Rhinoplasty

Is Piezosurgery Associated with Improved Patient Outcomes Compared to Conventional Osteotomy in Rhinoplasty? A Systematic Review and Meta-Analysis of RCTs

Background: Rhinoplasty is a common plastic surgery procedure with evolving surgical techniques. This systematic review and meta-analysis compares the outcomes of piezosurgery versus conventional osteotomy in rhinoplasty. Methods: A comprehensive search of six databases yielded 12 randomized controlled trials (RCTs) comparing piezosurgery (292 cases) to conventional osteotomy (338 cases) in rhinoplasty patients. The examined outcomes included postoperative edema, ecchymosis, complications, pain (using the Visual Analogue Scale-VAS), and operative time. Subgroup analyses were conducted based on the assessment timepoint, surgical approach, and outcome grade. The risk of bias was evaluated using the revised Cochrane tool. Results: Piezosurgery showed a significant reduction in the degree of postoperative edema (second and seventh postoperative days) and ecchymosis (second, fourth, and seventh postoperative days). The external approach in piezosurgery demonstrated greater benefits for both outcomes. Piezosurgery was associated with a significant reduction in overall complications, especially mucosal injuries, compared to conventional osteotomy, with no significant difference regarding postoperative hemorrhage. A significant reduction in pain scores and the need for analgesia was observed with piezosurgery. No significant difference was found in operative time. Conclusions: Piezosurgery offers significant benefits in patient outcomes, with similar operative time between both techniques. However, long-term investigations are still needed.

Comparison of 1 Year Nasal Tip Projection Results of Triple Cartilage Combining Suture (Flexible Tongue-in-Groove) and Classical Tongue-in-Groove Techniques

Objectives: In the present study, we compared patient satisfaction with classical tongue-in-groove (TIG) technique and triple cartilage combining suture (TCCS; flexible tongue-in-groove) techniques applied to the nasal tip in rhinoplasty. Methods: In this retrospective study, 80 patients who underwent rhinoplasty operations with TIG or TCCS techniques applied to the tip region were included. There were 40 patients in both groups. All patients in groups 1 and 2 were evaluated by the criteria written below at preoperative, postoperative first month, and postoperative first year: (1) Rhinoplasty Outcomes Evaluation Questionnaire (ROE), (2) tip projection (cm), (3) nasal dorsum length (cm), (4) tip projection ratio (Goode), (5) nasofrontal angle, and (6) nasolabial angle. Results: The patients were followed up at 84.32 ± 19.38 months in the TIG group and 87.47 ± 18.01 months in the TCCS group. Our results showed that preoperative, postoperative first-month, and first-year tip projection (P = .013, P = .022, and P = .020, respectively), and nasal dorsum length values (P = .009, P = .020, and P = .020, respectively) of the TCCS group were significantly lower than those in the TIG group. There was a positive correlation between the postoperative first month and postoperative first year ROE scores. Lower preoperative tip projection ratio (Goode) values and higher nasolabial angle values were related to higher ROE scores showing patient satisfaction. Conclusion: For the patient satisfaction after tip rhinoplasty, lower projection ratio (Goode) and higher nasolabial angle values were related to ROE scores. Although there are no significant results, lower tip projection results in the TCCS group may be related to more patient satisfaction due to natural appearance.

Turn Your Vision into Reality-AI-Powered Pre-operative Outcome Simulation in Rhinoplasty Surgery

BACKGROUND

The increasing demand and changing trends in rhinoplasty surgery emphasize the need for effective doctor-patient communication, for which Artificial Intelligence (AI) could be a valuable tool in managing patient expectations during pre-operative consultations.

OBJECTIVE

To develop an AI-based model to simulate realistic postoperative rhinoplasty outcomes.

METHODS

We trained a Generative Adversarial Network (GAN) using 3,030 rhinoplasty patients' pre- and postoperative images. One-hundred-one study participants were presented with 30 pre-rhinoplasty patient photographs followed by an image set consisting of the real postoperative versus the GAN-generated image and asked to identify the GAN-generated image.

RESULTS

The study sample (48 males, 53 females, mean age of 31.6 ± 9.0 years) correctly identified the GAN-generated images with an accuracy of 52.5 ± 14.3%. Male study participants were more likely to identify the AI-generated images compared with female study participants (55.4% versus 49.6%; p = 0.042).

CONCLUSION

We presented a GAN-based simulator for rhinoplasty outcomes which used pre-operative patient images to predict accurate representations that were not perceived as different from real postoperative outcomes.

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 .

Structural Rhinoplasty as an Effective Surgical Approach for Frontonasal Dysplasia

Frontonasal dysplasia (FND), a rare congenital craniofacial disorder, primarily influences the development of midline craniofacial structures. A notable manifestation of this condition is nasal hypoplasia. This report details the treatment of a 19-year-old male patient diagnosed with FND accompanied by a severe case of nasal hypoplasia. The authors used structural rhinoplasty to achieve total nasal reconstruction. Albeit with some minor sequelae, the outcome of this surgery was markedly positive, enhancing both the cosmetic appearance and functional capacity of the nose. This case underscores the effectiveness of structural rhinoplasty as a feasible therapeutic approach for individuals suffering from FND and its associated nasal hypoplasia.

Clinical Practice Patterns and Evidence-Based Medicine in Rhinoplasty: A 10-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery (ABPS) has collected data on cosmetic surgery from member surgeons since 2003. These data offer valuable information on national trends in clinical practice.

OBJECTIVES

The present study was performed to analyze trends in rhinoplasty over the last decade.

METHODS

Tracer data were compared between two cohorts 2012-2016 (early cohort "EC") and 2017-2021 (recent cohort "RC"). Data included patient demographics and surgical techniques. Results were considered in the context of current EBM-based guidance in the plastic surgery literature.

RESULTS

Data from 730 rhinoplasties (270 EC and 460 RC) were analyzed. The median age was 30 years, and the most common patient concern was the nasal dorsum (79%). In the RC group, fewer patients voiced concerns about tip projection (58% vs 43%, p = 0.0002) and more complained of functional airway problems (38% vs 49%, p = 0.004). An open approach was most common (83%). Septoplasty (47% vs 52%, p = 0.005), caudal septum repositioning (14% vs 23%, p = 0.002), and tip rotation maneuvers (32% vs 49%, p < 0.0001) became more popular. There was also an increase in the use of spreader grafts (35% vs 45%, p = 0.01) and columellar strut grafts (42% vs 50%, p = 0.04), while there has been a decrease in alar base resection (17% vs 10%, p = 0.007) and non-cartilaginous dorsum/radix augmentation (9% vs 4%, p = 0.02).

CONCLUSIONS

ABPS tracer data provide an excellent resource for the objective assessment of procedures in plastic surgery. The present study is the first to highlight evolving trends in rhinoplasty over the last 10 years.

