Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches

Internal Nasal Valve Collapse Treatment by Endonasal Hyaluronic Acid Injection

OBJECTIVE

Internal nasal valve collapse (IVC) is a common functional complication of rhinoplasty and injecting hyaluronic acid is one of the treatment options available, but its effectiveness has never been evaluated. The objective of this study was to assess the evolution of IVC after injection of hyaluronic acid using objective and subjective measures of nasal obstruction.

STUDY DESIGN

A prospective interventional study was conducted.

METHODS

Adult patients consulting for nasal obstruction after (septo)rhinoplasty and diagnosed with IVC were included. Patients underwent 4-phase rhinomanometry, completed nasal obstruction symptoms evaluation (NOSE) and visual analog scale (VAS) questionnaires and received hyaluronic acid injections. Measurements were repeated immediately, one month and one year later. The primary outcome measure was the proportion of patients below the rhinomanometric diagnostic threshold for IVC at one month.

RESULTS

Among the 22 patients included, 20 (91%) had rhinomanometry measurements below the diagnostic threshold for IVC one month after injection. It decreased to 53% (8/15 patients) at one year post injection. The mean NOSE score decreased from 74.5 (± 18.0) before injection to 35.2 (± 23.3) after injection (p < 0.0001). The mean VAS score decreased from 7.0 (± 1.4) before injection to 3.4 (± 1.9) after injection (p < 0.0001). In these patients with post-(septo)rhinoplasty IVC, hyaluronic acid injection into the internal nasal valve substantially improved subjective and objective measures of nasal obstruction.

CONCLUSION

These results suggest hyaluronic acid injection (performed as described) is an effective treatment for IVC and is an excellent alternative to surgical treatment.

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 https://www.springer.com/00266 .

Limited Incision Rhinoplasty: An Approach for All Primary and Revision Cases

INTRODUCTION

Rhinoplasty was one of the most frequently performed aesthetic surgeries in the USA in 2022. Traditionally, the open approach has been preferred by the majority of surgeons often due to familiarity and ease of visualization. However, patient interest in closed and preservation rhinoplasty is driving a resurgence in the popularity of endonasal techniques. We present a series of 100 consecutive endonasal primary and revision rhinoplasty cases using bilateral isolated modified rim incisions.

METHODS

One-hundred consecutive patients underwent closed rhinoplasty via isolated modified rim incisions at a single-surgeon private practice. The senior author performs 100% endonasal rhinoplasty. A retrospective chart review was performed from 06/25/20 to 09/21/22. Information on demographics, complications, and need for revision was collected.

RESULTS

Eighty-four patients underwent primary rhinoplasty, 11 underwent secondary rhinoplasty, 4 underwent tertiary rhinoplasty, and 1 underwent quaternary rhinoplasty. Isolated modified rim incisions were used in all cases except in cases of septoplasty when a unilateral Killian incision was added, or in cases of lateral osteotomy when vestibular stab incisions were added. Post-operatively, six (6.0%) patients required revision, all of which were performed under local anesthesia.

CONCLUSION

Limited incision rhinoplasty is a reliable surgical approach that produces predictable results with a low revision rate. This technique is highly effective in minimizing soft tissue disruption to ensure safe, reliable, and effective outcomes in primary and revision rhinoplasty. It is an easier technique to learn compared to traditional endonasal and even arguably open rhinoplasty, thus lending itself to widespread adoption especially among novice rhinoplasty surgeons. 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 .

Surgical treatment of dynamic nasal collapse

Nasal obstruction is a prevalent issue that significantly impacts patient quality of life and contributes to a large-scale financial burden. Internal or external nasal valve collapse may play a role in nasal obstruction, with varying etiologies. Surgical correction of nasal valve collapse is indicated when septal and/or turbinate surgery alone are not sufficient in correcting the nasal obstruction. The choice of how to address nasal valve repair depends on presenting findings, associated aesthetic concerns, particularly of the nasal tip, patient anatomy, and surgeon preference. This article provides a methodical approach to the diagnosis of nasal valve collapse, indications for repair, and provides detailed explanation of the operative techniques used to address nasal valve collapse, while also discussing the advantages and disadvantages of each approach.

Composite Tissue Columella Wedge Excision for Nasal Tip Overprojection

BACKGROUND

The overprojected nasal tip is a challenge in facial surgery. Although several techniques are available, none has been proven to be superior. The aim of this study was to introduce a novel approach to overcome nasal tip overprojection and to evaluate its safety and efficacy.

METHODS

All patients with protruding nasal tip who underwent correction by means of a novel columella wedge technique were included in this study. In addition to detailed description of the novel surgical approach, its efficacy was analyzed by comparison of preoperative and postoperative nose dimensions. In addition, patients were examined during follow-up, and complication and revision rates were determined.

RESULTS

Forty-two patients were included in this study. Columella wedge technique involved resection of a 2- to 5-mm section of the middle part of the columella. Postoperatively, nose projection and length decreased by 9 and 12 percent, respectively. The relation between projection and length of the nose changed from 0.68 preoperatively to 0.61 postoperatively. This difference was statistically significant (p = 0.002). After a mean follow-up of 28 months (range, 6 to 144 months), revision operations were necessary in seven patients (16.6 percent). No instabilities, impairment of breathing, or other complications occurred.

