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PubMed1996

Rhinoplasty patients' critical self-evaluations of their noses.

Many applicants for cosmetic rhinoplasty do not appear to have grossly deformed noses. This study was undertaken to determine the accuracy of nasal evaluations in a group of 20 female cosmetic rhinoplasty patients, before and after surgery, relative to a matched nonrhinoplasty control group composed of 25 subjects. Self-assessments and surgeon assessments were obtained for both groups. Compared with those of controls, the noses of patients were found to be more deformed before and better shaped after the operation, according to both self-assessments and surgeon assessments. Rhinoplasty patients, in contrast to controls, tended to downgrade the shape of their noses compared with surgeon assessments both before and 4 months after surgery. Faulty evaluation was not associated with sociodemographic parameters, brief symptoms index (BSI) scores, or the degree of patient satisfaction from surgical outcome. Replication and longer-term follow-up studies are needed and are anticipated.

Adolescent↗
PubMed1997

The lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic comparison of the external versus the internal approach.

A precise and reproducible lateral osteotomy is a requirement for successful rhinoplasty. Two basic techniques have evolved: the external perforated method and the internal continuous method. The literature supporting the external perforated technique maintains that it contributes to a controlled, stable fracture and produces less nasal airway narrowing, hemorrhage, edema, and ecchymosis; however, the continuous internal method is used by many rhinoplasty surgeons. Our study was designed to compare the two techniques in the fresh cadaver nose using a blinded endoscopic evaluation of the nasal mucosa after the osteotomies were performed by one of these two techniques. Nineteen fresh cadaver heads had an external perforated lateral osteotomy performed on one side and an internal continuous lateral osteotomy performed on the alternate side by an investigator with experience in the use of both osteotomies. In a blinded fashion, four different investigators used nasal endoscopy to detect mucosal perforations and bony irregularities. Eleven percent of the perforated osteotomies resulted in mucosal tearing as opposed to 74 percent of the continuous osteotomies (p < 0.001). This anatomic study confirms our clinical experience that the external perforated osteotomy results in a more controlled fracture with less intranasal trauma and can minimize the associated morbidity (hemorrhage, edema, and ecchymosis) in the rhinoplasty patient.

Adult↗
PubMed1998

An alar base flap to correct nostril and vestibular stenosis and alar base malposition in rhinoplasty.

Nostril and vestibular stenoses can be properly reconstructed by composite grafts from the alar lobule or ear. However, when alar base malposition accompanies the nostril stenosis, composite grafting will enlarge the nostril but not correct the alar base displacement. An alar base flap designed as a crescent adjacent to the alar base, elevated, and transposed on subcutaneous and musculocutaneous perforators corrects the nostril stenosis and repositions the alar base simultaneously. Anterior, active rhinomanometry demonstrates a substantial increase in mean nasal airflow from this reconstructive maneuver alone. The author has used the flap successfully in 29 secondary rhinoplasty patients; survival has been uniformly complete even when the donor tissue has been scarred or burned. All rhinoplasties were performed endonasally, however; the survival of this flap performed simultaneously with open rhinoplasty has not been established.

Adult↗
PubMed1998

A 6-year experience with the use of expanded polytetrafluoroethylene in rhinoplasty.

To date, there are few published large series within the literature on the use of expanded polytetrafluoroethylene (Gore-Tex) in rhinoplasty. This retrospective study, based on chart and photographic reviews, serves to contribute a 6-year experience (mean patient follow-up period, 17.5 months) with the alloplast in nasal surgery amassed by one surgeon. The same technique was used in all the 189 patients reviewed, who received 211 procedures. The 189 patients, 44 male and 145 female and from 15 to 70 years of age, were reviewed 3 months to 6 years after Gore-Tex implantation rhinoplasties. The results were assessed according to the follow-up notes in the chart reflecting patients' and surgeon's comments and full preoperative and postoperative photographic documentation. Patient satisfaction was expressed with respect to aesthetic and functional outcome in all cases. Patient impressions were verified by critical assessment during follow-up examination. The implants showed excellent stability and tissue tolerance. Complications requiring removal occurred in 2.7 percent of implants placed. The authors are of the opinion that, in rhinoplasty, with the exception of the nasal tip, columella, or problems in which corrections would require rigidity of the grafted or implanted material, the Gore-Tex alloplast is an excellent alternative to autografts. Nasal tip or columellar sites do not render adequate soft-tissue cover, allowing the implant to rest close to the surgical incision. Because this creates additional risk of implant extrusion, such locations were avoided in the series of patients presented.

