Analysis of Nasal Obstruction Patterns Following Reductive Rhinoplasty

Comparison of Nasal Airways After Classical Structural Rhinoplasty and Dorsal Preservation Rhinoplasty

Purpose: To investigate whether there was a difference in the nasal airway dimensions after dorsal preservation and classical structural rhinoplasty. Introduction: The surgical approach to rhinoplasty has improved over many decades. The first was the classic structural rhinoplasty (CSR) developed by Joseph, where the excess tissues are removed from the dorsal hump. In the following decades, dorsal preservation rhinoplasty (DPR) was established to prevent complications associated with CSR. Methods: One hundred twenty-four patients without self-reported nose obstruction syndromes underwent DPR or CSR according to the authors' shared surgical regime. Nasal airway dimensions of rhinoplasty patients were measured preoperatively and postoperatively with acoustic rhinometry (AR), and minimum cross-sectional areas (MCA) and internal nasal volumes (VOL) were acquired. Results: Dorsal preservation rhinoplasty was performed on 64 patients (51.6%), while classical structural rhinoplasty was performed on the remaining 60 (48.4%). There were no significant differences between the 2 techniques regarding VOL and MCA. (MCA1left side DPR vs CSR P = .539, VOL1 right side DPR vs CSR P = .843). Conclusion: We postulate that nasal airway dimensions do not predict or indicate whether the DPR or CSR technique will be/have been used in rhinoplasty surgery, and the employed technique does not significantly alter the dimensions of the nasal airways. Any significant change in nasal airway dimensions is more likely due to the septal intervention.

Application of Submucosal Trans-Septal Suturing Technique in a Septal Extension Graft With Porous High-Density Polyethylene and Concurrent Nasal Lateral Osteotomy

BACKGROUND

Recently, a submucosal trans-septal suturing (STSS) technique was introduced to obviate the dead space of septum after septal extension graft (SEG) with porous high-density polyethylene (pHDPE).

OBJECTIVE

To investigate STSS technique after SEG with pHDPE and concurrent nasal lateral osteotomy (LO).

METHODS

A retrospective study was conducted in 53 patients who underwent a STSS technique after SEG with pHDPE and concurrent LO. The postoperative discomfort (nasal pain and obstruction), the width of the nasal bony base, Nasal Obstruction Symptom Evaluation (NOSE), Rhinoplasty Outcomes Evaluation (ROE), and complications were recorded and assessed.

RESULTS

The mean surgical duration of STSS was 862.53±227.73 seconds. The maximal mean score of postoperative nasal pain and nasal obstruction was 2.132±0.921 and 1.868±0.8995, respectively. The values on the width of the nasal bony base and ROE were significantly improved after surgery. There was no significant difference in NOSE values preoperatively versus 6 months postoperatively. An infection was found in 1 patient, a recurrent minor bleeding of septum in another patient, and a symptomatic nasal obstruction in other 2 patients. There was no major bleeding, hematoma, foreign body sensation, septal perforation, and other infection.

CONCLUSION

STSS can eliminate the postoperative dead space of nasal septum with low discomfort and complications, and help to avoid a lateral displacement of osteotomized nasal bony segment (ONBS) in patients undergoing SEG with pHDPE and concurrent LO.

Autospreader Flaps in Closed Rhinoplasty: Our Technique and Long-Term Results

INTRODUCTION

 Rhinoplasty is a common and complex surgical procedure. Respiratory and aesthetic dissatisfaction are major causes of revision surgeries. Multiple techniques were described to reconstruct the middle nasal vault and improve functional outcomes. One of these techniques is the use of autospreader flaps. These flaps were constantly modified by different surgeons. In our practice, we use a modified technique of autospreader flaps in closed rhinoplasty. Neither upper lateral cartilage scoring nor suture fixation to the septum was done.

METHODS

 We conducted a retrospective study on 183 patients, analyzing revision rates and long-term functional results using the NOSE scale. Data analysis was done using IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.

RESULTS

 Long-term results showed satisfactory aesthetic outcomes with low revision rates (13.6%). Concerning the NOSE score, it was completed by 87 of the 183 patients, yielding a response rate of 47.5%. A mean NOSE score of 18.1 +/- 21.1 at 4.4 years of follow-up was obtained.

