Intradermal hyaluronidase: The answer to treatment in softening a fibrous thick supratip skin in rhinoplasty?

@# It is a common goal for rhinoplastic surgeons to make the best-looking tip with proper projection, maintaining the tip lobule appearance with a supratip break. (Figure 1) However, a fibrous thick skin with fullness may not achieve the ideal tip. It is one of the nuisances in rhinoplasty that makes tip definition surgery difficult. The supratip area remains firm and convex causing a wide bulbous feature of the tip. Several techniques have been introduced with good results however some may still result in supratip fullness because of the firm fibrous nature of thick skin.1-3 Hyaluronidase is an enzyme that depolymerizes hyaluronic acid which is present in the epithelium.4 The use of intradermal hyaluronidase for thick skin was discovered by the junior author (JMP) in one of his rhinoplasties when he injected hyaluronidase in a nose with fillers containing hyaluronic acid. The fillers not only instantly dissolved but the skin also softened, so he tried injecting intradermally in his subsequent rhinoplasties on non-filler noses with fibrous thick skin and indeed found the same effect of softening of the fibrous supratip skin. We here describe the technique used in this preliminary clinical series.

Use of sail excision in Alar Morphology modification of asian noses

@#Globular hanging nasal alae, described as convex round shaped alar lobule which may be an aesthetic nuisance in the final result of rhinoplasty, are commonly seen among Southeast Asian noses. Such alar lobule morphology is an important part of nasal aesthetics and should not be disregarded. Surgical techniques used to address a hanging ala include direct external approaches. External rim excision was proposed to address hidden columella, sigmoid alae, small nostrils, dropped rim and foreshortened nose.1,2 Rim tissue was excised in full thickness fashion and sutured in one layer. Others proposed alar groove excision followed by alar repositioning and full-thickness skin grafting to reposition the alar base and correct hanging alae.3 Although these approaches have been proven to correct hanging alae, they leave a visible scar and/or permanent alar rim deformity if not done cautiously, especially on thick skinned patients.1-3 The alar rim may not be natural looking since it is lined by a scar, thus losing the lobular texture of the rim. A vestibular incision has been proposed to correct a hanging ala with unsightly scar.4 A maximum of 3mm elliptical vestibular skin was recommended to be removed to lift the alar rim with significant results. However, this recommendation was based on estimates and surgeon’s experience in western noses and may be insufficient for Asian noses. In addition, performing this technique without specific landmarks is difficult in achieving accurate results, especially when performed by a novice surgeon. Hence, further modification is important to address these concerns. Attempting to address the hanging alae in Asian noses, the senior author (ECY) modified the vestibular incision and came up with the sail excision technique based on the patient’s nasal anatomy.5 By presenting definite landmarks, the technique resulted in an alar lift procedure with reproducible outcomes. Furthermore, after performing sail excision in several patients, the authors noted the effect of this technique on alar morphology. This procedure is done by excising a precisely marked piece of inner nasal vestibular skin that is shaped like the sail of a boat to achieve a symmetrical and redictable result. This creates a lifting effect and improves the alar columellar disproportion specially when combined with septal advancement techniques.6,7 Furthermore, limiting the excision along the inner vestibular area and rolling the alar rim skin inwards results in correction of hanging ala (with a hidden scar) without an obvious, external scar. After performing the technique on several patients, we observed that in addition to its effect on lifting a hanging ala, the sail excision technique also changes the alar morphology from a globular-shaped lobule to a more aesthetically pleasing ridge-shaped lobule. To the best of our knowledge, such an effect of sail excision on alar morphology has not been described in the literature. This article aims to demonstrate the effect of the sail excision technique on alar rim morphology of Asian noses by describing the step-by-step procedure, surgical landmarks, and pearls in performing this technique.