CONCLUSION

The introduced columella wedge technique is efficient and safe for correction of the overprojected nasal tip.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Principles and Practice of Endonasal Rhinoplasty: Special Topics for Clinics in Plastic Surgery Journal

Endonasal rhinoplasty is a minimally invasive approach in which esthetic and functional improvements are made solely through intranasal, without transcolumellar, incisions and with limited soft tissue and skeletal disruption. In addition to intentionally limiting surgical dissection, the rhinoplasty surgeon must preoperatively recognize and surgically correct 4 common anatomic variants which predictably create all 3 patterns of secondary deformity. In combination, respecting these principles gives the surgeon greater predictability in achieving esthetic and functional improvements, and the ability to limit the adverse effects of skin contractility and postoperative scar contracture, thus reducing the risk of secondary deformity, patient dissatisfaction, and reoperation.

In-office Endonasal Minor Revision Rhinoplasty

The revision rhinoplasty presents many unique challenges to the facial plastic surgeon. While many cases will require a full revision in the operating room, there are several isolated deformities which may be repaired in the office via an endonasal approach. This provides many benefits to the patient and surgeon including decreased cost, shorter recovery time, avoidance of general anesthesia, and less discomfort. It is critical to identify defects appropriate for endonasal repair, establish clear expectations with the patient, and work within one's skill set and level of experience. The surgeon who can comfortably navigate both open and endonasal techniques can offer their patients a comprehensive set of solutions for revision rhinoplasty. In this article we outline the defects amenable to this type of repair as well as technical considerations for each defect addressed. We hope it serves as a useful framework for the range of deformities the rhinoplasty surgeon may take on for in-office repair.

Mastery of Basic Rhinology: An Important Tool for the Modern Rhinoplasty Specialist

Rhinology is the branch of medicine that deals with nasal function as part of the respiratory apparatus. It is a fundamental component of otolaryngology curricula and thus generously found in that specialty's literature. Ear, nose, and throat specialists who have made aesthetic rhinoplasty a cornerstone of their practice have understood the importance of rhinology for years. We propose that deeper knowledge and understanding of rhinology would be incredibly useful for the cosmetic rhinoplasty surgeon, especially the one who has no formal training in otolaryngology. This is of critical importance because sometimes, cosmetic rhinoplasties may have negative repercussions on nasal function, a problem that must be dealt with either preemptively at the time of surgery or at a revision procedure. Moreover, many of today's rhinoplasty patients are seeking comprehensive surgical care by a specialist who can manage both aesthetic and functional concerns in a single operation.

Grafts in Endonasal Rhinoplasty

Rhinoplasty is arguably one of the most challenging but rewarding procedures for the facial plastic surgeon. To adequately improve facial aesthetic parameters and preserve nasal function, the appropriate utilization of grafts is of utmost importance. While there is no best method, I found that in my hands, the endonasal approach allowed me to achieve greater control over my results by limiting dissection, utilizing less cartilage, and minimizing variables. In this manuscript, I outline the surgical pearls I have developed throughout my career that have helped me execute these grafts efficiently and effectively.

A Modified Closed-Open Approach as Part of a Graduated and Integrative Approach to Rhinoplasty

Introduction Open versus closed approach in rhinoplasty is a frequently debated topic in aesthetic plastic surgery. Although good results can often be achieved with either technique, both have unique advantages and disadvantages. In this investigation, we present our experiences of a modified closed-open approach that has been applied on 482 complex primary and secondary rhinoplasties. Three representative cases are described in more detail.

Materials and Methods The procedure begins as a closed approach through an intracartilaginous incision allowing cephalic trimming of the lateral crura, dorsal rasping, and/or excision. Patients requiring extensive nasal tip maneuvers are subjected to exposure of the alar cartilage framework through a transcolumellar/limited marginal incision. This provides not only adequate exposure of the alar cartilages but also easy access to the septum.

Conclusion In our hands, this approach is easy and expeditious. It requires less tip dissection, and therefore may avoid the prolonged postoperative edema that is often a consequence of open or extended closed tip delivery approaches.

Prevalence of considering revision rhinoplasty in Saudi patients and its associated factors

Background

Primary rhinoplasty outcomes may not meet individual expectations. Consequently, reoperation may be advocated to improve results. This study examines the prevalence of individuals considering revision rhinoplasty, while identifying the main cosmetic and functional complaints and factors associated.

Methodology

This is a cross-sectional study conducted in Saudi Arabia using a self-reported online questionnaire distributed through social media channels. The sample included 1370 participants who were all Saudi nationals over the age of 16 who had undergone primary rhinoplasty at least 1 year prior.

Results

The prevalence of individuals considering revision rhinoplasty was 44.7%. The primary reason for considering it was the desire for further esthetic improvement in an already acceptable result (50.16%). The most common cosmetic complaints subjectively reported were poorly defined nasal tip (32.35%). The most prevalent nasal function symptom was nasal obstruction (56.9%). Significant factors associated with considering revision rhinoplasty included the physician not understanding the patient’s complaints, short consultation time, low monthly income, inadequate information about the expected results, not using computer imaging to predict outcomes, lack of rapport with the surgeon, and inadequate information about the risks and complications.

