Wide-Open Dorsal Approach Rhinoplasty for Droopy Noses

Effects of Functional Rhinoplasty on Nasal Obstruction: A Meta-Analysis

BACKGROUND

Functional rhinoplasty (FRP) is used to improve nasal ventilation by correcting problems with the nasal valves. It has not been systematically reviewed on a large scale.

METHODS

A comprehensive literature search was conducted in the PubMed, EMBASE, and Cochrane Library databases to identify studies evaluating nasal obstruction before and after functional rhinoplasty in patients with nasal valve problems.

RESULTS

A total of 57 cohorts from 43 studies involving 2024 patients were included in the current meta-analysis. The Nasal Obstruction Symptom Evaluation (NOSE) scores indicated significant improvement in nasal obstruction at the 1-month follow-up (WMD = 38.12; 95% CI, 29.15-47.10; I²= 83.6%; P = 0.00), 3-month follow-up (WMD = 48.40; 95% CI, 43.16-53.64; I²= 69.1%; P = 0.00), 6-month follow-up (WMD = 44.35; 95% CI, 36.65-52.04; I²= 96.6%; P = 0.00), 12-month follow-up (WMD=43.07; 95% CI, 26.56-59.58; I²= 97.9%; P = 0.00), and the last follow-up (WMD = 46.90; 95% CI, 43.92-49.88; I²= 95.9%; P = 0.00) with respect to the preoperative baseline. The Visual Analogue Scale (VAS) scores indicated a similar trend at the 1-month follow-up (WMD = 4.68; 95% CI, 3.79-5.57; I²= 86.8%; P = 0.00), 3-month follow-up (WMD = 4.46; 95% CI, 3.19-5.74; I²= 93.3%; P = 0.00), 6-month follow-up (WMD = 4.91; 95% CI, 4.04-5.78; I²= 88%; P = 0.00) and last follow-up (WMD = 4.22; 95% CI, 3.12-5.32; I²= 97.1%; P = 0.00). Nasal obstruction was obviously relieved through rhinomanometry (SMD=0.56; 95% CI, 0.27-0.84; I²= 0.0%; P = 0.00) but not through peak nasal inspiratory flow (PNIF) (SMD=-1.51; 95% CI, -3.10 to 0.07; I²= 98.9%; P = 0.09).

CONCLUSION

FRP may have a positive effect on nasal obstruction caused by nasal valve problems. Broader and well-designed studies are needed to shed more light on the relationships in this area.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Impact of Isotretinoin Therapy on the Nasal Skin Thickness and Elasticity: An Ultrasonography and Elastography Based Assessment in Relation to Dose and Duration of Therapy

BACKGROUND

This study aimed to evaluate the impact of isotretinoin therapy on the nasal skin thickness and elasticity with regard to implications for rhinoplasty METHODS: A total of 40 acne vulgaris patients (mean±SD age: 20.9 ± 3.0 years, 65.0% were females) initiating oral isotretinoin treatment (0.25 mg/kg/day, n = 16 or 0.5 mg/kg/day, n = 24) were included in this prospective 4-month isotretinoin follow-up study. Ultrasonography assessments regarding nasal skin thickness (dermis and soft tissue) and elastography were repeated at second and fourth months of treatment.

RESULTS

No significant difference was noted between isotretinoin dose groups in terms of second month and fourth month nasal skin thickness (dermis and soft tissue) values measured at any region. Each dose revealed significant decrease in dermis and soft tissue thickness from baseline at any region (p ranged  < 0.001 to  < 0.001), while only fourth month values at nasal tip and second month values at rhinion for dermis and only fourth month values at rhinion and glabella for subcutaneous tissue significantly differed from baseline (p < 0.01 for each) in the 0.25 mg and 0.50 mg dose groups, respectively. Elastography values at fourth month of isotretinoin treatment were significantly higher than pre-treatment and second month values in both 0.25 mg (90.4 ± 20.6 vs. 59.5 ± 21.8 and 76.4 ± 22.9, p < 0.01 for each) and 0.5 mg (86.7 ± 20.6 vs. 61.8 ± 23.2 and 76.9±24, p < 0.01 for each) dose groups.

CONCLUSIONS

In conclusion, our findings revealed the association of isotretinoin treatment with a significant decrease in dermis and subcutaneous soft tissue thickness measured at each anatomical landmark, regardless of the treatment dose.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Concurrent Excision of Dorsal Nasal Scars and Reduction Rhinoplasty: A Retrospective Cross-sectional Study

Skin lesions and traumas can affect the skin by leaving scars. The purpose of this study was evaluating the results of a new technique in reconstructive surgery of scars on the nose. In this technique, extra skin remaining from reduction rhinoplasty is applied to the defect remained from removing the scar.

Methods

This is a retrospective cross-sectional study performed on 33 patients who underwent reduction rhinoplasty from 2013 to 2018 due to scars on the dorsal nasal skin. Five sets of standards, criteria, and questionnaires were used to evaluate the cosmetic outcomes, scars, and nasal function. These included the Cakir concept, visual analogue scale, patient reported outcome measurement, Stony Brook scar evaluation scale, and sino-nasal outcome test-22.

Results

According to the surface polygon concept, or Cakir concept, the number of affected polygons due to scars decreased in all included patients (P < 0.05). In addition, constant improvement in patients' satisfaction, based on patient reported outcome measurement (P < 0.001) and visual analogue scale (P ≤ 0.05), as well as physicians' satisfaction, based on Stony Brook scar evaluation scale, were determined. Furthermore, evaluating the patients' breathing, based on sino-nasal outcome test-22 criteria (P < 0.09), indicated no adverse effects.