Adolescent↗
PubMed1998

An 18-year experience with the umbrella graft in rhinoplasty.

Inadequate nasal tip projection is the most common problem of primary and secondary rhinoplasty. Inadequate nasal tip projection with inadequate septal support requires an umbrella graft. The umbrella graft consists of a vertical cartilaginous strut between the medial crura and a horizontal onlay graft overlying the alar domes. The umbrella graft supports the nasal tip pyramid and reestablishes nasal tip projection. The statistics included in this report involve 1252 cases from 1986 to 1996, and it was discovered that 22 percent of the patients required an umbrella graft. Most of these patients had secondary rhinoplasties. The revision rate was 5 percent; the most common complication was cartilaginous show. Cartilage graft loss or significant absorption was not observed. A closed rhinoplasty approach with autologous tissue to reconstruct nasal tip projection was used. The umbrella graft technique is time proven, successful, and reproducible.

Adolescent↗
PubMed1999

Asymmetric incision for open rhinoplasty in cleft lip nasal deformity.

One of the problems in the correction of the unilateral cleft lip nasal deformity is the alar web deformity on the mediosuperior side of the nostril. A number of methods for the correction of the alar web deformity have been introduced, but no single procedure has been identified as the standard. In this report, the incision line of the open rhinoplasty was modified and the alar web deformity was corrected by using an incision and closure. Open rhinoplasty with the asymmetric incision was performed on 18 patients with unilateral cleft lip nasal deformity. The incision line used in the normal side was the usual intranasal rim incision line and that used for the columella was the transcolumella incision line. For the cleft side, an intranasal rim incision line was plotted after the rim was lifted upward with forceps to achieve symmetry of the nasal tip. After removal of the forceps, the incision line of the cleft side was displaced outside the nostril. After such an incision, the alar cartilage mobilization and suspension were performed with or without the conchal cartilage graft. All patients used nasal retainers for 6 months after the procedures. So far, satisfactory results have been obtained with the modification of the incision line for open rhinoplasty. This method is unique in designing the incision line, and its procedure is rather simple. The postoperative follow-up period has been 12 to 26 months. A long-term follow-up is still needed, especially in growing children.

Adolescent↗
PubMed2000

The Turkish delight: a pliable graft for rhinoplasty.

In nose surgery, carved or crushed cartilage used as a graft has some disadvantages, chiefly that it may be perceptible through the nasal skin after tissue resolution is complete. To overcome these problems and to obtain a smoother surface, the authors initiated the use of Surgicel-wrapped diced cartilage. This innovative technique has been used by the authors on 2365 patients over the past 10 years: in 165 patients with traumatic nasal deformity, in 350 patients with postrhinoplasty deformity, and in 1850 patients during primary rhinoplasty. The highlights of the surgical procedure include harvested cartilage (septal, alar, conchal, and sometimes costal) cut in pieces of 0.5 to 1 mm using a no. 11 blade. The fine-textured cartilage mass is then wrapped in one layer of Surgicel and moistened with an antibiotic (rifamycin). The graft is then molded into a cylindrical form and inserted under the dorsal nasal skin. In the lateral wall and tip of the nose, some overcorrection is performed depending on the type of deformity. When the mucosal stitching is complete, this graft can be externally molded, like plasticine, under the dorsal skin. In cases of mild-to-moderate nasal depression, septal and conchal cartilages are used in the same manner to augment the nasal dorsum with consistently effective and durable results. In cases with more severe defects of the nose, costal cartilage is necessary to correct both the length of the nose and the projection of the columella. In patients with recurrent deviation of the nasal bridge, this technique provided a simple solution to the problem. After overexcision of the dorsal part of deviated septal cartilage and insertion of Surgicel-wrapped diced cartilage, a straight nose was obtained in all patients with no recurrence (follow-up of 1 to 10 years). The technique also proved to be highly effective in primary rhinoplasties to camouflage bone irregularities after hump removal in patients with thin nasal skin and/or in cases when excessive hump removal was performed. As a complication, in six patients early postoperative swelling was more than usual. In 16 patients, overcorrection was persistent owing to fibrosis, and in 11 patients resorption was excessive beyond the expected amount. A histologic evaluation was possible in 16 patients, 3, 6, and 12 months postoperatively, by removing thin slices of excess cartilage from the dorsum of the nose during touch-up surgery. This graft showed a mosaic-type alignment of graft cartilage with fibrous tissue connection among the fragments. In conclusion, this type of graft is very easy to apply, because a plasticine-like material is obtained that can be molded with the fingers, giving a smooth surface with desirable form and long-lasting results in all cases. The favorable results obtained by this technique have led the authors to use Surgicel-wrapped diced cartilage routinely in all types of rhinoplasty.

