Search

Background: Postoperative infections after rhinoplasties are rare, yet devastating on patient outcomes. The literature reports an overall incidence of

Preservation rhinoplasty is making a resurgence as a reliable method of performing primary rhinoplasty. Dorsal preservation is an important part of the approach to preserve favorable nasal contours when performing rhinoplasty. Keys to success require proper patient selection and careful execution. There are potential sequelae, such saddle nose deformity, recurrence of the dorsal convexity, cerebrospinal fluid leak, and radix step-off. This article discusses methods and adjustments in technique to help minimize these potential problems when performing dorsal preservation.

Nasal valve collapse has multiple causes, including congenital, traumatic, and, unfortunately, iatrogenic. Recognition of the causes of nasal valve collapse and the methodology for treatment is paramount not only for the otolaryngologist but also for any physician managing the nasal airway. This article focuses on the cause and surgical management of internal and external nasal valve collapse.

Significant nasal septal deviation may require complex reconstruction to achieve complete correction. Subtotal septal reconstruction is a method for addressing deviations in the L-strut.To review the long-term outcomes of subtotal septal reconstruction and provide objective evidence of functional and aesthetic improvement.This medical record review obtained data on 144 patients who underwent subtotal septal reconstruction from September 1, 2008, to September 1, 2013. Data analysis was performed from September 1, 2013, to September 1, 2014.Functional outcomes were measured using the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, and objective aesthetic outcomes were measured using 3-dimensional (3-D) stereophotogrammetry. Follow-up times were classified as time point 1 (TP1; preoperative), time point 2 (TP2; early postoperative), and time point 3 (TP3; final postoperative).Of the 144 patients who underwent subtotal septal reconstruction, 104 (72.2%) were female; the mean (SD) age was 37.3 (13.7) years; 57 underwent primary septorhinoplasty; and 87 (60.5%) underwent revision septorhinoplasty. The NOSE scores improved in all 5 categories of nasal obstruction, with mean (SD) survey completion at 270 (260.1) days. Aesthetic results were measured with 3-D imaging after a mean (SD) follow-up of 613.5 (434.4) days postoperatively. No statistically significant loss was found in mean (SD) nasal length over time (TP2 to TP 3, -0.16 [1.36] mm; 95% CI, -0.54 to 0.22 mm; P = .41) or between mean (SD) postoperative loss of projection (TP2 and TP3, -0.19 [0.92] mm, 95% CI, -0.45 to 0.07 mm; P = .17). An increase in mean (SD) rotation (nasolabial angle) generated with septorhinoplasty (4.24° [11.08°]; 95% CI, 1.14°-7.34°; P = .01) and a mean (SD) decrease in rotation detected during postoperative healing (-2.63° [6.96°]; 95% CI, -4.63° to -0.63°; P = .01) were found. Although measurement of symmetry was improved in the early postoperative period (TP1 to TP2, -0.16 [1.26] mm; 95% CI, -0.52 to 0.20 mm; P = .40), this finding did not become statistically significant until the final measurement (TP1 to TP3, -0.43 [1.07] mm; 95% CI, -0.73 to -0.13 mm; P = .007; TP2 to TP3, -0.28 [0.87] mm; 95% CI, -0.53 to -0.03 mm; P = .03). A mean (SD) decrease in columellar show was achieved with surgery (-0.66 [1.37] mm; 95% CI, -1.05 to -0.27 mm; P = .001). No statistically significant change was found in the alar-columellar association from TP2 to TP3 in this patient population, confirming no unwanted alar or columellar retraction over time (0.10 [0.61] mm; 95% CI, -0.07 to 0.27 mm; P = .25). A total of 114 patients (79.2%) required costal cartilage harvest for adequate reconstruction.Subtotal septal reconstruction yields improved functional and aesthetic outcomes and has the potential to be a useful tool for the rhinoplasty surgeon in the treatment of severe septal deviation.4.

