Perfil epidemiológico dos pacientes submetidos à rinoplastia em um centro hospitalar de reabilitação / Epidemiological profile of patients undergoing rhinoplasty in a hospital rehabilitation center

Introdução: A rinoplastia é uma das cirurgias plásticas mais comuns em todo o mundo. O desenvolvimento do conhecimento da anatomia do nariz é um dos ensinamentos mais refinados em cirurgia plástica e exige além de dedicação e estudos, a experiência técnica visual para uma compreensão adequada das estruturas e ligamentos. O objetivo deste estudo é descrever o perfil epidemiológico de pacientes submetidos à rinoplastia em um hospital terciário. Métodos: Foram estudados pacientes submetidos à rinoplastia no serviço de Cirurgia Plástica do Centro de Reabilitação e Readaptação Dr. Henrique Santillo (CRER), de janeiro de 2013 a dezembro de 2019, em pacientes do sistema único de saúde. Resultados: Foram estudados 179 pacientes, sendo a maioria do sexo feminino, com média de idade de 35 anos, como principal causa o trauma, sendo a maioria rinoplastia primária por técnica aberta. Conclusão: O perfil dos pacientes é do sexo feminino, com média de idade de 35 anos, sendo principalmente devido à deformidade nasal após trauma, com abordagem de cirurgias primárias abertas sendo comum a utilização de enxertos de cartilagem.

Introduction: Rhinoplasty is one of the most common plastic surgeries worldwide. The development of knowledge of the nose's anatomy is one of the most refined teachings in plastic surgery. In addition to dedication and studies, it requires visual technical experience for an adequate understanding of structures and ligaments. This study aims to describe the epidemiological profile of patients undergoing rhinoplasty in a tertiary hospital. Methods: Patients who underwent rhinoplasty at the Plastic Surgery Service of the Centro de Reabilitação e Readaptação Dr. Henrique Santillo (CRER), from January 2013 to December 2019, were studied in patients from the single health system. Results: 179 patients were studied, the majority of whom were female, with a mean age of 35 years, as the leading cause of trauma, the majority being primary rhinoplasty using an open technique. Conclusion: The patients' profile is female, with a mean age of 35 years, mainly due to nasal deformity after trauma, with open primary surgery approach and cartilage grafts are common.

Reconstrução de columela com enxerto condrocutâneo após lesão causada por CPAP / Columellar reconstruction with chondrocutaneous graft after injury caused by CPAP

Introdução: A pressão positiva contínua nas vias aéreas nasais (CPAP) é uma forma não invasiva de ventilação utilizada em recém-nascidos prematuros em unidades de terapia intensiva. Porém, ela pode acometer o nariz destes pacientes, evoluindo até mesmo com isquemia e necrose columelar. Diversas técnicas são descritas para reconstruir a columela, como enxertos de pele, enxertos compostos, retalhos locais e retalhos livres; mas o enxerto composto condrocutâneo auricular tem se destacado. O objetivo deste trabalho é descrever um caso de necrose de columela por uso de CPAP com reconstrução utilizando enxertia condrocutânea auricular posterior. Relato do Caso: Paciente do sexo feminino, parda, com história de prematuridade e uso prolongado de CPAP quando recém-nascida devido à síndrome da membrana hialina, evoluiu com necrose de columela. Foi submetida à enxertia composta condrocutânea auricular posterior para reconstrução da columela. A paciente apresentou resultado cirúrgico satisfatório, evoluindo com 100% de vitalidade do enxerto. Discussão: A necrose columelar associada ao uso do CPAP pode ser estética e funcionalmente debilitante, e representa um desafio reconstrutivo. As opções para obter resultados aceitáveis são limitadas, porém o uso de enxertos de orelha é tecnicamente simples, utiliza tecidos doadores estruturalmente semelhantes, não provoca cicatrizes adicionais no nariz, é realizado em um tempo cirúrgico e geralmente tem um resultado muito bom. A enxertia composta auricular posterior para reconstrução columelar se mostrou segura, com resultado estético e funcional satisfatório e mínima morbidade da área doadora.

