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PubMedDate not supplied

Prevention and correction of nasal tip bossae in rhinoplasty.

OBJECTIVE: To describe our experiences with nasal tip bossae, suggest a standard nomenclature, discuss causative factors, and provide a comprehensive, analytic approach to the prevention and correction of bossae. BACKGROUND: Nasal tip bossae are knoblike protuberances of the alar cartilages that can arise after rhinoplasty. Early bossae are due to uncorrected or inadvertently created asymmetries, while late bossae are due to fibrosis and scar contracture acting on a weakened or unreconstituted cartilaginous framework. Numerous techniques may be used to prevent and treat bossae; however, we found no article in the existing literature that presents an in-depth, analytic description of management techniques. METHODS: We analyzed the predisposing factors and techniques leading to bossa formation and studied principles of prevention and correction. All rhinoplasty cases that presented for revision from 1985 through 2000 were reviewed for bossae formation via internal computer search. Previous operative records for rhinoplasty cases were examined when available. Intraoperative notes and photgraphs of the revision surgery were examined. RESULTS: Etiologies for bossae were consistently found, and successful treatment modalities were noted. CONCLUSIONS: Nasal tip bossae are most often due to dynamic forces acting on iatrogenic changes and/or weakness in the alar cartilages. By minimizing cartilage excision, reinforcing areas of weakness, avoiding asymmetry and irregularity, and maintaining alar integrity, formation of bossae may be prevented. The treatment of bossae must be individualized and can range from simple suture stabilization techniques to complex domal cartilage replacement grafts, depending on the observed defect.

Adult↗
PubMedDate not supplied

Evaluation of the Goldman tip procedure in modern-day rhinoplasty.

OBJECTIVES: To present a critical review of a single surgeon's long-term results using the Goldman tip procedure and to examine the current attitudes of a select group of experienced rhinoplasty surgeons concerning the Goldman tip procedure. DESIGN: A retrospective review was conducted of the medical records of all patients who underwent a Goldman tip procedure performed by the senior author (R.L.S.) between 1975 and 2001. Demographic data, long-term outcomes (minimum follow-up, 1 year), complications, and surgeon-patient satisfaction were analyzed. Also, surveys were mailed to a select group of 50 experienced rhinoplasty surgeons. The survey recipients were asked about their current use of the Goldman tip procedure and any concerns about the technique. RESULTS: A total of 166 cases were eligible for analysis. The mean age of the patients was 33.7 years, and a large percentage of the patients (43.4%) were male. The overall complication rate was 5.4%, with a revision rate of 1.2%. The survey response rate was 78% (39/50). Of the respondents, 14 (41%) are still using the Goldman tip procedure in their practice, although most of them use the technique relatively infrequently. The most common concerns regarding the procedure were unnatural appearance (41%), thin skin (13%), and adverse functional sequelae (8%). Nearly one third of the respondents had no major concerns about using the technique. CONCLUSIONS: The Goldman tip procedure is a safe, effective technique for a select group of patients. A polling of experienced rhinoplasty surgeons revealed that only a small subset of surgeons support the continued viability of the Goldman technique as a surgical option.

Adolescent↗
PubMedDate not supplied

Intermediate crural overlay in rhinoplasty: a deprojection technique that shortens the medial leg of the tripod without lengthening the nose.

OBJECTIVE: To review the indications for, surgical techniques of, and results of intermediate crural overlay of the alar cartilages in rhinoplasty. DESIGN: Prospective study of patients undergoing intermediate crural overlay of the lower lateral cartilages. The setting was a facial plastic surgery private practice. Patients included 10 primary rhinoplasty patients and 1 revision rhinoplasty patient who underwent intermediate crural overlay of the lower lateral cartilages. The main outcome measures were postoperative photographs and patient records, which were reviewed for tip projection and rotation, preservation of the double break, bossae, and knuckling. RESULTS: Intermediate crural overlay decreased projection in all 11 patients and increased the nasolabial angle in 7 patients. One patient had no change in the nasolabial angle, and 3 patients had counterrotation of 1 degrees , 3 degrees , and 4 degrees . A postoperative physical examination revealed that no patient had developed bossae, tip asymmetries, or knuckling. In addition, the double break was maintained in all the study patients. CONCLUSIONS: Intermedial crural overlay is a reliable technique for achieving tip deprojection. Overall, the nasolabial angle is maintained (although in 3 patients, clinically insignificant counterrotation did occur). In addition, the length of the intermediate crura is reduced, but the double break is preserved. In the group of patients with thin skin and tip overprojection secondary to overdevelopment of the lower lateral cartilages, intermediate crural overlay achieves tip deprojection while controlling the nasolabial angle and preserving the natural curvature of the dome.

