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Conservative subtraction-addition rhinoplasty.

The deviated external nose remains a difficult technical challenge to even the most masterful rhinoplastic surgeon. The classic septorhinoplasty approach to the deviated nose demonstrated a 9.8% revision rate in this study. During a 2-year period, the conservative subtraction-addition rhinoplasty procedure was developed, which subsequently reduced the revision rate to 1.3%. Conservative subtraction-addition rhinoplasty foregoes aggressive septal surgery and equalizes and enhances the airway through asymmetric turbinate volume reduction. Minimal bony and upper lateral work through rasping, soft tissue removal, and/or cartilage grafting allows for external nasal alignment. Both internal and external conservative subtraction-addition rhinoplasty components thus maintain perioperative structural stability and ensure long-term nasal symmetry.

Humans↗

Revision rhinoplasty: review of deformities, aetiology and treatment strategies.

Rhinoplasty has always been one of the most challenging aspects of facial surgery as it requires a precise assessment of the deformity, a strong grasp of nasal support mechanisms plus soft tissue skin envelope and a realistic appraisal of the outcome expected acutely and over a long period of time. This fine balance is often achieved by retrospective analysis of post-rhinoplasty results in order to highlight repeated problems and improve upon them. This study reviews 110 patients in which a total of 407 deformities were found. These are divided into upper, middle and lower thirds with a subdivision of individual deformities within each group. There is also a comparison of the results obtained from similar studies over a period of four decades to those in our study, which reveals that the post-rhinoplasty deformities noted in these studies occur with a similar frequency to those in our paper.

Adult↗

Open tip rhinoplasty along with the repair of cleft lip in cleft lip and palate cases.

This paper is a report on a procedure to perform open tip rhinoplasty at the time of lip repair in unilateral and bilateral cleft lip and palate deformity. A total of 69 patients who had this operation between 1994 and 1997 have been reviewed. Conventionally there is hesitation to do radical nasal correction for the cleft lip patient because of the fear of possible growth retardation. The present technique, while it achieves excellent postoperative results constantly, does not entail any more trauma to the cartilage complex than any of the conventional closed rhinoplasty techniques. Early results obtained by this method appear to be superior to those by closed rhinoplasty techniques.

Child, Preschool↗

Reconstructive rhinoplasty.

Reconstructive rhinoplasty for larger nasal defects requires a three-dimensional perspective using many of the aesthetic and functional techniques commonly employed in rhinoplasty. There are numerous ways of addressing a deficiency of the internal lining and each technique is detailed. Structural grafting is imperative in order to resist the contracture and collapse of the reconstructive nose. These grafts are also used to enhance contour and definition. Resurfacing of large cutaneous defects is frequently achieved through the midline forehead flap. There are many subtle maneuvers which can significantly impact the final aesthetic outcome and these are discussed below. This article highlights the three-layered approach to subtotal and total reconstructive rhinoplasty.

Adult↗

A systematic, graduated approach to rhinoplasty.

Rhinoplasty may be viewed as one of the most technically demanding procedures in facial plastic surgery and requires a level of sophistication derived from diligent study, repetitive execution, and critical review. During the preoperative evaluation, the physician must exercise a systematic approach that includes a thorough investigation into the psychological and physical aspects of the individual patient. A systematic, graduated approach should be undertaken in every rhinoplasty in which the three cornerstones-planning, simplicity, and flexibility-are recalled. Planning entails a thoughtful and critical analysis of what surgical techniques may be best enlisted to achieve the envisioned aesthetic effect. Simplicity argues in favor of performing only those surgical procedures needed to accomplish the task at hand to minimize the variables that arise from protracted, ill-defined surgery. Flexibility implies that the surgeon be capable of modifying his plan if unforeseen operative events disrupt the proposed course of action. All three principles reflect the authors' philosophy about the surgical approach to rhinoplasty, that is, the discretionary use of endonasal (nondelivery and delivery) and external incisions as warranted by circumstance.

Attitude to Health↗

Structural grafting in rhinoplasty.

Many surgeons consider cosmetic rhinoplasty to be one of the most challenging facial plastic surgical procedures. Open-structure rhinoplasty allows for visualization of bony-cartilaginous deformities, preservation of nasal structural integrity, and precise nasal reshaping. The ultimate, external appearance of the nose is the sum of the interaction of the bony-cartilaginous skeleton and the skin soft-tissue envelope. This article describes the use of autologous, structural cartilage grafts in primary and secondary rhinoplasty. Emphasis is placed on the use of septal, auricular, and costal cartilage grafts to provide for a structurally sound skeletal framework and thereby a predictable postoperative result. Deformities of the middle and lower third of the nose are specifically addressed.

Biocompatible Materials↗

Rhinoplasty in the older adult.