Cartilage↗
PubMed2001

Endoscopically assisted, intraorally approached corrective rhinoplasty.

In the field of facial surgery, operations that require guesswork can result in unexpected complications. One example of such "blind" facial surgery is the lateral osteotomy procedure in corrective rhinoplasty. In most conventional corrective rhinoplasties, the postoperative results of a lateral osteotomy can be controlled by the surgeon's visual perception or manual dexterity; therefore, an experienced surgeon is indispensable in such elaborate operations. Until now, reports have focused on the endoscopic approach through the nasal dorsum or septum through the nostril. However, because of the difficulty in handling the endoscope with osteotomy instruments, it is considered difficult to perform a precise lateral osteotomy procedure using that approach. The authors think the intraoral endoscopic approach should be considered a viable alternative in corrective rhinoplasty. Through small, bilateral gingivobuccal incisions, both the piriform apertures and nasal bones can be easily exposed, and the exact level of the lateral osteotomy can be confirmed directly under the endoscope. The lateral osteotomy is made simply with a reciprocating saw, and symmetrical cutting can be ascertained during the operation. Sometimes, a particular osteotomy level or the proper repositioning of osteotomed segments can be readily evaluated with assistance from the endoscope during the operation. Eleven cases using this procedure were performed over the past 3 years. These endoscopic repairs for a deviated nose were quite helpful for visual confirmation and accurate correction. No complications occurred when using the endoscope with this procedure.

Adult↗
PubMed2001

Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution.

To achieve success in rhinoplasty, the plastic surgeon takes advantage of numerous intraoperative techniques designed to manipulate nasal soft tissue and the osseocartilaginous framework. Although the postoperative result may meet preoperative aesthetic goals, an element of nasal airway obstruction can persist from failure to acknowledge the role of inferior turbinates. Surgically responsive inferior turbinate hypertrophy is frequently not addressed secondary to inadequate history taking, incomplete physical examination, and/or surgeon reluctance to handle these sensitive structures. The goal of this article is to discuss the anatomy and physiology of the inferior turbinates, to present the role for inferior turbinate surgery during rhinoplasty, and to delineate the evolution of the current technique of submucosal resection of the inferior turbinates. Over the past 14 years, the senior author (R.J.R.) has performed inferior turbinates surgery on 648 patients as part of a rhinoplasty.

Adolescent↗
PubMed2003

Rhinoplasty in the African-American patient.

Because of the increasing popularity of rhinoplasty in the African-American patient, we delineate how a rhinoplasty surgeon can perform this challenging technique to obtain uniform and consistent results. First, we address how one can appreciate and analyze the various aesthetic concepts of beauty and the unique anatomic characteristics of the African-American nose. Second, we present a pragmatic, systematic analysis of the African-American nose. Last, we describe the techniques consistently used to modify the African-American nose while achieving or maintaining facial harmony using the open approach to rhinoplasty. Specific case analyses are presented to demonstrate utilization of the technique.

Adult↗
PubMed2003

Correction of intrinsic nasal tip asymmetries in primary rhinoplasty.

Preoperative nasal analysis for the rhinoplasty patient is not complete without recognition and characterization of asymmetries. A simplified classification of columellar and intrinsic nasal tip asymmetries has evolved from 15 years' experience with rhinoplasty. Nasal tip asymmetries have vertical and horizontal dimensions. The vertical, or cephalocaudal, causes of tip asymmetry are primarily extrinsic factors. Elements that contribute to tip asymmetry and are extrinsic to the lower lateral cartilages are the bony and cartilaginous septum, the nasal bones, the upper lateral cartilages, and the maxilla. Horizontal or side-to-side asymmetries can be the result of intrinsic lower lateral cartilage abnormalities. The importance of this distinction is to differentiate the patient with a deviated nose and concomitant tip asymmetry from the patient with an isolated, intrinsic deformity of the nasal tip cartilages. A simplified classification system for nasal tip asymmetries is presented along with proposed methods for surgical correction. Case examples are analyzed also. A description of nondestructive suturing techniques and cartilage grafts to restore nasal tip symmetry is provided for each deformity. An open rhinoplasty approach is advocated in all cases.

