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External rhinoplasty is a valuable tool in the surgical armamentarium of all nasal surgeons. It does not change the dynamics of the operation but offers a new method of exposure. The purpose of this paper is to present our experience with the external rhinoplasty technique in 601 patients, and review the results and complications of this approach to nasal surgery. Two patient reports are presented to demonstrate use of the technique in nasal surgery.
Traditionally surgeons have avoided performing rhinoplasty in conjunction with sinus surgery for rhinosinusitis. With advances in rhinoplasty and endoscopic sinonasal surgery and its added benefits of precision, minimal trauma, and hemorrhage, the combined procedure is now feasible. The indications, management, and results are discussed in 40 patients who underwent the combined procedure. Patients were divided into three categories based on the location and severity of the sinus disease: mild, moderate, or severe. The majority of patients had mild or moderate sinus disease. The most common presenting symptoms were nasal obstruction and postnasal drip. All patients had a history of sinusitis recalcitrant to conservative medical management. Results demonstrate the combined treatment modality to be safe and effective in patients with mild to moderate sinus disease and in selected patients with severe sinus disease.
During the past 6 years the authors have treated 406 patients with classic silicone augmentation rhinoplasty. The types and incidence of complications after subcutaneous or subfascial implantation are examined and discussed. They propose that most complications are related to the depth of the implant and the character of the tissues. To improve their operation and to prove their hypothesis, they performed subperiosteal augmentation rhinoplasty in 22 patients with satisfactory results. At the same time, they investigated the biomechanical properties of human nasal periosteum and fascia, including tensile strength, the stress-strain relationship, and stress relaxation characteristics under uniaxial tension. Although it has less failure strain, the periosteum has more tensile strength than fascia. So, in the view of biomechanics, the periosteum is thicker, tougher, and stiffer than fascia, and thus more suitable for covering silicone implants.
OBJECTIVES: To compare external and internal lateral osteotomy in rhinoplasty. STUDY DESIGN: Retrospective review and study on cadavers. METHODS: One hundred forty-two patients who underwent aesthetic rhinoplasty were examined. The following criteria were taken into consideration: edema and ecchymosis around the eyes, the degree of closure of the roof, symmetry and level of fractures, solidity of the bone pyramid, and any scarring at the access point of the osteotome. In the last 25 patients who had surgery, a nasal endoscopy with optical fibers was carried out to evaluate any damage to the mucosa caused by the 2-mm osteotome. Furthermore, to compare the two routes in vivo, for five of these patients a lateral osteotomy was carried out externally for one side and internally for the other. Lateral osteotomy were performed on five cadavers by an external route on one side and by an internal one on the other. A midface degloving procedure was performed to expose the osteotomy sites. RESULTS: Edema and ecchymosis were always much less severe in patients who were treated with external osteotomy. The control of the fracture line was always excellent. Endoscopic evaluation and study on cadavers revealed damages to the mucosa caused from the internal osteotomy and a better control of fracture line in external osteotomy. CONCLUSIONS: External osteotomy is an easy and precise approach. Because the fracture is of a greenstick type, the bone stumps are stable. The reduced bleeding reduces the formation of edemas and ecchymosis around the eyes. The damage to the nasal mucosa is minimal, and the cutaneous scars are virtually invisible a month after surgery.
Secondary rhinoplasty is a highly complex, judgmental type of surgery. It is only through analysis of the successful treatment of various problems in secondary rhinoplasty that meaningful information can be obtained.
After applying 5% or 10% cocaine to the nasal mucosa, blood concentration were measured in 9 patients undergoing rhinoplasty and in 6 unoperated controls. The concentrations in the unoperated persons were lower than in those undergoing rhinoplasty, and lower concentrations were found after 5% solutions in both groups than in those exposed to 10% solutions. There was no correlation between the strength of the solution used and the degree of bleeding or the success of the anesthesia. One patient developed symptoms of toxicity within two minutes of a 5% cocaine application to his nasal mucosa. The cocaine concentrations in his blood were the highest seen in our studies, and we cannot explain this.
An aid to achieving a more precisely symmetric and individualized result in tip rhinoplasty is presented as an aid to both neophytes and experienced surgeons. It is thought to be particularly helpful in teaching variations of tip rhinoplasty and anticipating the results of proper resection.