CONCLUSION

 Autospreader flaps offer simplicity, reproducibility, and effectiveness in closed rhinoplasty. It represents a valuable option for selected patients, especially in populations with high dorsal reduction surgery demand.

Dorsal preservation rhinoplasty versus dorsal hump reduction: a randomized prospective study, functional and aesthetic outcomes

PURPOSE

To compare the functional and esthetic outcomes of dorsal preservation rhinoplasty (DPR) and conventional dorsal hump reduction (DHR) in primary rhinoplasty using patient-reported outcome measures (PROMs) and cone beam computed tomography (CBCT).

METHODS

In our randomized prospective double-blinded clinical trial, 50 patients had dorsal nasal hump surgery between October 2021 and November 2022 in our tertiary referral center. All surgeries were done by the same surgeon. Patients were randomly assigned to two groups: Group (A): 25 patients had DPR, and group (B): 25 patients underwent DHR. Pre-operative and post-operative evaluations were conducted using standardized cosmesis and health nasal outcomes survey (SCHNOS), surgeons' rhinoplasty evaluation questionnaire (SREQ), and the CBCT.

RESULTS

Following an average of 7.22 ± 2.07 months, patients in both groups reported significantly higher levels of satisfaction, as measured by the SCHNOS score (p < 0.001) and the average of three SREQ scores (p < 0.001). These results align with the radiological analysis, which denoted an overall improvement in the average of both sides' internal nasal valve angle and cross-sectional area after surgery with (p = 0.001) and (p = 0.085), respectively, for the DPR group and with (p = 0.281) and (p = 0.014), respectively, for the DHR group. There was no statistically significant difference in outcomes between both groups (p > 0.05).

CONCLUSION

Dorsal preservation is a viable alternative to conventional dorsal hump reduction in primary rhinoplasty. There was no difference in the functional and esthetic outcomes between both techniques, which were verified by radiological investigation.

Comparison of Dorsal Preservation Rhinoplasty Techniques: Functional and Aesthetic Review of Subdorsal Septal Strip Methods

Objective: To compare subdorsal strip excisions in patients undergoing dorsal preservation (DP) rhinoplasty using patient-related outcome measures (PROMS). Methods: Patients were treated from 2020 to 2022 using the modified subdorsal strip method (MSSM) or Z flap approach. A two-sample t-test determined whether there was a difference in functional and aesthetic scores using the NOSE, Sinonasal Outcome Test (SNOT-22), SCHNOS, and ESS scales. Results: Seventy-one primary rhinoplasty patients met inclusion criteria at 12 months with an average age of 23 years (62 female, 9 male), with 35 (49%) undergoing the MSSM technique, while 36 (51%) receiving the Z flap. PROMS at 1, 3, 6, and 12 months postoperatively were compared. The average preoperative and postoperative NOSE score was 9.36 and -4.4 (standard deviation [SD] 3.1, p < 0.001). The average preoperative SNOT-22 score was 23.9 and -16.4 (SD 10.2, p < 0.001). ESS scores was average was 6.2 and -1.6 (SD 3.2, p = 0.01). The average SCHNOS total, functional, and cosmetic scores were 27.6 (6-47), 8.2 (0-20) and 18.7 (0-37), respectively, and -5.7 (SD 8.2, p < 0.001), -5.73 (SD 6.24, p < 0.001), -18.1 (SD 9.7, p < 0.001). No significant complications were found and no difference in PROMs among groups. Conclusion: There was no difference in septal strip techniques as evaluated by PROMS.

Comparison in Patient Satisfaction Between Structural Component and Hybrid T-bar Preservation Rhinoplasty: A Retrospective Propensity Score Matched Cohort Study

BACKGROUND

Recently, a modified dorsal split preservation technique has been described. In this method, the integrity of the elastic keystone area is preserved by separation of the upper lateral cartilages from the septal T-bar. Our study aimed to evaluate the aesthetical and functional outcome in patients treated with the dorsal T-bar preservation versus the 'gold' standard dorsal split component reduction approach.

