Comparative Functional Effect of Alternative Surgical Techniques Used in Rhinoplasty.

OBJECTIVE: The purpose of this investigation is to compare the functional effect of the different surgical techniques used for addressing each section of the nose. METHODS: Prospective study of 57 consecutive rhinoplasty patients. Patients were evaluated with peak nasal inspiratory flow (PNIF), Nasal Obstruction Symptom Evaluation (NOSE), and Visual Analog Scale (VAS) for nasal obstruction before and 1 year after rhinoplasty. Additionally, esthetic evaluation of the nose was obtained with Rhinoplasty Outcomes Evaluation (ROE). According to the surgical technique used to address each portion of the nose, groups of patients were created and the functional improvement of these groups was compared. RESULTS: Using the TukeyHSD multiple pairwise-comparison test, the estimated difference of the increase of PNIF between using spreader grafts and using spreader flaps was 94.9 (95% CI 24.3, 165.5, P = .004) between spreader grafts and neither grafts or flaps was 79.2 (95% CI 5.8, 152.6, P = .03), between spreader grafts and bilateral spreader flaps plus a unilateral spreader graft was 90.2 (95% CI 22.1, 158.2, P = .005). In all other portions of the nose, no significant difference was found in the functional improvement between different surgical techniques. CONCLUSIONS: Spreader grafts increase PNIF more significantly than other surgical techniques used for dorsal mid-vault reconstruction. Spreader grafts should be preferred over other techniques whenever an improvement of nasal airflow is required. No significant differences were found between the functional effect of alternative techniques used in other sections of the nose. Additional cohort studies will be necessary to further confirm data from this investigation.

Generic Health-Related Quality-of-Life Changes after Rhinoplasty: A Prospective Study with Long-Term Results.

OBJECTIVES: Our objective was to investigate changes in specific generic health-related quality-of-life (HRQoL) domains achieved by rhinoplasty, to investigate whether modifications of somatic-, psychologic-, and social-related HRQoL domains are different in patients with functional or aesthetic motivation for rhinoplasty, and to investigate if HRQoL changes are related to a functional or an aesthetic nasal improvement. STUDY DESIGN: This was a prospective study with 1 year of follow-up. METHODS: Fifty-four consecutive Caucasian patients submitted to rhinoplasty were evaluated with 36-item Short Form Health Survey (SF-36) and EuroQuality-of-Life 5 Domain (EQ-5D) questionnaires. To correlate changes in generic HRQoL with functional and aesthetic modifications achieved by rhinoplasty, evaluation of patients also included assessment of Peak Nasal Inspiratory Flow and Nasal Obstruction Symptom Evaluation, Visual Analogue Scale for nasal airway obstruction (NAO), and Rhinoplasty Outcome Evaluation scores.Modifications in each generic HRQoL health-domain were analyzed to investigate the possible relation with motivation for surgery and with functional or aesthetic improvement. RESULTS: There was a significant improvement in EQ-5D (p < 0.001), EQ-5D VAS (p = 0.002) and in the SF-36 domains of general health (p < 0.001), energy (p < 0.001), physical functioning (p < 0.001), physical limitation (p = 0.005), pain (p = 0.003), and well-being (p = 0.018). Improvement was significant in groups of patients with NAO or in whom a septoplasty was performed and was associated with patient-reported functional improvement. There was a significant improvement in health change (p < 0.001), verified in all groups of patients. CONCLUSIONS: This prospective study with long-term results demonstrates that rhinoplasty significantly improves most domains of generic HRQoL. This improvement is associated with patient-reported functional improvement. Emotional limitation and social functioning are not significantly changed by rhinoplasty. LEVEL OF EVIDENCE: IV.

Which Nasal Airway Dimensions Correlate with Nasal Airflow and with Nasal Breathing Sensation?

Background: Rhinoplasty modifies the nasal pyramid, thereby also modifying the nasal airway. Objectives: To correlate the sensation of nasal breathing, as measured by patient-reported outcome measures, and nasal airflow, as assessed by peak nasal inspiratory flow (PNIF), with nasal airway dimensions, as measured on computed tomography (CT) images. Methods: Fifty Caucasian patients were studied through visual analogue scale (VAS), nasal obstruction symptom evaluation (NOSE) and PNIF. Measurements of the nasal airway were made on CT images: minimal distance between septum and inferior and middle turbinates, nasal valve angle, and nasal valve area. Results: There was a significant association between PNIF and nasal valve area, between VAS and the narrower nasal valve angle and between NOSE and minimal distance between septum and middle turbinate of the narrower side. Conclusions: This study suggests that the dimensions of the nasal valve and of the middle nasal airway have a substantial impact on nasal breathing capacity. It also highlights the importance of unilateral nasal airway obstruction to nasal breathing.