Conclusions

A thorough understanding of patient concerns and expectations, as well as thoughtful consideration of risk factors, may help surgeons achieve more successful outcomes and potentially reduce the incidence of revision rhinoplasties.

Level of evidence

III

The Use of Expanded Polytetrafluoroethylene in Short Nose Elongation: Fourteen Years of Clinical Experience

BACKGROUND

Short nose elongation is a relatively common rhinoplasty procedure, especially in Asia. The selection of the adequate graft material is challenging. Previous reports have described the application of expanded polytetrafluoroethylene (ePTFE) for dorsal augmentation rhinoplasty, but studies using ePTFE for nose elongation are lacking. We propose ePTFE as an alternative treatment for short noses, describe the technique, and discuss outcomes, patient selection, and complications based on our 14-year experience.

METHODS

From February 2003 to December 2016, 206 patients with varying degrees of short noses were included in this retrospective study. All patients underwent nose elongation surgery using an ePTFE implant. Nasal lengths before and after surgery were measured using a 3-dimensional simulation technology. Outcomes and complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey.

RESULTS

Nasal elongation was successfully achieved using ePTFE. Mean increase in nasal length was 4.36 ± 0.85 mm. The mean follow-up period was 13.3 months, ranging from 6 months to 8 years. Follow-up examinations demonstrated stable results. The overall complication rate was 6.8%. Complications included infection, implant extrusion, migration, deviation, visibility, and/or prominence, tissue reaction, and reddening of the nasal skin. Most patients (93.6%) rated their outcome as improved and much improved.

CONCLUSIONS

Nasal elongation using ePTFE implantation is a feasible therapeutic approach for patients with short noses. Reliable outcomes and the absence of donor site morbidity contribute to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

Simultaneous Rhinoseptoplasty and Orthognathic Surgery: Outcome Analysis of 250 Consecutive Patients Using a Modified Le Fort I Osteotomy

BACKGROUND

The purpose of the present study was to assess the safety and efficacy of both functional intranasal procedures and cosmetic rhinoplasty combined with bimaxillary surgery.

METHODS

The author executed a retrospective cohort study derived from patients who underwent combined rhinoseptoplasty and bimaxillary surgery at a private practice setting (Face Surgery Center, Parma, Italy) between April 2006 and 2015 by a single surgeon. The minimum follow-up was 12 months. Patients underwent bimaxillary orthognathic surgery, functional nasal surgery and cosmetic rhinoplasty.

RESULTS

Two-hundred and fifty (250) consecutive, non-randomized patients met the inclusion criteria to enter the study. The overall complication rate was 5%, whereas the revision rate was 9%, showing an overall low rate, comparable to that of primary rhinoplasty (control group). About 94% of the patients polled after this procedure asserted they definitely accepted to have rhinoplasty only because it was included in one single surgical act together with orthognathic surgery.

CONCLUSION

Cosmetic rhinoplasty shows great potentials to change our patients' appearance, whereas orthognathic surgery corrects jaw skeletal deformities and builds the right foundation for facial harmony. The combination of both procedures magnifies the single results reciprocally and significantly enhances the final outcomes. The quality of the overall aesthetic results, the scarcity of complications and the low percentage of defects that require revisions lead to the conclusion that when alterations to both the jaws and the nose are detected, a single intervention can grant great benefit to the patients in terms of morbidity and costs.

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 .

Surgical Management of Nasal Valve Collapse

Nasal valve collapse has multiple causes, including congenital, traumatic, and, unfortunately, iatrogenic. Recognition of the causes of nasal valve collapse and the methodology for treatment is paramount not only for the otolaryngologist but also for any physician managing the nasal airway. This article focuses on the cause and surgical management of internal and external nasal valve collapse.

Assessment of Functional Rhinoplasty with Spreader Grafting Using Acoustic Rhinomanometry and Validated Outcome Measurements

BACKGROUND

Rhinoplasty is 1 of the most common aesthetic and reconstructive plastic surgical procedures performed within the United States. Yet, data on functional reconstructive open and closed rhinoplasty procedures with or without spreader graft placement are not definitive as only a few studies have examined both validated measurable objective and subjective outcomes of spreader grafting during rhinoplasty. The aim of this study was to utilize previously validated measures to assess objective, functional outcomes in patients who underwent open and closed rhinoplasty with spreader grafting.

METHODS

We performed a retrospective review of consecutive rhinoplasty patients. Patients with internal nasal valve insufficiency who underwent an open and closed approach rhinoplasty between 2007 and 2016 were studied. The Cottle test and Nasal Obstruction Symptom Evaluation survey was used to assess nasal obstruction. Patient-reported symptoms were recorded. Acoustic rhinometry was performed pre- and postoperatively. Average minimal cross-sectional area of the nose was measured.

RESULTS

One hundred seventy-eight patients were reviewed over a period of 8 years. Thirty-eight patients were included in this study. Of those, 30 patients underwent closed rhinoplasty and 8 open rhinoplasty. Mean age was 36.9 ± 18.4 years. The average cross-sectional area in closed and open rhinoplasty patients increased significantly (P = 0.019). There was a functional improvement in all presented cases using the Nasal Obstruction Symptom Evaluation scale evaluation.

