Surgical anatomy for Asian rhinoplasty: Part III

This article, which comprises the third part of a series on surgical anatomy for Asian rhinoplasty, addresses the lower one-third of the nose, including the alar cartilage and tip-supporting structures, known as distal mobile framework. As discussed in earlier parts of this series, diversity in surgical anatomy results in different surgical techniques in Asian rhinoplasty compared to rhinoplasty in Caucasian patients. Nasal tip structures are especially important due to their crucial importance for changing the nasal shape in Asians. This article, along with the previous ones, will provide both basic and advanced knowledge of practical surgical anatomy for Asian rhinoplasty.

Surgical importance of the posterior auricular ligament when harvesting ear cartilage in rhinoplasty

Background@#Ear cartilage is a preferred graft material in rhinoplasty. However, after harvest, instability of the auricular framework may arise as a form of donor site morbidity. In the harvest of ear cartilage, the posterior auricular ligament (PAL) is usually sacrificed in order to obtain as much cartilage as possible. Since damage to the PAL may cause auricular instability, we studied the periauricular anatomy using cadavers and evaluated auricular stability during surgery. @*Methods@#Six ears from hemifacial cadavers were studied to clarify the exact anatomy of the PAL. Then, the recoil force of the auricle was serially measured to evaluate the stability of the auricular framework in 30 patients during surgery: before making the skin incision (M1), before and after cutting the PAL (M2, M3), and after harvesting the cymba concha (M4). The differences in force observed after cutting the PAL (ΔM2–M3) and after harvesting the cymba concha (ΔM3–M4) were statistically analyzed. @*Results@#In the cadaveric study, the PAL was identified between the superficial and deep mastoid fasciae and connected the caudal aspect of the cymba concha to the deep mastoid fascia. During surgery, the PAL accounted for 16.20% of the total auricular recoil force. The recoil force decreased by 13.61 N and 11.25 N after cutting the PAL and harvesting the cymba concha, respectively. These decreases were statistically significant (P<0.05). @*Conclusions@#The results suggest that the PAL is a supporting structure of the auricle. Therefore, to preserve auricular stability, minimizing damage to the PAL while harvesting the ear cartilage may be helpful.

Deviated nose: Physiological and pathological changes of the nasal cavity

Deviated nose is highly challenging in rhinoplasty since the surgeon should consider both aesthetic and functional aspects of the nose. Deviated nose correction is surgically complex, and a thorough understanding of the mechanical and physiological changes of intranasal structures, including the septum and turbinates, is necessary for functional improvement.

Cadaveric study of deep temporal fascia for autologous rhinoplasty grafts: Dimensions of the temporal compartment in Asians

Background@#Due to the anatomical complexity of the deep temporal fascia (DTF), practical guidelines for its safe harvest are lacking. However, since the upper temporal compartment (UTC) contains no vital structures, it may provide safe access for DTF harvest. This study aimed to identify the anatomical structures of the temporal compartment in Asian cadavers and to measure their dimensions to enable safe DTF harvest. @*Methods@#The anatomical structures surrounding the temporal compartment were identified in 27 hemifaces from 15 Korean cadavers. After dissection, digital images were acquired and craniometric landmarks were placed upon them to identify the boundaries of the temporal compartment. The horizontal and vertical lengths of the temporal compartment were measured and their surface areas were computationally assessed. Subsequently, differences in the results by sex were evaluated. @*Results@#The five-layer anatomical structure of the UTC was clearly visualized. The UTC was bounded by the temporal septa superiorly and inferiorly, the innominate fascia laterally, and the DTF medially. No vital structures were present within the UTC. The vertical and horizontal lengths of the UTC were 6.41±0.67 cm and 10.44±0.83 cm, respectively, and the surface area of the UTC was 48.52±5.65 cm2. No statistically significant differences were observed in any dimensions between male and female patients. @*Conclusions@#During rhinoplasty, DTF can be harvested as an autologous graft material from the UTC. An anatomical understanding of the UTC will aid in the safe and simple harvest of a sufficient amount of DTF.

