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.

Differences in cartilage-forming capacity of expanded human chondrocytes from ear and nose and their gene expression profiles.

The aim of this study was to evaluate the potential of culture-expanded human auricular and nasoseptal chondrocytes as cell source for regeneration of stable cartilage and to analyze the differences in gene expression profile of expanded chondrocytes from these specific locations. Auricular chondrocytes in monolayer proliferated less and more slowly (two passages took 26.7 ± 2.1 days and were reached in 4.37 ± 0.30 population doublings) than nasoseptal chondrocytes (19.3 ± 2.5 days; 5.45 ± 0.20 population doublings). However, auricular chondrocytes produced larger pellets with more cartilage-like matrix than nasoseptal chondrocytes (2.2 ± 0.71 vs. 1.7 ± 0.13 mm in diameter after 35 days of culture). Although the matrix formed by auricular and nasoseptal chondrocytes contained collagen X, it did not mineralize in an in vitro model or after in vivo subcutaneous implantation. A DNA microarray study on expanded auricular and nasoseptal chondrocytes from the same donors revealed 1,090 differentially expressed genes. No difference was observed in the expression of known markers of chondrogenic capacity (e.g., collagen II, FGFR3, BMP2, and ALK1). The most striking differences were that the auricular chondrocytes had a higher expression of anabolic growth factors BMP5 and IGF1, while matrix-degrading enzymes MMP13 and ADAMTS5 were higher expressed in nasoseptal chondrocytes. This might offer a possible explanation for the observed higher matrix production by auricular chondrocytes. Moreover, chondrocytes isolated from auricular or nasoseptal cartilage had specific gene expression profiles even after expansion. These differently expressed genes were not restricted to known characterization of donor site subtype (e.g., elastic), but were also related to developmental processes.

Irradiated homologous rib grafts in nasal reconstruction.

OBJECTIVE: To assess the long-term efficacy of irradiated homologous rib grafts (IHRGs) for both augmentation and support function in rhinoplasty in general and for specific recipient sites within the nose. DESIGN: A retrospective study was conducted at an academic medical center to evaluate the loss of volume and support function of IHRGs in 9 specific recipient sites in the nose. RESULTS: We studied 66 patients, with a total of 177 IHRGs, dating back 9 years, with an average follow-up of 51 months. The rate of resorption increased with duration of follow-up. Complete resorption was found in 1 IHRG, and moderate resorption was observed in 55 IHRGs (31%). Resorption was characterized by a loss of support function rather than a loss of volume. Moderate resorption had a negative clinical outcome for shield grafts only. CONCLUSIONS: Irradiated homologous rib grafts were safe to use in rhinoplasty. In cases requiring a shield graft, IHRGs should be avoided.

Reconstruction of the nasal septum using polydioxanone plate.

OBJECTIVES: To evaluate the usefulness of resorbable polydioxanone plate attached to nasal septal cartilage in external septoplasty, to assess its mechanical stability until healing of cartilage fragments, and to describe the surgical technique and clinical experience. DESIGN: External septoplasty with polydioxanone plate has been performed in 396 patients since 1996. Indications were severe septal deformities (usually posttraumatic). Surgery included removal of the quadrilateral cartilage and division into straight fragments, which were sutured to resorbable polydioxanone plate and replaced as a free graft. If the nasal septal cartilage was partly or completely missing because of prior surgery or trauma, the missing cartilage was supplanted with auricular conchal cartilage. The study settings were Medicent Linz, Linz, Austria, and the Ear, Nose, and Throat Department, General District Hospital Steyr, Steyr, Austria. RESULTS: Functional and cosmetic outcomes were satisfactory. All patients experienced varying degrees of improvement in nasal blockage. There were no immediate (bleeding, septal hematomas, inflammatory reactions, or necrosis) or long-term (septal perforation, thickening of the nasal septum, or rejection of the implant) complications. CONCLUSION: Use of polydioxanone plate attached to nasal septal cartilage facilitates surgical correction of severe septal deformities and supports the nasal dorsum until healing.

Revision rhinoplasty: an overview of deformities and techniques.

This article provides an overview of assessment, planning, and correction of deformities in revision rhinoplasty surgery. Common deformities are described with tips for preventing such postoperative problems, and corrective strategies are suggested. Assessment remains the key to successful rhinoplasty surgery, and its importance in revision operations is emphasized. The external approach is preferred for complex revision surgery due to its unparalleled exposure of the underlying anatomy, but closed approaches are still used for dorsal correction or minor tip deformities. The use of and options for graft material in reconstruction are detailed.