METHODS

We performed a retrospective propensity score matched analysis in 234 patients enrolled for rhinoplasty. The severity of nasal obstruction was measured with the nasal obstruction symptom evaluation questionnaire (NOSE score). Aesthetic evaluation was performed with the FACE-Q nose and nostrils and Utrecht Questionnaire (UQ). Assessments were conducted prior to surgery, at 3 and at 6 months after surgery. After propensity score matching, 172 patients in two cohorts were retained. The following covariates were taken into the statistical calculation: age, gender, ethnicity, previous nasal surgery, nasal trauma, respiratory allergy, and preoperative NOSE scores. The first cohort of 110 patients underwent rhinoplasty with T-bar preservation technique (TDP). The control cohort consisted of 62 patients who underwent dorsal split component reduction (SCR).

RESULTS

The mean preoperative scores for FACE-Q nose, FACE-Q nostrils, UQ and VAS score improved significantly in all patients postoperatively. Both techniques had comparable aesthetic outcome measures that remained unchanged between 3 and 6 months postop. Functional outcome as measured by the NOSE score was in favor of SCR at 3 months postop but the difference between both techniques was not significant anymore at 6 months postop. In contrast to SCR, in TDP, only 31% of the patients needed spreader grafts or autospreader flaps at the internal valve area only for functional reasons.

CONCLUSION

The data in this study suggest similar patient satisfaction with SCR and TDP techniques for aesthetics as well as nasal function after 6 months postop. TDP is a very versatile cartilage-sparing method to aesthetically adapt the middle vault without interrupting the keystone area. It combines the popular component separation concept with the preservation of the delicate anatomy of the mid-vault.

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 .

Functional and Aesthetic Outcomes of Let Down Dorsal Preservation Rhinoplasty

Background: Preservation rhinoplasty is a re-emerging technique that lacks data on functional and aesthetic outcomes. Objective: To measure the change in patient-reported nasal aesthetic perception, nasal breathing, and sleep and compare outcomes between two different septal cartilage manipulation techniques among patients undergoing preservation rhinoplasty. Methods: Functional and aesthetic outcomes of a let down dorsal preservation rhinoplasty using either the modified subdorsal strip method (MSSM) or subdorsal Z-flap are assessed pre- and postoperatively using the validated assessment tools Nose Obstruction Symptom Evaluation (NOSE), Sinonasal Outcome Test (SNOT-22), Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), and Epworth Sleepiness Scale (ESS). Results: Fifty-two patients, 40 women and 12 men ages 15-69 years, underwent dorsal preservation rhinoplasty and the majority reported at 1, 3, 6, and 12 months postoperatively significant improvement based on a paired t-test in NOSE, SNOT-22, SCHNOS, and ESS scores except for ESS scores at 6 and 12 months. No significant difference based on a two-sample t-test was observed between the MSSM and Z-flap techniques implemented. Conclusion: Let down dorsal preservation rhinoplasty with either the MSSM or Z-flap cartilage manipulation technique can achieve significant improvement in nasal aesthetics, nasal breathing, and sleep according to patient responses on validated assessment tools.

Comparison of Dorsal Preservation and Dorsal Reduction Rhinoplasty: Analysis of Nasal Patency and Aesthetic Outcomes by Rhinomanometry, NOSE and SCHNOS Scales

BACKGROUND

Dorsal preservation techniques have been preferred and gained popularity in recent years. The current study compares the effects of dorsal preservation and dorsal reduction rhinoplasty on nasal patency and aesthetic outcomes by using Patient-Reported Outcome Measures (PROMs) and rhinomanometry. To our knowledge, this is the first study to compare dorsal preservation and dorsal reduction techniques with rhinomanometry.

METHODS

This is a prospective study of 34 patients who underwent rhinoplasty between January 2021-June 2022. The patients were randomly selected preoperatively and divided into two groups as structural rhinoplasty (SR) and preservation rhinoplasty (PR). Nasal Obstruction and Symptom Evaluation (NOSE), Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) scales and rhinomanometric evaluation were performed preoperatively, at 3rd month and 12th month postoperatively.

