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PubMed2002

The potential pitfalls of concurrent rhinoplasty and endoscopic sinus surgery.

OBJECTIVE: As the largest portion of the population is becoming middle aged and our society becomes increasingly interested in youth and appearance, so does the number of esthetic surgeries. Rhinoplasty is being performed with increased frequency in recent years. Many surgeons are performing rhinoplasty combined with endoscopic sinus surgery as a means to decrease operating times, healing times, as well as patient cost. Many surgeons may be unaware of several potential life-threatening complications when these two safe procedures are performed concurrently. STUDY DESIGN: A rare but illustrative case depicting a serious complication of concurrent surgery. A retrospective review of our experience and an extensive literature review were performed documenting the type and incidence of minor and serious postoperative complications. RESULTS: A case demonstrating multiple near-fatal complications after rhinoplasty and endoscopic sinus surgery, which are two safe, commonly performed procedures when performed individually. A review of our 268 rhinoplasties performed between 1997 and 2001 demonstrated 11 cases with concurrent surgery. There were no complications noted in this population. CONCLUSION: We conclude and agree with the literature that concurrent surgery is safe and effective.

Adult↗
PubMed1983

An investigation of bacteremia during rhinoplasty.

The rarity of infection after rhinoplasty is not well understood. Despite the apparent low incidence of this complication, many surgeons administered perioperative antibiotics to prevent infection. We studied whether a bacteremia composed of nasal flora can originate during rhinoplasty. Fifty-two health patients admitted for rhinoplasty were studied. Blood and nasal cultures were drawn immediately before operation and blood cultures 5 and 15 minutes after completion of the nasal osteotomies. With the exception of one instance of likely contamination, none of the blood cultures grew microorganisms. Neither local nor systemic infections occurred in any patient. The negative results of this study suggest an exceedingly low incidence of bacteremia during rhinoplasty. For this reason, the value of perioperative antibiotic prophylaxis is questionable.

Adolescent↗
PubMed1996

Open rhinoplasty without transcolumellar incision.

Traditional open rhinoplasty produces a scar on the columella. To avoid such a scar and still obtain a wide exposure of the nasal framework, the bilateral paramarginal incisions close to the columella were extended into the nasal floors, and a wide undermining of the base of the columella was performed. The nasal tip with the crura together could then be presented through one of the nostrils. Conditions similar to those of the traditional open rhinoplasty wer thus achieved. The technique has been used in selected patients for 8 years with satisfactory results. In conclusion, the open rhinoplasty without transcolumellar incision can replace the traditional transcolumellar open rhinoplasty technique.

Adult↗
PubMed1996

The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty.

Despite the apparent association of nasal airway obstruction with septal deviation and/or inferior turbinate hypertrophy, increasing clinical evidence suggests that incompetence of the internal or external nasal valves may also affect airflow. But how much? What is the relative importance of the valves and septum in causing nasal airway obstruction? One-hundred and sixty consecutive patients (88 primary rhinoplasty, 72 secondary rhinoplasty) without turbinate hypertrophy or septal perforation and operated on for correctable nasal airway obstruction were evaluated prospectively by anterior active mask rhinomanometry preoperatively and from 1 to 43 months (mean 8.4 months) postoperatively after 1% phenylephrine decongestion to eliminate mucosal factors. Patients were stratified according to the site(s) of preoperative obstruction at the internal valves, the external valves, the septum, or any combination of the three. Geometric mean nasal airflow was calculated from independent measurements of each nasal airway. Surgical treatment consisted of submucous septal resection, internal valvular reconstruction with dorsal or spreader grafts, and external valvular reconstruction with cartilage or bone grafts; inferior turbinectomy was not performed. All procedures were performed endonasally. In the entire 160 patient study group, septal and/or valvular surgery corrected the airway in 152 patients (95 percent); 8 patients had partial residual obstruction. Our data support the prior rhinologic data in showing only a modest (and statistically insignificant, p < 0.4, n = 25) improvement in (geometric) mean nasal airflow following septal surgery alone. However, external valvular reconstruction alone increased airflow 2.6 times over preoperative values (n = 10). Internal valvular reconstruction alone by dorsal grafts (n = 17) or spreader grafts (n = 29) increased nasal airflow 2.0 times; spreader grafts and dorsal grafts were equally effective in supporting the internal valves. The largest improvement in postoperative airflow was seen in the patients with septal plus internal and external valvular incompetence (n = 21), in which flow increased 4.9 times over preoperative values (p < 0.0003). Patients in whom valvular incompetence alone was corrected experienced as much relative improvement as patients in whom valvular plus septal obstruction was corrected. Finally, valvular reconstruction in 54 secondary rhinoplasty patients who had previously undergone septoplasty corrected the airway obstruction in 49 patients (91 percent). Notably, 110 of 160 patients (69 percent) had a lateralized preoperative obstruction; however, the septum was deviated toward the clinically obstructed side in only 51 of these patients (46 percent); in the other 54 percent, the subjectively obstructed side was contralateral to the side toward which the septum was deviated. Nasal valvular function should be assessed in all preoperative rhinoplasty patients with airway obstruction; in many individuals, valvular effects may equal or surpass septal deviation as the primary cause of nasal airflow obstruction.

