TITLE: Handy Grafts for Head and Neck
Reconstruction: An Overview of How-To
SOURCE: Grand Rounds Presentation, Department of Otolaryngology
The University of Texas
Medical Branch (UTMB Health) <=
/span>
DATE: September 27, 2012
RESIDENT PHYSICIAN:
Angelia Natili, MD
FACULTY PHYSICIAN: Vincente Resto, MD, PhD
SERIES EDITOR: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Quinn, MSICS
"This
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program =
of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not
intended for clinical use in its present form. It was prepared for the purp=
ose
of stimulating group discussion in a conference setting. No warranties, eit=
her
express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes=
of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
Outline:
Introduction: Much has =
been
written about free and rotational flaps, but there are few book chapters
dedicated to grafts. This
presentation is designed to discuss techniques for harvesting grafts for a
variety of head and neck reconstruction challenges. It will focus on the
procedures and complications of harvesting autologous grafts with a few pea=
rls
thrown in. It will mention so=
me
common general indications for harvest.
· =
Grafts:
o
Bo=
ne
§
Calvarium—split
in situ and full thickness
§
Iliac
crest
o Cartilage
§
Costal
§
Auricular
§
Septal
o&nb=
sp;
§
Split
thickness
§
Full
thickness
o&nb=
sp;
Bone grafts:
Bone biology is important to understand for grafting. Similar to stages o= f skin graft assimilation, bone undergoes several interrelated processes before integration and replacement by new bone.&n= bsp; Critical to all of these is blood supply.
Suprisingly, most donor osteoblasts necrose after harvesting. Instead, most act= ive osteoclasts and osteoblasts producing new bone on the devitalized graft are delivered by new blood vessel invasion in a process called osteoconduction.= The few surviving osteoblasts do produce new bone through osteogenesis. Finally, the third process of new = bone production comes from the grafted bone itself. It releases active factors called = bone morphogenetic proteins that stimulate osteoprogenitor cells from the host to differentiate into osteoblasts for bone production.1
Cancellous bone grafts generate bone more quickly= than cortical bone grafts, but a greater portion is resorbed. Depending on the defect and type of= graft used, bony consolidation can be expected within 4-10 weeks, and once bone is consolidated, the effect is permanent. 2 Bone grafts are usually used to co= rrect bony deformities in the facial skeleton.
Tips on bone grafting in general to reduce complications:<= /p>
Limit length of skin incisions. Avoid subcutaneous dissection: ins= tead, directly incise superficial fascia and periosteum. Periosteal elevators should be sha= rp, and chosen for width and curvature appropriate to harvested graft. Retractors specific to anatomic si= te should be chosen. Osteotomes = are specific to chosen graft: thin for the ilium, thin and short for the calvarium. Use swabs compress= ed under the retractors to obtain hemostasis instead of cautery—more time efficient which leads to less bleeding.&nb= sp; Use Hemovac in the scalp, but not in the thorax or ilium. Do not use saws or burrs that are = dull as they can burn the bone. Bo= ne dust from burring or sawing is useless to fill dead space as it will be resorbed, whereas filler bone chips milled in an osteomicrotome encourage osteoblastic activity and new bone production. 2
Calvarium:
A study of calvaria in 281 skulls from the Hamman= -Todd osteological collection was used to map thickness at 40 different points and compare res= ults among sexes, races, and ages. They found female skulls to be slightly thick= er on average than male skulls. = The thickest area of the parietal bone for female skulls was lateral and poster= ior, whereas male skulls tended to be thicker in the posterior midline. African American skulls were found to be thicker than Caucasian, particularly in the posterior parietal bone. There was no significant thickness difference among the ages studied (21 to 105 years), but bone becomes more brittle with less diploe thickness as age advances. The authors suggest that the ideal = area for bone grafting is 2 cm lateral to the sagittal suture line and 2 cm medi= al to the squamous suture in the posterior parietal bone. 3