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 .

Anthropometry of the nose pre- and post-photogrammetric adjustments in a sample of Syrian medical students. A cross-sectional study

Background and Aims

The individual's perceived beauty, sense of identity, and general well-being are all influenced by the social implications of the esthetics of their facial appearance. One of the major indicators of one's facial beauty is anthropometric proportions. This study was conducted to measure and evaluate the anthropometric proportions in a Syrian population, and to determine their desired nasal shape.

Methods

A cross-sectional study was conducted on Syrian university students. Lateral and frontal pictures of the participants were taken using Canon EOS 250D from a standard distance of 100 cm. These pictures were analyzed, then nasal measurements were adjusted according to the participants' desire using Adobe Photoshop 2020. All anthropometric measurements were conducted on AutoCAD® 2019 software before and after the adjustments. Data was analyzed using the SPSS-25 using paired samples T test to compare the means.

Results

The study included 53 females and 47 males. The mean age was 22.25. The mean unadjusted nasofrontal angle, nasolabial angle, nasomental angle, nasofacial angle, nasal index, Byrd and Hobar ratio, and Powell-modified Baum ratio were 141.80, 102.18, 129.21, 34.60, 71.71, 0.62, and 3.08 in the rhinoplasty-negative participants, and 145.89, 102.03, 130.20, 32.44, 67.96, 0.64, and 3.06 in the rhinoplasty-positive participants, respectively. While the mean of the adjusted previously mentioned angles were 144.59, 106.32, 131.19, 31.15, 62.91, 0.60, and 3.19 in the rhinoplasty-negative participants, and 146.31, 102, 130.20, 31, 62.55, 0.62, and 3.08 in the rhinoplasty-positive participants, respectively.

Conclusion

In contrast to other populations, our study concluded that Syrians had unique anthropometric measurements and facial esthetics preferences. Moreover, the local plastic surgeons were able to identify most of the preferred nasal measurements for rhinoplasty in this ethnic group. It is advisable to use photogrammetry before rhinoplasty to identify the preferred nasal measurements of each individual to ensure the patient's satisfaction with the outcome of the surgery.

Level of Evidence

Level IV, cross-sectional study.

Harmonizing Beauty and Function: A Comprehensive Exploration of Patient Satisfaction in Rhinoplasty

Background

Rhinoplasty has become a globally prevalent esthetic procedure, necessitating precise facial analysis and comprehensive preoperative planning for favorable postoperative outcomes. We aimed to assess patient satisfaction levels concerning nasal appearance following rhinoplasty.

Methods

A case series interventional study was conducted involving 52 subjects referred to Rhinoplasty Clinics of Taleghani Hospital, Tehran, Iran from Mar 2021 to Mar 2022. Patients' satisfaction levels were evaluated using a concise checklist before and three months after surgery.

Results

The mean age of the patients was 29.23 ± 7.26 years, with 19 (36.5%) being male. Statistically significant improvements were observed in all assessed factors, including nasal obstruction, nasal size, hump presence, nasal bridge width, nasal tip bulbosity, nasal deviation, radix, nostril asymmetry, and tip ptosis (P < 0.001). These findings reveal a consistent pattern of patients' satisfaction levels predominantly shifting from moderate to low across various aspects of nasal appearance post-rhinoplasty.

Conclusion

The study demonstrated a significant enhancement in patients' satisfaction with their nasal appearance following rhinoplasty, indicated by statistically significant changes across all assessed factors. However, certain aspects exhibit more limited enhancement.

Beyond Alar Base Resection: Contouring of the Alar Rim and Base

SUMMARY

Alar base surgery is approached with hesitancy and is often avoided by many surgeons because of inexperience and a lack of understanding. However, with a thorough knowledge of the anatomy and dynamic nature of the lower third of the nose, alar base resection can achieve favorable and reproducible results. Beyond correcting alar flare, an appropriately diagnosed and performed alar base procedure serves to contour both the alar rim and the alar base. The following article presents a case series of 436 consecutive rhinoplasties from a single surgeon, 214 of which underwent alar base surgery. The outcomes demonstrate that the procedure is safe and yields desirable results without a single revision being required. As the third in a series of three articles on alar base surgery by the senior author (R.J.R.), this article unifies the management of the alar base. An intuitive approach to the classification and management of alar flare and the implications of alar base surgery on contouring of the alar base and alar rim is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

An Innovative Stent Consisting of Expanded Polytetrafluoroethylene and Ear Cartilage in Rhinoplasty For Asians: Application I of Dai's Exogenous Extension Stent Concept

BACKGROUND

Restricted ventilation is common after rhinoplasty with an endogenous extension stent. The authors proposed an exogenous extension stent concept for Asian rhinoplasty patients to avoid this problem. Herein, we introduce an innovative stent in rhinoplasty for Asians, which is an application of this concept.

METHODS

An L-shaped expanded polytetrafluoroethylene is hand-carved, and the long arm is placed at the nose back to improve the flatness of the nose, while the short arm supports the nasal column to raise the nose tip. The prosthesis does not occupy nasal volume and therefore theoretically does not affect nasal ventilation. The fan-shaped ear cartilage was placed at the nasal tip to prevent visualization of the nasal tip. The safety and effectiveness of this method were verified through 20 years of clinical practice. The difficulty of learning and popularizing the method was tested through the course of rhinoplasty among 22 plastic surgeons.

RESULTS

After 20 years of clinical practice, it was found that this stent could not only effectively improve the nasal dorsum and tip morphology, but also did not actually affect the nasal volume and thus did not affect the nasal ventilation of patients. Among the trainees in plastic surgery, we found that it was not difficult to learn this method of rhinoplasty and the trainees could complete the prosthesis carving well after standardized training.

CONCLUSION

This stent consisting of expanded polytetrafluoroethylene and ear cartilage is suitable in rhinoplasty for Asians with significant advantages, one of which is that it has no risk of resulting in restricted nasal ventilation.

LEVEL OF EVIDENCE

Level IV.

Refinements in Component Dorsal Reshaping in Primary Rhinoplasty

SUMMARY

Dorsal reduction and reshaping is an essential part of many rhinoplasty procedures. The steps of component dorsal reduction have been well established. The authors describe refinement of the dorsal reshaping process to improve the quality and consistency of results.

The Myrtiformis Muscle: Identification of a Forgotten Entity That Is Distinct From the Depressor Septi Nasi Muscle

INTRODUCTION

Nasal musculature anatomy is a topic that plastic surgeons pay attention to. However, the presence and role of the myrtiformis muscle (MM) remain controversial. To elucidate these aspects, an anatomy-based study was conducted.