Introduction: Continuous positive pressure in the nasal airways (CPAP) is a non-invasive form of ventilation used in premature newborns in intensive care units. However, it can affect the nose of these patients, even evolving with ischemia and columellar necrosis. Several techniques are described to reconstruct the columella, such as skin grafts, composite grafts, local flaps, and free flaps, but the atrial chondrocutaneous graft has stood out. This study aims to describe a case of columella necrosis using CPAP with reconstruction using posterior atrial chondrocutaneous grafting. Case Report: A brown, female patient, with a history of prematurity and prolonged use of CPAP when she was born due to hyaline membrane syndrome, developed columella necrosis. The patient underwent posterior auricular chondrocutaneous grafting to reconstruct the columella. She presented a satisfactory surgical result, evolving with 100% graft vitality. Discussion: Columellar necrosis associated with the use of CPAP can be aesthetically and functionally debilitating, and represents a reconstructive challenge. The options for obtaining acceptable results are limited. However, the use of ear grafts is technically straightforward, uses structurally similar donor tissues, does not cause additional scarring on the nose, is performed in a surgical period, and generally has an excellent result. Posterior auricular composite grafting for columellar reconstruction proved safe, with satisfactory aesthetic and functional results and minimal morbidity in the donor area.

Reconstrução nasal com retalho frontal paramediano após ressecção oncológica / Nasal reconstruction with paramedian frontal flap after cancer resection

Introdução: O carcinoma basocelular é o tipo mais frequente de lesão tumoral de pele acometendo frequentemente a região nasal. Os defeitos resultantes exigem o emprego de técnicas de reconstrução nasal. A primeira cirurgia plástica descrita é a reconstrução nasal segundo o método indiano. Ao longo dos séculos sofreu diversas modificações pelos maiores nomes da especialidade, culminando no retalho frontal paramediano. Relato do Caso: Paciente do sexo masculino, 62 anos, apresentou-se no serviço de Cirurgia Plástica do Hospital Federal de Ipanema com lesão ulcerada, descamativa, ocupando toda a região lateral do nariz com três anos de evolução, sugestiva ao exame físico de tumor maligno de pele. Foi realizada exérese da lesão cutânea e imediata reconstrução com retalho frontal paramediano e posterior cirurgia de refinamento. Conclusão: Devido à sua vascularização pela artéria supratroclear e textura semelhante ao tecido nasal, o retalho frontal paramediano constitui-se como o gold standard para a correção de grandes defeitos nasais.

Introduction: Basal cell carcinoma is the most frequent type of tumoral lesion of the skin, often affecting the nasal region. The resulting defects require the use of nasal reconstruction techniques. The first plastic surgery described is the nasal reconstruction, according to the Indian method. Over the centuries, it has been the object of several modifications by the biggest names in the specialty, culminating in the paramedian frontal flap. Case Report: A 62-year-old male patient went to the Plastic Surgery Service of the Federal Hospital of Ipanema, presenting an ulcerated, scaly lesion, occupying the entire lateral region of the nose with three years of evolution, suggesting at physical examination malignant skin tumor. It was performed cutaneous lesion excision and immediate reconstruction with a paramedian frontal flap and further refinement surgery. Conclusion: Due to its vascularization by the supratrochlear artery and texture similar to the nasal tissue, the paramedian frontal flap is the gold standard for the correction of significant nasal defects.

Rinomodelação ou rinoplastia não-cirúrgica: uma abordagem segura e reprodutível / Rhinomodelation or non-surgical rhinoplasty: a safe and reproducible approach