Morphological and histological findings after typical surgical manipulations on growing septal cartilage in rabbits.

One remaining problem of nose surgery is surgical correction of a prepubertal distortion of the septum. Unfortunately, the growing cartilage reacts differently upon a surgical intervention; in most cases this might cause iatrogenic disturbance of the development. Our clinical and histological studies with polydioxanone (PDS) foil in septal reconstruction showed that the PDS foil successfully prevented postoperative sequelae like dislocation of the reimplanted cartilage fragments and recurrent deviation caused by overlapping of the cartilage borders. Furthermore, it seemed to stimulate cartilage regeneration. The question occurs whether the same effect can be expected if growing septal cartilage is supported by the PDS foil. This animal study showed remarkable effects of the resorbable PDS foil in healing and regeneration of the growing septum up to complete resorption of the PDS, which coincidentally paralleled the outgrowth of the septal cartilage in rabbits, such as in cartilage regeneration and in prevention of secondary septal deviations due to bending of the newly formed cartilage or incomplete healing of cut edges.

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.

Open rhinoplasty in children.

Septorhinoplasty in children carries the risk of growth disturbance of the nose and premaxilla. The open or external approach has the advantage that the cartilaginous nasal skeleton remains intact. This open approach enables the surgeon to excise dermoid cysts and to realign lower lateral cartilages (unilateral cleft) without disturbing the integrity of the cartilaginous skeleton. In our experience, absolute indications for open rhinoplasty in children include dermoid cyst, cleft lip nose, and septal abscess. Relative indications include septal deviations causing severe nasal airway obstruction and or progressive distortion of the nose. In this article, we discuss the indications, advantages, disadvantages, and operative technique of open rhinoplasty in children. Our indications for open rhinoplasty in children and some selected cases are illustrated.

Long-term patient satisfaction after revision rhinoplasty.

OBJECTIVE: In cases of dissatisfaction after rhinoplasty for esthetic or functional reasons, or both, revision rhinoplasty may be advocated to improve the patients' nasal performance. In contrast to studies on primary rhinoplasty, no objective outcome evaluation parameter has been validated in revision rhinoplasty, nor has there been a study specifically looking at long-term satisfaction after revision rhinoplasty. We aim at studying patient satisfaction after a long-term follow-up of revision rhinoplasty performed at an academic referral center. METHODS: At a mean period of 2.5 years after revision rhinoplasty, 90 patients who underwent a revision rhinoplasty at the Academic Medical Center in Amsterdam, The Netherlands, were sent a questionnaire on general satisfaction together with the validated rhinoplasty outcome evaluation (ROE) questionnaire. RESULTS: Of the 46 patients who responded to the questionnaire, 88% experienced a significant improvement in nasal performance by revision rhinoplasty, and 79% would choose to undergo the revision procedure again. Subgroup analysis of the ROE scores demonstrated that good satisfaction was mainly obtained in the young adult and middle-aged groups, without major differences between males and females. Satisfaction was unrelated to the open or closed technique used for revision, or to the graft material used. Interestingly, an inverse correlation was found between satisfaction and the number of previous rhinoplasties. CONCLUSIONS: This retrospective study demonstrates that revision rhinoplasty in an academic practice provides most patients with long-standing satisfaction.

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.

Reconstructive septal surgery.

To attain without compromise the surgical goal, a straight and concurrently solid septum, especially in cases of marked deviations or severe post-traumatic deformities (sometimes combined with external deformities), an excellent proven and well-known technique is extracorporal or external septoplasty. Surgery consists of excision of the quadrilateral cartilage and its division into straight fragments. To avoid postoperative sequelae such as saddling, the pieces of cartilage must be reconnected meticulously to form a straight and at the same time solid plate. This difficult and time-consuming procedure can be assisted by the use of a connecting material. Since 1996 we have been using a polydioxanone foil (PDS, Ethicon Norderstedt Germany) as the supporting material for this purpose. The PDS as well as the suture material is completely resorbed within 5 months, excluding long-term complications of other artificial implants.

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.

Objective computerized determination of the minimum cross-sectional area of the nasal passage on computed tomography.