Adolescent↗
PubMedDate not supplied

Analysis of outcomes after functional rhinoplasty using a disease-specific quality-of-life instrument.

OBJECTIVE: To measure the efficacy of functional rhinoplasty techniques with a validated quality-of-life instrument. DESIGN: Prospective observational outcomes study of patients with severe nasal obstruction owing to septal deviation, internal or external valve collapse, and turbinate hypertrophy who subsequently underwent functional rhinoplasty. Preoperative and postoperative evaluations were performed using the Nasal Obstruction Symptoms Evaluation scale. RESULTS: Forty-one patients completed preoperative and postoperative evaluations. No complications occurred. There was a significant improvement in mean Nasal Obstruction Symptoms Evaluation score postoperatively for the entire cohort (P<.01). Nasal Obstruction Symptoms Evaluation scores were also examined based on the procedure performed, such as spreader grafting, septoplasty, external valve suspension, and turbinectomy. Each subgroup also demonstrated airway improvement. CONCLUSIONS: Functional rhinoplasty techniques are effective in improving nasal airway function as measured by a patient-based, disease-specific, quality-of-life instrument. The specific techniques considered to treat nasal obstruction can be tailored to address the areas of concern, including septal deviation, internal or external valve collapse, and turbinate hypertrophy.

Adolescent↗
PubMedDate not supplied

Quantitative analysis of lateral osteotomies in rhinoplasty.

OBJECTIVE: To statistically analyze the long-term results of osteotomy after rhinoplasty. DESIGN: In a consecutive series of 51 patients who underwent reduction rhinoplasty from May 1, 2000, through September 30, 2003, all underwent the same method of bilateral lateral osteotomies, performed by one of us. Twenty patients agreed to participate in this study. The follow-up ranged from 7 to 36 months (mean, 12.6 months). By using preoperative and postoperative photographs, comparisons were made of the change in the dorsal width of the nose (the anterior junction of the nasal bones) and of the ventral width of the nose (where the nasal processes of the maxilla meet the body of the maxilla). RESULTS: There was a significant change (P = .003) in the ventral width of the nose after nasal bone osteotomy. There was no significant change (P = .24) in the dorsal width of the nose. CONCLUSIONS: By using this technique of osteotomy, it is possible to narrow the ventral width of the nose with statistical significance. The dorsal width of the nose is maintained in reduction rhinoplasty. To our knowledge, this is the first attempt to quantify the amount of narrowing achieved after nasal osteotomies.

Female↗
PubMed1984

Revision rhinoplasty. A decision dilemma.

Although most of the previous literature on revision rhinoplasty discusses a certain nasal deformity with its specific management, patients seen for revisional rhinoplasty are usually seen with a combination of different problems that confuse the surgeon. The aim of this article is to offer a simplified and systematic approach to revision rhinoplasty. Examples of preoperative cases, their step-by-step analysis, and postoperative results are given.

Esthetics↗
PubMed1992

The external rhinoplasty approach for rhinologic surgery in children.

The external rhinoplasty is a versatile approach for exposing nasal anatomy in children and has been utilized for a variety of rhinologic problems (N = 35). These have included septal deviation (11), cleft lip nasal deformity (10), unilateral choanal atresia (five), nasal dermoids (four), and problems of the sphenoidal sinus (five). For children with septal deformities, the external approach allows complete intranasal visualization, providing access for careful and conservative reconstruction. In children with cleft lip nasal deformity, decortication allows for direct sculpting of the alar cartilages. For unilateral choanal atresia, the external technique provides exposure of the posterior vomer as in the transpalatal approach, but without the risk to palatal growth. For nasal dermoids, the open rhinoplasty offers wider exposure with more control over the medial osteotomies, a better view of the cribriform plate, and enhanced cosmesis. For problems of the sphenoid, the external route utilizes the guiding midline intranasal structures for rapid and direct entry into the sinus. In our study, the age range of the children was between 7 months and 18 years. The range of follow-up was between 6 months and 5 years. The techniques for the individual procedures are described, along with a rationale for their employment. There were no postoperative complications, and no long-term problems associated with the use of the external technique. In conclusion, the enhanced exposure provided by the external rhinoplasty approach in children facilitates rhinologic procedures on the soft tissues of the nose and the nasal architecture, as well as in the central core of the face.