Female↗
PubMed2004

Diced cartilage grafts in rhinoplasty surgery.

The use of diced cartilage grafts in rhinoplasty surgery was recently revived by Erol with the publication of his technique for "Turkish delight" grafts (i.e., diced cartilage grafts wrapped in Surgicel). The present study details the authors' experience with 50 consecutive diced cartilage grafts used in three configurations during a prospective study of 50 primary and secondary aesthetic rhinoplasty procedures performed by the senior author (Daniel). Part I consists of 22 diced cartilage grafts wrapped in Surgicel and placed in the radix (n = 14), radix/upper dorsum (n = 4), and full-length dorsum (n = 4). All grafts were performed adhering meticulously to Erol's technique without modification. This portion of the study was halted abruptly at 4 months because of the unexpected absorption and clinical failure of all diced cartilage grafts wrapped in Surgicel. Subsequently, five patients had revision surgery, and biopsy specimens were taken at the prior grafting site and analyzed histologically. After this clinical failure, part II of the study began, consisting of 20 patients who had diced cartilage grafts wrapped in fascia. The range of applications was comparable: radix (n = 12), radix/dorsum (n = 3), and full-length dorsum (n = 5). Because of our prior practice of overcorrecting by 20 percent with diced cartilage grafts wrapped in Surgicel, we had excessive amounts of material in six of our initial diced cartilage wrapped in fascia radix grafts, but no subsequent grafts. The overcorrections were easily reduced at 6 weeks to 11 months postoperatively using a pituitary rongeur under local anesthesia, and the material was sent for histologic analysis. Minimum 1-year follow-up of all 20 cases has shown maintenance of the grafts without evidence of absorption. Part III of this study comprised eight patients who had diced cartilage grafts without a fascial covering placed throughout the nose, including on the sides of osseocartilaginous rib grafts to the dorsum. At 14 months, there was no evidence that any of these grafts had been absorbed. Histologic analysis of the biopsy specimens from the diced cartilage grafts wrapped in Surgicel showed evidence of fibrosis and lymphocytic infiltrates with small amounts of Surgicel visible on birefringent microscopy. Remnants of cartilage were present but were metabolically inactive on the basis of negative glial fibrillary acidic protein staining. Control specimens of fresh septal cartilage and banked septal cartilage were remarkably similar to each other and demonstrated normal cartilage architecture and cellular activity. The diced cartilage grafts wrapped in fascia showed coalescence of the diced cartilage into a single cartilage mass, with viable cartilage cells and normal metabolic activity on the basis of glial fibrillary acidic protein staining. All of the diced cartilage grafts wrapped in Surgicel absorbed and failed to correct the clinical problem for which they were performed. All of the diced cartilage grafts wrapped in fascia and pure diced cartilage grafts did correct the clinical deformities and appear to have survived completely. The diced cartilage grafts wrapped in fascia placed along the dorsum were distinctly palpable throughout the postoperative period, as was one prior case with a 6-year follow-up. The authors' clinical experience confirms the experimental studies of Yilmaz et al. that question the use of Surgicel for wrapping diced cartilage grafts in clinical rhinoplasty surgery.

Absorption↗
PubMed2004

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

Augmentation rhinoplasty of the Asian nose may be effectively accomplished with alloplastic materials. However, certain circumstances mandate the use of autologous grafts (e.g., dorsal augmentation that exceeds 8 mm and patient intolerance of alloplastic implants). Septal and auricular cartilages are inadequate for dorsal augmentation of the Asian nose. The use of costal cartilage for autologous augmentation in select Asian patients has proven to be a reliable method in more than 500 operative cases during a 10-year period. This study was designed to evaluate the ideal costal cartilage graft for augmentation rhinoplasty. Forty-two preserved cadavers were studied for the relationship of the individual rib cartilages to the surrounding tissue and for the length and caliber of each costal cartilage. The seventh rib was found to be the ideal rib graft by virtue of its safe location and overall size for grafting. The seventh rib is situated over the abdominal cavity, so the risk of pneumothorax is insignificant. The internal thoracic artery and vein descend in close apposition behind the first to sixth ribs but begin a course medial to the ribs inferior to this point, and therefore vascular injury during seventh-rib harvesting is unknown. The seventh rib also provides the greatest overall available length (90.7 mm, right; 89.6 mm, left) and thickness (17.6 mm, right; 17.5 mm, left). Despite the more conspicuous location of the incision required to harvest the seventh rib, the limited 3-cm incision that is used has healed favorably in almost all cases. The other major drawback for seventh-rib harvesting is the dissection required through the overlying rectus abdominis muscle, but little technical difficulty or postoperative morbidity is added with muscle dissection. The seventh rib is advocated as the ideal choice for augmentation rhinoplasty and potentially other recipient sites.