Adolescent↗
PubMed2000

Importance of the depressor septi nasi muscle in rhinoplasty: anatomic study and clinical application.

An active depressor septi muscle can accentuate a drooping nasal tip and shorten the upper lip on animation. We have found that dissection and transposition of the depressor septi muscle during rhinoplasty can improve the tip-upper lip relationship in appropriately selected patients. Although the anatomy of the depressor septi muscle has been described, the anatomic variations of this muscle have not been previously reported. The goals of this study were two-fold: (1) to define the anatomic variations of the depressor septi muscle using 55 fresh cadaver dissections and (2) to develop a clinically applicable algorithm for modification of this muscle during rhinoplasty in those patients with a short upper lip and/or tip-upper lip imbalance. Fifty-five fresh cadavers were dissected, and the anatomic variations of the depressor septi muscle were recorded. Three variations of the depressor septi muscle were delineated: type I inserted fully into the orbicularis oris (62 percent); type II inserted into the periosteum and incompletely into the orbicularis oris (22 percent); and type III showed no, or rudimentary, depressor septi muscle (16 percent). Sixty-two patients over a 4-year period (from 1995 to 1999) were identified preoperatively with a hyperactive depressor septi diagnosed by a descending nasal tip and shortened upper lip on animation. These patients underwent dissection and transposition (not resection) of the paired depressor septi during rhinoplasty with improvement or correction of the tip-upper lip imbalance in 88 percent of cases. The anatomic study, surgical indications, rationale for the operative technique, and clinical cases are presented. Dissection and transposition of the depressor septi is a valuable adjunct to rhinoplasty in patients with a type I or II muscle variant.

Adult↗
PubMed2002

The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty.

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem. Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.

Adolescent↗
PubMed2004

The two essential elements for planning tip surgery in primary and secondary rhinoplasty: observations based on review of 100 consecutive patients.

Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that will make nasal tip surgery successful. It is the author's contention that only two such features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or cephalically rotated ("malpositioned"). Data were generated from a review of 100 consecutive primary rhinoplasty patients on whom the author had operated. The results indicate that only 33 percent of the entire group had adequate preoperative tip projection and only 54 percent had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura (78 percent and 61 percent) than in patients with orthotopic lateral crura (57 percent and 20 percent, respectively). Tip projection can be reliably assessed by the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. The data suggest that the surgeon treating the average spectrum of primary rhinoplasty patients will see a majority (61 percent) who need increased tip support and a significant number (46 percent) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment. Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23 percent of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in this series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully and secondary deformities can be avoided.

Adolescent↗
PubMed2005

Hemodynamic effects of perioperative stressor events during rhinoplasty.