RESULTS

Nineteen patients (10 female, 9 male) were in SR group, 15 patients (7 female, 8 male) were in PR group. There was not significant difference in terms of age and gender between groups. In both groups, NOSE, SCHNOS-O and SCHNOS-C results were found to be significantly lower at postoperative 3rd and 12th month compared to preoperatively (p < 0.001 for the entire SR group, p = 0.001 for the entire PR group). There was no significant difference between groups in terms of PROMs. Mean total nasal volume (TNV) at 12th month were statistically higher than preoperative value in PR group (p = 0.031). Also there was no significant difference in SR group and between groups in terms of rhinomanometry results.

CONCLUSION

Dorsal preservation with pushdown technique provides good functional and aesthetic results comparable with structural rhinoplasty.

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 . A well-designed prospective clinical trial.

Using Nasal Self-Esteem to Predict Revision in Cosmetic Rhinoplasty

BACKGROUND

It would be useful if existing tools or outcomes measures could predict which patients are at greater risk of revision surgery following rhinoplasty.

OBJECTIVES

The authors sought to determine if a single question assessing nasal self-esteem could be utilized to predict which patients are at greatest risk of revision surgery following rhinoplasty.

METHODS

The authors conducted a retrospective chart review of 148 patients who underwent cosmetic rhinoplasty. Results of pre- and postoperative Standardized Cosmesis and Health Nasal Outcomes Survey questionnaires and rates of revision or patient-initiated revision discussions (RD) were collected. Patients were stratified based on answers to Standardized Cosmesis and Health Nasal Outcomes Survey question 5 (SQ5), "Decreased mood and self-esteem due to my nose."

RESULTS

Of the 148 patients included in the analysis, 72.9% were women, and the mean age was 30.9 (15-59, standard deviation = 10.3) years. Those patients who selected 4 or 5 on SQ5 had an overall revision rate of 16.7% and 18.8%, respectively, and a RD rate of 27.8% and 31.25%, respectively. Those patients who selected 0 through 3 on SQ5 had an overall revision rate of 0% and an overall RD rate of 10.4%. Only SQ5 was predictive of revision and RD on logistic regression analysis (P = 0.0484 and P = 0.0257) after Bonferroni correction.

CONCLUSIONS

SQ5 appears to offer a useful adjunct to guide surgical management of the cosmetic rhinoplasty patient. Those patients who reported worse nasal self-esteem and associated mood preoperatively were more likely to request and undergo revision.

LEVEL OF EVIDENCE: 4

The Evidence Base for the Benefits of Functional Septorhinoplasty and its Future Post COVID-19

Ever since the introduction of the concept of Procedures of Limited Clinical Value (PoLCV), procedures such as functional septorhinoplasty have been subject to additional funding restrictions within the British National Health Service. Recent publications have suggested that 10% of Clinical Commissioning Groups in the United Kingdom no longer fund septorhinoplasty surgery irrespective of the indications, including congenital malformations or post-trauma, and despite the strong evidence available in the literature in treating a range of health conditions. Thus, inequity exists across the country. At present functional septorhinoplasty surgery is frequently but incorrectly grouped together with aesthetic rhinoplasty, both of which are deemed to be cosmetic interventions. Moreover, as we exit the peak of the current coronavirus disease 2019 (COVID-19) pandemic, procedures deemed to be of lower clinical priority will potentially be at risk throughout Europe. The purpose of this review is twofold; the first is to put forward the evidence to commissioners in favor of functional septorhinoplasty surgery on patient well-being and mental health; the second is to demonstrate why functional septorhinoplasty surgery is a distinct procedure from aesthetic rhinoplasty and why it ought not to be classified as a procedure of limited clinical value.

Nasal Obstruction and Rhinoplasty: A Focused Literature Review

BACKGROUND

There is a significant variation in the assessment, treatment, and outcomes of nasal airway obstruction and management in the published literature. This study aimed to: (1) define key components of the nasal airway, (2) identify frequent causes of nasal obstruction, and (3) review existing treatment methods.

METHODS

A systematic review of the literature was performed, and 135 studies were included via the following criteria: English, human subjects, and a primary endpoint of nasal airway improvement. Exclusion criteria were: abstract only, no airway data, pediatric patients, cleft rhinoplasty, sleep apnea, isolated traumatic nasal reconstruction, and cadaveric-only or animal studies.