MATERIALS AND METHODS

Seven midsagittally split and two total cadaver head's nasal bases, embalmed with modified Larssen solution (MLS), were dissected for MM anatomy. The features of this muscle were photographed, and a video of its function was recorded.

RESULTS

It was found that MM originates from the maxillary alveolar process and continues as two heads, one reaching the alar base with spicular fibrotendinous endings and the other extending to depressor septi nasi fibers. Owing to its bi-vectoral muscle fibers, MM is found to constrict the nares by simultaneously forcing the alar base and lowering the columella. It was also found that left-sided muscles were larger than right-sided muscles.

CONCLUSIONS

The MM is found to be a constrictor muscle of the nares in this study, contrary to recent observations.

Introducing a New Technique for Correcting Nasal Soft Tissue Triangle Deformity Using a Modified Fine Graft (Cartilage Graft) and Evaluating Its Effect on Deformity Correction: A Prospective Study

Background

The management of deformities of the nasal soft triangle (ST) is a difficult and very sensitive discussion in rhinoplasty. So far, the standard method for correcting these deformities has yet to be introduced. We aimed to introduce a new technique using modified fine graft (MMG) for correcting nasal ST triangle deformity and evaluate the effects of using this method.

Methods

This prospective study was conducted on 20 rhinoplasty candidates who underwent surgery at 15 Khordad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran between August 2021 to the February 2022 with the new technique of using an MMG to correct nasal ST triangle deformities. Follow-up was performed immediately after surgery, 3 and 6 months after surgery. Post-operative findings included ST deformity correction, graft exposure, graft visibility, recurrence rate, and the need for revision were evaluated by photography for all patients.

Results

The mean age of patients was 33.65± 11.047 years, 85% of the cases were female and 90% of surgeries were primal rhinoplasties. The ST triangle deformity was not corrected in 2 cases (10%). Both patients were women with primary rhinoplasty, and cartilage was removed from the septum in both. Graft exposure, recurrence, and visibility were not reported in any cases.

Conclusion

MFG was highly effective in correcting the deformity of the nasal ST triangle and did not cause serious complications in patients. This method is a suitable method with high efficiency for correcting nasal ST triangle deformity.

A Canadian Experience With Off-the-Shelf, Aseptically Processed, Costal Cartilage Segment Allografts in Complex Rhinoplasty

Background

Complex primary and secondary rhinoplasties usually necessitate grafting materials when native nasal cartilage is inadequate for reconstruction. Fresh frozen, aseptically processed, and nonterminally sterilized costal cartilage segment allografts (CCSAs) are a novel grafting material for such cases that avoid donor-site morbidity, improve operating efficiency, and mitigate the postoperative risks.

Objectives

To report the early experience using fresh frozen, aseptically processed, and nonterminally sterilized CCSAs used in complex primary and secondary rhinoplasties, in Canada.

Methods

We retrospectively reviewed 21 patients (17 female and 4 male patients) who underwent a primary or secondary rhinoplasty surgery using CCSAs from June 2019 to April 2022.

Results

The mean age was 39 years (range, 27-58 years), and the mean body mass index was 23.7 kg/m² (range, 24-40 kg/m²). Of the 21 procedures, 11 were primary (52.4%) and 10 were secondary (47.6%) rhinoplasties. The mean operative time was 185 min (range, 85-330 min), with a mean follow-up time of 15.0 months (range, 2.0-37.8 months). At follow-up, 19 patients (90.5%) reported being "very satisfied" with their aesthetic results, and only 2 (9.5%) underwent revision surgery. No serious complications were reported, and only 1 case showed evidence of graft resorption.

Conclusions

Based on early experience, this CCSA avoids donor-site morbidity and reduces operative time while maintaining a low complication rate, providing a viable alternative to the use of autologous costal cartilage when indicated in complex primary or secondary rhinoplasties with inadequate native nasal cartilage.

Level of Evidence 4

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.

Prevalence of Facial Asymmetry and Correction Methods for Rhinoplasty in Individuals with Deviated Nose: A Brief Review

Background:

Surgeons frequently perform rhinoplasty on individuals who have facial asymmetry. Patients’ discontent following rhinoplasty has been linked to facial asymmetry. On the other hand, correction of a deviated nose is a tough procedure, and it is not the same as septal deviation correction. Surgeons, who often perform rhinoplasty for deviated nose in people with asymmetrical faces, focus primarily on correcting nasal defects and overlook such facial asymmetry.

Aim:

We aimed to summarize and review the prevalence of facial asymmetry in patients subjected for rhinoplasty for deviated nose correction.

Methods:

A systematic search was conducted covering PubMed, Scopus, ISI, and Google Scholar using related key words and MeSH (Medical Subject Headings) terms from 2000 until November 2021 for English published articles.

Results:

The majority of subjects had more facial asymmetry such as chin deviation, nasal deviation, and face breadth. Facial asymmetry is typically found in patients undergoing rhinoplasty for a deviated nose, and its presence frequently results in the failure to achieve a straight-looking nose.

Conclusion:

Patients considering rhinoplasty frequently have facial asymmetries, and careful attention should be devoted to these elements in both surgical planning and patient counseling. In order to create facial harmony and apparent symmetry after rhinoplasty, it is critical to center the nose on the midglabellar to mid–bow Cupid’s line.

Controlling Nasal Tip Projection and Rotation with New Composite Septocolumellar Flap Approaches

BACKGROUND

Rhinoplasty is one of the most common and challenging surgeries in the field of aesthetic surgery. For obtaining an aesthetically pleasing nose, it is extremely important to control nasal tip projection and rotation as much as possible. Since the last decade, septocolumellar suture techniques have been most frequently used for modifying and controlling nasal tip rotation and projection and for obtaining a better columellar-labial angle during rhinoplasty. In the present study, the author has described 10 different approaches using composite septocolumellar flaps with the aim of obtaining better outcomes, such as the control of nasal tip projection and rotation, in addition to obtaining better tip refinement.

METHODS

The records of 68 patients were included in the present study based on the inclusion and exclusion criteria. Ten composite septocolumellar flap approaches were followed by the same surgeon.

RESULTS

The initial median Rhinoplasty Outcome Evaluation score was 60.5 points; the score increased to 92.5 points at 12 months after the surgery (p < 0.001). Satisfaction was excellent in 87.5 percent of the patients. The patients were also evaluated in terms of functionality. Their patency scores increased from 6.0 to 9.0 (out of 10) after a 12-month follow-up (p = 0.001).

