For Canada, I haven't heard or read any information about Insurance Coverage, I would suspect it would be the same as in the U.S. However If you have had nose surgery and problems with your breathing as a condition prior to you purchasing your Insurance I would pretty much guess most if not all the Insurance Company's wouldn't cover you. And I like many others had primary surgery when I was 18.

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Revision rhinoplasty: How to find the perfect nose surgeon

If your looking to have your nose operated to improve a cosmetic or functional problem that wasn't properly corrected or occurred from your primary surgery, then you are considering a revision rhinoplasty, or secondary rhinoplasty.

Some nose surgeons will correct a minor cosmetic defect at no charge if they did the surgery.  However if your problem is much more serious then being upset about a very minor cosmetic change then you will have to do a lot of research and see top specialists in determining what is the problem and how it can be corrected properly.

That is one of the reasons i put this blog together. As a resource and to pass on my experience as a nose patient.

In my first post, i mention revision nose surgeons who have experience with rib grafts. I also have listed different websites you can link to for more information.  There is no perfect nose surgeon, just have to find the right one who has experience correcting the problem you want corrected. If you need to travel outside your city or Country for someone who is more of an expert, then you should do so. Never settle for someone who simply say's they can do the surgery, and they can do what the other top experts promised you. Never underestimate the complexity of rhinoplasty especially revision rhinoplasty, its very challenging and specialized.  Never underestimate what could go wrong either. I would of never thought i could end up with neuropathic permanent pain from nose surgery, but i did. You could also end up with serious condition called Empty Nose Syndrome. I have this to mild degree on my left side nostril. This occurs from removal of too much turbinate tissue. Just because the nose is relatively a small part of your anatomy, doesn't mean a serious side effect  can't occur  from the surgery. Take the surgery very seriously, its your body and only trust someone you feel absolutely comfortable with and has the experience and /or knowledge to fix your specific problem. If your uncomfortable with the surgeon and you are not getting a clear outline about what the surgeon plans to do with  your nose  then you may want to  look elsewhere. If you are having doubts about their experience or approach to the surgery , that is a serious red flag. Don't  expect a surgeon to change their approach because its not in line with what you think is right for yourself. . It's not  likely going to happen, and it will likely lead to great disappointment after the surgery.

Neuropathy caused by Nose Surgery. It does happen!

Can a permanent neuropathic condition occur as a result of nose surgery?

Answer: YES.

After my second major revision nose surgery by a young inexperienced surgeon in Toronto, Ontario, i developed within 6 months time severe neuropathic pain all around the tip lobe and, columella regions. The pain was so excruciating it felt like someone was taking a scalpel to my nose and slashing it. Without proper medication the pain continues to intensify feeling like a ball of  intense fireworks going off all around the tip area. Tingling leading to burning sensation would precede or accompany the severe intense pain. Another phenomena in conjunction with this pain, is hyperesthesia and allodynia.  This means the pain could be triggered further, by light sensation to the nose by touch, blowing fan, cold temperature, rain, etc.. I finally realized normal pain medication doesn't take away the pain. The only thing that helped control the pain, was anti-convulsant pills such as neurontin (gabapentin) however even though that helped somewhat, my neurologist recommended Lyrica (Pregabalin). That worked far better then gabapentin and you don't have to take as many pills. It however does have side effects one being lack of concentration and making you lethargic.

So what may of caused this? The likely explanation in my opinion according to the operative report would be the combination of or the single result of performing one of the following: excessive removal of residual scar tissue around the tip which can contain nerve tissue, and/or injuring a nerve while dissecting along the floor of the septum in order to resect a small portion of the maxillary crest. Other factors may of been use of dull scalpel, re-opening incision over previous open surgery incision along columella, improper elevation of the S-STE and/or nerve impingement or division during closing of S-STE.  My reason for mentioning this is so you are aware of this as a future patient, and that surgeons should be aware of this as well, and will hopefully make future patients aware of this as a possible side effect from the surgery, even though its remote. In fact I am not aware of anyone else with this condition, however i have read forums where a couple people mentioned they experienced nerve pain after surgery, but they never mentioned they required to be medicated with special medications like i take, or that they have a permanent condition.  One very plausible explanation for my pain according to one reconstruction rhinoplasty surgeon  is that I developed Traumatic Neuroma as a result of the surgery.

What have I done for my neuropathic pain, besides taking medication?
I first had to do a lot of research. I discovered a site which i have linked on this blog, which is a great site about facial neuropathic pain.  The section about Trigeminal nerve pain explains how this pain works. It's atypical however in my case, i have pain on both sides of my nose. I've had CT Scan to rule out Trigeminal Condition caused by pressure on a nerve in the brain.  I have had temporary nerve blocks, at a pain clinic, i almost had radio pulsed frequency-sphenopalatine block done, but after the pain specialist  after many appointments told me that the freezing injection could cause permanent loss of sight, i backed down from going ahead with that procedure. In fact the pain clinic in my city never performed radio pulse frequency until i mentioned it to them that it has been used as a treatment elsewhere for facial neuropathic pain. I have had botox injection in my tip area's, cortisteroid Kenalog, and inside my nose a sphenopalatine and ethmoid freezing block. I've tried cold lidocaine ointment and gabapentin cream and hot cayenne ointment cream. None had worked. The injections may of worked temporarily, but even that was inconclusive.