CONCLUSIONS

Closed rhinoplasty with spreader grafting may play a significant role in the treatment of nasal valve collapse. A closed approach rhinoplasty including spreader grafting is a viable option in select cases with objective and validated functional improvement.

Does videoendoscopy provide three-dimensional vision in closed rhinoplasty?

Rhinoplasty is a common procedure in cosmetic surgery all over the world. Patients desire enhancement of their facial beauty by the correction of preexisting nasal deformities. Precisely performed operations lead to better results, and enhancing technical accuracy accordingly results in more successful outcomes. Endoscopy helps us visualize the closed parts of the body with the aid of an illuminated optical device. The objective behind the present case series was to bring the advantages of open and closed rhinoplasty together by using endoscopic vision systems. A total of 312 patients with unoperated nasal deformities from private practice were operated, and videoendoscopic closed rhinoplasty was performed on each patient. Postoperative patient satisfaction was assessed using the Rhinoplasty Outcome Score; the level of satisfaction was found to be excellent. In the present case series, it was hypothesized that trocar mobility under the skin flap allows virtual binocular vision that eventually leads to stereoptic depth perception. This allows virtual three-dimensional (3D) vision on the screen of the endoscope with a regular trocar. The mobility of the tip in the transverse axis created a virtual 3D appearance. Our experiences with videoendoscopic closed rhinoplasty are shared in this report.

Septorhinoplasty: Our Experience

Rhinoplasty is one of the oldest known surgeries to the human kind. However, being a cosmetic of surgery of utmost importance, it has been an attractive and fascinating surgery for the otolaryngologists and plastic surgeons. Along with the evolution of improved techniques and better surgical modalities, this surgery has been growing in panorama including its indications, needs and techniques. We present our experience with rhinoplasty in a tertiary care center of north India. We have included all cases operated with septorhinoplasty from 2001 to 2014 by the senior author in the manuscript. We reviewed their presentations, investigations, preoperative counselling records, operative details and post-operative clinical records to audit our results and hence to document our experiences in septorhinoplasties. A total of 53 cases including 37 males and 16 females had undergone rhinoplasty surgeries. The most common reason of disfigurement was road traffic accident (58.5%). All these patients included different deformities and required varied corrections. There were no major post-operative complications except persistent edema with longest lasting for 23 weeks. Thermal splints gave a better patient satisfaction in post-op compared to POP splints. Results were completely and partially satisfying for 50 patients and not satisfying for three. Unrealistic expectations from the procedure might be the reason for non-satisfactory results in rhinoplasty. Rhinoplasty is a delicate procedure and has greater aesthetic implications in planning surgical techniques and approaches. For better satisfaction of patients, adequate preoperative counseling and realistic expectations are warranted. Skillful surgical techniques null chances of complications.

Primary Open Rhinoplasty

Rhinoplasty is perhaps the most complex cosmetic surgery procedure performed today. It is characterized by an intricate interplay between form and function, with patient satisfaction being dependent not only on improvement of nasal appearance but also resolution of preexisting airway symptoms. The prerequisite for successful execution of this challenging procedure is a thorough understanding of nasal anatomy and physiology. Hence, a thorough preoperative evaluation is at least as important and the surgical skill in performing the operation. Establishing an accurate diagnosis through a comprehensive nasal analysis is obligatory. As to the surgical approach, much has been written about the advantages and disadvantages of closed vs open rhinoplasty. The more commonly chosen open approach has numerous advantages, including improved visualization without distortion, thus, enabling precise diagnosis and correction of deformities. While the surgical treatment of existing nasal deformities is tailored to the needs of the individual patient, the authors have noted a total of 10 essential components to form the foundation for successful technical execution of rhinoplasty. These include: (1) septoturbinotomy; (2) opening the nose; (3) humpectomy/spreader flaps; (4) tip-plasty; (5) supratip-plasty; (6) columellar strut; (7) dorsal augmentation; (8) nasal base reduction; (9) osteotomies; and (10) rim grafts. Postoperative, a variety of problems, such as edema, may be successfully addressed without surgical intervention. Diligent postoperative management is critical in ensuring a positive patient experience. Finally, a comprehensive understanding of possible postoperative complications, such as bleeding, ecchymosis, edema, and persistent or new iatrogenic deformity is mandatory prior to offering rhinoplasty to patients.

Rhinoplasty Complications and Reoperations: Systematic Review

Introduction This article is related to complications of rhinoplasty and its main causes of reoperations.

Objectives The objective of this study is to perform a systematic review of literature on complications in rhinoplasty.

Data Synthesis The authors conducted a survey of articles related to key terms in the literature by using three important databases within 11 years, between January 2002 and January 2013. We found 1,271 abstracts and selected 49 articles to this review.

Conclusion The main results showed that the number of primary open rhinoplasty was 7902 (89%) and 765 closed (11%) and the percentage of reoperations in primary open complete rhinoplasties was 2.73% and closed complete was 1.56%. The statistical analysis revealed a value of p = 0.071. The standardization of terms can improve the quality of scientific publications about rhinoplasty. There is no difference between primary open or closed rhinoplasty techniques in relation to reoperations.

Surgical Treatment of the Middle Nasal Vault

The middle nasal vault is a sensitive region of the nose from both an esthetic and a functional perspective. It is critical for the rhinoplasty surgeon to properly evaluate and identify abnormalities of the middle vault when considering patients for primary or secondary surgery. This article addresses the surgical management of the cosmetic deformities and functional deficits of the middle vault and provides guidance for avoiding complications in this structurally critical region of the nose.

