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Microsurgical correction of cocaine-injured nose offers new hope for patients

New Orleans — A University of Chicago plastic surgery team has developed an innovative and high-tech technique for repairing noses injured by cocaine abuse.

The microsurgical technique for nose correction is to be described in a paper expected to be published in the Journal of Plastic and Reconstructive Surgery, says Robert Walton, M.D., professor of plastic surgery at the University of Chicago, who developed the technique.

While former techniques offered some relief for those with mild to moderate injuries, there really was no option short of a prosthesis in the past for those with severe injuries, says Dr. Walton, who has been working with his technique for the past 10 years. "Recently we've developed a manner of doing this from the inside of the mouth so that there is no external scarring," he says.

Physiological effects

"The cocaine causes blood vessels to constrict, and if you continue to use cocaine on a regular basis, the blood vessels will stay in a constricted state, depriving the tissue of blood circulation," Dr. Walton says. "What happens is that the tissues die and are replaced by scar tissue. Everything shrinks and shrivels; the cartilage melts away. It's like a tent: If you remove the pole, everything collapses. The dead tissue can also serve as the nidus for an infection, such as strep and staph and pseudomonas.

"So, the first thing we do is to remove the diseased tissues from the face," he says. "Then, we replace them with the skin of the forearm, which has its own circulation."

That part of the operation consists of two delay procedures on the forearm plus a transfer procedure. The delay operations take about two hours each, and the microsurgical transfer operation takes about six to eight hours, Dr. Walton says.

"We design the template of the missing tissue, taken from the forearm, based on computerized models of the patient. We draw the template on the forearm, and train the forearm blood vessels to go to this template by creating a surgical injury. If you make a cut in the tissue, you can force the circulation to go to a certain part of the body," he says.

The team then cuts the blood vessels in the forearm.

"We transfer the vessels and the tissue to the nose, where everything is assembled anatomically, so that circulation is re-established, and the patients have a functional as well as an aesthetic reconstruction," he says. "It's just like having a new lease on life, or a new lease on your nose."

Microsurgical procedure

The procedure is described as microsurgical because the blood vessels are very small, Dr. Walton explains. "The sutures we use are smaller than the diameter of a hair, and we tie them using micro-instruments and a microscope," he says.

The blood vessels themselves are about a millimeter in diameter, according to Dr. Walton. "They are not actually sewn in the nose, but at the lower jaw. The blood vessels are on a leash or a length of pedicle of blood vessels about 6 to 7 centimeters long. We take the leash and tunnel it through the cheek to the border of the jawbone, we find the facial blood vessels there, and we repair them," he says.

Before the new technique, Dr. Ralph Millard actually advocated taking tissue from cheeks and turning it inside the nose to replace diseased lining, but that method "created scars on the face that were objectionable," Dr. Walton says.

"Dr. Jack Sheen is an internationally renowned laser surgeon who would very carefully place cartilage grafts to improve the external appearance," he says. The University of Chicago method has been employed in about 15 patients, eight of whom have enjoyed the benefit of the new internal-placement/minimal scarring method.

Be cautious

Doctors must be mindful of patients who come in with nasal injuries.


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