Surgical anatomy for Asian rhinoplasty: Part II

Surgical anatomy for Asian rhinoplasty Part I reviewed layered anatomy with neurovascular system of the nose. Part II discusses upper two-thirds of nose which consists of nasal bony and cartilaginous structures. Nasal physiology is mentioned briefly since there are several key structures that are important in nasal function. Following Part III will cover lower one-third of nose including in-depth anatomic structures which are important for advanced Asian rhinoplasty.

Feasibility of a polydioxanone plate as an adjuvant material in rhinoplasty in Asians

BACKGROUND: Nasal framework-supporting procedures such as septal extension grafts, derotation grafts, and columellar strut grafts are usually required in rhinoplasty in Asian patients because the skin envelope is tight, but the nasal framework is small and weak. Autologous materials are preferred, but they have some limitations related to the amount that can be harvested and the frequency of use. Therefore, synthetic materials have been used to overcome these limitations. METHODS: A total of 114 patients who received a polydioxanone (PDS) plate as an adjuvant material in rhinoplasty from September 2016 to August 2017 were retrospectively investigated. The PDS plate was used as to support the weak framework and to correct the contour of the alar cartilages. The PDS plate was used for reinforcement of columellar struts and septal L-struts, alar cartilage push-down grafts, fixation of septal extension grafts, and correction of alar contour deformities RESULTS: Primary and secondary rhinoplasty was performed in 103 and 11 patients, respectively. Clinically, no significant inflammation occurred, but decreased projection of the tip was observed in seven patients and relapse of a short nose was noted in five patients. CONCLUSIONS: PDS plates have been used in the United States and Europe for more than 10 years to provide a scaffold for the nasal framework. These plates can provide reinforcement to columellar struts, L-struts, and septal extension grafts. In addition, they can assist in deformity correction. Therefore, PDS plates can be considered a good adjuvant material for Asian patients with weak and small nasal cartilage.

Surgical anatomy for Asian rhinoplasty

Surgical anatomy is an important and fundamental aspect for all surgical procedures. Anatomy provides a surgeon with the basic and in-depth knowledge that is required and mandatory when performing an operation. Although this subject might be tedious and routine, it is compulsory and should not be overlooked or neglected to avoid any possible postoperative complications. An aggressive and hasty operation without anatomic considerations might cause adverse effects that are irreversible even though a surgical anatomy of the nose is quite simple.

Digital Videoscopic Retrograde Intrarenal Surgeries for Renal Stones: Time-to-Maximal Stone Length Ratio Analysis

PURPOSE: To investigate 100 consecutive cases of videoscopic retrograde intrarenal surgery (RIRS) by a single surgeon and to evaluate factors associated with stone-free status and the learning curve thereof. MATERIALS AND METHODS: We analyzed the results of videoscopic RIRS in 100 patients who underwent primary treatment for renal stones from January 2015 to August 2016. Videoscopic RIRS were performed with URF-V and URF-V2 flexible video uteroscopes (Olympus) or a Flex-Xc flexible ureterorenoscope (KARL STORZ). Non-contrast computed tomography was taken at 3 months postoperatively to confirm the absence of stones. The stone characteristics included the location, maximal stone length (MSL), stone heterogeneity index (SHI), and mean stone density (MSD). Fragmentation efficacy was calculated as operative time (min) divided by removed MSL (mm), and was evaluated in the sequential order of operations. RESULTS: The mean age of the total patient was 60.0±14.0 years. The mean MSL was 13.1±6.2 mm. The average MSD was 734.2±327.6 Hounsfield unit (HU) and the SHI was 241.0±120.0 HU. The mean operation time was 65.1±45.7 min considering each renal unit. The stone-free rate at 3 months post-surgery was 87%. The estimated cut-off of the time-to-MSL ratio below 5 min/mm was 50. Multivariate analyses indicated a lower MSD [odds ratio (OR): 0.998; 95% confidence interval (CI): 0.996–0.999; p=0.047) and the last 50 cases (OR: 5.408, 95% CI: 1.337–30.426; p=0.030) as independent predictors of stone-free status after videoscopic RIRS. CONCLUSION: Low MSDs and the last 50 cases were significant predictors of stone-free rate in videoscopic RIRS.