Comparison of Various Rhinoplasty Techniques and Long-Term Results

BACKGROUND

Various techniques are used in rhinoplasty. These techniques can be classified under transcolumellar approaches and endonasal procedures. Open rhinoplasty without transcolumellar incision (ORWTI) procedure can be described as a combination of these two techniques.

METHODS

In this study, we present patients who underwent nasal surgery utilizing one of these three techniques between 1999 and 2013 and discuss some modifications to the techniques.

RESULTS

Of a total of 1526 patients, 1131 were operated on with open rhinoplasty with transcolumellar incision, 219 were operated on with ORWTI, and 176 were operated on using the endonasal approach. With an average follow-up period of approximately 4 years, 4 % of the patients required revision. The patient satisfaction rate was more than 90 % for all of these techniques.

CONCLUSIONS

The endonasal approach is an appropriate choice for select patients due to the lower chance of complications and a shorter procedure time. With open rhinoplasty with the transcolumellar incision technique, the type of surgery can be more easily controlled, however, extended nasal tip edema and columellar scar are some of the disadvantages of this method. ORWTI allows a patient to avoid these disadvantages and provides a more controlled procedure, similar to the open method.

Treatment of gummy smile: Nasal septum dysplasia as etiologic factor and therapeutic target

Various techniques to improve gummy smile exist. Depending on the individual etiology, previous approaches have focused on osseous, dental, and soft-tissue aspects. On the basis of the identification of nasal septum dysplasia as etiologic factor of gummy smile, we propose a novel strategy for the improvement in the treatment of excessive gingival exposure. In this prospective controlled study, 121 Asian patients with gummy smile and 150 volunteers were examined and compared with regard to the developmental status of the nasal septal cartilage reflected by the columella upward maximum movability (CUMM) as objective measurement parameter. A total of 46 patients with significantly increased CUMM underwent surgical treatment for excessive gingival exposure by septum cartilage reinforcement and, where required, additional extension using an autologous cartilage graft or an expanded polytetrafluoroethylene (ePTFE) implant. Gingival exposure at the fullest smile was photographed, measured, and analyzed before and 1, 3, and 6 months after surgery, and all possible complications were recorded. The results were evaluated in a patient satisfaction survey. CUMM showed a significant statistical difference between the patients desiring treatment for gummy smile (5.6 ± 0.92 mm) and volunteers (3.1 ± 0.76 mm), (p < 0.05). In the 46 patients who underwent surgical correction of gummy smile, the measured maximum gingival exposure at the fullest smile was 4.52 ± 1.7 mm preoperatively and significantly decreased to 1.79 ± 0.26 mm at 6 months postoperatively (p < 0.05). The overall complication rate was low, including transient stiffness of smile, implant deformation, and acute infection. The postoperative results were highly satisfactory in terms of aesthetic smile. This study proposes a novel strategy of reinforcement and extension of the nasal septum cartilage for the improvement of gummy smile confirming septal cartilage dysplasia as the etiologic factor.

Evaluating current functional airway surgery during rhinoplasty: a survey of the American Society of Plastic Surgeons

BACKGROUND

Despite numerous reports outlining technical modifications in rhinoplasty, few publications discuss the importance of the perioperative assessment and surgical management of the nasal airway. This study's objective is to increase awareness regarding the functional aspects of rhinoplasty surgery and to encourage surgeons to incorporate functional airway management into their rhinoplasty practice.

METHODS

A web-based survey was given to all members of the American Society of Plastic Surgeons (ASPS). Survey results were analysed to determine if surgeons' experience, annual rhinoplasty volume, or postgraduate training affected their results. The relationship between surgeon satisfaction with the outcome of the airway management and the frequency of performing an inferior turbinate reduction was investigated.

RESULTS

Of the 4,383 listed ASPS members, 671 (21%) completed the web-based survey. Surgeons who performed a preoperative internal nasal exam were more satisfied with their results (p = 0.016) and report lower rates of postoperative nasal airway obstruction (p = 0.054). Inferior turbinate reduction did correlate to postoperative satisfaction with the nasal airway (p < 0.001). Overall, 85% of respondents were satisfied with their management of the nasal airway and 87% of respondents agreed that there is a need for more instructional courses on this topic.

CONCLUSION

There is considerable variation in the results and techniques of assessment and treatment of the nasal airway. Rhinoplasty volume and inferior turbinate reduction are associated with surgeon satisfaction of management of the nasal airway. Functional airway considerations should be incorporated into routine rhinoplasty training, assessment, and treatment.

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.

Presenting concerns and surgical management of secondary rhinoplasty

BACKGROUND

Secondary rhinoplasty is a challenging surgical procedure, and patients seeking this procedure tend to be difficult to please. However, psychological and functional improvements in patients and high satisfaction rates are achievable with secondary rhinoplasty.

OBJECTIVES

The authors reviewed a series of secondary rhinoplasties and tabulated patient concerns, underlying deformities, and corrective surgical procedures.

METHODS

The authors conducted a retrospective review of 109 patients for whom the senior author (B.M.) performed secondary rhinoplasty from 2009 to 2012. Concerns causing the patients to seek surgery and management of the secondary procedures were described.