Closure of septal perforations remains a technically difficult procedure to perform.To assess the use of costal perichondrium as an interpositional graft to enhance closure of septal perforations using bilateral mucosal flaps and the effectiveness of the procedure.This case series included all 51 consecutive patients presenting with septal perforations from January 1, 2006, to August 31, 2014, at a single institution. Mean (SD) follow-up was 19 (18) months. Patients with subtotal perforations did not have their perforations closed but underwent rhinoplasty with improved form and function. All patients underwent evaluation for changes in postoperative symptoms.Bipedicled mucoperichondrial flaps with placement of costal perichondrium between the repaired flaps.Success rate of septal perforation closures and the clinical impact of the success of closure as experienced by the patient using the validated Nasal Obstruction Symptom Evaluation (NOSE) questionnaire (range, 0-20; higher scores indicate greater obstruction).Of the 51 patients (14 male; 37 female; median age, 42.6 [range, 17-69] years), 44 underwent attempted closure of the perforation at the time of the procedure. Closure was successful in 42 of the 44 patients (95%).Two patients had persistent perforations, one of which was subsequently closed in a secondary procedure. Twenty-six of 51 patients with septal perforations completed preoperative and postoperative NOSE questionnaires. The mean (SD) preoperative and postoperative NOSE scores were 12.6 (4.2; range, 6-20) and 3.4 (3.8; range, 0-12), respectively (P .001). A mean (SD) improvement of 9.0 (3.9) points in the NOSE score was observed from patients after closure of their septal perforation, and 10 patients reported no symptoms (NOSE score, 0).Costal perichondrium is an effective interpositional graft to be used in conjunction with the bilateral mucoperichondrial flaps for closure of septal perforations. Costal perichondrium may be used to aid in closure rates of septal perforations.4.

In facial plastic surgery, attaining hemostasis may require adjuncts to traditional surgical techniques. Fibrin tissue adhesives have broad applications in surgery and are particularly useful when addressing the soft tissue encountered in facial plastic surgery. Beyond hemostasis, tissue adhesion and enhanced wound healing are reported benefits associated with a decrease in operating time, necessity for drains and pressure dressings, and incidence of wound healing complications. These products are clinically accessible to most physicians who perform facial plastic surgery, including skin grafts, flaps, rhytidectomy, and endoscopic forehead lift.

Rhinoplasty is commonly acknowledged as the most demanding and difficult of plastic surgical procedures. The demands of rhinoplasty in the aging patient are no different. Regardless of patient age, the principles of structure rhinoplasty remain constant: surgical manipulation of the nasal construct causes weaknesses susceptible to scar contracture. Augmentation is required to withstand the distorting forces of tissue healing. However, certain functional and aesthetic goals of the aging patient must also be taken into account in a procedure that involves tissue reorientation and augmentation, with careful attention to long-term surgical outcome consideration while adhering to this philosophy.

The unfavorable result in plastic surgery , The unfavorable result in plastic surgery , کتابخانه مرکزی دانشگاه علوم پزشکی تهران

After completion of this article, the reader should be able to describe the indications for lateral crural repositioning, understand the key steps to performing the procedure, and be able to manage the complications associated with this treatment strategy.

Surgical correction of defects of the internal nasal valve, ala, vestibule, and sill is widely regarded as a challenge due to concerns of poor outcomes of facial aesthetics and nasal function. Auricular composite grafting is a reliable method of reconstruction of deformities of the nasal vestibule and sill. A classification system of types of defects may help surgeons in understanding the indications for composite grafting. Furthermore, we have developed surgical techniques that enhance survival of composite grafts of larger size. Composite grafting is an effective technique to repair a wide range of defects of the internal nasal valve, nasal sill/ala, and vestibule with excellent functional and aesthetic results.

Costal cartilage grafting is increasing in popularity with increased demand for augmentation rhinoplasty and increased need for grafting material for structure rhinoplasty techniques. Use of costal cartilage for dorsal grafting is both art and science. The art is demonstrated in the act of carving a dorsal graft that will reflect the actual contour of the nasal dorsum. The science is linked to the methodology of how the grafts are contoured to match the patient's desires and how the graft is fixed to the bony dorsum to minimize the risk of warping and displacement. Variations in dorsal graft design and methods of fixation are described. Use of the perichondrial interface between dorsal graft and perforated/rasped nasal dorsum acts to ossify the dorsal graft to the underlying bone, creating an immobile and natural appearing nasal dorsum. The fixation of the dorsal graft limits movement and hence decreases the likelihood of warping or deformity. Use of microfat in rhinoplasty has tremendous potential for camouflage and to promote healing of compromised tissues. Using microfat-infused soft tissue augmentation (MISTA), the surgeon is able to deliver microfat to an open surgical field, promote healing, and provide soft tissue augmentation. In this technique, microfat is injected into soft tissue carriers (perichondrium, temporalis fascia, etc.) and then implanted into the surgical field. MISTA has tremendous potential utility in many areas of cosmetic and reconstructive surgery.

