Immediate secondary rhinoplasty using a folded dermofat graft for resolving complications related to silicone implants: A case report

BACKGROUND

Various surgical techniques have been developed to enhance the nose shapes of Asian patients. Silicone implant augmentation rhinoplasty is widely used because it is relatively easy to perform and often yields satisfactory outcomes. However, this technique may lead to complications, including ischemia, necrosis, and over-augmentation. The most appropriate management of these complications, including infection, is immediate implant removal and revision surgery once the accompanying inflammation has healed. Occasionally, the patient may experience distress from nasal deformities during the intervention period.

CASE SUMMARY

Herein, we describe the case of a patient who underwent a secondary dorsal augmentation, with a folded dermofat graft harvested from the inguinal area and simultaneous implant removal, successfully preventing dimpling of the nasal deformity.

CONCLUSION

This surgical method can effectively manage implant-related complications following augmentation rhinoplasty using a silicone implant and provide satisfactory patient outcomes.

Outcomes of Open Rhinoplasty for Unilateral Cleft Patients using Photogrammetric Analysis - An Evaluative Study

Introduction

Secondary cleft rhinoplasty is a challenge due to the complex anatomy of the nose, with structural deformity and difficulty in surgical management. This study aimed to evaluate the effect of an anatomical-based approach on enhancing tip and alar symmetry in secondary unilateral cleft rhinoplasty using photogrammetric evaluation.

Methods

The study was conducted on 57 adult patients seeking rhinoplasty after primary repair of congenital unilateral cleft lip deformity. All patients were operated upon using an external open rhinoplasty approach using an anatomical-based surgical technique. The cases were periodically followed up at three, six, 12 and 18 months for both aesthetic and functional outcomes with photogrammetric analysis of facial profile using the software Mirror Suite programme to compare before and after the surgical procedure.

Results

The photogrammetric analysis showed a significant improvement of facial angles (P = 0.05). The nasofrontal angle changed from a median of 146° to 132.5°, nasolabial angle of 73° to 95°, nasofacial angle of 21.5° to 32° and nasomental angle of 105° to 130°. The rotation angle of the nasal tip showed a significant cephalic rotation with a mean increase of the tip elongation of 1.8 cm achieved per lateralised millimetre.

Discussion

Secondary rhinoplasty in unilateral cleft deformities needs accurate evaluation of the anatomical and pathological abnormalities. Open approach is preferred with using costal cartilage graft allowing adequate columellar lengthening, maxillary enhancement and alar repositioning which leads to optimise the definition, projection and cephalic rotation with better stabilisation and symmetry of the nasal tip.

Anatomy of the nasal latero-lateral cartilage articulation: a micro-MRI study in human specimens

PURPOSE

To study the anatomy of the latero-lateral joint (LLJ) between the upper lateral (ULC) and lower lateral (LLC) crus of the nasal cartilages, usually described as a scroll articulation.

METHODOLOGY

Six nasal pyramids were taken in monobloc from fresh cadavers and imaged on micro-MRI with 0.4 mm slice thickness. Images were jointly interpreted by two head and neck radiologists and one surgeon. The junction between the ULC and LLC, the presence of ligaments and of sesamoid or accessory cartilages were assessed.

RESULTS

Eight LLJs could be analyzed, with four types of junctions: hook-shaped cephalic border of the LLC turned towards the nasal fossa and linear caudal border of the ULC (n = 3), hook-shaped caudal border of the ULC and linear cephalic border of the LLC lateral crus (n = 1), hook-shaped border of both cartilaginous edges with clinging (n = 1) (scroll articulation) or without clinging (n = 3). No ligament or sesamoid cartilage was found, but posterior accessory cartilages were seen in 75% of the cases.

CONCLUSION

The classical scroll articulation of the LLJ has been observed in only 1/8 cases on micro-MRI images. The anatomy of the LLJ could explain the surgical difficulty in raising the tip of the nose in some patients and not in others.