RESULTS

The mean patient age at time of surgery was 33.2 years (range, 18-61 years), and most patients (71.6%) were women. The mean number of previous procedures was 1.6 (range, 1-8). Chief presenting concerns were asymmetry (36.7%), large tip (24.8%), and breathing difficulties (22.0%). The most common clinical findings were nostril asymmetry (33.9%), septal deviation (32.1%), overresection (26.6%), and tip asymmetry (26.6%).

CONCLUSIONS

Patients seeking secondary rhinoplasty present with various concerns. Preoperative identification of the underlying problems and determination of the techniques required to correct them are important to successful secondary procedures. LEVEL OF EVIDENCE 4: Therapeutic.

Improved access in endonasal rhinoplasty: the cross cartilaginous approach

BACKGROUND

The popularity of open rhinoplasty has increased such that it is the first choice of approach for many surgeons undertaking primary rhinoplasty. Despite the benefits of this approach, the drawbacks are often not emphasized. We present a review, with quantitative assessment of 24 rhinoplasty patients using the cross-cartilaginous incision. This new approach optimizes access without an external scar and ligament disruption that ensues after the open approach.

METHODS

24 consecutive patients underwent primary rhinoplasty from March 2009 to April 2011 using the cross-cartilaginous approach. Preoperative measurements of defined anatomical sites of the nose were taken. Independent assessments of the postoperative results were undertaken by a surgical resident and a senior nurse using preoperative and postoperative photographs using the new Independent Rhinoplasty Outcome Score (IROS). Evaluation of patient satisfaction and postoperative patient concerns were carried out.

RESULTS

The range of preoperative measurements (average) were: radix 12-19 mm (15.0), keystone 20-34 mm (24.5), alar base 14-20 mm (17.0), nose length 48-58 mm (50.2), tip width 11-25 mm (15.9), and tip projection 21-37 mm (29.6). Three months after the operation, the patient satisfaction scores were rated 67% good to excellent, 25% were acceptable, and 8% were dissatisfied. After 3 months, 17% of patients reported swelling, 0% bruising, 8% irregularities, 8% asymmetry, and 4% airway issues. Independent assessment of the photographs showed that overall result was: 31% good, 56% average, and 13% had no improvement.

CONCLUSION

Preoperative anatomical measurement allows reliable assessment of nasal characteristics and comparison with postoperative outcomes. Our simple grading system for outcome assessment in rhinoplasty allows the assessment to be reliable and reproducible (IROS). The cross-cartilaginous approach is suitable for a majority of primary rhinoplasty patients, providing good access and visibility, although, open rhinoplasty is required for selected complex revision cases.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Incidence and risk factors of functional upper airway complications of primary esthetic closed rhinoplasty in two residency programs: A 6-month preliminary prospective cohort study

BACKGROUND

Although esthetic rhinoplasty has many advantages, it might lead to some complications as well. The literature includes scarce and severely controversial studies on these issues, and there is no research on complications of cosmetic closed rhinoplasty. In addition, some complications are not assessed after any rhinoplasty types. Besides, there is no investigation on the outcome of rhinoplasty carried out by graduate students. The purpose of this study was to determine these.

MATERIALS AND METHODS

In this preliminary prospective cohort study, 96 healthy patients underwent closed esthetic rhinoplasty by senior residents of otolaryngology and maxillofacial surgery at Taleghani Hospital (Tehran, 2004-2006). Afterward, at 11 follow-up sessions (the 1(st), 2(nd), 3(rd), 4(th), 6(th), 8(th), 10(th), 12(th), 16(th), 20(th), and 24(th) postoperative weeks), five functional complications (hyposmia/anosmia, nasal obstruction, unpleasant voice changes, recurrent colds, and synechiae) were questioned/examined. The presence of a symptom during at least four subsequent sessions (without elimination until the sixth postoperative month) and the appearance of synechiae in any session were regarded as positive. The data were assessed using Spearman's correlation coefficient (α = 0.05).

RESULTS

The incidence rates of synechiae, nasal obstruction, unpleasant voice changes, hyposmia/anosmia, and recurrent colds were 56.25%, 37.5%, 0%, 1.04%, and 29.17%, respectively. No statistically significant relationship was found between the complications with age, gender, or the surgeon's specialty (P > 0.05), but the correlation with home care compliance was significant (ρ = -0.29, P = 0.01).

CONCLUSIONS

High complication rates were observed in both residency programs. Failure to follow home care instructions might prevent/delay recovery. Further in-depth studies are needed to assess this.

Rhinoplasty

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty.

SUMMARY

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.

Patient complaints with primary versus revision rhinoplasty: analysis and practice implications

BACKGROUND

Rhinoplasty patients often present with specific concerns and are frequently exacting in their demands and expectations of the surgical experience.

OBJECTIVES

The authors assess the presenting complaints expressed during the rhinoplasty consultation process and compare the presentations of primary versus revision rhinoplasty patients.

METHODS

A retrospective review of 400 consecutive rhinoplasty patients was performed. Demographic information and patient concerns regarding nasal appearance and function were recorded. Complaint frequencies (as well as rank order) were compared between primary and revision patients. Statistically significant associations were compared in more detail through logistic regression models.