CONCLUSIONS

The technique has the following advantages: control of nasal tip projection and rotation, fixation of mild deviations, and shortening of the nose with better aesthetic and functional outcomes. Furthermore, because the septocolumellar region is completely protected and remains solid, a dynamic nasal tip is obtained. Surgeons will be able to choose the most suitable approach when a composite septocolumellar flap is needed.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Preoperative Evaluation of the Rhinoplasty Patient

Requiring both high-level technical skills and artistic sense, rhinoplasty continues to be one of the most challenging procedures in plastic surgery despite its popularity. A thorough preoperative consultation of the rhinoplasty patient forms the foundation of a successful case. During the consultation, the physician should obtain a detailed medical and nasal history, understand the patient's areas of concern, conduct a nasal analysis, and evaluate the patient's candidacy for surgery. This article reviews the key functional, esthetic, and psychosocial considerations that should be taken into account during a preoperative consultation for a rhinoplasty patient.

Why Primary Rhinoplasty Fails

SUMMARY

Rhinoplasty remains one of the most challenging operations performed by plastic surgeons. The complexity lies in the ability to have a consistent and predictable aesthetic result. The unpredictability is mainly attributable to the interplay of manipulated internal structures and wound healing dynamics. In addition, setting realistic expectations with the patient is essential for achieving high postoperative patient satisfaction. An open rhinoplasty approach enables an accurate and in-depth evaluation and intervention. The authors provide a detailed analysis and discussion on why primary rhinoplasty fails, along with the surgical approach for preventing these failures.

Reduction Rhinoplasty Re-Endorsed: When Conservative and Measured

Reduction rhinoplasty has been widely criticised and dismissed due to the current preference for structural rhinoplasty. The criticism is related to airway compromise and secondary structural deformities, both early and late, due to overzealous resection. This two-year study attempted to prospectively assess the risk of airway and structural problems following reduction rhinoplasty in 30 consecutive patients. The findings showed no statistically significant difference either in the NOSE score (subjective sense of breathing) or in nasal valving (objective observations), at the 3-month follow-up. Subsequent 12-month telephone reviews revealed no change in the patients' functional or aesthetic outcomes. There was a 3% structural complication rate (requiring secondary surgery) and a 20% rate for further refining reduction surgery. The findings confirmed the author's impression that conservative, measured reduction rhinoplasty, performed with due consideration to preserving the nasal supportive framework, is a technique well worth endorsing with confidence to reduce the disproportionately large nose. Contemporary surgeons need not feel obliged to only use the more complex later-developed structural rhinoplasty techniques.

Perception of Risk Among Aesthetic Plastic Surgeons

BACKGROUND

With continuous innovation in plastic surgery, new procedures are constantly being introduced. A number of these procedures are generally safe but have the potential for rare yet serious complications. Many surgeons steer clear of these procedures due to safety concerns.

OBJECTIVES

The aim of this paper was to survey the membership of The Aesthetic Society to elicit perception of risk of several novel or less mainstream procedures.

METHODS

A 24-item survey was sent out to members of The Aesthetic Society. The survey focused on surgeon experience and attitude towards 3 procedures: filler rhinoplasty, gluteal augmentation with fat grafting, and submandibular gland excision.

RESULTS

In total, 189 completed surveys were returned. Of the responders, 50%, 49%, and 89% of surgeons said they do not perform filler rhinoplasty, gluteal augmentation with fat grafting, or submandibular gland excision in their practices, respectively. The majority of those who do not perform the procedures selected "danger to the patient" as the primary concern for each of the 3 procedures. Surgeons overwhelmingly reported not learning these procedures in training. Additionally, surgeons perceive the risks of more common procedures such as abdominoplasty and breast augmentation-mastopexy to be significantly lower and more acceptable than those of the studied procedures.

CONCLUSIONS

When comparing the perceived complication rates with data published in the literature, particularly when looking at rates of serious or life-threatening complications, plastic surgeons overestimate the risks of procedures with which they are less familiar. This perception of risk, accompanied by the lack of exposure to novel techniques in training, may contribute to surgeons avoiding these procedures.

Differences between Primary and Revision Rhinoplasty: Indications, Techniques, Grafts, and Outcomes

BACKGROUND

The nose is at the center of the face and has essential functional and aesthetic properties. Over recent years, rhinoplasty has gained increasing popularity through the influence of "selfies" and social media. As a result, a growing demand for secondary correction has also emerged. Revision rhinoplasty is more complex than primary cases and often requires the use of extranasal grafting material. The authors sought to analyze the indications, techniques, and outcomes after primary and revision rhinoplasty.

METHODS

A total of 245 patients (153 primary cases and 92 revisions) undergoing surgery at the authors' specialized clinic for facial plastic surgery were included. All patients were treated by an experienced facial plastic surgeon according to the authors' established clinic standards. A retrospective data analysis was performed to evaluate the differences between the groups regarding the indications, intraoperative techniques, and postoperative outcomes.

RESULTS

Although more patients sought revision surgery for aesthetic reasons alone than isolated functional issues, almost two-thirds of the revision patients had functional and aesthetic problems in combination. Complex reconstructive techniques, extracorporeal septoplasties, and extranasal grafts were more commonly used in revision cases. The occurrence of another revision during the follow-up period was significantly higher after revision surgery compared to primary rhinoplasty cases (primary rhinoplasty, 10.5 percent; revision surgery, 23.9 percent; p = 0.006).

CONCLUSIONS

There are differences between primary and revision rhinoplasty that must be appreciated by the treating surgeon. The patient should be informed about the increased complexity of the secondary procedure, the possible need for extranasal grafts, and the increased risk of a further revision.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Predictive indicators for revisional surgery in nasal reconstruction after Mohs surgery

Background

Reconstruction of nasal lesions is complex due to the topography, mobile free margins and borders of anatomical subunits. Reconstructive challenges can lead to multiple revisional surgeries to achieve the final aesthetic result. This study aimed to evaluate risk factors and predictors of revisional surgery in patients undergoing reconstruction after Mohs micrographic surgery for nasal tumours.

Methods

This was a prospective cohort study from April 2, 2008 to February 26, 2019. The study population included all consecutive patients who underwent Mohs micrographic surgery for nasal skin cancer. Resection and reconstruction of nasal skin cancer was performed by the Mohs team.

Results

A total of 988 cases met our study inclusion criteria with 64 (6.5%) cases requiring unplanned surgical revision. Revision rates were highest in the ala (9.0%, p < 0.05) and complex anatomical subunits (16.7%, p < 0.0001). In contrast, revision rates for dorsum lesions were lowest (1.8%, p < 0.001). In terms of reconstructive modalities, local flaps resulted in significantly higher rates of revision when compared to grafts (relative risk, 2.37; 95% CI, 1.15–5.0; p < 0.01). In terms of histological diagnosis, squamous cell carcinoma had significantly higher revision rates when compared to basal cell carcinoma (p < 0.05).

Conclusions

To our knowledge, this is the first study to report the risk factors and predictors of revision surgery in patients undergoing MMS for nasal tumours. This study highlights that the reconstructive modality utilised affects the functional and cosmetic outcome of MMS. We note that ala complex subunit lesions, squamous cell carcinoma and flap reconstruction were associated with an increased risk of revision after Mohs reconstruction of nasal lesions.