Understanding the use of polycaprolactone in East Asian Structural Rhinoplasty: Questions and Answers

@#Surgery as an art in rhinoplasty involves grafting techniques wherein materials (usually autologous) are taken from the septum and supplemented by conchal cartilage. However, not all noses have adequate cartilage material. The quest for materials as possible replacement for human tissue have led to invention of synthetic (e.g. silicone, e-PTFE, porous polyethelene) and non-synthetic products (e.g. processed homograft and xenograft). In this era of advanced medical science, tissue engineering has started the use polycaprolactone (PCL) as a template and scaffold for tissue growth. Because of this characteristic feature, PCL as a mesh has a significant role in structural rhinoplasty.

Techniques in the safe use of polycaprolactone in structural rhinoplasty

@#<p><strong>Structural Rhinoplasty</strong> is a term use by rhinoplastic surgeons wherein the existing structures are reconstructed and strengthened for functional and aesthetic improvement of the nose. The function refers mainly to breathing by correcting septal deviation and enlarging the internal valves.1</p><p>The usual surgical method is open rhinoplasty approach and all anatomical structures are analyzed. The central septal cartilage is removed while the remaining dorsal and caudal strut are reconstructed for better breathing and tip support.2 The general concept is to alter the length and height of the existing dorsal and caudal strut by restructuring with the use of the central harvested cartilage. Cartilages used for strengthening the struts are called structural grafts while cartilages used for tip reshaping and projection are called contour grafts.3</p><p>Structural grafts commonly include the columellar strut graft, septal extension graft (SEG), spreader graft or extended spreader graft (ESG).1 The columellar strut and SEG are used for lower cartilage and tip support. The spreader graft is used for strengthening the dorsal strut and enlarging the internal valve. The ESG is a spreader graft that is extended beyond the anterior angle of the septum for support of lower cartilage and tip. Among the structural grafts for lower cartilage tip support it is the Septal Extension Graft (SEG) that gives the best longevity.4 The SEG is either placed side-to-side to the caudal strut or end-to-end supported by bilateral extended spreader graft (ESG). (Figures 1 & 2) Sometimes, a combination of ESG with SEG is needed to correct weakness of the struts. (Figure 3) Contour grafts are usually the dorsal graft and tip grafts. (Figure 4)</p><p>Because Asian (specifically South East Asian) noses are usually small, the harvested septum is often small and soft.3,4 Occasionally, the septum may look strong but upon harvest the dorsal and caudal struts weaken. Additional cartilage grafts are usually needed either from the auricle or from the rib. Auricular cartilage is too soft as support graft while the rib cartilage is strong because of its resemblance to septum in its histology. Autologous rib rhinoplasty is not only tedious and invasive but also more expensive which most patients do not prefer. Because of the paucity of septum, there are many substitute commercial materials in the market which can simulate the strength of septal cartilage as support graft. These can be homologous processed human rib cartilage, or alloplastic non-absorbable porous polyethylene. These materials are prone to long term complications e.g. warping, fracture, infection, resorption and extrusion.5,6 Scientists and bioengineers recently developed polycaprolactone (PCL) which is a new synthetic absorbable porous material. It is marketed as a better material because not only it gives support but it also serves as a scaffold for tissue regeneration.7-9</p><p>Polycaprolactone (PCL) is an absorbable material used in craniomaxillofacial surgery as a scaffold for defects.10 It is absorbed completely in 2 years. It is also a material used as threads in facial rejuvenation.11-13 Recently, PCL has been fashioned into mesh for use in septoplasty and rhinoplasty as implants and support.14,15 Its use is mainly as a scaffold for tissue regeneration and support. It has been shown in studies that osteoblasts, chondroblasts and mesenchymal tissues grow into its pores.10, 15 It comes in various shapes and sizes. The ideal ones for use in nasal surgery are the 10 mm x 30-40 mm mesh plate with thickness variety of 0.8-1.2 mm. (Figure 5)</p><p>Polycaprolactone is not used routinely; it is still best to use all autologous tissues. The indication of the use of PCL depends on the structure of the nose (mainly the septum). It is best for use in cases of small septum with inadequate septal material for correction of deviation. It is also best for use in cases of weak septum or weak dorsal/ caudal struts after septal harvest to correct any possibility of collapse. Moreover, PCL is not advisable in severe contracted nose because forces of healing may lead to wound dehiscence, extrusion and infection. Extrusion and infection may also happen while PCL is still not completely absorbed in 2 years. </p><p>Since PCL is noted to lose its strength but provide well as a template for tissue regeneration, it is recommended to cover the PCL with septal or conchal cartilages whenever possible for 2 reasons: firstly, for protection against mucosal erosion; and secondly, as cartilage regeneration template for future support. (Figure 6). The decision to use PCL is made intraoperatively. The PCL mesh is fashioned into either an end-to-end SEG or ESG; both techniques of grafting are covered majority with cartilages. Following is the algorithm showing the indications when to use PCL after open rhinoplasty approach and assessment of the strength of the septum:</p><p>There are times wherein minimal surgery is needed for tip projection. Since Asian noses have weak medial crura with heavy skin and soft tissue envelope, PCL can be used just as a columellar strut - either floating or fixed to the posterior caudal septum. Fixing to the posterior caudal septum functions similar to a SEG too. However, these techniques may be unstable. (Figures 12 & 13)</p><p>Polycaprolactone was commercially available locally in the latter part of 2018. From August 2018 to March 2020, I used PCL in 213 (40.7%) out of 523 cases of septoplasty for structural rhinoplasty for various indications. All outcomes were followed up through calls and/or texts and all results were good with all patients satisfied with their results as of this writing, except for two. One patient developed post-operative deviation of the SEG after a week; the etiology was due to the improper choice of PCL strength. Revision surgery was done with replacement by a thicker PCL. Another patient developed infection after 4 months. Revision surgery involved removal of PCL and placement of columellar strut for support. This initial experience with the use of PCL is promising but it is too early to conclude. Long term follow-up should be done to see changes in structure when the PCL is totally absorbed.</p><p>In summary, PCL is a strong absorbable tissue template mesh in septoplasty and rhinoplasty. It is gradually absorbed within 2 yrs. While it is in its early stage as a mesh graft, it gives strength. However, as it is slowly absorbed, it imbibes the surrounding tissue cells for regeneration for future strength. It is highly recommended to cover the PCL with cartilages to prevent erosion to surrounding mucosa. Aside from protection of the PCL against erosion and extrusion, the cartilage also gives the future strength as chondrocytes grow into the PCL mesh.</p>