The Infratip Strut Graft.

Introduction: The infratip strut graft (ISG) is a trapezoid-shaped graft for the infratip area. The graft is used in combination with tongue-in-groove (TIG). The combination ISG-TIG is indicated in patients with weak lower lateral cartilages or a heavy soft tissue envelope. The hybrid technique shortens the nose with the control of the TIG and provides stability and refinement in the nasal tip. Methods: The ISG can be placed through an endonasal or external approach rhinoplasty. After one or two TIG sutures the ISG can be placed in the groove of the infratip lobule reaching as far as the tip defining points. A temporary needle stabilized the graft between the medial crura. The graft was fixated in between the medial crura of the infratip lobule with 2-3 absorbable mattress sutures. Results: We used the TIG-ISG hybrid technique in >50 patients. In conjunction to TIG the ISG is helpful to increase the stability of the infratip lobule and tip defining points to refine the nasal tip. Conclusions: The TIG-ISG technique is a proven technique to support and stabilize the medial crura in patients with weak lower lateral cartilages, a thick skin soft tissue envelope or a low caudal septal border in both primary and revision cases.

Objective measurement and patient-reported evaluation of the nasal airway: Is correlation dependent on symptoms or on nasal airflow?

BACKGROUND: Evidence has shown that the sensation of nasal breathing is related to variations in nasal mucosa temperature produced by airflow. An appropriate nasal airflow is necessary for changing mucosal temperature. Therefore, the correlation between objective measurements of nasal airflow and patient-reported evaluation of nasal breathing should be dependent on the level of nasal airflow. OBJECTIVES: To find if the correlation between patient-reported assessment of nasal breathing and objective measurement of nasal airflow is dependent on the severity of symptoms of nasal obstruction or on the level of nasal airflow. METHODS: The airway of 79 patients was evaluated using NOSE score and peak nasal inspiratory flow (PNIF). Three subgroups were created based on NOSE and three subgroups were created based on PNIF level to find if correlation was dependent on nasal symptoms or airflow. RESULTS: The mean value of PNIF for the 79 patients was 92.6 L/min (SD 28.1 L/min). The mean NOSE score was 48.4 (SD 24.4). The correlation between PNIF and NOSE was statistically significant (P = .03), but with a weak association between the two variables (r = -.248). Evaluation of correlation based on symptoms demonstrated a weak or very weak association in each subgroup (r = -.250, r = -.007, r = -.104). Evaluation of correlation based on nasal airflow demonstrated a very weak association for the subgroups with middle-level and high PNIF values (r = -.190, r = -.014), but a moderate association for the subgroup with low PNIF values (r = -.404). CONCLUSIONS: This study demonstrated a weak correlation between NOSE scores and PNIF values in patients non-selected according to symptoms of nasal obstruction or to airflow. It demonstrated that patients with symptoms of nasal obstruction have different levels of nasal airflow and that low nasal airflow prevents the sensation of good nasal breathing. Therefore, patients with symptoms of nasal obstruction may require improving nasal airflow to improve nasal breathing sensation.

An Overview of Computational Fluid Dynamics Preoperative Analysis of the Nasal Airway.

Evaluation of the nasal airway is crucial for every patient with symptoms of nasal obstruction as well as for every patient with other nasal symptoms. This assessment of the nasal airway comprises clinical examination together with imaging studies, with the correlation between findings of this evaluation and symptoms reported by the patient being based on the experience of the surgeon. Measuring nasal airway resistance or nasal airflow can provide additional data regarding the nasal airway, but the benefit of these objective measurements is limited due to their lack of correlation with patient-reported evaluation of nasal breathing. Computational fluid dynamics (CFD) has emerged as a valuable tool to assess the nasal airway, as it provides objective measurements that correlate with patient-reported evaluation of nasal breathing. CFD is able to evaluate nasal airflow and measure variables such as heat transfer or nasal wall shear stress, which seem to reflect the activity of the nasal trigeminal sensitive endings that provide sensation of nasal breathing. Furthermore, CFD has the unique capacity of making airway analysis of virtual surgery, predicting airflow changes after trial virtual modifications of the nasal airway. Thereby, CFD can assist the surgeon in deciding surgery and selecting the surgical techniques that better address the features of each specific nose. CFD has thus become a trend in nasal airflow assessment, providing reliable results that have been validated for analyzing airflow in the human nasal cavity. All these features make CFD analysis a mainstay in the armamentarium of the nasal surgeon. CFD analysis may become the gold standard for preoperative assessment of the nasal airway.