Level of evidence: Level III, risk/prognostic; therapeutic study.

Trial registration number

(Ref: PLA-19-20_A03) 04/02/2020.

Systematic Surgical Approach to Alar Base Surgery in Rhinoplasty

In an era with smartphone photography and social media (specifically, "selfies"), basal view aesthetics is becoming increasingly important. Achieving balance between the nasal base and the remainder of the nose and face while preserving or restoring external valve function are essential to a successful rhinoplasty. Without a systematic approach to the nasal base, it is more difficult to achieve an ideal outcome from both aesthetic and functional standpoints. This article outlines an organized and systematic approach to the nasal base, beginning with comprehensive nasofacial analysis. The authors continue by describing idealized basal view aesthetics and provide a treatment algorithm for common deformities that include alar flaring and a wide nasal base. The authors attempt to provide a comprehensive approach to the treatment of the nasal base by discussing the implications of treating columellar deformities, tip positioning, or alar-columellar discrepancies on the overall aesthetics of the lower third of the nose. Furthermore, technical considerations are given for common surgical maneuvers addressing the alar base to help guide treatment and prevent complications such as poor scarring, notching, nostril asymmetry or stenosis (external valve obstruction), and alar deformities ("parenthesis" or "bowling pin"), to name a few.

Post-Rhinoplasty Acne, Frequency and Role Players

Introduction

Acne is a common complain among post rhinoplasty patients. While rhinoplasty is done for aesthetic reasons and acne expressively affects the individual’s appearance, we aimed to study its incidence and role players.

Materials and Methods:

A descriptive cross-sectional study was performed on 152 (143 females and 9 males) patients admitted for rhinoplasty during January 2016 to March 2017. Patients were examined by a dermatologist prior to surgery and 7, 30 and 90 days after rhinoplasty using the Global Acne Grading System and responded to a list of questions on the probable risk factors of acne. Psychological status was examined by the perceived stress scale-14 and the Hospital Anxiety and Depression Scale.

Results:

The patients' mean age was 28.9±3.82 yrs. Mild and moderate acne were observed in 21.7% (n=33) of the cases in the preoperative visit. The incidence of mild and moderate acne was 36.1%, 42.8% and 23% after 7, 30 and 90 days of surgery, respectively. One week after rhinoplasty, acne manifested in 14.9% of cases with no history of acne. Mean age significantly differed between those with and without post-surgical acne at all post-surgical visits (P> 0.001 and P=0.001 and P=0.015, respectively). Hospital anxiety and depression and perceived stress levels were significantly higher in patients who presented with acne on the first post-surgical visit compared to those with no acne presentations (P=0.04 and P=0.02, respectively).

Conclusion:

External psychological stress may be the main role player in post-rhinoplasty acne. Consultation or referral of patients to an experienced psychologist is highly recommended for a better outcome and fewer complications.

Assessment of functional and aesthetic outcomes in septorhinoplasty

PURPOSE

The aim of this study is to review the aesthetic and functional outcomes of septorhinoplasty using questionnaires that have never been collectively used, as well as surgeons' evaluation.

MATERIALS AND METHODS

Our study was conducted prospectively among 100 patients who underwent septorhinoplasty operation. We evaluated the effects of septorhinoplasty's functional and aesthetic outcomes on patients' emotional status using a combination of NOSE, ROE, DAS-24, and GBI questionnaires as well as surgeons' evaluations.

RESULTS

Our study did not detect any significant difference between preoperative and postoperative levels of patient satisfaction with regard to age, sex, and surgery type and the number of surgeries. Our study, on the other hand, revealed significantly higher postoperative GBI scores among patients with higher preoperative DAS-24 and NOSE scores. However, we showed no significant difference between the preoperative ROE score and postoperative GBI score CONCLUSION: This study demonstrated that septorhinoplasty can not only significantly alter a nose's functional and aesthetic appearance, but it can also boost patient satisfaction.

Catgut Versus Polypropylene Sutures for Transcolumellar Incision Closure in Open Rhinoplasty: A Retrospective Cohort Study

Background

Open rhinoplasty, including the transcolumellar approach, is commonly performed as it has fewer side effects and provides superior anatomical control to the surgeons compared to closed rhinoplasty. However, the postoperative scar outcomes, such as scar appearance, vary depending on the type of suture used in wound closure, and the optimal suture type is not firmly established.

Objective

To compare the impact of catgut versus polypropylene sutures on the postoperative transcolumellar scar outcomes and patient satisfaction following open rhinoplasty.

Methods

This retrospective cohort study, including 100 patients who underwent transcolumellar open rhinoplasty, was conducted at otolaryngology department of King Abdulaziz University Hospital, Riyadh, KSA. The patients were divided into two groups: the propylene suture group (group 1), which included 15 males and 35 females with a mean age of 31.5 years and underwent surgery using propylene sutures, and the catgut suture group (group 2), which included 10 males and 40 females with a mean age of 30.5 years and underwent surgery using catgut sutures. The postoperative transcolumellar scar outcomes, as determined by visual analogue scale (VAS) and Stony Brook Scar Evaluation Scale (SBSES) scores, and patient satisfaction, as assessed using a self-assessment scale, were compared between groups.

Results

The scars were unnoticeable in the majority of both groups: 88% in group 1 and 86% in group 2. The VAS and SBSES scores did not significantly differ between groups. Patients' satisfaction rates were also comparable and did not significantly differ between groups (p = 0.341).

Conclusion

Both catgut and polypropylene sutures lead to similar outcomes and patient satisfaction rates in terms of postoperative rhinoplasty transcolumellar scars. Thus, catgut may be the optimal suture for closing transcolumellar incisions following open rhinoplasty.

Treating Symptomatic Midvault Soft Tissue Collapse in Revision Rhinoplasty with a Nasal Wall Implant

Persistent nasal airway obstruction (NAO) due to midvault soft tissue collapse in patients following rhinoplasty or nasal surgery is a clinical challenge for surgeons. An absorbable lateral nasal wall implant is one option available to help treat midvault soft tissue collapse and to improve NAO symptoms. Previous studies have not investigated its use in complex revision functional rhinoplasty with respect to patient-reported outcomes. Data were collected on all patients with a history of previous nasal procedures who underwent Latera implant placement in conjunction with functional rhinoplasty from January to December 2018. The Nasal Obstructive Symptom Evaluation and Visual Analogue Scale were used to evaluate functional outcomes. Eight implants were placed in 6 revision functional rhinoplasty patients with midvault collapse. All patients responded to the survey. Mean follow-up was 16 ± 4 months. There were no implant-related adverse events. Mean Nasal Obstructive Symptom Evaluation score was 33 ± 33, and mean Visual Analogue Scale score was 20 ± 9. In total, 1 patient reported complete resolution of NAO, whereas 2 patients reported mild, 1 reported moderate, 1 reported severe, and 1 reported extreme symptoms. Four of the 6 patients reported nasal obstruction improvement, with all reporting improvement in midvault soft tissue collapse. Apart from being used in nasal valve collapse treatment, a lateral nasal wall implant is a potentially useful solution that may help surgeons improve patients’ NAO symptoms in complex functional rhinoplasty cases. However, in certain cases, a patient’s nasal obstructive symptoms may continue to be multifactorial.