In recent years, with the advent of 3-dimensional (3D) imaging techniques, it has become possible to objectively measure rhinoplasty results. However, few studies have used 3D imaging software to assess postoperative rhinoplasty results of the nasal tip.To analyze nasal tip volumes of patients with bulbous tips and measure postoperative nasal tip volume changes in patients who have undergone lower lateral cartilage (LLC) repositioning.A prospective study of patients with a preoperative diagnosis of bulbous nasal tip and cephalically oriented LLC as measured intraoperatively (with angles less than 30 degrees from the midline) who underwent rhinoplasty by a single surgeon and preoperative and postoperative 3dMD imaging at a university hospital.Rhinoplasty with LLC repositioning and preoperative and postoperative 3dMD system imaging. We also used 3dMD Vultus software for the analysis of nasal tip volume changes.Changes in nasal tip volume and LLC angle.Thirty-one patients met the inclusion criteria (25 women and 6 men; mean age, 33 years). Among these, there were 16 primary and 15 revision cases with a follow-up range of 1 to 19 months. Statistical tests included a paired t test on volume and angle changes as well as correlative and exploratory analyses to gain further insight into the analysis population over time. The change in the LLC angle after repositioning was found to be statistically significant. The mean decrease in volume on the right was 0.0254 mL, and the mean decrease on the left was 0.0249 mL. The mean total volume change was a decrease of 0.0503 mL. An exploratory analysis suggested that subjects with longer follow-up displayed a greater reduction in volume. Using 5 months as a cutoff, we found that the subgroup with longer follow-up displayed a mean total bilateral volume change of -0.07 mL compared with -0.03 mL in the subgroup with shorter follow-up.We found that LLC repositioning when used to address bulbous nasal tips and cephalically oriented LLCs leads to significant increase (preoperative to postoperative) in the angle of the LLC (to a more caudal orientation). We also found an overall trend of decreasing nasal tip volume throughout follow-up. Although not statistically significant, the overall decrease in volume is clinically meaningful when paired with favorable positioning of the LLC. Exploratory analyses suggest that treatment effect is consistent across sexes and that greater decrease in total volume might be found with longer follow-up.4.

IMPORTANCE It is unknown whether poly-4-hydroxybutyric acid (P4HB)-reinforced superficial musculoaponeurotic system tissue (SMAS) plication techniques will support SMAS imbrication and plication and potentially improve outcomes in rhytidectomy. OBJECTIVES To evaluate the biomechanical properties (tissue breaking strength, suture tearing force, and stress relaxation) of the SMAS with vs without reinforcement with P4HB absorbable mesh and to correlate these results with potential clinical applications. DESIGN, SETTING, AND SAMPLES In a cadaver study at an academic setting, 12 fresh frozen cadaver heads were used. Rhytidectomy incisions were made, and the SMAS was harvested and prepared for strength and stress testing using an Instron device. MAIN OUTCOMES AND MEASURES Tissue breaking strength and suture tearing force were analyzed. Stress relaxation test results were also assessed. The results of the SMAS samples alone were compared with those reinforced with P4HB absorbable mesh. RESULTS Overall, there were significant differences noted in tissue breaking strength and suture tearing force between the 2 groups. When the SMAS was reinforced with absorbable mesh, significant improvements were observed in tissue breaking strength (P .001) and suture tearing force (P .003). In addition, less variability was demonstrated in the maximum tensile load-bearing quality of the SMAS when the repair was reinforced with P4HB. CONCLUSIONS AND RELEVANCE Reinforcement with P4HB absorbable mesh improves tissue breaking strength and suture tearing force in cadaveric SMAS. It also reduces the variability in load vs displacement seen among samples tested. These data suggest that P4HB-reinforced SMAS imbrication would support higher loads and provide more consistent, long-lasting SMAS support among patients undergoing rhytidectomy. Further studies are needed to correlate these data with clinical outcomes in rhytidectomy.

