Septic cavernous sinus thrombosis after rhinoplasty: case report.
We report a rare entity, septic thrombosis of the cavernous sinuses complicated by a subdural empyema in rhinoplasty.
Adult↗
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Total rhinoplasty with a free osteocutaneous flap.
A new approach to total rhinoplasty, using a free dorsalis pedis flap containing part of the second metatarsal bone, is reported.
Adolescent↗
The use of cartilage grafts in primary aesthetic rhinoplasty.
Our experience with the use of cartilage grafts in 430 primary rhinoplasties is presented. We find grafts indicated when operating on small noses with thick skin to increase and define the dorsum, to add projection and angularity to the tip, to project the columella, and to correct the acute nasolabial angle. The procedure is technically simple and relatively free of complications. Long-term evaluations show no absorption of the grafts and preservation of the desired shape.
Cartilage↗
Toward refinement in rhinoplasty.
Three interrelated principles can help to achieve nasal refinement: creation of nasal planes, attention to lateral light reflexes, and maintenance of skin sleeve size. These principles are detailed and illustrated in primary and secondary rhinoplasty patients.
Esthetics↗
Temporoparietal free fascia grafts in rhinoplasty.
The temporoparietal fascial graft provides adequate coverage, contour, and bulk on the cartilage dorsum of the nose, as well as an inconspicuous donor site. In my opinion, this technique not only prevents the occurrence of noticeable sharp edges of the cartilage graft, but also adds to the smooth contour of the reconstructed nasal dorsum. The improved results either in primary and secondary rhinoplasty would seem to justify this technique. Some variations in fascia grafts are presented with clinical examples.
Adult↗
A model for planning rhinoplasty.
A rhinoplasty model is detailed in which nasal shape is conceived as a dynamic system, the result of powerful expansive and contractile forces, of a skin sleeve in equilibrium with a dynamic skeleton, in which the alar cartilages are external to the remaining skeleton and support a large area of lower nasal skin. In this system, changes in one region have "global" effects. Consequently, one powerful way to control nasal shape is to maintain skin sleeve size and thus maintain the preoperative nasal equilibrium. The surgeon who controls the postoperative equilibrium controls the postoperative result.
Female↗
A different rasp for rhinoplasty.
A new rasp for rhinoplasty is presented. It can be dismantled and has a renewable blade that looks like the one you find in a plane. The main advantage of this rasp is that it rasps the cartilaginous septum as well as the bony part of the hump.
Humans↗
Various uses of the septum in rhinoplasty.
The nasal septum can be used with impunity to assist in cosmetic and reconstructive rhinoplasty if an L-shaped bridge with anterior prow is preserved or constructed to maintain normal support to the nose. The septum can serve, of course, as a reservoir of cartilage grafts. Under special conditions, it can spare mucosal and chondromucosal or even osteochondromucosal flaps to aid in the supply of lining and support in reconstructions. The L-shaped septal chondromucosal flap has been found of value in total distal reconstructions and is now offered as a possible adjunct in the correction of certain intact but congenitally flat and/or short noses.
Adult↗
Precision rhinoplasty. Part II: Prediction.
This retrospective study was undertaken to investigate the soft-tissue response rate to the skeletal and soft-tissue alterations following a rhinoplasty. Ninety-eight patients, 80 females and 18 males, with a mean follow-up of 13 months, were included in this study. The tracings of the outline of preoperative cephaloxerograms and life-size photographs were superimposed on the postoperative ones, and the differences were measured and confirmed with measurements of intraoperative resected segments. The soft-tissue response to skeletal alterations was measured in seven different zones. Zone 1 (nasion) and zone 7 (nasal spine area) had the lowest mean response rate of approximately 25 percent. Zone 2 (proximal bridge) and zone 3 (midbridge) had a 60 percent response rate. Zone 4 (supratip area) had a 43 percent response, zone 5 had a 41 percent response, and zone 6 had a 40 percent response rate. There were statistically significant differences among the response rates of thick, medium, and thin noses. Age was an important factor in zones 1, 4, 5, 6, and 7. The patient's sex did not influence the soft-tissue response rate to skeletal alterations. The soft-tissue response in relation to the alar base narrowing was about 52 percent. This study reveals a predictable soft-tissue response to skeletal alterations on all zones except zone 7 (nasal spine area).
Adolescent↗
The depressed nasofrontal angle in aesthetic rhinoplasty.
Certain patients seeking cosmetic rhinoplasty present with a so-called depressed nasofrontal angle. In this condition, the most careful part of the nasal bone is underdeveloped. This gives the illusion of a nasal hump. Complete removal of this hump will create a hypoplastic nose. Partial reduction of the hump and augmentation in the nasofrontal area are indicated in these patients. Autogenous material is preferable for this purpose. A number of patients are presented with illustration of the technique.
Adult↗
Crushed cartilage grafts over alar dome reduction in open rhinoplasty.