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

BACKGROUND

Dorsal hump reduction during open rhinoplasty disrupts the continuity between the upper lateral cartilages and the dorsal septum. Options to reconstitute the midvault include primary closure of the upper lateral cartilages to the dorsal aspect of the septum, placement of spreader grafts, and creation of spreader flaps. The authors sought to clarify from highly experienced rhinoplasty surgeons their decision-making rationale for midvault reconstruction, distilling down the group consensus into algorithmic guidelines.

METHODS

A panel of internationally recognized rhinoplasty surgeons participated in a two-part organized communication method. An introductory summit consisted of open discussions on various topics in midvault reconstruction. The summit transcription was analyzed by thematic content analysis to develop a survey encompassing clinical scenarios for primary rhinoplasty, which was then individually administered to each panelist. Data gathered from both parts were used to generate technical guidelines and a decision-making algorithm.

RESULTS

The panelists identified the following anatomical features as pertinent to their selection of midvault reconstruction method: size of the dorsal hump reduction, width of the midvault relative to the upper vault, presence of dorsal angulation, and presence of nasal obstructive symptoms. Individual panelist preference was gathered from the 24-scenario survey divided into either cosmetic or functional rhinoplasty cases.

CONCLUSIONS

Management of the midvault after dorsal hump reduction is important to establish proper aesthetic relationships and to provide functional integrity of the internal valve. Our authors present an algorithmic approach to decision-making based on the systematic analysis practiced by senior rhinoplasty surgeons.

Rhinoplasty Combined With Centrofacial Lipofilling to Optimize Facial Proportions

Background

The perceived appearance of the nose is influenced by its foundations (ie, malar areas, lip, and chin). The association of nasal hump and centrofacial volume deficiency is not uncommon.

Objectives

We evaluated and analyzed the role of centrofacial lipofilling simultaneously to rhinoplasty to sculpt facial proportions and shapes all in one procedure.

Methods

Volumes and placement of fat graft were determined preoperatively. Centrofacial microfat grafting was performed concomitantly to the rhinoplasty. Treated areas were malar, upper lip, pyriform aperture, and chin.

Results

From January 2016 to January 2019, concurrent lipofilling was performed in 23 rhinoplasties. Fat graft volumes ranged from 2 to 31 mL.

Conclusions

Centrofacial lipofilling is a simple and effective tool that can easily be associated with rhinoplasty techniques to optimize the results and may even influence the procedure towards a more conservative approach.

Level of Evidence: 4

3D photogrammetric analysis in hump nose correction based on nasal tip projection without dorsal augmentation in Asian rhinoplasty

INTRODUCTION

Hump nose in Asians should be managed differently in consideration of the lateral profile and the balance between the dorsal height and nasal tip projection. We suggest an alternative approach comprising mild rasping and nasal tip projection using a septal extension graft.

MATERIAL AND METHODS

In this retrospective study, patients who underwent hump nose correction with rhinoplasty between March 2012 and July 2015 were recruited. Instead of applying conventional dorsal augmentation after humpectomy, our approach involved only smooth dorsal contouring in limited cases. 15 patients were evaluated, with surgical outcomes demonstrated using three-dimensional photogrammetry.

RESULTS

Over the postoperative period, hump height decreased (pre 2.77 ± 2.07, post 0.31 ± 0.55, p = 0.001). Regarding the efficacy of tip projection, both nasal tip protrusion (pre 17.64 ± 4.82, post 20.46 ± 4.05, p = 0.001) and tip projection (pre 19.75 ± 4.26, post 21.83 ± 4.17, p = 0.023) were increased. The hump nose reduction ratio was 84.94% after 6 months and 76.47% after 1 year, whereas increases in nasal tip projection and dorsal augmentation were minimal, with ratios of 14.75% and 12.76%, respectively, after 6 months).

CONCLUSION

Therefore, creating a balance between the nasal tip and nasal dorsum in hump nose correction is more important than dorsal augmentation after hump resection in Asians.

Developing Consistency in Rhinoplasty

This invited Special Topic article outlines the authors' evolution and technique to optimize consistent results in rhinoplasty.

Assessment of Wellbeing and Anxiety-related Disorders in Those Seeking Rhinoplasty: A Crowdsourcing-based Study

BACKGROUND

Recently, it has been proposed that psychosocial concerns may motivate the demand for aesthetic rhinoplasty. Although successful operations often improve the quality of life and self-esteem symptoms in patients with sound mental health, they may actually result in unsatisfactory outcomes in those patients with significant depression, anxiety, or other severe psychological disorders. The purpose of this study was to assess the incidence of psychological disorders in patients seeking rhinoplasty.

METHODS

A prospective cross-sectional study of 298 random volunteers was conducted, with each participant completing a survey instrument that was administered through an internet crowd-sourcing service (Amazon Mechanical Turk). Participants were asked to complete a 10-item standardized SHNOS scale, and a 26-question PRIME-MD questionnaire in order to assess functional and aesthetic need for rhinoplasty, and the incidence of psychological disorders respectively.

RESULTS

38.95% of female participants reported a willingness to undergo aesthetic rhinoplasty, with a significantly lower number of men reporting the same (27.78%, P = 0.042). Adults between the ages of 18-24 (52.92%) were more willing to undergo aesthetic rhinoplasty, as compared to any other age group (P < 0.01). It was found that 57.84% of patients interested in surgery reported a psychological disorder as determined by the PRIME-MD questionnaire.

CONCLUSIONS

Those suffering from major depressive disorder, generalized anxiety disorder, or body dysmorphic disorder may seek aesthetic rhinoplasty as a solution. It is important that surgeons assess patient mental health prior to treatment in order to avoid unsuccessful outcomes secondary to psychosocial illness.

How Patient Decision-Making Characteristics Affect Satisfaction in Facial Plastic Surgery: A Prospective Pilot Study

BACKGROUND

The main objective of this study was to prospectively analyze which personality traits, clinical psychiatric states, and patient decision-making characteristics predict who will be less satisfied after facial plastic surgery.