Introdução: A rinoplastia é uma cirurgia que muitas vezes apresenta resultados imprevisíveis, mesmo em mãos de cirurgiões experientes. Neste sentido, a rinomodelação com preenchedores é um procedimento não-cirúrgico para corrigir pequenas alterações externas nasais em casos específicos. Métodos: Os autores descrevem a técnica de aplicação de preenchedores (ácido hialurônico ou hidroxiapatita de cálcio) para modelação nasal. Foram incluídos todos os pacientes submetidos ao preenchimento nasal, entre 2009 e 2012. Foi avaliado o edema da ponta nasal, a dor e o grau de satisfação dos pacientes com o resultado. Resultados: Foram incluídos 39 pacientes no estudo. Com relação aos desfechos analisados com ácido hialurônico: 52% apresentaram edema leve; 74% tiveram dor leve; 15% se mostraram muito satisfeitos e 74% satisfeitos com o resultado. Com relação aos pacientes submetidos à rinomodelação com hidroxiapatita de cálcio: 67% apresentaram edema moderado; 50% dor moderada; 17% dor intensa e 84% se mostraram satisfeitos com o resultado. Conclusão: A rinomodelação com preenchedores reabsorvíveis é um procedimento simples, com resultados estéticos aceitáveis, sendo necessário um profundo conhecimento anatômico para diminuir o risco de complicações.

Introduction: Rhinoplasty often leads to unpredictable results, even in the hands of experienced surgeons. However, in specific cases, rhinomodelation with fillers, a non-surgical procedure to correct minor nasal external changes, can be used. Methods: This study describes the application technique of fillers (hyaluronic acid or calcium hydroxyapatite) for nasal modeling. Patients undergoing nasal filling between 2009 and 2012 were included. Edema of the nasal tip, pain, and the degree of patient satisfaction with the outcome were assessed. Results: Thirty-nine patients were included in the study. Regarding the outcomes of rhinomodelation with hyaluronic acid, 52% patients presented with mild edema, 74% had mild pain, 15% were very satisfied, and 74% were satisfied with the result. For the outcomes of rhinomodelation with calcium hydroxyapatite, 67% patients presented with moderate edema, 50% had moderate pain; 17% had severe pain, and 84% were satisfied with the result. Conclusion: Rhinomodelation with resorbable fillers is a simple procedure with acceptable esthetic results. However, a deep anatomical knowledge is necessary to decrease the risk of complications.

Triangular Resection of the Upper Lateral Cartilage for Middle Vault Deviation

OBJECTIVES: Middle vault deviation has a significant effect on the aesthetic and functional aspects of the nose, and its management continues to be a challenge. Spreader graft and its modification techniques have been focused, but there has been scarce consideration for removing surplus portion and balancing the upper lateral cartilage (ULC). This study aimed to report the newly invented triangular-shaped resection technique (“triangular resection”) of the ULC and to evaluate its efficacy for correcting middle vault deviation. METHODS: A retrospective study included 17 consecutive patients who presented with middle vault deviation and underwent septorhinoplasty by using triangular resection at a tertiary academic hospital from February 2014 and March 2016. Their outcomes were evaluated pre- and postoperatively including medical photographs, acoustic rhinometry and subjective nasal obstruction using a 7-point Likert scale. RESULTS: The immediate outcomes were evaluated around 1 month after surgery, and long-term outcomes were available in 12 patients; the mean follow-up period was 9.1 months. Nasal tip deviation angle was reduced from 5.66° to 2.37° immediately (P < 0.001). Middle vault deviation also improved from 169.50° to 177.24° (P < 0.001). Long-term results were 2.49° (P=0.015) for nasal tip deviation and 178.68° (P=0.002) for middle vault deviation. The aesthetic outcome involved a complete correction in eight patients (47.1%), a minimally visible deviation in seven patients (41.2%) and a remaining residual deviation in two patients (11.8%). Pre- and postoperative minimal cross-sectional areas (summation of the right and left sides) were 0.86 and 1.07, respectively (P=0.021). Fifteen patients answered about their nasal obstruction symptoms and the median symptom score had alleviated from 6.0 to 3.0 (P=0.004). CONCLUSION: Triangular resection of the ULC is a simple and effective method for correcting middle vault deviation and balancing the ULCs without complications as internal nasal valve narrowing.