Bulbous Tip Correction Focusing on Skin Soft Tissue Envelope in Asian Rhinoplasty

BACKGROUND: Correction of a bulbous tip is a difficult procedure in Asians, because their lower lateral cartilage is relatively small and structurally weak to support the thick skin soft tissue envelope (SSTE). Therefore, lower lateral cartilage manipulation alone yields inadequate bulbous tip correction. In this study, authors aim to provide a new bulbous tip definition reflecting nasal tip SSTE and categorization with a suitable surgical procedure. METHODS: One hundred sixty-three patients with tip rhinoplasty between January 2009 and December 2012 were studied who had a tip lobular width greater than 60% of the alar base width. Depending on cartilage size and characteristics of the nasal tip superficial musculoaponeurotic system (SMAS) with SSTE thickness, the following classifications were made: Group I: thin SSTE with a large lower lateral cartilage, Group II: thick SSTE with a small lower lateral cartilage, Group IIa: thick SSTE with loose SMAS, and Group IIb: thick SSTE with dense SMAS. We evaluated the degree of surgical improvement by comparing pre- and postoperative photographs. RESULTS: After comparing pre- and postoperative photos, we observed improvements in tip bulbosity by 11.7% in Group I (n=41), 11.9% in Group IIa (n=64), and 7.1% in Group IIb (n=58). CONCLUSIONS: In Asians, nasal tip bulbosity is often due to excess SSTE. Therefore, a bulbous tip should be defined and evaluated based on its underlying SSTE. Adequate soft tissue resection in addition to lower lateral cartilage support and manipulation are warranted to achieve a refined tip.

Obtaining Maximal Stability with a Septal Extension Technique in East Asian Rhinoplasty

Recently, in Korea, the septal extension graft from the septum or rib has become a common method of correcting a small or short nose. The success rate of this method has led to the blind faith that it provides superior tip projection and definition, and to the failure to notice its weaknesses. Even if there is a sufficient amount of cartilage, improper separation or fixation might waste the cartilage, resulting in an inefficient operation. Appropriate resection and effective fixation are essential factors for economical rhinoplasty. The septal extension graft is a remarkable procedure since it can control the nasal tip bidirectionally and three dimensionally. Nevertheless, it has a serious drawback since resection is responsible for septal weakness. Safe resection and firm reconstruction of the framework should be carried out. Operating on the basis of the principle of "safe harvest" and rebuilding the structures is important. Further, it is important to learn several techniques to manage septal weakness, insufficient cartilage quantity, and failure of the rigid frame during the surgery.

Herpes Simplex Virus Infection after Corrective Rhinoplasty through External Approach: Two Case Reports

PURPOSE: Eczema herpeticum, caused by herpes simplex virus, is an infectious disease involving skin and internal organs. Varieties of physiologic, psychosocial, or environmental stress reactivate reservoir virus which exists in the trigeminal nerve ganglia. Authors report rare cases of nasal eczema herpeticum following corrective rhinoplasty. METHODS: First case, 22-year-old female underwent corrective rhioplasty through an external approach in a local clinic. She developed progressive and painful erythema, nodules and vesicles on nose on the 9th day postoperatively. This unfamiliar lesion lead to a misdiagnosis as a bacterial infection, and had accelerated its progress to the trigeminal innervation of the nasal unit. Second case, a 23-year-old female underwent corrective rhinoplasty by external lateral osteotomy. Ten days after the surgery, disruption occurred on the external osteotomy site, and the ulceration gradually worsened. The surgeon misdiagnosed it as secondary bacterial infection and only an antibacterial agent was applied. RESULTS: Both cases were healed effectively without any complication with proper wound dressing and antiviral therapy, and show no sequelae during an 8-month follow-up period. CONCLUSION: Eczema herpeticum is rare in the field of plastic surgery, but it should be kept in mind that secondary bacterial infections may lead to serious complications such as full-thickness skin loss. Thus, acknowledgement of the patient's past history regarding perioral or intraoral lesion may provide the surgeon with the possible expectancy of eczema herpeticum. Thus, if anyone develops eczema herpeticum, following facial plastic surgery, early diagnosis and immediate proper antiviral therapy will allow fast recovery without serious complications.