Adolescent↗
PubMed1996

Alar reductions in rhinoplasty.

OBJECTIVE: To ascertain if avoiding the vestibular portion of alar reductions during rhinoplasty could improve the cosmetic result of the postoperative nasal sill. DESIGN: Blind, randomized review of base-view photographs (40 patients) 1 year after rhinoplasty. SETTING: A surgical clinic, accredited by the Accreditation Association of Ambulatory Health Care. PARTICIPANTS: A consecutive sample of 40 patients (2 groups) who underwent alar reduction as a part of their rhinoplasty and whose 1-year postoperative photographs were reviewed by 2 facial plastic surgeons and 3 plastic surgeons. MAIN OUTCOME MEASURES: Midway through a 2-year period, the method of alar reduction was changed to include only the cutaneous portion of the nostril. Twenty-two patients had cutaneous-vestibular excisions; 18 patients had cutaneous-only excisions. The surgeon participants reviewed randomized photographs taken 1 year postoperatively and were asked to rate the alar sill for the degree of scarring and notching. RESULTS: Tabulation of the surgeons' ratings revealed significantly less perception of notching and scarring in the alar reduction group with the cutaneous-only excisions. CONCLUSION: Modification of alar reduction to avoid crossing the nostril rim appears to improve the aesthetic result.

Cicatrix↗
PubMed1997

Tumefactive cartilage proliferation after rhinoplasty. A newly reported complication.

OBJECTIVE: To describe and document the development of tumoral proliferation of cartilage in 4 patients after nasal surgery, a complication that, to our knowledge, has not been reported before. DESIGN: Similar postoperative nasal masses were excised from 4 patients who underwent rhinoplasty. Histopathologic evaluation was carried out to identify the nature of the lesions and to provide a basis for rational management of similar lesions subsequently encountered. SETTING: Academic tertiary referral center. PARTICIPANTS: Four healthy patients (3 women and 1 man) ranging in age from 21 to 49 years. Two of the patients underwent routine rhinoplasty with resection of cephalic margins of alar cartilages, and 2 underwent augmentation procedures with implantation of auricular cartilage. INTERVENTION: Discrete firm masses were excised from each patient's nose approximately 1 year after the most recent rhinoplastic procedure was performed. Histological evaluation was carried out on each specimen. RESULTS: All 4 masses were found to consist of tumefactive proliferation of cartilage. Clonal proliferation and mild nuclear atypia were observed. CONCLUSIONS: After rhinoplasty, progressive asymmetrical fullness in or adjacent to cartilaginous structures or graft material should suggest the possibility of tumefactive proliferation of cartilage and should be evaluated with surgical exploration. All areas of thickened cartilage should be excised completely, with immediate auricular cartilage reconstruction of resulting anatomical defects. Perichondrium should be completely removed from auricular cartilage implants in the nose, and mechanical injury to the graft should be minimized. We strongly caution against morsellizing dorsal cartilage implants for nasal reconstruction.

Adult↗
PubMed1994

Predictability of the computer imaging system in primary rhinoplasty.

One hundred consecutive cases of primary rhinoplasty were planned with a computer imaging system. All the preoperative and one-year postoperative profile pictures were discussed with the patients. Not one patient complained that the planned result was not achieved, and all patients considered the postoperative picture identical to the planned preoperative screen picture. To analyze the results better, a comparison between computer screen and postoperative profile lines was made. Two orthographic negatives were made: one of the picture from the computer screen, the other from the slide one year after rhinoplasty. The negatives are of the same proportions, i.e., the distance between eye and mouth is the same. The negatives were converted into line drawings using a photographic process called solarization. The two resulting lines were superimposed to produce the final picture. The differences in position of other features of the face are due to different positions of mouth, head, hair, and expression or slide changes in the camera angle. Using a computer to plan rhinoplasty allows the surgeon to eliminate patients with unrealistic expectations, to analyze the patients' wishes better, and to plan the operation more accurately.

Adult↗
PubMed1984

After aesthetic rhinoplasty: new looks and psychological outlooks on post-surgical satisfaction.