METHODS

This prospective study enrolled 60 adult subjects into one of three groups: aesthetic, functional, and reconstructive facial plastic surgery procedures (n = 20 in each group) from November of 2011 to February of 2016. Self-report surveys of personality traits (i.e., NEO Personality Inventory-Revised), psychiatric state (i.e., Patient Health Questionnaire, Generalized Anxiety Disorder, Health Anxiety Inventory-Short Form), and decision-making characteristics (maximizer/satisficer survey) were given during the preoperative clinic visits. In postoperative follow-up, satisfaction questionnaires at 3, 6, and 12 months were administered. Data analysis examined associations between patient satisfaction, decision-making characteristics, and psychiatric variables.

RESULTS

Bivariate analyses showed that maximizer/satisficer decision-making style was significantly related to patient satisfaction scores in the year following surgery. This difference reached statistical significance at 6 months and remained a strong trend at 12 months. Patients who were less than extremely satisfied at both postoperative time points were more likely to portray the maximizer decision-making style. No other variables were associated with patient satisfaction at any time point. Maximizer/satisficer survey scores were not associated with self-reports of depression, anxiety, or illness anxiety. Mean scores on the maximizer/satisficer survey did not differ among the aesthetic, functional, and reconstructive groups.

CONCLUSIONS

The maximizer/satisficer survey captures an aspect of patient care not traditionally measured by standard clinical psychometric screening tools to help predict satisfaction. A short questionnaire targeting consumer decision-making may be a helpful tool for preoperative counseling.

Primary Open Rhinoplasty

LEARNING OBJECTIVES

After studying this article and viewing the videos, the participant should be able to: 1. Describe the operative technique necessary to perform open rhinoplasty. 2. Summarize the steps necessary in performing a component dorsal reduction. 3. Develop a surgical plan for nasal tip shaping and cephalic rotation of the nasal tip. 4. Identify the need for aesthetic improvement of the alar base, and perform successful alar base surgery. 5. Demonstrate consistency, safety, and predictability in rhinoplasty.

SUMMARY

Rhinoplasty remains one of the most challenging procedures in plastic surgery, and continues to be one of the top five aesthetic surgical procedures, with over 223,000 performed in 2016. Rhinoplasty may be performed by means of the "open" or the "closed" approach, and each approach has its advantages and disadvantages. This article focuses on the open approach, and the principles and techniques necessary to achieve consistent and gratifying results. As with all plastic surgery procedures, successful rhinoplasty begins with a thorough clinical analysis, definition of the goals, meticulous preoperative planning, precise operative execution, vigilant postoperative management, and a critical analysis of one's results.

Nasal Analysis: Considerations for Ethnic Variation

As the United States continues to be more ethnically and racially diverse, it is important for the rhinoplasty surgeon to have an appreciation and understanding of nasal variations that exist to plan for and execute ethnically congruent results. The nasal analysis is a critical component of the patient evaluation, which has been used as a tool by surgeons to identify deviations from anatomical norms or canons. In this article, the authors describe common nasal anatomical variations that exist between ethnic groups as a guide for nasal analysis. Understanding these variations will facilitate and help define important cultural aesthetics, which can be used to plan for rhinoplasties in a diverse patient population.

Vertical Alar Folding (VAF): A Useful Technique for Correction of Long and Concave Lateral Crura in Rhinoplasty

BACKGROUND

The tripod theory explains the dynamics of the nasal tip, where surgery is difficult because of anatomic variations and pathologies and the various surgical possibilities. Abnormalities or weaknesses of the lateral crura can result in concavity in ala or alar collapse and cause aesthetic and functional impairments of the nose. Several tip plasty techniques and lateral crura modifications are used in rhinoplasty.

OBJECTIVE

To describe the vertical alar folding (VAF) technique for making modifications in the lateral crura (LC) and rotation of the tip.

METHODS

Included in the study were 83 patients (59 women, 24 men) undergoing rhinoplasty using VAF with the senior author as surgeon between 2013 and 2018. The mean age was 26.3 years (range 18-47). Mean postoperative follow-up period was 26.7 months (range 12-64). Patients who completed the 1-year postoperative period completed the rhinoplasty outcome evaluation (ROE) questionnaire. Outcome measures were performed at examinations, and preoperative and postoperative photographs of the patients were analyzed.

RESULTS

In the span of 5 years, no revision surgery was required for technique-specific reasons. In patients who had a droopy or asymmetric tip or long and concave lateral crura, we saw remarkable functional and aesthetic improvements with VAF. According to the ROE questionnaire, 90.3% (75 out of 83) of the patients were content with the aesthetic and functional results.

CONCLUSION

VAF is a useful and effective method for modifying the LC and tip of the nose. VAF allowed for controlling the rotation and projection of the tip, changing the length of the lateral crus and nose with durability and smooth, symmetric contours, and correcting concavity of a lateral crus for better functioning and aesthetics.

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 .

Satisfaction in Patients After Rhinoplasty Using the Rhinoplasty Outcome Evaluation Questionnaire

Introduction

Rhinoplasty is a challenging procedure. The goal of the surgery is not only to restore the function and youthful appearance of the nose but also to improve quality of life. With the passage of time, the trend has been changing rapidly from more invasive to less invasive procedures. Although the technical aspects of rhinoplasty are important, patient satisfaction is the factor that dictates the success of the procedure.

Materials and methods

A total of 118 rhinoplasties were performed in our department between 2016 and 2018. The Rhinoplasty Outcome Evaluation (ROE) questionnaire was used to study the patients' satisfaction level. Ninety out of 118 patients took part in this study. Rhinoplasty was done using an open technique in all cases. The ROE questionnaire was filled preoperation and six months postoperation. Data analysis was done using SSPS statistic version 20 (IBM Corp., Armonk, NY, US).

Results

The main reasons for rhinoplasty in our patients were: aesthetic 23.3% (n=21), functional 25.5% (n=23), and a combination of both in 51% (n=46) patients. The mean ROE score of all patients preoperation was 30.5 (males: 31.3, females 29.8) and the mean score postoperation was 79.5 (males 78.2, females 80.9) at six months with no statistical differences (CI 17.11 - 12.59, P=0.762). However, both genders showed a statistically significant improvement between the preoperative and postoperative scores (mean difference = 49.3, CI 63.25 - 35.34, P<0.01), indicating an overall good satisfaction level after surgery. The satisfaction level of patients was inversely proportional to their level of understanding and knowledge of the surgical procedure. This difference was statistically significant ( CI 7.36-10.42, P<0.01). Minor corrections or modifications were done in eight patients under local anesthesia, with no significant difference in ROE scores as compared to those who had single surgery (CI 0.7 - 1.6, P=0.92). There was no statistically significant difference in the before and after surgery ROE scores among patients operated by different surgeons as well (P=0.82).