RESULTS

Primary rhinoplasty patients were significantly more likely to cite "too large" and "dorsal hump" as motivating concerns. Conversely, revision rhinoplasty patients were far more likely to cite concern regarding a "crooked nose," "tip asymmetry," "wide or large nostrils," "dorsal sloop," and "columellar show." Revision rhinoplasty patients also complained of issues such as "alar retraction," "pointy tip," and "nasal scarring," which were almost negligible in frequency in the primary rhinoplasty group.

CONCLUSIONS

Patients presenting for primary rhinoplasty commonly seek a smaller, more refined nasal appearance. Patients with prior rhinoplasty operations are far more likely to raise concern regarding crookedness or asymmetries. By comparing the presentations of primary and revision rhinoplasty patients-and delineating the common indications for revision operations-novice rhinoplasty surgeons may be able to avoid certain pitfalls at the outset, thereby reducing their revision rates. The data may also assist surgeons in developing a more targeted approach to the consultation process in the revision setting.

[Suture tip plasty using an endonasal approach]

BACKGROUND

Over the last two decades, the use of the external approach for primary and secondary rhinoplasties has become increasingly popular. This article illustrates the versatility of endonasal techniques for the correction of nasal tip deformities on the basis of four cases.

PATIENTS AND METHODS

The approach to the nasal tip and the chosen technique as used in 100 consecutive rhinoplasties were reviewed.

RESULTS

For primary and revision tip plasty, endonasal approaches were used in 81% of cases. Preferred incisions were the infracartilaginous approach and the transfixion incision. Using these approaches, correction of the tip was achieved by using sutures to reposition and reshape the alar cartilages and the columella without grafts to the nasal tip in most cases.

CONCLUSION

Nasal tip plasty via endonasal approaches using sutures is technically more challenging compared to the external approach with its superior exposure. This drawback is outweighed by less operating time and faster patient recovery. Contrary to the general trend, the authors believe that endonasal tip plasty techniques using sutures can obviate the external approach and grafts in many cases and should form an integral part of the rhino-surgeon's repertoire.

The endonasal lateral crural underlay and sandwich grafts

BACKGROUND

Previously, the problem created by overly convex, wide, and robust lower lateral cartilages (LLC) required an external or endonasal approach with delivery. Although this method has proven invaluable, it may not be indicated in all patients with large tips, specifically those with overly convex LLC or with thin skin and robust LLC.

OBJECTIVE

The authors present the results of their straightforward technique for narrowing the bulbous tip through an endonasal nondelivery approach that reinforces the nasal airway while at the same time preventing alar notching, lateral crus recurvature, and bossa formation.

METHODS

From August 2008 to February 2010, 29 patients underwent endonasal lateral crural underlay and sandwich graft with the authors' technique. All patients had medium to thin skin and prominent, bulbous, symmetric LLC. Three of the patients presented for secondary rhinoplasty. The authors identified no specific contraindications for this procedure. All patients who remained for follow-up were given a questionnaire that analyzed their nasal tip satisfaction on a five-point categorical scale at seven separate points of follow-up.

RESULTS

Among the 27 patients who remained for follow-up, the results were highly satisfactory, mostly satisfactory, or satisfactory in 25 of the 27 cases (as indicated by patient survey). The two remaining patients requested a thinner nasal tip. No significant complications were noted.

CONCLUSIONS

The lateral lower crural underlay sandwich graft is an adjunct to the traditional endonasal approach, further enhancing and expanding the possible outcomes. It appears to equal the predictability and stability identified with traditional tip-narrowing techniques in the external approach but with less operative time, less surgical dissection, and presumably less edema, thereby allowing us to better meet our patients' demands.

Closed rhinoplasty approach for excision of nasal dermoids

OBJECTIVE

To assess the efficacy of excision of nasal dermoids through a closed rhinoplasty incision. This is the first description of the use of this approach for excision of superficial nasal dermoids.

METHODS

Three boys aged five, nine and 12 years presented with midline nasal dermoids with minimal cutaneous involvement. Magnetic resonance imaging demonstrated distinct, cystic, superficial nasal masses. The cysts were excised through a closed rhinoplasty approach. In each case, completeness of extirpation was judged by histopathological examination of the excised specimen. Aesthetic outcome was recorded photographically.

RESULTS

All three patients' cysts were completely excised, with excellent cosmetic results.

CONCLUSIONS

The closed rhinoplasty incision is another approach in the surgeon's armamentarium for excision of small, superficial nasal dermoid cysts. In well selected cases, this approach gives optimal cosmetic results, provides adequate exposure with minimal dissection, and allows total extirpation.

The infracartilaginous approach revisited

The last decade has seen a marked increase in the use of the external approach for primary and secondary rhinoplasties. As a consequence, endonasal techniques are taught less and the external approach is increasingly being used for minor corrections. We review the infracartilaginous approach as an elegant variant of the endonasal approach and, for many procedures, a suitable alternative to the external approach and describe the technique of the infracartilaginous approach and illustrate its options with cases that, for the majority of rhinoplasty surgeons, would call for an external approach. We adopted the infracartilaginous approach as the preferred technique for most tip sculpting and repositioning procedures. The infracartilaginous approach is technically more challenging compared with the open approach in teaching situations. This, however, does not imply that the technique should therefore be abandoned. On the contrary, we are convinced that the technique can and should be taught and learned.