Two variations for harvesting parietal bone graft= s are total splitting or the split in situ methods. The preoperative CT should be eval= uated for parietal bone thickness and any midline abnormalities. Plan the grafts = at least 1 cm from coronal suture and 1.5 cm from sagittal suture. A posterior coronal incision optimizes hair coverage and reduces paresthesias. After incision, clamp the posterio= r edge with Dandy clamps. Incise the pericranium and elevate with sharp square elevators, then pull the scalp do= wn with firm hand pressure. Obta= in hemostasis with cautery on the scalp and Gelfoam and bone wax on the skull.= 4
Split in situ grafts are first outlined on the ou= ter table with an oscillating saw, then a burr is used to deepen the incisions = to the diploe. About 5-10 mm ant= erior to the initial graft, a saw is used to tangentially remove a leading edge to allow calvarial splitting with sharp osteotomes. The outer table grafts are removed= and the diploe is taken in sheets down to the inner table. Once hemostasis is obtained excess= bone wax should be removed. Any du= ral tears should be exposed and sutured, then covered with bone chips. The skull is then covered with Sur= gicel, a Hemovac is placed, and the scalp closed in layers. 4
The total splitting technique is the same as any neurosurgical approach. Crani= al perforations are created with a brace, then the dura is elevated with Penfi= eld elevators. A Gigli saw is use= d to perform the beveled craniotomies. The strips obtained should be split manually so bone is not burned or wasted as dust. Closure start= s by suspending the dura at the edges of the defect, then placing half the split segments back. They will not = need fixation if they are replaced in continuity from their source. Fill the burr holes with extra bony tissue, then cover with Surgicel and place Hemovacs posteriorly. Close in layered fashion. 4
Ilium:
The ilium can provide a sizeable corticocancellous graft up to 11 cm in length with no weak points. When properly harvested and reconstructed, postoperative pain is decreased, and the bone can regenerate= in 2 years for reharvesting. The= key portion of the procedure is the splitting of the crest between the abdominal and gluteal aponeuroses, then wiring the crest back together to preserve it= s structure and function. The distal ends= must be wired to stable bone, bridging the defect created by the harvest. 5=
Position the patient supine or with one hip sligh= tly elevated. Arrange the surgica= l team for the most efficient movement. Incision is 5 cm below the crest to avoid the lateral femoral cutane= ous nerve. Be vigilant to avoid laceration of the outer periosteum and gluteal muscles. Pull the skin medially to position= the planned incision over the iliac crest. Incise through the superficial fascia and use hemostats to control bleeding vessels. Insert two serrated Farabeuf retra= ctors to medialize abdominal soft tissues. Palpate the anterior spine, crest, and tuberosity. Incise through the periosteum and aponeurosis without elevating the periosteum of the crest. Use sharp osteotomes to split the = crest obliquely one cm longer than the planned harvest anteriorly and posteriorly. Then use a sharp osteotome inferomedially to create the medial leaf of the split crest. Cut all along the desired length b= efore elevating medially so it may move as a single piece. The lateral part is split in the s= ame manner, but the curve of the split must follow the convexity of the crest to save the most bone without driving into the gluteal muscle. This is also retracted in one piece. Spong= es and specialized retractors are used to reflect the leafs. Exctract the bone gra= fts as planned for reconstruction. Control bleeding by applying bone wax or cau= tery of the gluteus.