Conclusion

Excision of scars from dorsal nasal skin and conducting rhinoplasty surgery from the same access can be considered an option for reconstructing nasal scars.

Soft Tissue Thickness Variations of the Nose: A Radiological Study

BACKGROUND

Soft tissue thickness (STT) is a major factor affecting the outcome in rhinoplasty. However, limited information is found in the literature on the age- and gender-related variations of the nasal STT.

OBJECTIVES

The purpose of this study was to measure STT at various landmarks over the nasal framework and compare the age- and gender-related differences.

METHODS

STT measurements were made at 11 landmarks in 325 patients by employing magnetic resonance imaging. Patients were divided into subgroups to compare the STT differences between female and male and between the age groups as young, middle age, and elderly.

RESULTS

Soft tissue was thickest at the nasion and thinnest at the rhinion. The soft tissue coverage was significantly thicker in the male population at the supratip, tip, nasal bones, upper lateral cartilages, and alar lobules, whereas it is thicker in females at the rhinion. Average thickness of the soft tissues over the entire nasal framework increases with age except the rhinion.

CONCLUSIONS

The STT is variable over different parts of the osteocartilaginous framework. Gender and age influence the STT. The soft tissue is thicker at the distal half of the nose in male patients, and these areas become gradually thicker with age, whereas the soft tissue over the midvault becomes thinner. Increasing age presents a particular challenge to achieve predictable results in rhinoplasty, and an understanding of the soft tissue envelope allows for improved aesthetic outcome.

LEVEL OF EVIDENCE 2

Nasal obstruction symptom evaluation (NOSE) score outcomes after septorhinoplasty

OBJECTIVES/HYPOTHESIS

The time interval at which Nasal Obstruction Symptom Evaluation (NOSE) scores stabilize after functional septorhinoplasty has not been determined. Our goal was to characterize longitudinal trends of patient-reported outcomes of nasal obstruction using the NOSE survey instrument following functional septorhinoplasty.

STUDY DESIGN

Prospective longitudinal cohort study.

METHODS

Adult patients (≥18 years) with nasal obstruction who underwent functional septorhinoplasty by three different surgeons at a single academic, tertiary referral center were identified. NOSE scores were obtained preoperatively and prospectively during three postoperative intervals defined as early (1-3 months), middle (4-6 months), and late (≥10 months.) Longitudinal analysis included repeated measures analysis of variance and adjustments for multiple comparisons.

RESULTS

A total of 49 patients met inclusion criteria. For the total cohort, mean NOSE scores significantly improved between preoperative and early postoperative evaluations (71.4, standard deviation [SD] ± 17.0 vs. 24.2, SD ± 19.5; P < .001) but did not significantly change between early and middle (20.6, SD ± 19.1; P = .543) or middle and late (23.1, SD ± 24.9; P > .999) time intervals.

CONCLUSIONS

Patients with nasal obstruction who undergo functional septorhinoplasty can be expected to have significant improvement in self -reported nasal obstruction as early as 1 to 3 months postoperatively with a continued, durable, long-standing benefit lasting at least 10 months after surgery. Future studies can consider the 3-month time frame as a proxy for 1 year outcomes to help reduce survey burden.

LEVEL OF EVIDENCE

2c Laryngoscope, 129:841-846, 2019.

External Approach for the Treatment of the Aging Nasal Tip

Changes seen in the nose from increased skin elasticity, weakened nasal cartilages, and detachment of ligaments can lead to cosmetic and functional impairment. Esthetically, the nasal tip droops, the nose lengthens, the columella shortens, and the ala collapse. Functionally, the internal and external nasal valves weaken, the anterior nares narrow, and airway turbulence increases, thus contributing to the effect of nasal obstruction. Skin redundancy of the elderly nose may compromise outcomes when typical rhinoplasty techniques are applied. Herein is described a technique pioneered by Fred Stucker, involving a direct external approach to address the aging nasal tip. The technique can be performed under local anesthesia and in combination with other procedures for the aging nose, such as rhinophyma excision or septoplasty for the aging nose.

How to cite this article

Hu M. External Approach for the Treatment of the Aging Nasal Tip. Int J Head Neck Surg 2016;7(3):165-167.

Skin Excision as an Adjunctive Technique to Rhinoplasty in Middle-Aged and Elderly Patients

Supplemental Digital Content is available in the text.

Rhinoplasty in middle-aged and elderly patients comes with its own set of challenges. There is relative lengthening of the nose with drooping of the nasal tip. With aging, the skin loses its elasticity, and the combination of nasal skeletal reduction along with overlying inelastic skin provides a setup for skin redundancy and poor postoperative outcome. We describe a surgical technique involving lenticular skin excision as a part of rhinoplasty in 12 patients older than 50 years to improve the aesthetic outcome. Skin width up to 1.6 cm was excised. Included is a literature review of skin excision in rhinoplasty. In elderly patients with thin, inelastic skin and long nose with a drooping tip, a reduction rhinoplasty technique might result in skin redundancy. Lenticular skin excision along the radix of the nose in these 12 patients improved the aesthetic outcome by decreasing the redundancy and preventing nasal tip ptosis. The wound from the skin resection healed in all the patients with minimal scar, and no complication was noted after at least 1 year of follow-up for each patient.