UNLABELLED What is the single most difficult challenge in revision rhinoplasty and how do you address it? During revision rhinoplasty, when dorsal augmentation is necessary and septal and ear cartilage is not available, what is the best substance for correcting the problem? If rib cartilage is used for dorsal augmentation during revision rhinoplasty, what is the technique to prevent warping of the graft? Alloplast in the nose--when, where, and for what purpose? Does the release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid-one-third nasal pinching in reductive rhinoplasty?' ANALYSIS Over the past 5 years, how has your technique evolved or what have you observed and learned in performing revision rhinoplasty?

Subtotal septal reconstruction is a surgical technique used to reconstruct severe septal deviations that are not easily repaired using less invasive methods. Patients with identifiable septal fractures across the caudal or dorsal segments of the L-strut are good candidates. These patients may present with deformities such as the deviated nose or saddle nose. Adequate autologous cartilage is needed to reconstruct the septum. The deviated segments of the nasal septum are removed and then reconstructed by replacing the caudal septum with a straight piece of septal cartilage fixated to the nasal spine. The bilateral extended spreader grafts fixated to the remnant dorsal strut is then fixed to the caudal septal replacement graft to reconstitute the L-strut. In some cases, the dorsal strut may overlap the caudal portion of the L-strut to complete the repair. Care must be taken in setting nasal length, projection, rotation, and supratip break. If these parameters are not set very carefully deformity may ensue. Other potential complications include change in the upper lip smile or a crease forming in the upper lip when the patient smiles. This is a complex technique and must be performed with special care to avoid deformity.

Resolution of ptosis is a key step to the success of many plastic surgery procedures. Ptosis is a manifestation of tissue stretch. Tissue stretch can occur as a result of the natural aging process or health of the patient, or tissue may stretch under added weight or volume, such as when implants are placed. Surgical rejuvenation of ptotic tissues is very effective and results in marked changes in the patient profile yet the tissue that resulted in the need for the procedure first place has not improved and ptosis can recur. Recent developments in long-term resorbable porous materials have provided surgeons with the opportunity to experiment with tissue reinforcement in plastic surgery procedures. These new materials have a low profile, rapid tissue integration, and a long-term strength retention profile. Long-term resorbable scaffolds such as poly-4-hydroxybutyrate (P4HB) natural scaffold (GalaFLEX scaffold, Galatea Surgical, Inc., Lexington, MA) have shown promise for a host of plastic surgery indications. This article presents clinical experience with GalaFLEX for soft tissue reinforcement in three different clinical applications; including the reinforcement of the superficial muscular aponeurotic system (SMAS) in minimally invasive facelift, reinforcement of the skin envelope in mastopexy, and reinforcement of the breast capsule (pocket) in revisional breast surgery. Soft tissue reinforcement has been shown to provide increased mechanical strength as well as improved maintenance of postoperative results. Level of Evidence 5![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

Revision rhinoplasty is a complex operation with many variables that may influence the final esthetic and functional outcome of the procedure. Cartilage forms the structural framework of the lower two-thirds of nose and is essential for long-term support and maintenance of a patent nasal airway. The use of autologous cartilage grafting is the primary source of this material, limited by donor site quantity, quality, and harvest morbidity. Alloplastic materials, solid and injectable, are often used for augmentation purposes and may have devastating consequences. This article discusses past and current treatment concepts for various nasal deformities using available autologous grafting techniques.

The short nose deformity may arise from multiple etiologies including iatrogenic following rhinoplasty. The weakening of the cartilaginous support and the contractile forces imposed by the healing soft tissue envelope may result in the short nose deformity. The focus of this article is to present the senior author's approach to this nasal deformity.

This cohort study compares the results of major augmentation rhinoplasty using autologous costal cartilage vs irradiated homograft costal cartilage and analyzes the histologic properties of both types of cartilage.

Maintaining structural integrity during rhinoplasty often necessitates adding support to the nose. Autologous grafting material is the safest and most reliable source of this structural support. A variety of sources in the body can serve as donor sites for such grafts. The most common sites are septal cartilage, auricular conchal cartilage and rib cartilage. Less common sites include tragal cartilage, calvarial bone and iliac bone. This article reviews the surgical techniques for accessing, harvesting, and modifying these grafts for use in rhinoplasty.

This article describes the equipment and software used to create facial 3D imaging and discusses the validation and reliability of the objective assessments done using this equipment. By overlaying preoperative and postoperative 3D images, it is possible to assess the surgical changes in 3D. Methods are described to assess the 3D changes from the rhinoplasty techniques of nasal dorsal augmentation, increasing tip projection, narrowing the nose, and nasal lengthening.