To close, place a large piece of Gelfoam into the= donor site. Four 26 gauge wires are= used to approximate the medial and lateral leafs of the split iliac crest. The ends of the leafs should rest o= n the anterior superior spine for stability.&nbs= p; Turn the ends of the wires in to avoid postoperative pain on palpati= on. Close in layers. 5
Fractures of the leafs of the crest can occurR= 12;they can be managed the same way if only one leaf is fractured. Bleeding is managed with cautery o= r bone wax. 5
Cartilage:
An excellent graft material: easy to carve but maintains structural integrity, easy to harvest or procure from donor banks, and easily preserved. It is f= requently used in reconstruction of nasal or ear defects, or in cosmetic nasal surgery. Cartilage can also be useful for orbital reconstruction and correcting tarsal plate defects.= 6
Rib cartilage:
For constructing a helical framework in ear reconstruction, the 6th and 7th ribs are most useful because the synchondrosis between them creates an adequate size donor for t= he majority of the helix. The ri= m is often carved separately from the 8th or 9th rib as it must have adequate length. It has been noted that the cartilage at the periphery of the rib is more prone to warping over time than the central portion of the cartilage. This consideration is most critical to rhinoplast= y grafts.7
Complications of costal cartilage harvest are most commonly pain, chest wall deformity, clickin= g of the ribs, and donor site scar. Pneumothorax and infection are less frequent. Postoperative pain peaks at 7 days, then resolves slowly and steadily. Most patients do not complain of significant pain after three months. Chest wall deformity can be reduced or eliminated with reimplantatio= n of left over cartilage if the perichondrium is preserved during harvest. The perichondrium provides necessa= ry support for regeneration of cartilage, or the cartilage is simply resorbed.= 8 Pneumothorax or pleural tears may = be managed intraoperatively with suturing, patching, or a chest tube if necess= ary.11
The= re are several variations of costal cartilage harvest techniques designed to limit complications. One of these is patient selection. There is g= eneral agreement that a child should have chest circumference of at least 60 cm be= fore undergoing rib graft harvest.8-9 Agreement also exists regarding preserving the posterior perichondrium in situ to decrease risk of pneumothorax.8-10,12
One of the larger series reported in the literatu= re uses the following method. The incision is planned to overlie the 7th rib in males and along the inframammary crease in females. The dissection is carried down to the perichondrium. This is incised along the center o= f the cartilage with care not to damage the cartilage itself. The perichondrium is raised with specially curved elevators to limit damage posteriorly which co= uld result in pneumothorax. Perichondrium is raised 1 cm past the costochondral junction for eas= e in harvest. A Doyen raspatory is inserted around the cartilage 1 cm away from the costochondral junction and used as a template to incise through the cartilage while protecting the posterior perichondrium from damage. The perichondrium is then sutured in interrupted fashion with 4-0 ny= lon, leaving one area open. The cartilage left over from carving the auricular framework is cut into 2-3 mm blocks and a funnel is used to introduce the cartilage back into the perichondrial pockets which are then sewn shut. Local anesthetic is used to create a nerve block of the area. The = stub of cartilage is left at the costochondral junction to promote continued longitudinal rib growth, especially important in children.9
Another method of harvesting a large amount of cartilage for ear reconstruction suggests that a bupivicaine pump may be le= ft in the operative field to reduce postoperative pain for the first 48 hours. This study advocated reconstruction of the donor site with left over cartilage as well, and found that it does reduce chest wall deformity.&= nbsp; Scars were noted to be an average of 5.5 cm in length, of little consequence to most patients compared to the benefit of a new ear.8
Usually, less volume of costal cartilage is requi=
red
for rhinoplasty. One method
describes a central segment harvest of costal cartilage grafts without remo=
val
of the rib. Once the rhinopla=
sty
surgeon determines that septal and conchal bowl cartilage will be insuffici=
ent
for correction of nasal defects, the assistant begins harvesting rib cartil=
age
in vivo. A 3 cm incision is
made. Dissection is carried d=
own to
the perichondrium, which is incised and elevated. A 45 degree wedge is removed from =
the
anterior rib, usually the seventh, and grafts are sequentially harvested,
keeping the superior and inferior curvature of the rib structure intact.