In attempting to determine the suitability of an older person for cosmetic rhinoplasty, the surgeon must keep in mind not only anatomical considerations, but also, even more important, the emotional and psychological expectations of each patient. The surgeon should make every attempt preoperatively to arrive at a meeting of the minds with the patient, so that he has a thorough understanding of that patient's desires, needs, and hopes. If the surgeon believes he is able to achieve or even come close to his patient's goals by a conservative operative approach, there is no reason why a rhinoplasty should not be undertaken. However, it is the author's experience that rhinoplasty in the older patient often fails to produce a result wholly satisfactory to the patient and the physician, and it is necessary to keep this in mind when selecting patients.

Adult↗

Functional sequelae of rhinoplasty.

Rhinoplasty is one of the most challenging surgical procedures. Surgeons should strive to obtain maximum aesthetic and functional results with minimal operative intervention. Excessive surgery often results in unwarranted impairment of nasal function. The obstructive or sensory complications of rhinoplasty can occur in the early or late postoperative periods. The most common functional sequelae of rhinoplasty, and their causes, prevention and therapy, are discussed.

Airway Obstruction↗

Constriction of the internal nasal valve in rhinoplasty: treatment and prevention.

The anatomy and functional physiology of the internal nasal valve and the potential problems that may develop with it during rhinoplasty are discussed. The operative maneuvers that may compromise the nasal valve serve as a basis for explaining a treatment approach. Treatment primarily deals with the problems generated by scar contraction, excision of lining and cartilage, and malposition of various nasal parts. In rhinoplasty, one must preserve the integrity of the internal nasal valve by preventing scar constriction and maintaining cartilage support. All intranasal incisions should be closed carefully with meticulous suturing. The surgeon should strive to preserve the medial attachment of the upper lateral cartilage to the septum. The caudal border of the upper lateral cartilage should not be trimmed. Lining should not be excised at the level of the internal valve, or distally. If scar constriction occurs or cartilage instability develops, the goal of treatment is restoration of valve function by excision of all scar tissue, repositioning the cartilage framework, and reconstruction using full-thickness and composite skin-cartilage grafts. The value of the intracartilaginous incision in preventing injury to the internal nasal valve is emphasized. Many of the established procedures in rhinoplasty that may endanger the nasal valve are discussed.

Cicatrix↗

Rhinoplasty saw: a modified design.

One of the instruments used for osteotomies of the nasal bones in rhinoplasty is the saw. During the initial sawing movements, it is not uncommon to make multiple cuts in the bone. To avoid this problem, we have designed a modification of the Joseph's saw. The new design essentially fixes the saw along a single axis, producing a single and precise bone cut. This saw is useful for basal and superior osteotomies in rhinoplasties and is especially indicated in secondary rhinoplasties.

Equipment Design↗

A prospective study of patients' psychological reactions to rhinoplasty.

One hundred twenty-one of 200 patients requesting a rhinoplasty completed a study designed to assess their psychological reactions to the operation. Preoperatively, each patient filled out a questionnaire about their expectations (both cosmetic and psychological), relationships, self-confidence, self-esteem, what they disliked about their noses, and other questions pertinent to an evaluation of the psychological effects of rhinoplasty. They also completed the Brief Symptom Inventory (BSI), a standardized psychological test. One month and 6 months postoperatively, they completed similar questionnaires. Preoperative and postoperative information was also obtained from the surgeon and nurse. Statistical analysis showed several interesting findings. A number of patients had increased self-confidence and self-esteem. Male patients did not show any sustained changes on the BSI, but female patients did with improved scores on the obsessive-compulsive, interpersonal sensitivity, depression, anxiety, and phobic anxiety scales. A number of patients described mild-to-moderate depression postoperatively. This was correlated with preoperatively high levels of anxiety. The surgeon was usually more critical of the surgical result than were the patients. The patients whose strong positive feelings about the results he most misjudged were actually depressed. These and other findings are noteworthy to enhance the understanding of postoperative psychological reactions and provide insight into the psychological management of rhinoplasty patients.

Attitude of Health Personnel↗

Experience with a three-point method for planning rhinoplasty.

Three aesthetic parameters, based entirely on nasal surface soft tissue morphology, can be used to formulate a practical rhinoplasty strategy. They are, in order of ascending importance: (1) skin thickness and distribution, (2) tip lobular configuration, and (3) the balance between nasal base size and bridge height. These three parameters, chosen because of their broad ramifications for a successful rhinoplasty result, help determine the need and method for dorsal and tip reduction or augmentation, and recognize the constancy of preoperative skin sleeve distribution, particularly at the nasal base. The strategy is equally useful in primary and secondary rhinoplasty. Because their effects are regional, all other decisions (e.g., osteotomies, alar wedge resection, nasal shortening, valvular reconstruction) are secondary and can be made independently.

Adult↗

The 'butterfly' graft in functional secondary rhinoplasty.