This study is a 6-year experience with 305 cases in which the technique was used for large noses. The techniques described is based on the Skoog rhinoplasty principle: autografting the osteocartilagineous nasal dorsum after its reduction to the best suitable shape and size, so that the osseous part of the graft lies on the remaining nasal bones. The authors have conjointly used the intracartilaginous approach, which leaves a unique scar away from the graft, and the extramucosal dissection, which keeps the graft separated from the nasal cavity by an intact mucosal lining. They also used the internal lateral osteotomy, which reduces postoperative swelling. The technique is described with all details. The cases shown demonstrate that this type of rhinoplasty prevents the middle third retraction because of the osteocartilaginous graft and most of the common secondary deformities. The analysis of results obtained in this series show 89 percent excellent (patient and surgeon pleased). Secondary correction had to be done in eight cases, by reducing or removing the graft.
Cerebrospinal fluid rhinorrhea, whatever the etiology, is a serious and life-threatening problem. We present a case following rhinoplasty. To our knowledge, this specific complication has not been reported, most likely because it has gone unrecognized, since most cerebrospinal fluid leaks cease spontaneously. Surgeons performing rhinoplasty should be aware of this potential complication, how to confirm the diagnosis, and methods for its treatment.
Rhinoplasty was performed in 134 non-Caucasians over a 16-year period. The indications and techniques for operative approaches pertinent to achieving facial balance and symmetry in the non-Caucasian are described. Alar flaring is best addressed with alar base resection. Alar base resection does not significantly narrow alar width. Reduction in interalar distance is best performed with interalar reduction. If alar flare and wide interalar distance coexist, one should always consider a secondary or tertiary procedure. Planning a secondary procedure avoids devitalizing tissues and multiple super-imposed incisions and permits minor revisions. A simplified approach to removal of excessive tip fat is discussed. Methods of addressing complications peculiar to non-Caucasian rhinoplasties are described. In order to avoid racial incongruity, one must incorporate an alar narrowing procedure, i.e., interalar reduction or alar sill advancement. The results of this study reemphasize the importance of analyzing the nose with respect to the rest of the face in order to establish guidelines for these often difficult nasal reconstructions.
The ingenious division and suture of the mesial crura of the lower lateral cartilages devised by Goldman has found little utilization in recent years, even by surgeons familiar and experienced with this procedure. However, in secondary rhinoplasty, many of the disadvantages inherent in the Goldman tip can be turned to the surgeon's advantage and used to correct nasal tip defects which might otherwise prove refractory to treatment. Cartilage deficit, tip asymmetry, unacceptable bifidity, excessive tip elevation, hanging columella, and insufficient bulk are readily corrected with the Goldman tip and variations on its basic theme. This report covers the authors' 20-year experience with the Goldman tip, including a recent increase in the utilization of this procedure for secondary rhinoplasty.
Total inferior turbinectomy was carried out in 38 patients who complained of nasal obstruction following rhinoplasty or rhinoseptoplasty and in whom hypertrophied inferior turbinates were found to be the cause of obstruction. Postoperatively, relief of nasal obstruction was reported by 84 percent of patients, while rhinoscopy showed wide, clean nasal airways in 92 percent. Nasal airflow measurements in 32 tested patients showed increased patency in all of them, including 3 who still complained of nasal obstruction postoperatively. The follow-up period ranged from 1 to 7 years (mean 2.8 years). Atrophic changes of the nasal mucosa or chronic purulent infection was not observed in any of the patients. Because the results of partial procedures on the inferior turbinates are often unsatisfactory, I suggest performing total inferior turbinectomy in patients with obstructing inferior turbinates following rhinoplasty.
For the last 4 years, the author has been using the open lower cartilaginous vault rhinoplasty, making an external cutaneous incision on the columella. After observing the improved results in patients with nasal tip, lateral crura, and medial crura difficulties, the author widely recommends the use of this procedure in selected patients. In addition to multiple advantages which have been reported useful in open-tip rhinoplasty in the past, the author has contributed two additional advantages: that it avoids scarring columella skin and that it can be extended to cope with defects of the entire lower cartilaginous vault. Disadvantages are some residual edema in some patients over a 6-months period and prolongation of operating time.