Auricular cartilage:
Conchal cartilage is a convenient graft for use in rhinoplasty, particularly secondary rhinoplasty when septal cartilage is insufficient. Usually the cym= ba concha and cavum concha are harvested in one piece,12 but some authors endorse leaving a supporting strip continuous with the helical crus= for support.13
There is some disagreement in the literature rega= rding the anterior approach vs. the posterior approach. Both approaches seem to have a sim= ilar rate of complications, less than 5% hematomas. 12-14
The anterior approach is described. The auricular= graft harvest may be under general or IV anesthesia. Local anesthetic is infiltrated on= the anterior ear in the subperichondrial plane to assist in hydrodissection, an= d in the posterior ear in the subcutaneous plane. The anterior incision is carried a= long the lateral edge of the perpendicular concha. The flap is lifted in the subperichondrial plane with blunt dissection or scissors. Once exposed, the intended cartila= ge is incised into the posterior subcutaneous tissue. Most of the cymba concha and cavum concha can be harvested together. A rim of perpendicular cartilage should remain for structural integrity and to prevent scar inversion. The posterior perichondrium should be harvested with the cartilage and the graft should be placed in a saline bath on the back table. Care should be taken to avoid exce= ssive cautery use in obtaining hemostasis as this can cause tissue necrosis and f= lap loss postoperatively. 4-0 Chr= omic, prolene, or nylon may be used to close the incision. Chromic should be used for a delic= ate basting incision to bring the flaps together and reduce hematoma formation,= but the flaps will necrose if this stitching is too tight. Antibiotic ointment is used, then a bolster is placed and secured with 3-0 Prolene, gently as well, and left in place for 3 days.12
The posterior approach is described in a similar manner. In addition, these au= thors advocate leaving a 5 mm strut of helical crus intact to prevent step deform= ity or total collapse of the ear structure.13 Of note, other authors report no g= ross aesthetic deformities,12 even in studies of conchal cartilage complications.14 <= /p>
The authors that advocate a posterior approach and helical strut preservation approach the graft by preserving 2 mm rim of perpendicular cartilage throughout and a 5 mm lateral strut from the crus helicis to the outer rim. Fir= st, local anesthetic is infiltrated in the same manner, then the harvest is pla= nned from the anterior side and a 30 g needle is used to mark the boundary with multiple punctures with brilliant green.&n= bsp; The ear is then retracted forward and a posterior incision is made.<= span style=3D'mso-spacerun:yes'> The dissection proceeds down to the cartilage. The cartilage is g= ently incised along the markings and the dissection proceeds in the subperichondr= ial plane to avoid damage to the anterior skin. Only the marked portions of cym= ba concha and cavum concha cartilage are removed along with their posterior perichondrium. The subcutaneous laer is closed with 4= -0 chromic and the skin is closed with running locking 4-0 nylon. Separate bolsters are placed in ea= ch graft site and gently sutured with 4-0 nylon, removed 5 days later.13<= /sup>
The most common early complication of conchal car= tilage harvest is hematoma (3-5%), followed by hypesthesia, anesthesia, and pain at the harvest site (2% each). L= ate complications include hypesthesia at the incision (10%), hyperesthesia of t= he scar (3%) and unsightly scar formation (3%).14 A clever packing technique is desc= ribed: use Merocel that has been cut transversely to pack the cymba and cavum conc= ha, and gently secure them through a posteriorly placed full size merocel. Saline was used to expand the Mero= cel, and it was left in place for 5 days. The authors report no hematomas and no skin loss or wound dehiscence from dressing pressure in the Merocel treated patients.15
Septal Cartilage:
Nasal septal cartilage is the most common and des=
irable
material for rhinoplasty work. It
is strong and able to maintain its structure for a variety of
applications. However, 10 mm =
caudal
and dorsal struts must be left in place for structural integrity of the nos=
e,
and this limits the amount that can be harvested for grafts.16
Septal cartilage harvest is carried out in much t=
he
same way as a septoplasty. Fi=
rst
decongestion with cottonoids soaked in Afrin is performed. The septum is then infiltrated wit=
h lidocaine
and 1:100,000 epinephrine in the subperichondrial plane bilaterally to assi=
st
with hydrodissection. Time is=
given
for the vasoconstriction to take effect, then the mucosa is incised, often
using a hemitransfixion incision (at the caudal border of the septal cartil=
age)
or Killian incision (2-3 mm cephalic to the caudal border). The mucosa and perichondrium are t=
hen
raised in a bloodless plane back to the bony/cartilaginous junction and from
the dorsum down to the maxillary crest.&nb=
sp;
The incision is planned, then may be carried out with a variety of
instruments including a Cottle elevator, D knife, or 15 blade. The contralateral mucosal plane is=
then
elevated with a Freer, cottle, or even just suction or a nasal speculum, and
the graft is harvested, leaving at least 10 mm dorsal and caudal struts.
Septal cartilage may provide an insufficient amou=
nt of
cartilage for all planned grafts in a rhinoplasty. This is particularly problematic i=
n the
Asian population and in secondary rhinoplasty. The external nose size has not been
found to be predictive of the amount of cartilage available for harvest.