Conclusion

Our study shows that rhinoplasty, despite being a complex procedure, has proven benefits in terms of functional as well as aesthetic outcomes. The ROE questionnaire proves to be a valid tool for estimating patient satisfaction in our population. There is a need for further training and education of surgeons in Pakistan to improve the functional and aesthetic disabilities of nasal deformities.

Radiological assessment of the lateral osteotomy line-lacrimal system distance on three-dimensional models

AIMS

One of the most commonly performed operations in aesthetic, plastic, and reconstructive surgery is rhinoplasty, the aim of which is to construct an altered nasal shape, either for aesthetic or functional reasons. The lateral osteotomy is the most traumatic step of rhinoplasty, and is generally difficult to perform. The lacrimal system can be damaged during the lateral osteotomy procedure. In this study, we aimed to measure the distance between the lacrimal system and the lateral osteotomy line, and to determine the safe and ideal osteotomy level, which is very important in rhinoplasty procedures. We also evaluated the safe relationship of this osteotomy level with the lacrimal system by constructing a three-dimensional model.

MATERIALS AND METHODS

The three-dimensional models were constructed on axial planes using paranasal computed tomographic (CT) images of 40 male and 40 female patients. The 'lateral osteotomy model' was designed in three dimensions. The axial CT images were obtained from the model. On the CT images, the distance between the lateral osteotomy line and the lacrimal system was assessed by measuring three distances. The first was the distance between the anterior lacrimal crest and the lateral osteotomy line. The second was the distance from the midpoint between the anterior lacrimal crest and the inferior meatus to the lateral osteotomy line. The third was the distance between the opening of the lacrimal canal to the inferior meatus and the lateral osteotomy line.

RESULTS

No lacrimal system injury was seen on any of the models. The shortest distance was found between the anterior lacrimal crest and the lateral osteotomy line, measured at 4.5 mm and 5.0 mm in the female and male patients, respectively.

CONCLUSION

Performing the lateral osteotomy meticulously while paying attention to remaining anterior to the medial canthal ligament will not lead to any lacrimal system injury.

A Novel Method to Enhance Dynamic Rhinoplasty Outcomes: Double "V" Carving for Alloplastic Grafts

Augmentation rhinoplasty is one of the most common plastic surgery procedures performed in Asia. Most Asian patients desire not only a natural-looking nose but also a nose with natural feel. Achieving such rhinoplasty outcomes with grafts has been a challenge for surgeons due to rigidity of grafting material. We propose a novel technique to address this limitation. A total of 200 healthy adult patients aged from 18 to 25 years were randomly chosen and classified into 5 groups: A, B, C, D, and control. Each group included 40 patients. The patients assigned to conventional grafting underwent rhinoplasty with L-shaped silicone prosthesis (group A) or expanded polytetrafluoroethylene (e-PTFE; group B), using traditional carving methods. The patients assigned to dynamic rhinoplasty underwent silicone (group C) or e-PTFE grafts (group D) using the modified double "V" method, which involves removing bilateral wedges from the graft to decrease rigidity. Patients in control group do not undergo the surgery. A 3-dimensional raster surface scanner was used to capture the images of the patients accurately and nasal mobility was measured. Subjective evaluations were carried out by a series of questionnaires asked to the patients. The angle α of nasal mobility was significantly lower in conventional grafting (23.09 [5.34] mm for silicone and 17.88 [4.96] mm for e-PTFE) versus the "V" carving (30.53 [3.76] mm for silicone and 23.77 [4.53] mm for e-PTFE; P < .05). The double "V" carving method is a simple, effective, and practical method for improving dynamic nasal outcomes in patient undergoing augmentation rhinoplasty.

The Association Between Facial Proportions and Patient Satisfaction After Rhinoplasty: A Prospective Study

Hypothesis

Rhinoplasty is one of the most common aesthetic surgeries. The aim of the study was to evaluate facial proportions and patient satisfaction with the appearance of their nose after rhinoplasty compared to preoperatively.

Methods

This cross-sectional study was conducted at Islamic Azad University, Mashhad Branch. Eighty-two candidates with indications for primary cosmetic rhinoplasty were selected. Facial proportions and patient satisfaction with their nasal appearance were evaluated before and 6 months after rhinoplasty. Patient satisfaction was assessed using the Rhinoplasty Outcome Evaluation questionnaire.

Results

Eighty-two patients referred for cosmetic rhinoplasty (13.4% men and 86.6% women) with a mean age of 28.5 (6.4) years underwent open rhinoplasty and were evaluated. Facial proportions, including nasofrontal, nasolabial, and nasomental ratios increased significantly, while the nasofacial ratio, nasal tip projection, columellar show, alar base, and nasal length reduced significantly after rhinoplasty (P < .05). Furthermore, patient satisfaction with the appearance of their nose increased significantly after surgery (P < .001).

Conclusion

All of the facial proportions changed significantly following rhinoplasty. Although patient satisfaction with nose appearance increases significantly after the operation, there is no significant association between patient satisfaction and facial proportions. As beauty is a subjective, relative and qualitative issue, facial proportions may not be a proper tool to determine facial beauty and predict the satisfaction rate following rhinoplasty.

Outcome of Septorhinoplasty in Deviated Nose Deformity: One Year Cross-Sectional Study

To evaluate outcome of Septorhinoplasty in Deviated nose deformity using Nasal Obstruction Symptom Evaluation (NOSE) scale and Rhinoplasty outcome evaluation score (ROE). This observational study was conducted in the department of Otorhinolaryngology and Head and Neck Surgery of KLE University's Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Center, Belagavi from January 2015 to December 2015. Forty patients were evaluated and comparisons were made for NOSE score preoperatively and postoperatively. Comparison of decrease in NOSE score with age distribution, sex distribution, type of septorhinoplasty, ROE score of patients and ROE score of surgeons were also made. ROE score of patients and ROE score of surgeons were correlated. Their statistical significance (p value) and Cohen's kappa (k) were calculated. Out of 40 patients, there were total of 16 Open Septorhinoplasty cases and 24 Close septorhinoplasty cases. NOSE score preoperatively and postoperatively showed statistically significant i.e., total score (p = 0.001). ROE score of patients and surgeons had poor correlation (k = 0.1; p = 0.2). Decrease in NOSE score postoperatively with ROE score of patients showed statistically significant (p = 0.01). There was no significance on comparison of decrease in NOSE score postoperatively with ROE score of surgeons (p = 0.09), age distribution (p = 0.1), sex distribution (p = 0.2) and septorhinoplasty (open/close) (p = 0.2). The outcome of septorhinoplasty has been validated with NOSE scale and ROE score and has been proven that there is improvement in nasal obstruction and quality of life after septorhinoplasty. The quality of life scoring is essential for patients subjected to septorhinoplasty for assessing success of the surgery.

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.