The term tension nose is known to many rhinoplastic surgeons, yet confusion exists as to its precise meaning. We define the tension deformity as excessive growth of the quadrilateral cartilage, resulting in a high nasal dorsum and anterior and sometimes inferior displacement of the nasal tip cartilages. A review of the surgical literature shows that little attention has been given to the evaluation and management of this problem. We reviewed 50 consecutive primary rhinoplasty candidates and found that 46 percent had some manifestation of tension deformity that required correction at the time of surgery. The techniques of open structure rhinoplasty are ideally suited to manage the tension nose. The essence of correction is a deprojection-reprojection process. First, excessive elements of the septal cartilage and anterior nasal spine, which comprise what we have termed the nasal pedestal, are reduced, resulting in tip deprojection. Open structure methods are then employed to achieve reprojection of the domes by using cartilage grafts and suturing techniques to build strength, support, and elegance into the nasal tip.
A total of 859 patients presenting for outpatient rhinoplasty were divided into two groups that received intravenous sedation of midazolam 0.1 mg/kg either with or without ketamine 0.4 to 0.5 mg/kg immediately prior to conduct of the local anesthetic injections and surgery. Additional midazolam was given intraoperatively as needed. No patient received narcotic either as premedication or intraoperatively. Patients were evaluated by the surgeon on their response to the injections and surgery, and patients were given a questionnaire 1 week postoperatively to examine their response to and recall of the procedure. Scoring by both the surgeon and patients revealed that the great majority of patients in both groups had adequate "sedation." Patients from both groups related a high degree of satisfaction (> 90 percent) with the technique of sedation. The differences between the two study groups achieved statistical significance only on 4 of the 12 parameters investigated. Those who had received only midazolam were less likely to vocalize during the surgery or to experience the procedure as being of undue duration. Those who had also received ketamine had a lesser chance of remembering the local anesthetic injections (11.1 versus 19.8 percent) and a lesser likelihood of being dissatisfied with their surgical experience (3.3 versus 7.4 percent). In conclusion, the use of an opioid-free sedative technique of intravenous midazolam was highly successful in meeting the needs of both patients and surgeons. The addition of a single preblock dose of intravenous ketamine to intravenous midazolam sedation for rhinoplasty does not improve intraoperative conditions for the surgeon in terms of patient behavior.(ABSTRACT TRUNCATED AT 250 WORDS)
Historically, rhinoplasty has been conceptualized mainly as an excisional and reductional operation of the nasal framework; however, there is growing evidence showing that conservatism in terms of preserving as much skeleton as possible makes the final results more predictable and more physiologic. On the basis of this point of view and using modifications of Tebbetts' technique, a prospective study of 52 patients presenting for primary open rhinoplasty was made. In all the cases, the cephalic portion of the lateral crus was preserved, and the procedure was designed basically to create a better anatomy from an aesthetic point of view. The results were evaluated aesthetically and by cephalometry, and patients showed improvement; native crura preservation was maximized. This report suggests more prospective studies need to be conducted to demonstrate the efficacy of these surgical variations on the average patient.
In a prospective study, 15 consecutive patients who underwent simultaneous open rhinoplasty and alar base excision were included to investigate whether there is a problem with the blood supply of the nasal tip and columellar skin. During the surgical procedure in these patients, there was transection of the columellar arteries and external nasal arteries, and frequently of the alar branches of the angular artery. Yet, none of the patients had any evidence of ischemia of the nasal tip or columellar skin, and there was primary wound healing with a thin-line transcolumellar scar in all patients. Techniques to avoid injury to the lateral nasal artery and nasal tip plexus are discussed. It was concluded that simultaneous open rhinoplasty and alar base excision is safe as long as certain surgical principles are applied.
Over the past 35 years, aesthetic rhinoplasty has evolved from a generic, reductive operation to a highly individualized, problem-specific operation that often combines augmentation with reduction. The author's experience has been marked by the following conceptual and technical milestones that have contributed to an ongoing exploration and advancement of nasal surgery: (1) vestibular stenosis: diagnosis of a surgical consequence; (2) etiology and treatment of supratip deformity: the dynamic relationship of soft-tissue contour to skeleton; (3) etiology and treatment of the tip with inadequate projection: tip graft design; (4) practical aesthetics of balance: the augmentation-reduction approach to rhinoplasty; (5) support of the middle vault: functional and aesthetic effects; (6) malposition of the lateral crura: recognition and management; and (7) the significance of the middle crura: clinical and aesthetic considerations.