Skin grafts:
Compared to skin flaps, skin grafts have less opt= imal color match and texture. Skin grafts fall into two major categories: full thickness and split thickness.<= span style=3D'mso-spacerun:yes'> Split thickness skin grafts includ= e the epidermis and varying amounts of the dermal layer of skin. Full thickness grafts include the epidermis and the entire dermis.19
Split thickness skin grafts can be used to cover = any wound that has a blood supply sufficient to support its survival. Some areas cannot support a split thickness graft such as cortical bone without periosteum, cartilage without perichondrium, tendon, nerve, or any surface with intact squamous epitheliu= m. Sites that have undergone radiatio= n are more difficult to cover with a skin graft.= Split thickness skin grafts contract more than full thickness grafts= . Common donor sites are the thigh, abdomen, and buttock. They are harvested using a dermatome set to the appropriate thickness and the graft = may be meshed to provide larger coverage. Once the graft is placed, it is immobilized for 5-7 days for the ini= tial stages of healing to take place and prevent shear, seroma, or hematoma to f= orm, usually with a pressure dressing. The graft donor site can be covered with an occlusive dressing. A moist donor area heals more rapi= dly than a dry area.19,20
The phases of healing are as follows: serum imbib= ition, revascularization, and organization. Serum imbibition lasts about 2 days from initial placement on the site. Fibrin secures the graf= t in place initially and plasma transudate provides nutrients. Revascularization is believed to h= appen with two complementary processes: neovascularization (ingrowth of new vesse= ls from the site into the graft) and inosculation (direct anastomoses of graft= and host vessels). The last phase= is organization. Leukocytes init= iate this process shortly after graft placement, then as revascularization progresses, fibroblasts appear and proliferate, eliminating the fibrin layer. The organization phase resolves after about 9 days.21&= nbsp;
Full thickness skin grafts consist of the entire
epidermal and dermal layers of skin.
They retain their original color and texture after transplantation.<=
span
style=3D'mso-spacerun:yes'> If hair follicles are harvested, t=
hey
continue to grow on the grafted tissue.&nb=
sp;
They contract less than split thickness grafts but they take longer =
to
revascularize. Defects of nas=
al tip,
eyelids, and auricle are popular applications for full thickness grafts. Fat grafting: Fat may be harvested from a variety of sites and =
used
to fill cosmetic defects such as prominent nasolabial folds. It has the advantage over other fi=
llers
of being native tissue, but its disadvantages include unpredictable amounts=
of
reabsorption (up to 100%) and prolonged facial edema after
transplantation. It also may
require multiple procedures to obtain the desired results.6,22 One author has created a technique of harvesting,
refining, and injecting fat that takes a delicate approach to the fatty tis=
sue
and attempts to keep the structure intact.=
He reports near permanent results with little reabsorption in over 1=
000
cases. It does not use tradit=
ional
liposuction equipment, but a 10 cc luer lock syringe under gentle hand suct=
ion
is used to harvest the fat from the abdomen or buttocks. The fat is gently refined in a
centrifuge to spin the oil and lidocaine off. The intact fatty cellular tissue is
removed from the middle layer, and injected on withdrawing a blunt cannula =
in
small layered quantities under local anesthesia to achieve the desired
effect. Cold compresses or ice
packs are used for 2 to 3 days postoperatively. The emphasis of this technique is =
to
deliver intact fatty parcels to well vascularized recipient tissues, and th=
ey
become integrated seamlessly into the native tissue. The most consistent early complica=
tion
is prolonged facial edema, significant for up to 2 months, attributed to the
hundreds of passes with a blunt cannula.&n=
bsp;
Bruising and hematomas may be caused by sharp injection of local
anesthetic but usually resolve quickly.&nb=
sp;
The most common late complication is under correction, which may req=
uire
a repeat procedure. Fat necro=
sis
has also been noted when fat is injected into areas that had previous silic=
one
injections. Perforating the o=
ral
mucosa can cause infection of the injected areas if it is not noted and
managed. Damage to vital stru=
ctures
can occur but is less likely with the blunt cannula method. Donor site pain, swelling, and
infections can also occur.23 Conclusion: Many grafts are available to the reconstructive a=
nd
cosmetic head and neck surgeon for a variety of challenges. This grand rounds attempted to out=
line
some general “how to” for graft harvest, and point out some com=
plications
and considerations when planning.
This is by no means a comprehensive guide, and I point you to the
excellent resources in the reference section for further details. References 1.