Open Rhinoplasty Without Transcolumellar Incision

Traditional open rhinoplasty leaves a scar on the columella. No one can say that this scar is invisible. It is less noticeable in Caucasian patients but it is a problem in non-Caucasian patients like in our country. To avoid such a scar and still obtain a wide exposure of the nasal framework, the bilateral paramarginal incisions close to the columella were extended down to the nasal floors. The lower lateral cartilages forming the nasal tip could then be delivered out through one of the nostrils. An exposure similar to the traditional open rhinoplasty was then achieved. The technique has been used in 23 patients with satisfactory results. In conclusion, the open rhinoplasty without transcolumellar incision can replace the traditional transcolumellar open rhinoplasty technique in selected patients.

Prevention of Hanging Columella in Open Rhinoplasty

In this article we discuss the anatomy of the nasal base and explain the causes of postoperative hanging columella, distinguishing this entity from similar deformities with which it can be confused. We suggest measures that could be helpful in preventing this deformity. We performed external-approach rhinoplasty with the dome suturing method in 82 consecutive patients (64 women and 18 men) from 17 to 44 years of age (mean age, 22 years). Comparative measurements of the alar-columellar complex were made before and after operation. Among the 48 patients with conventional tip suturing (38 women and 10 men), 19 true hanging columellae were detected. In the 34 patients with a modified dome approximation (26 women and 8 men), no more than 5 cases of true deformity were diagnosed.

Nasal valve reconstruction: experience in 53 consecutive patients

OBJECTIVES

To determine the cause of nasal valve obstruction in a series of patients requiring surgical correction, to evaluate the efficacy of our surgical techniques, and to assess the cosmetic effect of nasal valve repair.

METHODS

Retrospective review of 53 consecutive cases involving adult patients who underwent nasal valve reconstruction over an 8-year period. The preoperative symptom severity, cause of nasal valve obstruction, preoperative photographs, anatomical findings at the time of surgery, and reconstructive techniques were reviewed. Postoperative photographs and resolution of symptoms were analyzed.

RESULTS

The most common cause of nasal valve obstruction was previous rhinoplasty (79%), followed by nasal trauma (15%) and congenital anomaly (6%). Spreader grafts were used in 42 patients (79%), and alar batten grafts were used in 19 patients (36%). The patients received a minimum of 1 year of follow-up. All 12 patients with external valve dysfunction showed improvement after surgery. Thirteen (93%) of the 14 patients with concomitant external and internal valve dysfunction had improvement in nasal obstruction after treatment. Twenty-four (89%) of 27 patients with internal nasal valve dysfunction reported improvement in nasal obstruction. Spreader grafts caused a widening of the middle third of the nose. Alar batten grafts resulted in effacement of deep alar creases and a widening of the nasal tip.

CONCLUSIONS

We have found that surgical correction of nasal valve obstruction is extremely effective in improving subjective nasal obstruction. Success of this procedure is predicated by correct diagnosis and appropriate surgical technique.

Nose surgery: how to prevent a middle vault collapse--a review of 50 patients 3 to 21 years after surgery

There is a conception, likely a misconception, that when performing a nasal osteotomy with a concomitant dorsal hump removal, the upper lateral cartilages are detached or damaged and, over the long-term, respiratory difficulties result because of a middle vault collapse or interference with the internal nasal valve. A follow-up of 50 patients between 3 and 21 years postoperatively provides evidence that this can be prevented. The vast majority (82 percent) reported they were breathing very well for an average of 6.5 years postoperatively. Of the authors' own 38 primary rhinoplasty patients, only two patients (5 percent) reported respiratory difficulties. The authors are unable to substantiate that either the osteotomy or the dorsal hump removal was responsible. Of the 12 patients who had their primary rhinoplasty performed elsewhere, six (50 percent) reported respiratory difficulties before the secondary rhinoplasty at this clinic. Furthermore, an appreciable improvement in breathing was reported by 66.7 percent of these patients after the secondary rhinoplasty. The authors conclude that their gentle proper surgical technique, combined with a good understanding of nasal physiology (with respect to the septum, inferior turbinates, and external and internal valves), allows them to perform a concomitant dorsal hump removal and osteotomy without interfering with nasal physiology.

Grafting the nasal dorsum with tandem ear cartilage

A technique for autogenous grafting of the nasal dorsum with ear cartilage is suggested based on the results of 25 consecutive cases. The technique involves (1) harvesting the entire cymba conchae and cavum conchae of the ear; (2) separating them and suturing them to each other in tandem fashion; (3) filling the underside concavity of the cymba conchae part of the graft with scraps of cartilage; (4) avoiding any bruising or crushing of the graft; and (5) filling any minor residual irregularities of the dorsum with soft tissue or cartilage from the cephalic trim of the lateral crus. The results suggest a consistent augmentation of the nasal dorsum for deficiencies from 3 to 6 mm in size. Four of the 25 cases did require secondary correction for dorsal convexity, inadequate augmentation, and surface irregularities. The technique, however, has been helpful in that ear cartilage is invariably available, allowing septum to be used for more important grafts. The procedure is easily performed under local anesthesia with no significant distortion to the donor site.