Cephalic Malposition of the Lateral Crura and Parenthesis Deformity: A Cadaver Study in Caucasians.

BACKGROUND: Improving the shape and contour of the nasal tip is a major goal in rhinoplasty. Extreme bulbosity and parenthesis deformity of the nasal tip are both frequently encountered. However, the underlying anatomical features that cause this kind of tip deformity are still not fully understood. OBJECTIVES: To evaluate the relation between the shape of the nasal tip and the anatomical position, orientation and shape of the lateral crura of the lower lateral cartilages and to estimate the incidence of cephalic malposition of lateral crura in Caucasian noses. MATERIALS AND METHODS: Nineteen Caucasian cadaver noses were studied, and the alar cartilages were measured and evaluated using a standardized method. RESULTS: Fourteen of the total 38 lateral crura evaluated had cephalic malposition (long axis angle with the midline equal to or less than 30°). Of the nasal tips classified as having parenthesis deformity, 84.6% had cephalic malposition of lateral crura and 46.2% had convex lateral crura. Vertical orientation of the short axis of the lateral crura was no more common in noses with parenthesis deformity of the nasal tip than in other kinds of nasal tip. CONCLUSIONS: The incidence of cephalic malposition of the lateral crura in this series of Caucasian noses was 36.8%. There was a statistically significant association between parenthesis deformity of the nasal tip and cephalic malposition of the lateral crura, as well as with convex shape of the lateral crura. No statistically significant association was found between the sagittal angle of the lateral crura and the type of nasal tip. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Sarcoidosis in and around the nose: a diagnostic and therapeutic guideline]. / Sarcoïdose in en rond de neus.

In addition to its mucosal pathology, sarcoidosis of the nose may cause a range of skin abnormalities and destruction of the osteocartilaginous structures of the nose. Clinical presentation can mimic other diseases and a biopsy is often necessary. We propose a classification of nasal sarcoidosis based on disease location to help with recognition of the symptoms and, subsequently, treatment. Here we describe 4 patients with nasal sarcoidosis. In the first patient, a 53-year-old woman with a granuloma in the nasal vestibule, the lesion was excised. The second patient, a 38-year-old man with intranasal crusts, synechiae and atrophic mucosa, was treated with corticosteroid nasal drops. The third and fourth patients, a 36-year-old man with progressive widening of the nasal dorsum and a 60-year-old woman with a saddle nose, respectively, were treated with a rhinoplasty.

The Use of Osteotomies in Nasal Profileplasty.

In rhinoplasty, osteotomies are performed to manipulate the bony nasal vault to improve the function and/or the aesthetics of the nose. This article provides an overview of the instruments used for osteotomies, as well as the indications and techniques for osteotomies in nasal profileplasty.

Feeling Normal? Long-Term Follow-up of Patients with a Cleft Lip-Palate after Rhinoplasty with the Derriford Appearance Scale (DAS-59).

The stigma of nasal deformity due to a congenital cleft lip-palate has an undeniable influence on the affected patient's life. It is therefore of interest to investigate if efforts to reduce esthetic and functional impairments by rhinoplasty (single or multiple) can result in an increased satisfaction with appearance and a self-perception similar to the noncleft population. Retrospective scoring before and after rhinoplasty using the validated Derriford Appearance Scale (DAS-59) and subsequent statistical evaluation and comparison to datasets available in the literature for further classification was used. Of the 61 patients who underwent at least one rhinoplasty, 26 responded to all questions. The mean age of responders was approximately 30 years of age and the male:female ratio was 1:1.2. The scale showed a significant overall improvement after surgery. The full scale and all subscale scores of the DAS-59 were significantly reduced after surgery demonstrating an improvement in the respective categories. Most importantly, if postoperative results were compared with a population concerned and unconcerned about appearance, no difference "facial self-consciousness" of appearance was apparent. Also postoperative subscores for "general self-consciousness" (GSC) and "social self-consciousness" of appearance (SSC) showed no difference from those obtained from the population concerned about appearance. The postoperative subscore for "sexual and bodily self-consciousness" of appearance (SBSC) indicated improvement beyond the level found in the concerned control population. Due to only a low improvement in the difference compared with the subscore representing a "negative self-concept," a statistically significant difference to the concerned population remained, possibly indicating that therapy beyond surgery is needed for improvement. After rhinoplasty, the investigated group of cleft lip-palate patients with nasal deformities showed an improvement in their self-conceived appearance as measured by the DAS-59. Their assessment of self-appearance was comparable to that of a group of noncleft persons with concern about their appearance. Taken together, rhinoplasties, primary and revision, add to the psychosocial well-being and an improved self-perception enhancing quality of life and enabling a more normal life. Further research is needed to clarify how the low reduction found in the "negative self-concept" may be addressed successfully.