Primary and secondary nasal tip deformities can be repaired more easily with an open technique rather than with the traditional closed methods that have been used for the over-projecting tip. Division of the alar domes with a side-to-side repair followed by the onlay of a single crushed cartilage graft to prevent postoperative cartilaginous deformities has been shown to be a reliable maneuver in both primary and secondary rhinoplasties.
Adult↗
Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping.
Autogenous rib cartilage grafts have gained more widespread use in rhinoplasty as dorsal onlay grafts and columellar struts. However, the usefulness of rib as a donor site has been limited by difficulties with postoperative cartilage warping. We hypothesized that the internal stabilization of rib cartilage grafts with Kirschner wires would prevent warping. The costochondral cartilages of a fresh cadaver were harvested and carved into 4 x 10 x 40 nm blocks. A single 0.035-in K-wire was placed longitudinally into the center of each of the study specimens (n = 9), whereas no internal stabilization was utilized in the control group (n = 9). Over a 10-day study period, a mean of 2.2 degrees of warping was observed in the grafts with K-wires as compared to 8.9 degrees in the control group. This indicates that internal stabilization of rib grafts significantly reduces warping (p < 0.001). In a subsequent clinical study, 28 patients underwent placement of internally stabilized columellar struts (n = 19) and/or dorsal nasal grafts (n = 12) using autogenous rib cartilage. At a mean follow-up of 13.5 months (range 3 to 36 months), graft warping was not observed in any patient. Satisfactory aesthetic results were achieved in all but one patient, in whom mild displacement of a dorsal onlay graft occurred. Palatal extrusion of the K-wire occurred in 3 of the first 9 columellar struts. This prompted an alteration in technique with no subsequent extrusions. We conclude that the internal stabilization of autogenous rib cartilage grafts with K-wires effectively prevents graft warpage.
Adult↗
Elliptical horizontal excision and repair of alar cartilage in open-approach rhinoplasty to correct cartilaginous tip deformities.
Correction of nasal tip deformities, especially bulbous tip deformities, has improved greatly with the advancement of open-approach rhinoplasty. Bulbous and double-dome deformities of the nasal tip are more often cartilaginous, rather than fibrous, in nature. Therefore, direct alterations of the cartilage are necessary to achieve the desired effect. In the past, these alterations were accomplished by resection of the cephalic part of the lateral crura of the lower lateral cartilage and, less commonly, by resection of the caudal ends of the lateral crura. For the past several years, we have used elliptical excision of the central segment of the lower lateral cartilage in a horizontal direction. The upper and lower edges of the remaining cartilage are repaired with 5-0 nylon sutures. This procedure removes the most protruding and bulbous portion of the lateral crura, and the cephalic and caudal portions that remain are sutured together to form a flatter and more narrow lateral crura. It changes the bulge of the dome where a change is necessary, at the top. It also preserves the anatomically intricate relationship of the junctions of the upper and lower lateral cartilage. There are no free or loose edges of cartilage to warp or deform during the healing process. Satisfactory, long-lasting clinical results can be achieved consistently.
Adult↗
The transvestibular approach to the nasal tip and dorsum: a new refinement in rhinoplasty.
The limited exposure of the lower lateral cartilage using the transcartilaginous approach may result in significant asymmetries in the nasal tip, especially in the region of the nasal domes and intermediate or middle crura. The author presents a new technique for exposing the lower lateral cartilage. Through a marginal incision, the whole endonasal surface of the lower lateral cartilage can be exposed, allowing the performance of different reduction and rearrangement techniques to the lateral and medial crura. The author discusses results of his experience using this new approach, emphasizing the surgical steps, advantages, and disadvantages. The transvestibular approach has proven to be a reliable approach that improves the predictability of endonasal rhinoplasty.
Cartilage↗
Function of the nasal muscles in normal subjects assessed by dynamic MRI and EMG: its relevance to rhinoplasty surgery.
The external nose is generally considered to have a relatively static shape. Movement of the nose and the potential for change of external shape and the internal airway have been assessed by (1) cadaver dissection and (2) dynamic studies during a standardized series of facial expressions in 13 subjects; video recording of the movement of skin markers, electromyography, and moving magnetic resonance images. A standard description of muscle anatomy is presented. The dynamic investigations indicated the following. Video analysis showed the components of muscle action: dilatation, constriction of the nostril, depression of the tip, vertical contraction in the bridge, and elevation of the alar, in different expressions. Electromyography confirmed muscle actions during expression and phonation. Magnetic resonance imaging demonstrated large changes in the external shape of the nose and nasal aperture due to muscle actions. Muscle function should be given greater consideration in aesthetic and cleft rhinoplasty.
Electromyography↗
The infradome graft: a new technique to improve dome reshaping in rhinoplasty.