The use of bony septum as an extended spreader graft in primary and secondary rhinoplasty

@#<p><strong>OBJECTIVE:</strong>  To describe a surgical technique using bony septum, specifically vomer or perpendicular plate of the ethmoid (PPE), as an extended spreader graft (ESG) for securing septal extension graft (SEG) and for correcting internal nasal valve dysfunction.</p><p><strong>METHODS</strong>:</p><p>            <strong>Design:</strong>            Descriptive Case Series</p><p>            <strong>Setting:</strong>           Tertiary Private Hospital</p><p>            <strong>Participants:</strong> Thirty-two (32) patients who underwent aesthetic rhinoplasty from May 2016 to October 2017 were evaluated, and ten (10) patients presenting with symptomatic obstruction were considered for inclusion. The surgical technique was applied in patients with weak SEG for control of nasal length and tip projection who had inadequate septal cartilage for SEG and ESG intraoperatively. Results were evaluated grossly under direct vision intra-operatively and post-operatively to check the patency of the internal valve.</p><p><strong>RESULTS:</strong>  Bony septum was used as an ESG in five (5) patients (1 male, 4 females, ages 35 to 50-years-old) with inadequate septal cartilage. Intraoperative evaluation under direct vision showed anterior caudal septal deviation in all 5 patients in whom correction was confirmed after placement of SEG and ESG. Immediate post-operative evaluation confirmed bilaterally patent nasal valve in all 5, who reported subjectively improved breathing at 2 and 4 weeks post-operatively.  Post-operative photographs showed improvement of nasal length and tip.</p><p><strong>CONCLUSION:</strong> The use of the bony septum (vomer and PPE) as an ESG for primary or secondary rhinoplasty is a potentially effective means of supporting and securing the SEG for control of nasal length, preventing tip deviation or rotation and for improving internal valve function. Further trials are needed to establish its reliability and long-term effectivity.</p>