Surgical Treatment of the Twisted Nose.

The twisted nose is a challenging procedure in rhinoplasty. The goal of surgery is to realign the nasal skeleton to create symmetry in the face and restore nasal patency. Key in the surgical procedure is that all structures of the nasal skeleton be dissected free, mobilized, repositioned, and stabilized. Important surgical steps are intermediate osteotomies on the contralateral side of the deviation for the upper nasal third; for the mid nasal third, a unilateral spreader graft or splint on the nondeviated side, and for the lower nasal third, fixation of the caudal septum to the anterior nasal spine.

Does Functional Septorhinoplasty Provide Improvement of the Nasal Passage in Validated Patient-Reported Outcome Measures?

OBJECTIVE: The aim of this study was to determine whether functional septorhinoplasty provides improvement of the nasal passage in validated patient-reported outcome measures (PROMs) for adults with an anatomical obstruction of the nasal valve. All patients with an anatomical obstruction of the nasal valve area due to nasal valve pathology and/or septal deviations in this area were included. METHODS: A systematic PubMed, Embase and Cochrane Library search was performed to identify relevant articles. The articles were critically appraised and ranked according to validity and relevance. RESULTS: Sixteen articles met our inclusion criteria, and after critical appraisal, 10 were eligible for further analysis. In 9 studies, the Nose Obstruction Symptom Evaluation (NOSE) score improved from 35 to 60 points. In 1 study, the Sino-Nasal Outcome Test (SNOT-22) improved 3.5 points. CONCLUSION: The results suggest that there is a significant improvement of the validated PROMs after functional septorhinoplasty in the first postoperative year. We recommend that adults with nasal breathing problems due to an anatomical problem of the nasal valve area should consider undergoing functional septorhinoplasty.

Complications of balloon packing in epistaxis.

Although balloon packing appears to be efficient to control epistaxis, severe local complications can occur. We describe four patients with local lesions after balloon packing. Prolonged balloon packing can cause damage to nasal mucosa, septum and alar skin (nasal mucosa, the cartilaginous skeleton and the overlying soft-tissue envelope) and should, therefore, be avoided. We suggest early nasendoscopy in general anesthesia to identify and treat the bleeding focus, if bleeding cannot be controlled with regular packing.

The body dysmorphic disorder patient: to perform rhinoplasty or not?

By virtue of being a (primarily) aesthetic rather than a functional procedure, rhinoplasty is unique among rhinological operations. As such, it raises moral, philosophical and social issues that no other procedure does. The preoperative assessment of a rhinoplasty patient includes a number of considerations that are unique in this type of surgery; during the outpatient consultation, the patient's motivation for surgery, stability and overall psychological evaluation, with a special emphasis on body dysmorphic disorder, have to be taken into consideration. Body dysmorphic disorder is a relatively common obsessive-compulsive spectrum disorder defined by a constant and impairing preoccupation with imagined or slight defects in appearance. Body dysmorphic disorder is associated with poor quality of life, extremely high rates of suicide and--following cosmetic surgery--high rates of dissatisfaction, occasionally manifesting as aggressiveness. A combination of psychological and medical management is the treatment of choice and this review aims to address the frequently controversial rhinoplasty indications for these patients.

[Local complications of intranasal cocaine abuse: diagnostic and therapeutic guidelines]. / Lokale complicaties van intranasaal cocaïnegebruik: een diagnostische en therapeutische leidraad.

In addition to causing nasal septum perforation, cocaine abuse can cause extensive destruction of the osteocartilaginous structures of the nose. The clinical picture can mimic other diseases, such as vasculitis and lymphoma. Here we describe 3 patients with nasal deformities. One patient, a 39-year-old woman, had a large cocaine-related septum perforation, which caused a saddle-nose deformity. This deformity was corrected via external-approach rhinoplasty. The second patient, a 58-year-old man with limited granulomatosis with polyangiitis, presented with recurrent nose bleeds. He was treated with prednisolone for an exacerbation of symptoms. His nasal defects are now stable. The third patient, a 41-year-old man, had extensive deformities and tissue defects of the nose and palate. He was treated surgically, but this was followed by a relapse of the tissue defects due to persistent cocaine abuse. In patients with destruction of the nasal skeleton, the possibility of cocaine abuse should always be considered.