OBJECTIVES/HYPOTHESIS: Current methods that measure cross-sectional areas of the nasal passage on computed tomography (CT) do not determine the minimum cross-sectional area that may be an important factor in nasal airway resistance. Objective measurement of the dimensions of the nasal passage may help in the diagnosis, as well as the choice and evaluation of surgical treatment for upper airway insufficiencies. STUDY DESIGN: Retrospective and clinical study. METHODS: Software was developed that automatically calculates the minimum cross-sectional area of the nasal passage on CT. RESULTS: Evaluation shows that the minimization algorithm in the software reliably calculates the position and orientation of the oblique plane on which the minimum cross-section lies. CONCLUSION: The developed method may be used for objective and observer-independent evaluation of surgical treatment options.

Interest in facial plastic and reconstructive surgery among otorhinolaryngologists: a survey in The Netherlands.

OBJECTIVE: To assess the interest of Dutch otorhinolaryngologists in facial plastic and reconstructive surgery (FPRS). METHODS: We conducted a 22-question survey among otorhinolaryngology physicians and residents concerning their experience with and interest in FPRS. The response rate was 71% (335/475; 275 physicians and 60 residents). RESULTS: Most respondents associated FPRS with rhinoplasty, otoplasty, and the reconstruction of skin cancer defects. Of the physicians, 81% said that 1% to 33% of their practice involves FPRS; 62% were satisfied with this percentage, whereas 36% would like it to be higher. Approximately 70% of physicians regarded their training in FPRS as insufficient, although most (70%) had taken supplementary courses. Moreover, 73% of the otorhinolaryngology physicians and 72% of all respondents said that FPRS should be taught during and after residency, with a preference for hands-on courses. Finally, 84% of all respondents thought that FPRS should be part of the field of otorhinolaryngology, whereas 48% thought that it should become a subspecialty. CONCLUSION: There is interest in integrating FPRS training into the Dutch otorhinolaryngology residency program, as it is in the United States.

Otoplasty: a modified anterior scoring technique.

In the long history of otoplasty, the basic techniques used to correct prominent ears with a missing antihelix are based on incisions, scoring, and suturing of the cartilaginous framework of the auricle. In this article, modifications (subperichondrial dissection and adjusting sutures) of the anterior scoring technique of Chongchet are described.

Considerations in ethnic rhinoplasty.

Although it is difficult to define specific ethnic groups as they are multiracial mixtures determined by historical, geographical, and cultural factors, we can define basically five non-Caucasian groups that commonly request rhinoplasty. The specific anatomy, surgical options, implant material, grafts, and possible complications are discussed. The importance of blending the "new" nose with the ethnic features to achieve harmony in the facial aesthetic components is emphasized.

Influence of polydioxanone foil on growing septal cartilage after surgery in an animal model: new aspects of cartilage healing and regeneration (preliminary results).

OBJECTIVE: To determine whether late complications after septoplasty in growing septal cartilage in children can be prevented by the use of a resorbable polydioxanone (PDS) foil in combination with the cartilage. DESIGN: Animal study with 45 young rabbits, operated on at the nasal septum. Four typical septoplasty procedures were carried out, including elevation of the mucoperichondrium, cartilage excision, and reimplantation of crushed and noncrushed cartilage; for each of the procedures, resorbable PDS foil was used in half of the animals. Observation time ranged from 2 weeks to 5 months, to observe the healing process until complete outgrowth of the septum and complete resorption of the foil were achieved. SETTING: Ear, Nose, and Throat Department at University of Pécs, Pécs, Hungary. MAIN OUTCOME MEASURE: Histomorphologic findings on specimens of septum stained with hematoxylin-eosin and periodic acid-Schiff stains. RESULTS: Depending on the surgical procedure, there were various degrees of differences between the groups with and without PDS. After elevation of the mucoperichondrium, there were almost no differences between the 2 groups. After cartilage resection, reimplantation, and crushing, however, there was a remarkable difference between groups. In the group without PDS, septal deviations and poorly regenerated cartilage were observed, but in the group with PDS no significant deviation after complete regeneration of septal cartilage was observed. CONCLUSIONS: The resorbable PDS foil prevented a secondary deviation in the surgically treated growing septal cartilage in young rabbits. Use of this foil could reduce late complications such as septal deviations and possibly prevent growth inhibition in the growing nasal septum after septoplasty.