Decision-Making in Middle Vault Reconstruction following Dorsal Hump Reduction in Primary Rhinoplasty

Evidence-Based Dynamics in Rhinoplasty

Rhinoplasty is a delicate surgical procedure that requires a thorough understanding of the dynamic interplay between the various structures of the nose. Any changes made to one part of the nose can have downstream effects on the overall harmony and appearance of the nose. For this reason, it is crucial for surgeons to be aware of these potential impacts in order to achieve predictable and aesthetically pleasing results. In this article, we aim to provide a summary of the current evidence-based conclusions on the dynamic influence of the radix, dorsum, tip, and ala during rhinoplasty. By understanding the complex relationships between these structures, surgeons can make informed decisions and achieve the best possible outcomes for their patients.

Invited Discussion on: Video-Assisted Septo-Rhinoplasty, the Future of Endonasal Rhinoplasty-A Technical Note

This discussion critically evaluates the paper "Video-assisted septo-rhinoplasty, the future of endonasal rhinoplasty-A Technical Note." This discussion recognizes the substantial advantages offered by the novel endoscopic technique, such as improved visibility and the facilitation of surgical teaching. However, it also explores the inherent obstacles including potential restrictions in achieving full visibility of all nasal structures, a steeper learning curve for young surgeons due to the need to master endoscope manipulation, and difficulties in precision and accuracy during suture and graft placements in the confined operational field. This discussion underscores the importance of surgical adaptability as well as tailoring techniques to meet the specific anatomical and esthetic considerations of each patient. Even as the limitations of the endoscopic method are highlighted, its potential for advancing the field of rhinoplasty is affirmed. The inventiveness and dedication of the original authors are applauded, and we look forward to their continued innovation in this rapidly evolving discipline.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 .

Video-Assisted Septo-rhinoplasty, the Future of Endonasal Rhinoplasty-A Technical Note

INTRODUCTION

Surgeons have sought to improve outcomes in rhinoplasty through innovative techniques. Although many publications illustrate the advantages of endoscopic septoplasty over conventional methods, few have evaluated the benefits of endoscopy for rhinoplasty. In this article, the authors meticulously describe their own technique that offers a sustainable alternative to open approach rhinoplasty, with high reproducibility and enhanced knowledge for young surgeons.

METHODS

The technique involves using video-assisted endoscopy for enhanced visibility and access. Various steps are performed, including hemitransfixion incision, septoplasty if necessary, dorsal reduction, and the development of endoscopic spreader flaps. Nasal tip surgery follows standard endonasal rhinoplasty techniques.

RESULTS

This technique has been successfully performed for years in primary and secondary rhinoplasties, resulting in improved aesthetic and functional outcomes without external scars. The endoscopic view enhances understanding for surgeons and residents, while preserving internal valve function and minimizing swelling. Patients express high satisfaction with the procedure.

CONCLUSIONS

Video-assisted endoscopic septo-rhinoplasty offers a valuable alternative, providing natural outcomes with improved visualization and reduced complications. It is applicable to various indications and demonstrates its effectiveness compared to traditional approaches. The advanced endoscopic guided septo-rhinoplasty technique combines the benefits of open approach rhinoplasty while avoiding its drawbacks.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Cosmetic Rhinoplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Perform a systematic nasofacial analysis. 2. Identify the underlying anatomical cause of specific external nasal findings. 3. Recognize the interrelated effects of operative maneuvers. 4. Develop an appropriate operative plan to address patient concerns.

SUMMARY

The rhinoplasty operation is one of the most challenging procedures in plastic surgery, and requires a combination of surgical judgment, knowledge of anatomy, technical skill, and lifelong study. A foundation must be built on clearly defined patient goals and an accurate diagnosis, based on known ideals and their anatomical correlation. It is important to recognize the definitive impact of each operative maneuver to achieve predictable outcomes. This article provides a problem-based approach to common cosmetic nasal deformities.

Functional Nasal Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) understand the functional significance of nasal anatomy as it relates to rhinoplasty and perform a comprehensive functional nasal assessment. (2) Identify the anatomical level of obstruction based on the authors' algorithmic approach and understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, external nasal valve collapse. (3) Understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, and external nasal valve collapse. (4) Appreciate the objective assessment tools for functional nasal surgery from a clinical and research perspective.

SUMMARY

The intent of functional rhinoplasty is to improve nasal airflow (and the perception thereof) by surgically correcting the anatomical sources of obstruction in the nasal airway. Cosmetic and functional rhinoplasty are not mutually exclusive entities, and the techniques that address one area, inevitably may affect the another. The rate of functional problems after cosmetic rhinoplasty range from 15 to 68 percent with nasal airway obstruction found to be the most common indication for secondary surgery. The objective of this CME article is to provide readers with an understanding of the (1) functional components of nasal anatomy, (2) clinical functional assessment, and (3) the current evidence supporting corrective maneuvers for each component.

Modification of Nasal Dorsal Onlay Graft Based on Anatomic Findings of Rhinion Area

BACKGROUND

The angulation of nasal bones and superior border of septal cartilage forms a slight convex profile at rhinion area. Taking this angulation into account, we bring forth a modification of dorsal onlay graft.

METHODS

Sixty-one consecutive patients underwent primary rhinoplasty between the years of 2017 and 2020 were enrolled in the study. The angle between nasal bones and superior border of septal cartilage, angle of external dorsal contour, thickness of soft tissue at sellion and rhinion were measured on reformed computed tomographic scanning image. Three variants of dorsal onlay graft modification were designed.