The hemodynamic effects of perioperative stressors, including preoperative patient anxiety, intraoperative local anesthetic/adrenaline infiltrations, and some painful interventions, have not been fully elucidated in plastic surgery procedures. The present study was designed to determine the hemodynamic effects of perioperative stressor events in American Society of Anesthesiologists class I patients undergoing rhinoplasty procedures under general anesthesia. The study included 50 healthy patients, 18 to 51 years of age (mean age, 27 +/- 7 years), who underwent a rhinoplasty procedure in the authors' department. All patients were connected to a digital ambulatory Holter recorder for 24 hours starting on the day before the operation and continuing throughout the procedure. All of the patients received 10 ml of 2% lidocaine with 1:80,000 adrenaline 15 minutes after intubation. Observations consisted of heart rate, noninvasive blood pressure, and power spectral heart rate variability analyses, the latter of which is indicative of the sympathovagal balance of the patients. The majority of patients developed a persistent, moderate sinus tachycardia before the induction of anesthesia. After the infiltration of lidocaine/adrenaline, a mild to moderate and short-lasting tachycardia was detected. A similar increase in pulse rate was also noticed during lateral osteotomies. No significant blood pressure changes attributable to perioperative stressors (with the exclusion of general anesthesia induction, intubation, and extubation) were observed. Sympathetic activity was found to be responsible from marked tachycardia before the induction, which was attributable to preoperative anxiety. The authors' study has demonstrated that there are three hemodynamically unstable periods causing tachycardia for rhinoplasty patients that directly concern the plastic surgeon: immediate preoperative anxiety, local anesthetic/adrenaline injection, and lateral osteotomies. The authors conclude that these patients would benefit from routine use of premedications and that a lidocaine/adrenaline combination is a safe adjunct to general anesthesia in young rhinoplasty patients. In addition, a deeper anesthesia during local infiltration and osteotomies would be appropriate.

Adult↗
PubMed2005

The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on a theme--a study in 200 consecutive primary and secondary rhinoplasty patients.

BACKGROUND: Although "boxy" and "ball" nasal tips have received considerable attention in the rhinoplasty literature, their association with cephalic rotation of the alar cartilage lateral crura ("malposition") has not been emphasized. The thesis of this article is that most boxy and ball tips are not unique entities but rather constitute anatomical variants of alar cartilage malposition. METHODS: Data were generated from a review of 100 consecutive primary and 100 consecutive secondary rhinoplasty patients on whom the author had operated before February of 1999. RESULTS: The majority of the patients (68 percent of primary rhinoplasty patients and 87 percent of secondary patients) studied had alar cartilage malposition (axes toward the medial rather than the lateral canthi) (p < 0.001). Orthotopic lateral crura were significantly more common than malpositioned lateral crura among primary patients (p < 0.001); conversely, the frequency of malpositioned crura was significantly higher in secondary patients than in primary patients (p < 0.001). Most of the primary and secondary patients with malposition (74 percent and 72 percent, respectively) had boxy or ball tips. Among patients with alar cartilage malposition, ball tips were most common (31 percent of primary patients and 36 percent of secondary patients); boxy tips were second-most common (19 percent of primary patients and 27 percent of secondary patients); the remaining patients had lateral crura that were considered to be "flat" (18 percent and 24 percent, respectively). The most common configuration among primary patients was the malpositioned boxy or ball tip with inadequate projection (54 percent). All primary and secondary rhinoplasty patients with alar cartilage malposition, regardless of tip lobular configuration, had incompetence at their external nasal valves; valvular reconstruction at least doubled the geometric mean nasal airflow in most patients. In primary patients, treatment for each variant was identical: lateral crural resection, crushing, and replacement along the alar rim. Some secondary patients also required composite grafts. CONCLUSIONS: The morphological and functional results of this study indicate that the surgeon seeing a patient with a boxy or ball tip can predict that the patient has seven times the likelihood of having malpositioned, rather than orthotopic, lateral crura. The importance of most boxy and ball tips is therefore not only the lobular deformity itself but also the functional deficit associated with it.

Adolescent↗
PubMed2004

Advantages of adding a footplate incision in Asian rhinoplasty.

The dimension, shape, and projection of the nasal tip are significantly determined by the position of the footplates of the medial crura. The length of the footplate segment in Asians is much longer than that in Caucasians. A surgeon may be able to use a longer footplate segment when operating on an Asian to recreate the lower vault of the nose more effectively. The purpose of this study is to introduce the advantages of addition of a footplate incision to obtain greater satisfaction in esthetic rhinoplasty for Asians. This incision is extended along the caudal border of the footplate of the medial crura onto the floor of the nasal vestibule bilaterally, in endonasal or open approach rhinoplasty. By approximating the lateral curves of the medial crural footplates, the width and the length of the columella could be narrowed and lengthened. The columella can also be advanced caudally and thus elongate the shape of the nostrils. In addition, a cartilage graft or an implant insertion for alar base augmentation could be performed through this footplate incision, eliminating the need for an additional incision. Another advantage is that, during the correction of caudal septal deviation, displaced septal cartilage can be repositioned by suturing to the periosteum or soft tissue around the anterior nasal spine without drilling into it through an intraoral incision. One hundred ten consecutive patients who underwent esthetic rhinoplasty using our footplate incision technique between August of 1999 and May of 2002 were included in this study. A total of 66 patients had an adequate follow-up time of over 6 months. Patient satisfaction and postoperative complications were recorded. The majority of the patients (57/66 cases) were satisfied with the results of the procedure. The authors believe that the addition of the footplate incision in esthetic rhinoplasty is safe and reliable for effecting better results for Asians.