Asian People↗
PubMed2005

The use of spreader grafts in primary rhinoplasty.

Some candidates for primary rhinoplasty are at greater risk of postoperative complications due to the presence of certain very specific anatomic characteristics. The authors describe their experience with spreader grafts in primary rhinoplasty and provide an analytic method of identifying the types of patient needing such grafts who present a high risk of complications. Sixty patients were treated with spreader grafts during primary rhinoplasty. Bilateral spreader grafts were used in cases of "narrow nose syndrome" (short nasal bones, long and weak upper lateral cartilages, thin skin) and in cases of disproportionate nose with narrow middle vault and bulbous tip. Unilateral spreader grafts were placed on the concave side in cases of crooked nose. After an average follow-up of 17 months, all the patients reported improvement in functional and esthetic problems, with no complications related to the preoperative features.

Adult↗
PubMed2006

Augmentation rhinoplasty using injectable tissue-engineered soft tissue: a pilot study.

In a previous animal study, the authors reported that cultured human fibroblasts suspended in Restylane, which is a modified hyaluronic acid, can produce human dermal matrices with extended in vivo stability. This study was undertaken to evaluate the clinical efficacy of this method, particularly for augmentation rhinoplasty cases. Between January 2002 and June 2003, 11 patients were treated with subcutaneous implants of Restylane mixed with autologous fibroblasts for augmentation rhinoplasty. Of these 11 patients, a long-term follow-up for more than 1 year was possible in 6 patients. Appearance of reconstructed noses, degree and time of resorption, occurrence of complications, and patients' satisfaction were investigated. The injected implants remained in situ without evidence of significant resorption or loss of correction. All patients were satisfied with the achieved long-term results, and no complication occurred. The results obtained indicate that this method is well tolerated and may have a potential to be an effective means of performing augmentation rhinoplasty.

Adult↗
PubMed1993

Open structure rhinoplasty.

Open structure rhinoplasty (OSR) uses the open or external approach via a mid-columellar and bilateral marginal incision. In combination with grafting procedures, such as columellar struts, dorsal grafts and tip grafts, rhinoplasty has developed from a merely reductive procedure to a more graduated approach to the nose. Emphasis is now placed on repositioning, augmentation and restructuring the nasal anatomy to create as natural and functional a nose as possible. This retrospective study analyses our experience with 130 rhinoplasties over a 3-year-period. The study reveals OSR to be a safe and reliable technique which produces predictable results.

Adolescent↗
PubMed2000

Day case rhinoplasty.

Rhinoplasty is considered by many to be an inpatient surgical procedure. This may be because the operation is thought to be traumatic with a risk of epistaxis and periorbital haematoma. Since 1992 rhinoplasty surgery at St George's hospital has been routinely performed on a planned day case basis. The hospital records of 97 patients were examined of which 17 patients (18%) underwent planned admission and 12 (12%) unplanned admission. No patients were re-admitted to hospital after discharge. With the advances in day case surgical practice within the UK we consider that the practice of day case rhinoplasty is likely to have its place. Such surgery should ideally be performed in a dedicated day case unit and provision for admission overnight should be available.

Adult↗
PubMed2004

Severe facial dermatitis as a late complication of aesthetic rhinoplasty; a case report.

BACKGROUND: Contact dermatitis, as a cutaneous complication after rhinoplasty, is of early onset, limited and transient. The cause of this dermatitis is irritant or allergic. Late onset skin complications are rare and non-inflammatory. CASE PRESENTATION: We are reporting an unexpected, severe allergic contact dermatitis of the face, in a young female, appearing one month following aesthetic rhinoplasty. She failed to respond to ordinary treatments for dermatitis. We did standard battery--including nitrofurazone, tincture of benzoin and hydrocortisone--patch test for the patient that showed sensitivity to benzoin and corticosteroid. CONCLUSIONS: In summary we report a case of a severe allergic contact dermatitis of the face, in a 21-year-old girl who underwent corrective aesthetic rhinoplasty, appearing one month following surgical operation. We were unable to find a similar report in the medical literature.

Adult↗