RESULTS

Sixty-one patients underwent primary nasal augmentation were enrolled in this study. Mean follow-up was 13.1 months. The angle between nasal bones and the superior border of the septal cartilage was 166.7° by mean. Mean angle of external dorsal contour was 180.2°. Thickness of soft tissue at sellion was 4.01 and 2.03 mm at rhinion by mean. All cases showed content dorsal profiles. Two patients (3.3%) presented discernible nostril asymmetry due to the deviation of the columellar grafts and underwent secondary surgery with satisfying outcomes.

CONCLUSIONS

Modification of the dorsal onlay graft reserves nasal midvault to the most extent especially in small-humped nose and fits the dorsal contour properly.

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 .

Assessment of Different Middle Vault Reconstruction Techniques in Rhinoplasty from Multiple Patient-Reported Outcome Measures

It is important to assess the patient satisfaction with shape and function by patient-reported outcome measures (PROMs) following structural or dorsal preservation rhinoplasty (DPR) techniques on the middle nasal vault. To analyze the results of different middle vault rhinoplasty techniques with multiple PROMs and compare their differences according to the findings of PROMs. Four different techniques were performed for the middle vault: spreader graft, L-strut graft, DPR with high strip (DPRwHS), DPR with low strip. The outcomes were evaluated preoperatively, 2 and 12 months postoperatively with the following PROMs: Nasal Obstruction Symptom Evaluation (NOSE), Rhinoplasty Outcomes Evaluation, and Standardized Cosmesis and Health Nasal Outcomes Survey. This study included 129 patients. All techniques provided significant improvements in all PROMs (p < 0.001), except DPRwHS in NOSE. Between postoperative short- and longer-term, no significant differences were observed in DPR groups (p > 0.05), unlike structural techniques. In this comparative study of different middle nasal vault rhinoplasty techniques, we did not detect a difference in the improvement of the patient-reported outcomes of DPR techniques from as early as 2 months to 1 year postoperative.

Complications Associated with Spreader Grafts and Spreader Flaps: A Systematic Review

BACKGROUND AND PURPOSE

Spreader grafts and spreader flaps are one of the most common techniques utilized in rhinoplasty surgeries. The aim of this study was to determine the complications, satisfaction, and revision rates associated with spreader grafts and spreader flaps and to compare these two modalities.

MATERIALS AND METHODS

PRISMA guidelines were followed for conducting this systematic review. The authors searched the literature systematically for pertinent materials in PubMed/Medline and Google Scholar. Inclusion criteria of this search included: randomized and non-randomized clinical trials, cohorts, and case series with more than 5 participants on rhinoplasty using spreader grafts or spreader flaps with detailed report either on complications, revision, and satisfaction rates. Furthermore, exclusion criteria included: any cadaveric or non-human study, case reports, technical notes, and review articles.

RESULTS

The initial literature search yielded a total of 193 studies. Following screening each paper and implementing the inclusion and exclusion criteria, 40 articles were chosen. In the spreader graft group, from 21 studies reporting complications, 6 of them reported no complication. The most common complications were nasal obstruction, inverted V deformity and open roof deformity, deviation, and infection. In the spreader flap group, from 6 studies reporting any existing complications, 1 reported no complications. Five other studies reported some degree of complications. In terms of revision rate, 10 patients (0.62%) underwent revision surgery after spreader graft placement, while only 2 patients (0.35%) revised surgically in the spreader flap group.

CONCLUSION

These two methods seem to have no significant difference in terms of complication rates, and both are recommended as a choice in middle vault reconstruction when each of their clinical use is indicated.

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.

Dorsal Hump Reduction and Midvault Reconstruction

Dorsal hump reduction is one of the most common techniques used in modern rhinoplasty, yet it carries a high propensity for untoward aesthetic and functional sequelae, as evidenced by a nontrivial revision rate. Component dorsal hump reduction with stepwise deconstruction and manipulation of component parts allows for an adaptable and precise approach to variances in anatomy and in desired aesthetic result. Secondary changes must be anticipated and addressed at the index operation to avoid negative results and prevent the need for revision. Adequate reconstruction of the midvault is paramount to achieving optimal aesthetic and functional outcomes.

Preservation Rhinoplasty: Assessment of Anatomical Safe Boundaries on Computed Tomography

BACKGROUND

Nasal dorsum reconstruction is a crucial step of the rhinoplasty. For avoiding complications, techniques that preserve natural dorsal anatomy becomes popular recently. In preservation techniques, ethmoidal bone surgery may take part in the vast majority of defined techniques. Therefore, detailed anatomical knowledge is essential to avoid severe complications, especially cerebrospinal fluid leakage. Based on these, this study aimed to investigate anatomical safe boundaries of preservation techniques based on the measurements on computed tomography.

METHODS

A total of 100 patients who underwent paranasal computed tomography were enrolled in this retrospective study. Five groups were selected based on the age distribution. The distance of the dorsal osteotomy line to cranial base, amount of cartilaginous/bony septum overlaps under nasal bones, cartilaginous/bony septum length anterior and posterior to the nasal hump starting point, and anteroposterior distance of perpendicular plate was measured.

RESULTS

The mean distance between the starting point of the nasal hump and the cribriform plate was 29.5 mm. The amount of bony overlap above the cartilaginous septum was 10.9 mm in females and 10.5 mm in males. The length of septal cartilage posterior to nasal hump was 0 mm in 39 of 100 patients (39%) and the mean value was 2.38 mm in all populations. The mean distance from the starting point of the perpendicular plate to the cribriform plate was 28.17 mm.

CONCLUSIONS

Perpendicular plate may take part in the constitution of the nasal hump. Therefore, delicate surgery with appropriate tools needed for avoiding the risk of skull base injury.

LEVEL OF EVIDENCE

Level of Evidence: 3 (Therapeutic).