As the open approach rhinoplasty has gained popularity, newer techniques for aggressive reshaping of the alar cartilage have become available. The most effective way to increase alar dome definition is the dome plication technique described by Daniel, which places a horizontal mattress suture, applied with incremental tension, between the medial and lateral crura. The disadvantage of this technique is that it can produce either overtightening or distortion of the cartilage, with excessive pinching of the nasal tip. Also, as it relies on a single nylon suture to fight against the cartilage's shape memory, it has the potential for relapse. The present article describes a new technique to overcome these problems. It consists of placing two parallel strips prepared from the resected alar cartilage excess under the domes. These grafted cartilages block the plication suture, thus avoiding the risk of excessive pinching of the domes and ensuring symmetry and stability. Using this technique, I have consistently obtained a nasal tip that is well defined over the nasal dorsum line in my patients.
Adolescent↗
Silicone in nasal augmentation rhinoplasty: a decade of clinical experience.
A number of materials, both biologic and alloplastic, have been used for nasal augmentation. Although biologic bone and cartilage grafts are associated with lower infection rates, they are also associated with long-term resorption and donor-site morbidity. Alloplastic materials, in particular silicone, have been associated in the literature with extrusion and infection but have the advantages of being affordable and easy to reshape with no requirement for harvesting autografts. A 10-year experience with silicone nasal augmentation documenting clinical experience, acute and long-term complications, and patient satisfaction was reviewed. All patients undergoing silicone augmentation rhinoplasty between July of 1985 and December of 1995 were reviewed. Preoperative nasal phenotype, operative data, and postoperative outcome were recorded. Long-term follow-up was undertaken using a telephone survey. There were 422 patients who underwent silicone nasal augmentation from July of 1985 to December of 1995. Only nine were men. The indications were for aesthetic nasal augmentation in 98 percent, and the majority (98 percent) were of South East Asian origin. Mean age was 26 (range 17 to 36), and 41 of the 422 patients had had previous nasal augmentation performed before presentation. Twenty-three patients (5.5 percent) had complications requiring removal of the implant within 30 days of surgery. These included displacement, prominence, hemorrhage, and excessive pressure in addition to obvious supratip deformity. On late follow-up, a further 18 patients (4.3 percent) had subsequent removal of the prosthesis. The most common reason for this was either displacement or over-prominence, more often judged by the surgeon than the patient. There were only two patients (0.5 percent) who had extrusion of the prosthesis. A total of 266 patients (63 percent) were contacted for a telephone interview. The majority of patients (84.2 percent) were satisfied with their nasal shape. Of the 42 patients (15.8 percent) who were not satisfied, 21 patients still wanted further augmentation of their nose. Photographic analysis of 198 patients showed a mean augmentation of 16.5 percent (range 4.0 to 27.5). Amount of augmentation correlated with preoperative nasal phenotype. Silicone nasal augmentation is a safe and effective procedure when used for moderate increases in nasal height. Contrary to previous reports, this series showed no associated infection. If the implant is shaped appropriately to the patient's nasal phenotype, the risk of extrusion may be reduced.
Adolescent↗
The lateral osteotomy in rhinoplasty: clinical and radiographic rationale for osteotome selection.
A preferred osteotome for endonasal osteotomy would facilitate reliable, complete osteotomies with minimal soft-tissue trauma. In this report, a radiographic evaluation of the bony lateral nasal wall thickness along the track of a high-low-high osteotomy was undertaken to guide the determination of appropriate osteotome size. Bone window axial computed tomographic scans were evaluated in 56 patients with a mean age of 48 years (range, 19 to 86 years). The average thickness along the site of lateral osteotomy was determined to be 2.47 mm (standard deviation, 0.47) in male patients and 2.29 mm (standard deviation, 0.40) in female patients. On the basis of these data, clinical evaluation of prototype 3- and 2.5-mm low-profile guarded osteotomes was undertaken in comparison with a "standard" 4-mm low-profile guarded osteotome to assess both their reliability and the degree of intranasal trauma, as reflected by intranasal mucosal tears. Although 2- and 3-mm unguarded osteotomes are time-tested, they may be reliable only in the hands of the most experienced surgeons. Therefore, a low-profile guard was included in the osteotome design to allow the surgeon to engage the bone securely and minimize the risk of slippage. Forty patients underwent rhinoplasty, for a total of 80 lateral osteotomies; the mean age of the patients was 38 (range, 16 to 75). In all cases, lateral osteotomies were accomplished with one pass. The 4-mm osteotome causes intranasal mucosal tears in 95 percent of osteotomies, the 3-mm osteotome in 34 percent, and the 2.5-mm in 4 percent. Early postoperative edema and ecchymosis were comparable among the groups. One patient, who underwent osteotomies with a 4-mm osteotome, had excessive postoperative narrowing, possibly due to his wearing of eyeglasses earlier than directed. This report suggests that proper selection of osteotome and attention to proper surgical technique results in a reliable, minimally traumatic lateral osteotomy through the endonasal approach. The 2.5-mm osteotome was reliable and the least traumatic to soft tissue of the osteotomes evaluated.
Adult↗