Current
and Emerging Basic Science Concepts in Bone Biology: Implications in
Craniofacial Surgery. AJ Oppenheimer et al, J Craniofacial Surg 2012;23:30-=
36 2.
Autogenous
Bone Grafts and Bone Substitutes—Tools and Techniques. P. Tessier, et al, Plast. Reconstr.
Surg. 116 (Suppl.):6S, 2005 3.
Calvarial
Thickness and Its Relation to Cranial Bone Harvest. A Moreira-Gonzalez, et =
al,
Plast. Reconstr. Surg. 117: 1964, 2006 4.
Taking
Calvarial Grafts, Either Split in Situ or Splitting of the Parietal Bone Fl=
ap
ex Vivo—Tools and Techniques.
P. Tessier, et al, Plast. Reconstr. Surg. 116 (Suppl.):54S, 2005 5.
Taking
Bone Grafts from the Anterior and Posterior Ilium—Tools and Technique=
s.
P. Tessier, et al, Plast. Reconstr. Surg. 116 (Suppl.):25S, 2005 6.
Principles
of Facial Plastic and Reconstructive Surgery, Patel, Chapter 7, Biologic Ti=
ssue
Implants, page 74. 7.
Reconstructive
Facial Plastic Surgery: A Problem-Solving Manual, Weerda, Chapter 11 Rib
Cartilage, page 117-119 8.
Donor-Site
Morbidity after Autologous Costal Cartilage Harvest in Ear Reconstruction a=
nd
Approaches to Reducing Donor-Site Contour Deformity, RS Uppal, et al, Plast.
Reconstr. Surg. 121: 1949, 2008 9.
New
Method of Costal Cartilage Harvest for Total Auricular Reconstruction: Part=
I,
Y Kawanabe and S Nagata, Plast. Reconstr. Surg. 117: 2011, 2006 10.
Central
Segment Harvest of Costal Cartilage in Rhinoplasty, M Lee, et al, Laryngosc=
ope
121:2155-2158, 2011 11.
The
Versatile Autogenous Rib Graft in Septorhinoplasty, DA Sherris and EB Kern,
American Journal of Rhinology 12:221-227, 1998 12.
Auricular
Cartilage Grafts and Nasal Surgery, GL Murrell, Laryngoscope, 114:2092-2102,
2004 13.
How
to Harvest the Maximal Amount of Conchal Cartilage Grafts, K Han, et al,
Journal of Plastic, Reconstructive, and Aesthetic Surgery 61:1465-1471, 200=
8 14.
Donor
Site Morbidity of Ear Cartilage Autografts, RA Mischkowski, et al, Plast.
Reconstr. Surg. 121:79, 2008 15.
Merocel
Semicompressive Dressing to Prevent Donor-Site Hematoma on the Conchal
Cartilage Graft, SW Kim, et al, J Craniofac Surg 2012;23:57-60 16.
Septal
Harvesting Instruments in Rhinoplasty, N Kang, et al, Anesth Plast Surg
32:549-551, 2008 17.
Septoplasty
and Turbinate Surgery, DG Becker, Aesthetic Surgery J, 2003;23:393-403 18.
Intraoperative
Measurements of Harvestable Septal Cartilage in Rhinoplasty, JS Kim, et al,=
Ann
Plast Surg 2010; 65: 519-523 19.
Reconstructive
Surgery of the Face and Neck, Papel, Chapter ***, Minimally Invasive Options
and Skin Grafts for Cutaneous Reconstruction [***year] 20.
Current
Diagnosis and Treatment: Surgery, McGraw-Hill publishing company, 13 ed.
Chapter 41 Plastic and Reconstructive Surgery, Grafts and Flaps 21.
Otolaryngology
text *** Balleneger, [***year], Chapter 41 Flaps and Grafts in the Head and
Neck 22.
Diagnosis
and Treatment in Otolarygnology—Head and Neck Surgery, McGraw-Hill
publishing company, 3rd Ed., Chapter 80 Facial Fillers and Impla=
nts 23.
Facial
Recontouring with Lipostructure, SR Coleman, Clinics in Plastic Surgery, Vol
24, Number 2, April 1997
Handy Grafts
for Head and Neck Reconstruction: An Overview of How-To September 2012