Reconstrução de dorso nasal: relato de caso / Reconstruction of the nasal dorsum: a case report

INTRODUÇÃO: O dorso nasal é um local comum para o desenvolvimento de neoplasias cutâneas, predominantemente o epitelioma basocelular. Em 1964, Barsky preconiza um retalho quadrangular do dorso nasal, com base na região glabelar, utilizando somente pele da região dorsal. Baseava-se em um procedimento simples recobrindo áreas cruentas até a ponta nasal, resultando em cicatrizes pouco perceptíveis. RELATO DE CASO: Paciente de 82 anos procurou o Serviço de Cirurgia Plástica do Hospital Universitário Maria Aparecida Pedrossian apresentando lesão em dorso nasal de aproximadamente 3 × 2 cm, ulcerada com base eritematosa e limites mal definidos. A técnica utilizada para correção da perda de substância foi o deslizamento de um retalho frontoglabelar com pedículo randomizado. A paciente evoluiu com viabilidade do retalho, apresentando restauração do dorso nasal e resultado estético satisfatório. CONCLUSÃO: Em decorrência da cor e textura adequadas da pele desta região, o retalho frontoglabelar é reconhecidamente uma excelente área doadora para cobertura do dorso do nariz.

INTRODUCTION: The nasal dorsum is a common location for the development of cutaneous tumors, predominantly basal cell epithelioma. In 1964, Barsky recommended a quadrangular flap for coverage of the nasal dorsum, taken from the glabellar region, to most closely match the skin of the dorsal region. This was based on a simple procedure for covering raw areas up to the nasal tip, resulting in less noticeable scars. CASE REPORT: An 82-year-old woman presented to the Plastic Surgery Service of the University Hospital Maria Aparecida Pedrossian with a lesion on the nasal dorsum of approximately 3 x 2 cm, ulcerated with an erythematous base, and ill-defined limits. A fronto-glabellar sliding flap was used to correct the loss of substance. The patient progressed with flap viability, restoration of the nasal dorsum, and satisfactory esthetic results. CONCLUSION: Owing to the color and texture of the skin from this region, the fronto-glabellar flap is an excellent donor area for coverage of the nasal dorsum.

Correction of the Short Nose using Derotation Graft

Among several techniques to maintain the lengthened cartilagenous tip structure, septal extension graft with septal cartilage or rib cartilage is most widely used. But in many cases, nasal tip rigidity with unnatural appearance on smiling is one of the major drawbacks of septal extension graft. The authors used a piece of elastic cartilage graft harvested form ear that can act as a cushion buffer between alar cartilage and septum instead of directly fixing the alar cartilage to extended septum for obtaining a less stiff nasal tip with sufficient nasal tip elongation. We called this graft "derotation graft". Derotation graft was performed in 1197 patients via the open nasal approach. Among them, 432(36%) patients had preoperative short nose deformity and 765(64%) patients developed intraoperative cephalic rotation of the tip resulting from procedures for tip projection such as columellar strut. Excellent results were achieved in 1110(93%) patients. 87(7%) patients had unsatisfactory results requiring a revision surgery because of overcorrection or undercorrection of tip rotation, poor tip projection and visible graft on supratip. Derotation graft is a simple, and effective procedure for short nose correction preventing with less post-operative nasal tip rigidity.

Contracted Short Nose Correction Using Irradiated Homologous Costal Cartilage

Septal extension graft is a frequently used technique for correction of the contracted short nose, in which septal cartilage is a first choice for the graft. However, we sometimes encounter situations where septal cartilage is not available. Autogenous rib cartilage can be a good option, but some female patients fear of a bigger operation and do not want a scar around the breast. In such cases, irradiated homologous costal cartilage can be a useful alternative. 38 cases of contracted short nose deformities were treated using the septal extension graft with homologous costal cartilage (34 cases with Tutoplast(R)-processed cartilage, 4 cases with Allowash(R)-processed cartilage). Follow-up period ranged from 2 months to 32 months. Good aesthetic and functional results were obtained. Neither infection nor unfavorable results were found. There was no graft warping, except two cases of graft avulsion fracture and one case of minimal nasal obstruction. There was no definite evidence of greater graft resorption compared to the autogenous rib. Homologous costal cartilage can be a safe and reliable material for rhinoplasty, especially in the absence of available autogenous cartilage sources.