Herpes Simplex Virus Infection after Corrective Rhinoplasty through External Approach: Two Case Reports

PURPOSE: Eczema herpeticum, caused by herpes simplex virus, is an infectious disease involving skin and internal organs. Varieties of physiologic, psychosocial, or environmental stress reactivate reservoir virus which exists in the trigeminal nerve ganglia. Authors report rare cases of nasal eczema herpeticum following corrective rhinoplasty. METHODS: First case, 22-year-old female underwent corrective rhioplasty through an external approach in a local clinic. She developed progressive and painful erythema, nodules and vesicles on nose on the 9th day postoperatively. This unfamiliar lesion lead to a misdiagnosis as a bacterial infection, and had accelerated its progress to the trigeminal innervation of the nasal unit. Second case, a 23-year-old female underwent corrective rhinoplasty by external lateral osteotomy. Ten days after the surgery, disruption occurred on the external osteotomy site, and the ulceration gradually worsened. The surgeon misdiagnosed it as secondary bacterial infection and only an antibacterial agent was applied. RESULTS: Both cases were healed effectively without any complication with proper wound dressing and antiviral therapy, and show no sequelae during an 8-month follow-up period. CONCLUSION: Eczema herpeticum is rare in the field of plastic surgery, but it should be kept in mind that secondary bacterial infections may lead to serious complications such as full-thickness skin loss. Thus, acknowledgement of the patient's past history regarding perioral or intraoral lesion may provide the surgeon with the possible expectancy of eczema herpeticum. Thus, if anyone develops eczema herpeticum, following facial plastic surgery, early diagnosis and immediate proper antiviral therapy will allow fast recovery without serious complications.

A Report on the Questionnaire about Augmentation Rhinoplasty

Rhinoplasty is one of the most popular surgical procedures in plastic surgeries. Good results depend not only on the surgical technique but also on individual preference and philosophy of the surgeons. This article reports on the survey of the attitude, preference, and philosophy of surgeons, and finally to elicit the evidence based consensus of current trends mainly dealing with the primary rhinoplasty. The Korean Society of Rhinoplasty Surgeons(KSRS) prepared a questionnaire composed of 20 questions asking about the primary esthetic rhinoplasty. A total of 77 out of 450 plastic surgeons attending the rhinoplasty symposium, 2009, Korea replied and the answerswere assessed. Twenty questions were about operation techniques, preference of alloplastic implant, autologous materials and trivia about the complications rates, etc. Many plastic surgeons preferred silicone to Gore-tex(R). In cases of autologous cartilage grafts, experienced plastic surgeons were more likely to use septal cartilage. But generally, ear cartilages were more frequently used when it is concomitantly used with alloplastic implants. Among silicone implants, boat-shape implant was preferred to L-shape regardless of their surgical experiences. Many Korean plastic surgeons prefer open rhinoplasty to closed rhinoplasty and routinely use boat shape silicone with auricular cartilage when they are doing simple primary rhinoplasty.

Application of Osteotomies in Aesthetic Rhinoplasty

Nasal osteotomy for aesthetic results is required in patients who have broad nasal bone. Since the procedure is difficult, many operators hesitate the surgery. From January 2007 to July 2009, we performed 77 cases of nasal osteotomy, consisting of paramedian oblique medial osteotomy or median oblique-medial osteotomy and percutaneous lateral osteotomy. Most of the patients had satisfying results, however three patients had asymmetric shape and inappropriate inward movement of nasal bone which required revision with percutaneous lateral osteotomy. Osteotomy procedure varies, depending on surgeon's preference and experience, however, each surgeon should be aware of good and weak points of those procedures and use the most suitable method. In order to achieve maximal satisfying results, preoperative analysis of patients and minimal invasive handling should be done. Based on these efforts, this method could broadly be used in the aesthetic field.