Thirty-four female patients who underwent rhinoplasty were followed through assessment of post-surgical satisfaction (pss), perception of subjective improvement, objective improvement (surgeon's ratings), and objective post-surgical nasal deformity. Assessments of pss and subjective improvement were obtained on 3 occasions: T1, 1 week after surgery, on cast removal; T2, 1 month after cast removal; and T3, 3 months after cast removal. The investigation was aimed at examination of the relationship of patients' subjective post-surgical appraisals of the operation with objective indices of outcome of rhinoplasty. Results indicated that at T1, pss is totally dissociated from objective outcome or its appraisal by the patient. At T2 an association between objective outcome and pss and subjective appraisal of outcome is evident, but seems to reflect the total reliance of the patients' judgment on surgeons' appraisals. At T3 a paradoxical trend is indicated: slim objective favorable outcomes correlate with high pss, while a considerable share of patients with whom a highly favorable outcome has been attained express relatively low pss. This paradoxical trend may be well understood when applying Cognitive Dissonance Theory. The whole pattern of results point again at highly complex and powerful psychological processes, some of them seemingly irrational, operating within patients when relating to rhinoplasty, a simple superficial surgical procedure.

Adult↗
PubMed1985

The classification of complications after augmentation rhinoplasty.

The authors classify the complications resulting from augmentation rhinoplasty into 6 types according to the nasal areas involved, then guide the reader to the corresponding technique of management for each type. Their classification is based on the data of 113 patients whom they treated with a secondary rhinoplasty in their clinic during the past 10 years. In the case of augmented noses, it is especially noted that removal of the implant must precede any further treatment in a secondary rhinoplasty.

Female↗
PubMedDate not supplied

Two methods of anesthesia for rhinoplasty in outpatient setting.

This retrospective study was designed with the aim to evaluate suitability of two methods of anesthesia: local anesthesia combined with sedation (midazolam + pethidine) or dissociative (midazolam + ketamine hydrochloride) anesthesia for performing rhinoplasties in an outpatient setting. During 1985-1994, we performed 516 rhinoplasties in 464 patients. Sedation and local anesthesia was used in 263, and dissociative and local anesthesia in 253 procedures. Both methods were well tolerated by the patients, no serious anesthetic complications were seen, and the clinical problems in connection with anesthesia were acceptably low. The use of sedation technique and dissociative anesthesia in combination with local anesthesia have both proved to be safe and effective anesthetic methods for performing rhinoplasty.

Adolescent↗
PubMedDate not supplied

Does corticosteroid usage in rhinoplasty cause mood changes?

In this study, the psychological effects of single-dose corticosteroids administered to patients who had undergone rhinoplasty were assessed. A total of 30 rhinoplasty patients were included in the study and were randomly assigned to 1 of 2 groups. Preoperatively, patients completed the Bech Rafaelsen Mania Scale and the Beck Depression Inventory. Dexamethasone 10 mg was given intravenously just before surgery to the first group, but no medication was administered to the second group. On the first postoperative day, patients were seen again, and the Bech Rafaelsen Mania Scale and the Beck Depression Inventory were again completed. Periorbital edema and ecchymosis were graded, and psychological well-being was measured on a standard visual analog scale. All patients and physicians were blinded to treatment until the end of the study. Results show that administration of a single-dose of dexamethasone 10 mg caused neither euphoria nor depression. No significant differences were observed between steroid and control groups in terms of patients' psychological well-being. With single-dose dexamethasone, periorbital edema was significantly reduced on the first 2 postoperative days, and upper eyelid ecchymosis was significantly decreased only on the first postoperative day. However, reoperative steroid administration had no influence on ecchymosis of the lower eyelid. The authors conclude that single-dose dexamethasone 10 mg can be used safely to reduce periorbital edema and ecchymosis in rhinoplasty patients.

Adult↗
PubMed2004

Functional and esthetic rhinoplasty.

Rhinoplasty is performed to improve the appearance of the nose. However, conventional procedures may result in impairment of nasal breathing. The purpose of this article is to describe a "functional and esthetic" rhinoplasty technique designed to avoid adverse effects on ventilation by preserving the structure of the nasal vault. The main indication for this technique is treatment of cyphotic or tension nose. Since this procedure does not correct nasal obstruction due to septo-turbinal abnormalities and narrow nasal fossa, turbinoplasty must be performed concurrently if necessary. Our series of >1000 cases over a 15-year period demonstrates that this conservative rhinoplasty technique prevents most functional complications associated with conventional procedures and often improves ventilation. Immediate and long-term cosmetic outcome is excellent with a natural-looking appearance and fewer tip revisions.