Augmentation rhinoplasty with rib cartilage graft

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To investigate the outcome and complications of augmentation rhinoplasty with rib cartilage grafts.<br /><strong>METHODS:</strong><br /><strong>Design:</strong> Retrospective study<br /><strong>Setting:</strong> Tertiary Government Hospital<br /><strong>Subjects:</strong> Patients who underwent dorsal nasal augmentation with autologous rib cartilage grafts between June 2008 and October 2012.<br /><strong>RESULTS:</strong> A total of 12 patients (3 male, 9 female) were included in the study. Mean age was 29 years. Seven were cases of primary simple rhinoplasty with four cases of revision (previously using alloplastic materials) and one case of trauma. Indications for the procedure were all cosmetic. There was no incidence of infection, both in the donor and recipient sites, warping of the graft, graft extrusion, resorption, pneumothorax, chest wall deformity or prolonged edema. Post-operative pain in the donor site was relieved by oral pain medications. No revision surgery was required.<br /><strong>CONCLUSION:</strong> Costal cartilage is a good option for structural support of the nose. In our experience patients have become wary of the complication of allografts and have opted to use autografts. The surgeon's knowledge of the nasal anatomy as well as his or her experience with autologous grafts plays a major role in avoiding post-operative morbidity.</p>

Principles of structural rhinoplasty in South East Asian noses

@#What makes the majority of noses beautiful? It is the tip.1,2,3South East Asian noses are usually small and short with bulbous tip and thick skin and soft tissue envelope (SSTE).2 The tip is determined by the shape and strength of the lower cartilages.2,3,4The lower cartilages are usually soft and weak so there is a need for a strong support system for the attachment of the lower cartilages. Thus, the surgical term is called “Structural Rhinoplasty.”2,3The concept of the surgery involves re-structuring the tip to a new position for elongation and projection. Since the septum is the most stable structure, a central part of the septum is harvested and is used as extended septal support graft for fixation of the lower cartilage for a whole new tip position.2,3 The open approach is often used. The SSTE dissection is wide up to the pyriform aperture laterally, nasal spine inferiorly and glabella superiorly. Make certain that the dissection plane is below the superficial muscular aponeurotic system (SMAS) in the upper cartilage (UC) and lower cartilage (LC) and below the periosteum in the nasal bone.

A cross-sectional survey on the awareness and basic knowledge on newborn hearing screening of obstetric and pediatric residents

OBJECTIVES: To determine whether the obstetric and pediatric residents are aware of newborn hearing screening; To determine whether the obstetric and pediatric residents are knowledgeable regarding newborn hearing screening; To compare the results as a function of the type of training institution (private or government). STUDY DESIGN: Cross sectional study SETTING: Randomly selected tertiary hospitals in the National Capital Region METHODOLOGY: A structured questionnaire pertaining to the awareness and basic knowledge of newborn hearing screening was distributed to tertiary hospitals in the National Capital Region (NCR) of the Republic of the Philippines. All obstetric and pediatric residents of each of the tertiary hospitals were the respondents of this study. Frequencies were determined from the respondent's responses to the questionnaire. RESULTS: Out of 175 questionnaires distributed, there were 134 respondents (86 pediatrics and 48 obgyne) Eighty (93 percent) pediatric residents were aware of newborn hearing screening but only 43 (50 percent) of pediatric residents were knowledgeable of the hearing test. Thirty five (73 percent) of obstetric residents were aware of newborn hearing screening and only 5 (10 percent) were knowledgeable about the hearing test. Majority of those who were knowledgeable are from private institutions (79.2 percent) as compared to respondents from government institution (20.8 percent). CONCLUSION: A majority of obstetric and pediatric residents were aware of the newborn hearing screening but only a third of respondents had basic knowledge of the hearing test. Of those who were knowledgeable, most were training in private institutions where the machine was available. It is essential for the physician to be both aware and knowledgeable about newborn hearing screening to counsel and educate parents about the importance of early identification of and intervention for congenital or newborn hearing problems. A program to provide more knowledge regarding newborn hearing screening among pediatric and obstetric residents should be therefore developed. (Author)