Expansion Procedures of the Nasal Envelope in Short Nose Deformity : Release of the Transverse Nasalis Sling and Division of Muscle Confluence in Nasal Hinge Area

Cartilage extension and nasal envelop expansion play a main role incorrecting short or contracted nose. Despite numerous studies for cartilage expansion, there has been no reports of nasal skin elongation methods. We hereby preport a new method for expansion of nasal envelop with a comprehensive understanding of anatomical structures. From April 2009 to September 2010, 6 patients underwent operations to correct short or contracted nose. Two separating procedures were included for nasal envelop elongation; division of muscle(Procerus, Transverse nasali, Levator labii superior alaque nasi: PTL muscles) confluence located at nasal hinge and release of transverse nasalis sling. To estimate the degree of nasal envelop extension, forced skin traction test was performed. Comprehensive research with fresh cadaver was held to study the relationship between nasal SMAS and surrounding structures. Average 3.8mm elongation was documented by forced skin traction testafter the procedure. In the fresh cadaver study, transverse nasalis sling and PTL muscle confluence were firmly attached to the supportive framework. From our clinical experience and cadaver study, we discovered that release of transverse nasalis sling and division of PTL muscle confluence are the main factors for nasal envelop expansion in short or contracted nose.

Tripod Framework Rebuilding in Asian Nose: Tip Plasty Using Alar Advancement Technique

In Caucasians, the lateral crural complex is large and long, and the tip plasty is not difficult. In Asians, however, the nasal tissues are insufficient and the nasal tip needs more volume. Therefore, many operators rely on a graft insertion for augmentation effect. Occasionally, if the tip supporting framework is weak, nasal tip drooping is observed by the operators in long period of follow-up. Recently, release and division of tripod structure combined with framework rebuilding has made the correction of various tripod types of tip complexes possible. The main principle of alar advancement technique is that three limbs of the tripod should be properly separated. The nasal tip should be advanced toward upward and forward direction and reinforcement should be done with autologous graft. In other words, scroll ligament, which connects between the alar cartilage and upper lateral cartilage, and nasal hinge complex should be divided freely, inducing the pivot motion and gliding of alar cartilage which leads the V-Y fashioned advancement and projection of alar cartilage. This paper presents an operation method using auricular cartilage after examining the principle of alar advancement in patients who have lack of tip projection, based on my cadaver study and clinical experience.

Muscular System of Depressor Septi Nasi: Anatomical Study and Clinical Application

Hyper-activated depressor septi nasi is an important factor caused a nasal tip drooping and many studies have been carried out, however it still remains controversial. This study presents a surgical modality for its intervention, based on the anatomical study. Eleven fixed and six fresh cadavers were used for the study. We found that the depressor septi nasi was consisted of three fascicles. Medial fascicles were inserted into the dermocartilaginous ligament, and deep fibers of the medial fascicles were attached to the anterior nasal spine. After superficial fibers were interdigitated with the orbicularis oris, they were attached to the alveolar bone. Intermedial fascicles were inserted to the footplates of the medial cruses and the caudal septum. After they were interdigitated with the medial fascicle and the orbicularis oris, they were attached to the alveolar bone. From April to August 2008, five patients had surgical intervention for hyper-activated depressor septi nasi. Medial and intermedial fascicles were detached completely from the anterior nasal spine and the septum through intranasal approach. Tip droopings were improved in all cases. Specific complications were not found. We believe that surgical intervention through intranasal approach is a useful method for correction of tip drooping.

Short Term Comparative Analysis of Laparoscopic and Open Radical Cystectomy with Extracorporeal Urinary Diversion