Cicatrix↗
PubMedDate not supplied

External rhinoplasty for the Arabian nose: a columellar scar analysis.

This study aimed to evaluate columellar scar problems after external rhinoplasty in the Arabian population, and to analyze the technical factors that help prevent such problems and maximize the scar cosmesis. The investigation was conducted in university and private practice settings of the author in Alexandria, Egypt. A total of 600 Arab patients who underwent external rhinoplasty were included in the study. All the patients underwent surgery using the external rhinoplasty approach, in which bilateral alar marginal incisions were connected by an inverted V-shaped transcolumellar incision. At completion of the procedure, a two-layer closure of the columellar incision was performed. At a minimum of 1 year postoperatively, the columellar scar was evaluated subjectively by means of a patient questionnaire, and objectively by clinical examination and comparison of the close-up pre- and postoperative basal view photographs. Objectively, anything less than a barely visible, leveled, thin, linear scar was considered unsatisfactory. Subjectively, 95.5% of the patients rated the scar as unnoticeable, 3% as noticeable but acceptable, and 1.5% as unacceptable. Objectively, the scar was unsatisfactory in 7% of the cases. This was because of scar widening with or without depression (5%), hyperpigmentation (1.5%), and columellar rim notching (0.5%). The use of a deep 6/0 polydioxanon (PDS) suture significantly decreased the incidence of scar widening (p < 0.005).The columellar incision can be used safely in the Arab population regardless of their thick, dark, and oily skin. Technical factors that contributed to the favorable outcome of the columellar scar included proper planning of location and design of the incision used, precise execution, meticulous multilayered closure, and good postoperative care.

Adolescent↗
PubMedDate not supplied

Closed rhinoplasty with marginal incision: our experience and results.

Supporters of traditional rhinoplasty and promoters of open rhinoplasty have debated their approaches for many years. From among different possible techniques, a surgeon must always choose the approach that provides the best aesthetic result. The surgeon's experience and artistic sense are essential for the closed technique, whereby most of the corrections are performed without exposing the nasal frame. The open technique allows a greater operating range with a direct view of the nasal structure, resulting in improved precision in modeling the cartilages. However, the absence of intact skin cover exposes the surgeon to a less precise overall aesthetic evaluation. This report highlights the marginal technique, described in 1990 by Guerrerosantos, which uses a two-sided circular incision permitting complete dissection of the alar cartilages and the overhead skin cover of the columella. This approach, together with the extramucous technique, permits complete exposure of the skin and nasal septum without a columella incision. Therefore, the marginal technique is suitable for primary rhinoplasty cases in which complex modeling of the nasal tip and an excellent aesthetic result are required.

Adult↗
PubMedDate not supplied

Effects of different corticosteroids on edema and ecchymosis in open rhinoplasty.

A double-blind, randomized trial with placebo control was planned to evaluate the effects of corticosteroids (betamethasone, dexamethasone, methylprednisolone) in approximately equivalent doses (8 mg dexamethasone/day), and to compare their effects with that of tenoxicam, an antiinflammatory drug, on both the edema and ecchymosis in open rhinoplasty with osteotomies. For this study, 40 patients were divided randomly into five groups of 8 patients each, which received, respectively, betamethasone (group 1), dexamethasone (group 2), methylprednisolone (group 3), tenoxicam (group 4), and placebo (group 5). Open rhinoplasty with osteotomies was performed by the same surgeon with the patient under general anesthesia. Drugs were administered just before the induction of anesthesia and continued for 3 days. Only acetaminophen was used to control postoperative analgesia. Digital photographs of each patient were taken on postoperative days 1, 3, and 7. Scoring was performed separately for eyelid swelling and ecchymosis by three observers independently using a graded scale from 0 to 4. No statistically significant differences existed among the five groups in terms of age, sex, duration of surgery, amount of bleeding, and intravenous fluid administration during the surgery. On postoperative days 1, 3, and 7, no differences in the levels of ecchymosis or edema among the steroid groups, the tenoxicam group, and the control groups were observed. In conclusion, the authors observed no significant differences among the different kinds of steroids administered in equivalent doses (8 mg dexamethasone/day). Steroids used in these doses were not effective in preventing or reducing edema and ecchymosis after open rhinoplasty with osteotomies. Tenoxicam also was not effective. No complications caused by the use of steroids were observed during the 6-month follow-up period.

Adult↗