Adolescent↗
PubMed2006

Open rhinoplasty without transcolumellar incision.

Traditional open rhinoplasty leaves a scar on the columella. No one can say that this scar is invisible. It is less noticeable in Caucasian patients but it is a problem in non-Caucasian patients like in our country. To avoid such a scar and still obtain a wide exposure of the nasal framework, the bilateral paramarginal incisions close to the columella were extended down to the nasal floors. The lower lateral cartilages forming the nasal tip could then be delivered out through one of the nostrils. An exposure similar to the traditional open rhinoplasty was then achieved. The technique has been used in 23 patients with satisfactory results. In conclusion, the open rhinoplasty without transcolumellar incision can replace the traditional transcolumellar open rhinoplasty technique in selected patients.

Humans↗
PubMed1988

Reshaping the psyche. The concurrent improvement in appearance and mental state after rhinoplasty.

Rhinoplasty patients and matched elective-surgery controls completed the Facial Appearance Sorting Test, the General Health Questionnaire, a Repertory Grid and the Masculinity/Femininity Scale. Rhinoplasty applicants perceived appearance similarly to, and downrated their own appearance to the same extent as, controls. Impaired appearance and psychiatric symptoms are integral parts of the 'rhinoplasty applicant syndrome', but the degree to which they occur is not positively correlated. Interviews and tests were repeated 6 months after operation, when marked improvement in appearance was reported by the rhinoplasty patients, associated with the reduction of psychiatric-symptom scores. Control subjects showed no change.

Adult↗
PubMed1989

Steroids in rhinoplasty.

A prospective double-blind randomized pilot study was performed to test the benefits of steroids versus placebo in controlling edema and ecchymosis in rhinoplasty within the immediate postoperative period. Thirty consecutive patients who underwent rhinoplasty with osteotomies were entered into the study. Sixteen patients received 10 mg of intravenous dexamethasone before the procedure and 14 patients received placebo. All rhinoplasties were performed by residents under the supervision of staff otolaryngologists. A 4-point scale was used to assess the extent of periorbital edema and ecchymosis at 24 hours postoperatively. A one-time bolus of 10 mg of dexamethasone was beneficial in decreasing edema and ecchymosis in rhinoplasty. This benefit was demonstrated statistically (p less than .005). No complications were attributed to the administration of dexamethasone.

Adolescent↗
PubMedDate not supplied

Correction of the twisted nose deformity: a surgical algorithm using the external rhinoplasty approach.

Successful correction of the twisted nose is challenging due to the complex nature of the underlying anatomic deformity. Although the literature has in general supported endonasal rhinoplasty techniques for the twisted nose, we propose a surgical algorithm using the external rhinoplasty approach. The algorithm offer a stepwise, structured method that is adaptable to individual variations in anatomic deformity. The advantages and relative disadvantages of the external rhinoplasty approach are discussed, and a clinical experience of 30 patients is reviewed. Application of the external rhinoplasty algorithm in correction of the twisted nose can yield consistently satisfactory functional and aesthetic results.

Algorithms↗
PubMed1975

Adjunctive measures in rhinoplasty.

