Rhinoplasty approaches: current state of the art.

OBJECTIVE: To survey rhinoplasty surgeons to determine their current approaches and the reason for their use, how they have acquired their knowledge, and trends in the use of open and closed approaches. DESIGN: A rhinoplasty questionnaire on open and closed rhinoplasty approaches was presented to surgeons attending the annual meetings of the American Academy of Facial Plastic and Reconstructive Surgery and the American Academy of Otolaryngology-Head and Neck Surgery. The 178 questionnaires were reviewed for analysis, and the results were tabulated by a statistician. Raw data were analyzed and cross-tabulations of specific subsets were reviewed. Main outcome measures included proportion of surgeons in various demographic groups using each technique, preferred incision, reasons for using each technique, usage over the past 5 years, and expected trend in the next 5 years. RESULTS: Most of the surgeons were in private practice, and most described their practice as otolaryngology (ear, nose, and throat [ENT]), facial plastic surgery (FPS), or ENT/FPS. Of the 178 responding surgeons, 46% had FPS practices and 27% devoted 90% to 100% of their practice to FPS. Most perform 100 or fewer rhinoplasties annually, and 23% perform open rhinoplasty 90% to 100% of the time. Sixty-three percent of FPS surgeons and 55% of ENT/FPS surgeons perform open septorhinoplasty (OSR) more than 50% of the time. Surgeons learn OSR mostly during residency (56%) and in didactic courses (51%) and learn closed rhinoplasty mostly during residency (75%). The most common indications for open rhinoplasty were difficult tip surgery (74%), revision procedures (73%), and grafting procedures (68%). Simple tip (65%) and simple dorsal (73%) procedures were common indications for closed rhinoplasty. The preferred incision for open rhinoplasty was the inverted "V" transcolumellar gull wing (58%); for closed rhinoplasty, cartilage delivery (48%) and intercartilaginous (28%). Most surgeons performed OSR at the same frequency during the past 5 years and expected to use OSR at the same frequency in the next 5 years. CONCLUSIONS: Overall, 53% of respondents used OSR more than 50% of the time. The movement toward open rhinoplasty seems to be plateauing, with a possible slight upward trend in its use. Over the past 5 years, there was still some trend toward the increasing use of the OSR approach, and most surgeons are performing OSR at the same frequency. Those with more than 5 years' experience believe that they are unlikely to change their approach in the next 5 years. Open septorhinoplasty may be indicated for rhinoplasties by a large proportion of surgeons, especially for rhinoplasties that are "difficult" or revisions or those requiring grafting.

A simple and reliable method of patient evaluation in the surgical treatment of nasal obstruction.

We have developed a simple method of evaluating nasal obstruction both before and after corrective surgery. With our system, patients self-rate their nasal patency on a 10-point visual analog scale under different conditions. After a baseline self-assessment, patients rate their breathing while the examiner lifts the lower lateral nasal cartilage with an ear curette and again during lifting of the upper lateral cartilage. Separate assessments during cartilage support are made before and after the patient has received nasal decongestion therapy. The results of these manipulations help identify the specific structural abnormality and its anatomic site, thereby serving as a reliable aid to planning surgery (i.e., open septorhinoplasty, turbinoplasty, external valve surgery with alar batten grafts, and/or internal valve surgery with spreader grafts with or without composite skin/cartilage grafts). We tested our method in preoperative evaluation and surgical planning on 19 patients with nasal obstructions. Our method was just as useful in making postoperative assessments, and it allowed us to judge the effectiveness of specific procedures in restoring nasal patency. Of the 19 patients, 18 (94.7%) reported that their nasal breathing had improved following surgery.

Facial reanimation by cross-facial nerve grafting: report of five cases.

Facial nerve repair is a dynamic reanimation technique. Direct nerve repair by suturing or grafting can provide good results within a specific time frame. Immediate nerve repair has been successful in cases of laceration injuries, but nerve grafting techniques are typically delayed when it is clear that direct suturing to the nerve trunk cannot be achieved without tension. Delayed nerve grafting is also employed following ablative procedures and in cases of trauma that cause segmental nerve deficits. Cross-facial nerve grafting is particularly useful when the peripheral branches are intact and the main trunk of the facial nerve is inaccessible. This method is also typically performed in a delayed fashion. Rehabilitation of the facial nerve and subsequent reinnervation of the mimetic motor endplates are achieved through axonal growth. In this article, we describe a consecutive series of five patients who developed facial paralysis following cranial surgery for acoustic neuroma. Each underwent successful cross-facial nerve grafting during the first week following their initial surgery. Each received a sural nerve graft to at least two main divisions of the VIIth cranial nerve. We discuss our operative technique and the degree of restored nerve function.