Treatment of septal hematomas and abscesses in children.

The cartilaginous part of the nasal septum of a child with a septal hematoma or abscess is at risk of destruction. Consequently, the noses of these children can collapse, causing a saddle nose deformity, and in time, the normal outgrowth of both the nose and maxilla will be disturbed. In adulthood, they will have an underdeveloped saddle nose deformity with too much upward rotation of the nasal tip and a retroposition of the midface. Sequelae like these should be prevented by prompt diagnosis and surgical intervention. In this article, the management of septal hematomas and abscesses is discussed with special focus on reconstruction of destructed septal cartilage with the use of autologous cartilage grafts fixed to a polydioxanon plate.

Reconstructive surgery of the leprosy nose: a new approach.

There has still been no reduction in the detection rate worldwide for leprosy, despite supervised multi-drug therapy. In time, leprosy can result in a severe saddle-nose deformity leading to functional problems, disfiguration and stigmatization. In severe cases, only the nasal skin tissue and the lower lateral cartilages are preserved. In such cases, the ideal would be to restore the cartilaginous skeleton but, by contrast with other causes of saddle-nose deformities, this is complicated by the quantity and the poor quality of the remaining nasal mucosa. Leprosy-related saddle-nose deformities are therefore challenging and difficult to reconstruct with the techniques that have been proposed in the past. In this study, 24 patients underwent rhinoplastic surgery involving the use of autogenous costal and/or auricular cartilage or composite grafts. The nasal septum, the upper laterals and the anterior nasal spine were reconstructed with a dorsal onlay attached to a columellar strut with an extension on the proximal side. Before surgery, the saddle-nose deformities were classified according to severity with a new system based on clinical symptoms and signs. Postoperative evaluation was performed at least two years after surgery (N=17). Functional and aesthetic improvement, resorption rate, warping, infection and extrusion were analysed. Functional and aesthetic improvements were achieved in 15/17 patients. None of the patients developed an infection and extrusion or warping of the implants was not observed. The resorption rate depended on the localization and the type of cartilage implant. In general, auricular conchal cartilage implant grafts resulted in less resorption than costal cartilage. Least resorption (4/17 patients) was observed in the dorsal onlay grafts of both conchal (1/6) and costal cartilage grafts (3/11). Resorption of columellar strut implants and shield grafts was observed in 7/17 patients. No resorption was seen of composite grafts (0/4) and alar battens (0/7). Autogenous cartilage implants can be used to reconstruct saddle-nose deformities in leprosy with a minimum risk of complications. The preoperative grade of severity was used as a basis for the development of guidelines for optimal long-term functional and aesthetic outcome.

Postoperative management of nasal vestibular stenosis: the custom-made vestibular device.

OBJECTIVE: To evaluate the effect of a custom-made postoperative vestibular device on the occurrence and severity of restenosis. DESIGN: This was a retrospective study conducted at the Department of Otorhinolaryngology/Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery of the Academic Medical Center. In this tertiary care center between January 1994 and December 2000, 52 patients treated for nasal vestibular stenosis received a vestibular device directly postoperatively, with the intention to decrease the risk of restenosis. The vestibular device was composed of thermoplastic acrylic material and had a lumen to facilitate breathing. The shape of the device was custom-made within 1 week after surgery and was subsequently worn by the patient for 12 weeks (6 weeks continuously and 6 weeks only during the night). After this period, the occurrence and severity of restenosis of the nasal vestibule were evaluated and the necessity for a potential adjuvant operation was assessed. RESULTS: Preoperatively, of the 52 patients, 38 (73%) had severe stenosis, 13 (25%) had moderate stenosis, and 1 (2%) had mild stenosis. Postoperatively, 15 (29%) of the patients had mild restenosis, 1 had a case of moderate stenosis, and 1 had a case of severe stenosis. Only the latter patient required a subsequent revision. Functional improvement was noticed in 51 (98%) of the patients, whereas 49 (94%) of the patients showed aesthetic improvement after the initial procedure. CONCLUSIONS: In case of surgical treatment of vestibular stenosis, the use of a custom-made vestibular device may help prevent restenosis. In addition to functional improvement, the device may also improve the aesthetic result. The device does not seem to have any negative adverse effects, was easy to make, and was comfortable for the patient to wear.