PURPOSE: We analyzed the efficacy and safety of laparoscopic radical cystectomy (LRC) compared with open radical cystectomy (ORC). MATERIALS AND METHODS: Between November 2007 and April 2009, we performed LRC to treat bladder cancer in 23 patients and ORC in 64 patients. Data including the patients' clinical characteristics, peri-operative parameters, clinical outcomes, and oncologic outcomes were collected retrospectively and analyzed by use of the Mann-Whitney U test and chi-square test. RESULTS: There were no significant differences in demographic data between the two groups. Operative time was longer (595.2 min vs. 453.1 min; p<0.01) in the LRC group but blood loss was less (634.8 ml vs. 1,415.9 ml; p<0.01) and fewer transfusions were required (13.0% vs. 50.0%; p=0.002) in the LRC group. Days to oral intake (5.7 days vs. 7.3 days; p<0.01), days to drain removal (10.9 days vs. 13.9 days; p=0.014), and length of hospital stay (15.2 days vs. 22.3 days; p<0.01) were shorter in the LRC group. Postoperative complications occurred in 4 cases in the LRC group and 28 cases in the ORC group (17.4% vs. 43.8%, p<0.01). There were no cases with a positive surgical margin in the LRC group and 3 cases in the ORC group. There was no significant difference in the number of lymph nodes excised (17.4 vs. 19.6; p=0.132) between groups. CONCLUSIONS: These short-term clinical and oncological results suggest that LRC is a safe and effective method for the treatment of invasive bladder cancer.

Stabilization of Unilateral Septal Extension Graft Using Pivot Locking Suture

Septal extension graft is valuable in elongating the nasal length which projects and rotates the tip. It is very effective for improving the nasal tip, therefore, it has widely been applied to correct short noses and drooping tips. In the field of Asian rhinoplasty, many operations are conducted using a septal extension graft, and variable techniques and methods have been introduced by several surgeons. However, there are difficulties in harvesting a sufficient amount of septum from Asian noses, therefore, appropriate designs and definite fixation of a graft are important factors. Furthermore, when applying the harvested septal cartilage to the L-strut, stability depends on the method and the location of the graft fixation. When the graft is unstable due to its pivot motion, the tip will be drooping, deviated and decreased in projection. We herein introduce a pivot locking suture that can firmly stabilize the septal extension graft and explain the factors related with septal stabilization. From September 2006 to February 2008, we performed unilateral septal extension graft for aesthetic purposes in 64 patients. After classic compression suture between L-strut and unilateral septal cartilage graft, pivot locking sutures were performed. Pivot locking suture fixed the meeting site of septal extension graft, and cephalic and caudal margin of L-strut using "figure of 8" suture. Then, we confirmed the stability with a vertical stability test and horizontal stability test. We could follow up with 20 patients. All patients were satisfied except 2 patients with the tip deviation. Therefore, we believe that pivot locking sutures together with classic compression sutures can overcome limitations of stability inherent with conventional methods, due to unstable septal extension graft cartilage.

The Refill Rate and Reasons for Abandonment of Phosphodiesterase5 Inhibitors in Erectile Dysfunction Patients / 대한비뇨기과학회지

PURPOSE: The aim of this study was to determine the rate of abandonment of phosphodiesterase (PDE)5 inhibitor therapy in patients who had reported good treatment efficacy, and to assess the reasons for abandonment of therapy and rate of prescription refilling. MATERIALS AND METHODS: Between January 2004 and December 2005, patients with erectile dysfunction (ED) who had begun PDE5 inhibitor therapy in our center were enrolled in this study. A telephone survey of these patients was conducted to determine the rate of prescription refilling and the reasons for abandonment. After receiving the first prescription, patients were asked whether they had used the medication and whether the treatment improved their erectile function using a Global Assessment Questionnaire (GAQ). Medical records for these patients were reviewed retrospectively. RESULTS: 753 patients with ED began PDE5 inhibitor therapy. Only 200 subjects (26.5%) asked for a refill of PDE5 inhibitors. Of 553 subjects, 330 consented to the telephone survey and 226 subjects (68.5%) had positive response on the GAQ. Forty-one patients continued taking PDE5 inhibitors in other clinics. Finally, the reasons for abandonment were assessed in 185 patients who had reported good treatment efficacy but abandoned therapy. The majority reported that they had experienced improvement of spontaneous erectile function (21.6%). Two hundred subjects requested refills in our center (26.5%) and 41 patients (5.4%) continued a prescription in other clinics, so the rate of refill was greater than 31.9%. CONCLUSIONS: According to the results of this study, the improvement of ED was cited as the major reason for abandonment of PDE5 inhibitor therapy. The rate of prescription refilling was greater than 31.9%.