Unilateral cleft nose deformities at adulthood

Secondary rhinoplasty is a challenging procedure, requiring a precise preoperative diagnosis of nasal deformities before correcting them. As there is currently no accepted outcome measurement tool available to assess unilateral cleft lip and palate (UCLP) nose sequelae before secondary rhinoplasty. The goal of this retrospective study is to identify the nose deformities and rate them in an evaluation scale that allows collecting and analyzing cleft nose data. Our retrospective cohort is composed of 29 patients with UCLP, who underwent secondary rhinoplasty between 2010 and 2021 in a cleft center, with a mean age of 23years old. Evaluation of deformities is made from preoperative two-dimensional photography. The assessment photographic tool is a custom-designed scale of 16 items. A binary scoring system is used by two experts to assess nasolabial deformities. The most encountered sequelaes are the alar foot displacement (93%), the enlarged tip (90%) and the nostril horizontalization (86%). The inter-examiner ICC for total rating was calculated at 0.911 and indicated a strong level of reliability that was highly significant (P<0.05). The simplicity, reliability and reproducibility of the proposed assessment system could be interesting for clinicians, in order to diagnose the nasal deformities before surgery, but also to assess postoperative success of a secondary rhinoplasty and thus to compare several surgical techniques.

Nasal fractures: a dedicated clinic providing reduction under local anaesthesia improves time to manipulation

INTRODUCTION

Guidelines for nasal injury state that assessment should be at 7-10 days post-injury and manipulation within 14 days. We performed a plan, do, study, act improvement cycle to assess whether a dedicated nasal fracture service led to better outcomes.

MATERIALS AND METHODS

A retrospective study was carried out of all patients undergoing manipulation under anaesthesia for nasal trauma between February 2013 and December 2016 in a district general hospital. A dedicated nasal fracture clinic providing manipulation under local anaesthesia was implemented followed by a prospective study of all patients presenting to the clinic between February and November 2017. Main outcome measures included time from injury to otolaryngology assessment, time from injury to manipulation and incidence of secondary septorhinoplasty.

RESULTS

The retrospective series involved 525 patients including 381 males (72.6%) and 144 females (27.4%). Mean time from injury to assessment was 10 days. Mean time from injury to surgery was 14.5 days. Mean time from assessment to surgery was five days. The incidence of septorhinoplasty was 2.3%. The prospective series involved 119 patients including 78 males (65.5%) and 41 females (34.5%). Following implementation of a nasal fracture clinic, mean time from injury to assessment and manipulation was 6.1 days and 5.4% of patients underwent septorhinoplasty for secondary deformity.

DISCUSSION

Implementation of a nasal fracture clinic providing reduction under local anaesthesia reduced the time to assessment and manipulation. The incidence of septorhinoplasty is low following reduction under general or local anaesthesia. Assessment earlier than seven days is feasible and advice for referral can be changed accordingly.

A national survey of functional septorhinoplasty surgery performed in the United Kingdom: a clinician end-user questionnaire to assess current practice and help inform future practice

PURPOSE

The aim of this national survey is to assess the current practice of functional septorhinoplasty (SRP) surgery in the UK and better inform future practice.

METHODS

An ENT-UK approved questionnaire was sent out to all 135 consultant members of the British Society of Facial Plastic Surgery (BSFPS). Data was collected on numbers of functional SRPs performed on the NHS, use of outcome measures, psychology and photography support, antibiotic use, referral base and consenting practice.

RESULTS

The response rate was 38.5%, with 52 out of 135 completed. The median number of annual SRP cases per surgeon was 40. Most surgeons (95%) used clinical photography as an outcome measure. However, 27% of the respondents use a subjective outcome measurement and 3% of them use an objective outcome measurement. Only 34% had access to psychology support and 60% receive their referrals from primary care. All surgeons counsel patients for aesthetic change, 15% mention CSF leak and 38% mention olfactory disturbance. The key comment from our respondents was to relabel the rhinoplasty procedure as a functional SRP procedure with the aim to remove it from the Procedures of Limited Clinical Value (PoLCV) list.

CONCLUSION

The majority of our respondents perform a large proportion of the SRP surgeries in the UK with each of the respondents performing an average of 40 SRP surgeries per year. There is a need to recatergorise functional septorhinoplasty as a functional operation and recommend functional SRP surgery to be removed from the PoLCV list.