Modern day rhinoplasty demands more than a plan for a new nose. It requires consideration of the individual in terms of a new facial image. Adjacent skeletal and soft tissue weaknesses must be evaluated along with the primary nasal deformity. Frequently facial disharmonies may be corrected with relatively simple operative procedures or with cosmetics. When the procedure does not measurably increase the operative time, postoperative morbidity, or financial cose of the rhinoplasty, it will be more readily accepted by the patient. These criteria are considered in the suggested methods of chin augmentation with alloplastic implants and reduction mentoplasty, utilizing the intraoral subapical horizontal osteotomy of the mandible. At times, simple methods of camouflage will be inadequate. Significant jaw disharmony with unacceptable occlusion requires the interdisciplinary teamwork of the orthodontist, the surgeon, and possibly the prosthodontist. In these cases rhinoplasty waits upon skeletal and dental realignment. Almost without exception, the rhinoplasty patient appreciates and profits from the surgeon's concern over her general appearance. Advice regarding skin care, makeup, hair styling, and facial rejuvenation frequently aids that person in attaining a happy and satisfying rhinoplastic experience.

Beauty Culture↗
PubMed1996

External rhinoplasty approach for repair of posttraumatic nasal deformity.

Up to 50% of patients who have suffered a nasal fracture may seek reconstructive surgery because they are dissatisfied with their appearance and/or ability to breathe. Distortion of native anatomy and dissection planes increases with severity of the injury. The external rhinoplasty approach is a biologically sound technique that offers several advantages over endonasal access for the repair of complex nasal deformities. In 30 consecutive posttraumatic rhinoplasty cases over a 2-year period, 27 (90%) patients underwent correction of their deformities via the external rhinoplasty approach. No technique-specific sequelae were encountered, and all patients were satisfied with their respective result and the healing of the transcolumellar incision. This article reviews the advantages, disadvantages, and contraindications of the external rhinoplasty approach in the posttraumatic patient.

Cartilage↗
PubMed1977

[Rhinoplasty--a mainly aesthetic or functional operation (author's transl)].

Reviewing personal indications for rhinoplasty and subjective estimation of the postoperative result in 202 patients (104 male and 98 female) it is asked, whether rhinoplasty has to be regarded as a mainly aesthetic or functional surgical procedure. The catamnestic study showed, that most patients preoperatively complained about impediment of nasal breathing as well as of deformities of the external nose. In men we found about the same frequency of predominantly functional and aesthetic indications, respectively, whereas in women the aesthetic motivation distinctly prevailed. However, postoperative complaints of male and female patients mainly referred to the shape of the external nose. Many patients don't talk of those complaints before some time has passed: right after surgery 85% of 202 patients stated to be completely satisfied by the postoperative result, but 1/2 to 3 years later we only counted 67% (of 155 inquired cases) still expressing full satisfaction. In only a few cases postoperative dissatisfaction was likely to be caused by noticeable nasal deformities or (even less often) unimproved nasal obstruction. In many patients postoperative dissatisfaction appeared rather due to psychological disturbances than to aesthetic insufficiencies, this being demonstrated by two cases described. Faced with these observations one can call rhinoplasty neither a mainly aesthetic nor a mainly functional operation; rhinoplasty requires improvement and preservation of nasal function as well as a careful consideration of aesthetic principles.

Congenital Abnormalities↗
PubMed2004

The evaluation of the effects of lateral osteotomies on the lacrimal drainage system after rhinoplasty using active transport dacryocystography.

The lacrimal drainage system (LDS) is vulnerable to surgical trauma during rhinoplasty. We aimed to investigate the possible effects of the low lateral osteotomies on the LDS during rhinoplasty using active transport dacryocystography (ATD) at the late postoperative stage. Twenty patients who underwent open rhinoplasty were evaluated by ATD between the sixth and seventh postoperative months. Presence of the LDS dehiscence and the absence of the passage of the contrast material into the inferior meatus were noted as signs of injury to the LDS in ATD. The proximity of the osteotomy site to the LDS was measured using three different measurements in ATD. The distance from the lacrimal fossa to the lateral osteotomy site, the distance from the inferior meatus to the lateral osteotomy site and the distance from the middle point of the lacrimal fossa and inferior meatus to the lateral osteotomy site were measured. The anatomic integrity of the bone structure around the LDS was preserved in all patients and free drainage of contrast media from the fossa lacrimalis to inferior meatus was observed in ATD evaluation of all patients. The average distance from the LDS to the lateral osteotomy site was found to be between 7-8.8 mm. In conclusion, the low lateral osteotomy is a safe method in order to avoid trauma to the LDS, and ATD seems an appropriate diagnostic technique in evaluation of the LDS after rhinoplasty.

Adult↗