OBJECTIVE: To describe a surgical technique (the conchal cartilage "butterfly" graft) which, when used in properly selected patients, has been found to be a dependable method for alleviation of postrhinoplasty internal nasal valve dysfunction. STUDY DESIGN: Retrospective chart review. METHODS: Analysis of consecutive patients with weakness and/or collapse of the upper lateral cartilages following rhinoplasty. Seventy-two patients (37 women and 35 men, age range 17-76 y) had severe nasal obstruction and were found to have indications for this procedure. All patients had undergone at least one rhinoplastic procedure. All patients were followed for a minimum of 2 years after surgery. RESULTS: All 72 patients experienced significant subjective improvement in relative nasal obstruction. Two patients (3%) reported less than total resolution of their difficulty breathing through their nose; the remaining 70 patients (97%) reported complete resolution of their nasal airway problems. No patients reported their postoperative nasal obstruction as the same or worse than their preoperative baseline. Sixty-two patients (86%) reported improvement in the appearance of their nose, 8 patients (11%) felt that their appearance was unchanged, and 2 patients (3%) felt that the appearance of their nose was made worse by the procedure. CONCLUSIONS: Patients presenting with nasal obstruction after rhinoplasty are frequently found to have collapse and/or weakening of their upper lateral cartilages with resulting nasal valve dysfunction. The conchal cartilage "butterfly" graft is a technique which, when properly performed during revision rhinoplasty, yields predictable functional and cosmetic results with minimal morbidity.

Adolescent↗

External approach for secondary rhinoplasty.

A systematic approach, using the external rhinoplasty technique, is presented to aid the plastic surgeon in obtaining improved aesthetic and functional results in patients with postoperative nasal deformities. In over 100 external rhinoplasties, there were no problems with the stairstep transcolumellar incision used to provide complete visualization of the underlying nasal framework. The external approach allows for a more accurate intraoperative anatomic diagnosis and subsequent complete correction of the nasal deformity. Three case reports are presented to demonstrate the indications and versatility of the external approach in secondary rhinoplasty.

Adolescent↗

On rhinomanometry in rhinoplasty.

Changes in nasal obstruction, nasal airway resistance, and postoperative nose appearance were evaluated in 92 rhinoplasty patients. Fifty-six patients had a deviation of their nose from the midline preoperatively. They were improved according to rhinomanometry whether the rhinoplasty was combined with a functional septoplasty or with a submucous resection. Among the other 36 patients who did not have a deviation of the nose from the midline, 23 had a rhinoplasty combined with a functional septoplasty and 13 had no surgery on the septum at all. Rhinomanometrically, only patients operated on with the combined operation were improved; the rest became worse, even in terms of nasal obstruction. Among 58 patients from both groups with preoperative nasal obstruction, there was agreement for 76 percent between the subjective and rhinomanometric changes. The advantages of giving the rhinomanometric results in a polar coordinate system are discussed.

Adolescent↗

A fresh look at the open rhinoplasty technique.

Use of the open rhinoplasty technique (ORT) in certain nasal and septal deformities has proven to be an invaluable asset in the rhinoplasty armamentarium of the authors. Primarily owing to the markedly increased exposure with this technique, more accurate assessment of the deformities is possible and additional or improved surgical maneuvers become available, particularly in the tip. Sculpting the entire cartilaginous and/or bony vault, as well as correcting difficult septal malalignments, can be carried out under better direct vision with greater precision, accuracy, and predictability. This has led to improved and more consistent final results. Previous criticisms of unsightly columellar scars have been virtually eliminated through the use of improved surgical techniques and simple magnification. Overall, open rhinoplasty technique can provide many distinct advantages in certain nasal deformities with no real disadvantages over conventional closed techniques.

Adolescent↗

The external shaving technique in aesthetic rhinoplasty.

External shaving is an accepted technique in the treatment of rhinophyma. The application of external shaving to aesthetic rhinoplasty is also valuable in the treatment of a thick, sebaceous nasal tip that does not respond to standard reduction rhinoplasty. External shaving will reduce the thickness of the nasal tip skin and enhance tip definition. Fifty consecutive patients undergoing external shaving were followed over a 5-year period. The majority of the cases were secondary rhinoplasties. The results reveal a very high success rate, with one significant complication, a hypertrophic scar, and two minor complications. Proper diagnosis, patient selection, and surgical technique produce predictable and favorable aesthetic results.

Acne Vulgaris↗

A new technique for nasal tip cartilage graft in primary rhinoplasty.

Inadequate tip projection in traditional rhinoplasty led to postrhinoplasty deformity, which with time got worse. Sheen's vertical shield and Peck's horizontal multiple rectangular stacked cartilage graft have been used to reduce postrhinoplasty tip projection loss. The new two fixed column disk cartilage graft technique at the tip-defining points is designed to combine the advantages of both techniques. This technique can be used in both open and closed rhinoplasty, and the amount of projection can be adjusted to fit the dorsum with relative ease. This technique has been used in 38 primary rhinoplasties with satisfactory results.

Cartilage↗