RESULTS

The relevant obstructive sites include the ENV, septum, inferior turbinates, INV, and nasal bones. Addressing the alar rim alone may be insufficient, and inspection of the lateral wall and crura may be indicated. Correction of septal deviation involves attention to the bony base. Mucosal sparing treatment of inferior turbinates improves outcomes. INVs are a major source of nasal obstruction, and treatment includes spreader grafts. The bony nasal vault can contribute to nasal obstruction, including due to surgical osteotomies.

CONCLUSIONS

Anatomic causes of airway obstruction include the alar rims and lateral nasal walls, deviated nasal septum, inferior turbinate hypertrophy, decreased INV angle, and narrowed nasal bones. Treatments include graft placement; septoplasty; mucosal sparing turbinectomy; and lateral wall support. Pitfalls include failing to address the bony septum, over-resection of inferior turbinates, and narrowing of the nasal vault. Appreciation of airway management during rhinoplasty will improve functional outcomes.

LEVEL OF EVIDENCE V

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 .

Natural History of the Standardized Cosmesis and Health Nasal Outcomes Survey After Rhinoplasty

OBJECTIVES/HYPOTHESIS

To explore the natural history of nasal obstruction and cosmesis following rhinoplasty by utilizing the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).

STUDY DESIGN

Retrospective chart study.

METHODS

This study was carried out at a tertiary referral center, preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE), SCHNOS-Obstruction (SCHNOS-O), and SCHNOS-Cosmesis (SCHNOS-C) scores in patients who underwent rhinoplasty for functional, cosmetic, or both reasons from June 2017 to May 2019 were reviewed and analyzed. Postoperative intervals were defined as <2 months, 2 to 5 months, 5 to 8 months, 8 to 12 months, and >12 months.

RESULTS

A total of 302 patients (67% women), with a mean age (standard deviation [SD]) of 35 (13) years, who underwent rhinoplasty for functional (90, 30%), cosmetic (124, 41%), and combined functional and cosmetic (88, 29%) reasons, met inclusion criteria. The mean follow-up period (SD, range) was 5 months (4.2 months, 13 days-1.8 years). Compared to the preoperative mean NOSE score, SCHNOS- O, and SCHNOS-C scores, postoperative mean scores for the functional and combined subgroup were significantly lower (P < .05) across all five postoperative intervals. In the cosmetic subgroup, postoperative mean SCHNOS-C scores were significantly lower (P < .05) across all postoperative intervals compared to the mean preoperative scores.

CONCLUSIONS

The natural history of the SCHNOS-O and SCHNOS-C score in patients who underwent rhinoplasty demonstrates 1) after functional rhinoplasty, an improvement in nasal breathing symptoms is attained as early as <2 months postoperatively; and 2) after cosmetic rhinoplasty, an improvement in nasal cosmesis is seen as early as <2 months postoperatively. These improvements in nasal breathing and cosmesis are sustained through a follow-up interval >12 months.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E116-E123, 2021.

Impact of Dorsal Preservation Rhinoplasty Versus Dorsal Hump Resection on the Internal Nasal Valve: a Quantitative Radiological Study

BACKGROUND

This study evaluates the impact of different hump takedown techniques, namely the conventional hump resection with midvault reconstruction, the push-down (PD) and the let-down (LD) procedures, on the INV dimensions.

METHODS

In this cadaveric study, six heads were divided randomly into either the conventional hump resection technique (Group A; n = 6 sides) or DPR techniques (n = 6 sides). This latter group was subdivided such that initially a PD procedure was performed (Group B; n = 6 sides), followed by a LD procedure on the same heads (Group C; n = 6 sides). A validated radiological method was used to measure the INV angle and cross-sectional area (CSA) in a modified coronal plane both pre- and post-procedurally.

RESULTS

Group A did not show significant reduction in the INV angle nor in CSA (p = 0.068 and p = 0.156, respectively). In the push-down group (B), we observed a mean change of 2.05° in the angles and 0.3 cm² in the CSA (p = 0.0163 and p < 0.001, respectively). The LD group (C) did not show significant reduction in the INV angle nor in CSA (p = 0.437 and p = 0.331, respectively).

CONCLUSION

Neither the conventional hump resection nor the LD DPR technique reduced the INV dimensions. However, the PD preservation technique significantly reduced the INV dimensions.

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.