Complications in septoplasty based on a large group of 5639 patients

Purpose

Septoplasty is a common surgical procedure used for correction of the nasal obstruction caused by a deviated septum. The aim of the study was to identify complications in septoplasty and analyze incidence depending on the surgical technique, based on the material from 2009 till 2017.

Methods

The material consisted of 5639 medical records from patients aged 16–69, operated in the tertiary referral center. Patients were divided into two groups (2784 exclusively with septoplasty and 2855 with combined septoplasty and turbinoplasty). Z test for the equality of two proportions was made to investigate the assumption that the proportions from two populations are equal, based on two samples, one from each population.

Results

Complications were listed according to international standards. Among the whole study group, different types of complications were noted in 193 patients (3.42%). The most frequent complication was excessive bleeding. Significant differences were observed between the two investigated groups. In patients with combined septoplasty and turbinoplasty septal hematoma, hyposmia, prolonged healing due to infection, adhesions and temporary reduced visual acuity were significantly more often encountered.

Conclusions

Meticulous attention to detail in identifying the appropriate anatomy and maintaining good visualization is the key to a safe and effective septoplasty, enabling for very low complication rate.

Influence of nasal septum deformity on nasal obstruction, disease severity, and medical treatment response among children and adolescents with persistent allergic rhinitis

OBJECTIVE

To evaluate the impact of different types of nasal septum deformity (NSD) on nasal obstruction, rhinitis severity and response to medical treatment among pediatric persistent allergic rhinitis (PER) patients.

METHODS

In a prospective, real-life study, 150 children and adolescents (mean age 13 ± 2.8 years, females 32.6%) diagnosed with PER according to ARIA guidelines were assessed by nasal endoscopy for NSD according to Mladina's classification, their response to medical treatment (intranasal steroids and antihistamines or antileucotriens), the presence of comorbidities, rhinitis severity (modified-ARIA criterion) and nasal obstruction visual analog scale score (VAS).

RESULTS

Most patients (87%) had 1 of the 7 types of septal deformities. There was a high prevalence of bilateral (types 4 and 6; 46%) and anterior unilateral (types 1 and 2; 25%) NSD in patients not responding to medical treatment. Type 4 (OR = 6.4; p = 0.005) or type 6 (OR = 4.4; p = 0.03) NSD increased the risk of lack of improvement with medical treatment. Coexistence of anterior unilateral or bilateral NSD with severe turbinate enlargement increased >20-fold the risk of lack of improvement. Patients with bilateral NSD presented greater rhinitis severity. Non-responder adolescents displayed higher prevalence of bilateral NSD than children (53% vs. 23%; p = 0.02). Nasal obstruction VAS was higher for patients with anterior than posterior NSD, and greater for patients with bilateral NSD than any other type of septal morphology.

CONCLUSION

Nasal endoscopy shows that bilateral and unilateral anterior nasal septum deformities are strongly associated with a poor response to medical treatment, greater rhinitis severity and higher nasal obstruction VAS. Consequently, nasal endoscopy is necessary in the PER patients to understand the disease severity as well as to plan a specific surgical treatment in order to improve nasal obstruction, disease severity, and patient's quality of life.

The effect of a Le Fort I incision on nose and upper lip dynamics: Unraveling the mystery of the "Le Fort I lip"

INTRODUCTION

Postoperative flattening of the upper lip with loss of lip pout and down turning of the corners of the mouth is often seen after Le Fort I surgery. We aim to determine which facial muscles are involved in this phenomenon to update the literature on this subject.

METHODS

In 6 cadavers, a unilateral Le Fort I incision was executed. After removal of the skin, all individual facial muscles were identified and submitted to bilateral tactile traction, comparing incised sides with non-incised sides.

CONCLUSION

All the components of the deep layer of the modiolus alae nasi (transverse part of the nasalis muscle and the myrtiformis muscle) and the deep layer of the midface musculature (levator anguli oris muscle) were transected by the Le Fort I incision. After performing the incision, the majority of the depressor septi nasi is intact. Further, the superficial layer of the midface musculature is intact but it loses tension because of its connection to the deep layer. This study suggests the importance of correctly suturing the deep muscular layers to maintain the 3-dimensional facial contour. Moreover, in this cadaver study, we attempt to predict the functional consequences on the impairment of facial mimics related to the Le Fort I incision.