Developing the Optimal Osteotome Hand-Sharpening Method.

Background: Rhinoplasty osteotomes can be sharpened in various ways: professional sharpening or hand sharpening using whetstones or rotary powered devices. Objective: To compare the effectiveness of sharpening osteotomes using various sharpening methods with that of professional sharpening as measured by a custom edge tester. Materials and Methods: We performed repeated serial osteotome impacts on bovine femoral cortical bone. These dull osteotomes were sharpened using preidentified sharpening techniques. Edge morphology was evaluated. Sharpness was tested using a custom mechanical testing platform. Optimized sharpness was achieved with a whetstone sharpening method wherein the osteotome is flipped after every stroke. Results: Seven distinct sharpening methods were tested for sharpness five times each to determine the optimal sharpening method versus professional sharpening (control). The two sharpening methods, 5 (5.51 ± 0.32) and 6 (5.55 ± 0.32), that used this flipping technique were significantly sharper than other methods. Methods 5 (p = 1.0) and 6 (p = 1.0) were the only methods that were not significantly different from control. Conclusion: Single stroke with successively alternating surfaces created the sharpest blades that achieved results similar to professional sharpening.

Improving Projection of the Nasal Tip in Primary Endonasal Rhinoplasty.

Gaining, improving, and maintaining nasal tip projection is one of the most essential elements of successful endonasal rhinoplasty. For years the hallmark of inadequate nasal tip projection following rhinoplasty has been the Polly beak deformity. Early rhinoplasty technique consisted of intracartilaginous excision of the cephalic margin of the lower lateral cartilages, cartilage and bony hump reduction, and osteotomies. Some of these simple rhinoplasties still look good decades later, however, many are conspicuous in their lack of nasal tip projection. The reason for this inconsistency in rhinoplasty results was the surgeon's inattention to the structural integrity and anatomical position of the LLC. The senior author uses a combination of suture, strut, and cartilage grafting techniques to achieve ideal projection in a manor tailored to each patient's unique anatomic needs.

Upper Lid Thick Skin Blepharoplasty.

While many of the basic tenants of upper lid blepharoplasty remain constant regardless of skin type, the thick-skinned eyelid patient requires special consideration. The brow may be naturally lower in the thick-skinned patient. These patients are more prone to having the brow pulled downward while attempting to remove redundant skin. There may also be more fat in the medial and central compartments. There may be fat in a lateral compartment overlying the lacrimal gland. Patient's expectations for a deep lid sulcus and complete excision of redundant skin may not be possible. They are more prone to an observable scar, a small dog ear at the lateral wound edge, and prolonged postoperative lid edema. Patients with lifelong upper lid fullness must get some input from significant others because their upper face aesthetic will change. In these patients, the eyelid surgery is not a rejuvenation, but a creation.

Measured gain in projection with the extended columellar strut-tip graft in endonasal rhinoplasty.

IMPORTANCE: The extended columellar strut-tip graft was designed to improve nasal tip projection and tip definition in patients undergoing rhinoplasty. OBJECTIVE: To determine whether the extended columellar tip graft leads to a true and measurable increase in nasal tip projection or simply gives the illusion of an increase in projection. DESIGN: Retrospective case review. The mean time of follow-up photographs was 32 months after surgery (range, 8 months to 10 years). PARTICIPANTS: The study population comprised 15 patients who underwent primary or revision rhinoplasty during the last 10 years. INTERVENTION: Primary or revision rhinoplasty. MAIN OUTCOME MEASURE: The outcome measure was the long-term gain in nasal tip projection. Preoperative and postoperative images were cropped and sized equally for accurate comparison. All measurements were made from the alar-facial crease to the tip defining point. RESULTS: In all 15 patients, an increase in tip projection was obtained. The mean increase in projection was 19% compared with the preoperative projection. After applying a paired t test for analysis, there was a statistically significant increase in nasal projection (P < .05). CONCLUSIONS AND RELEVANCE: The extended columellar strut-tip graft effectively corrected poor nasal tip projection. The effect is maintained years later. The extended columellar strut-tip graft is an excellent choice in endonasal rhinoplasty to improve poor tip projection and definition. LEVEL OF EVIDENCE: 4.

Preventing complications in facial plastic surgery.

PURPOSE OF REVIEW: The demand for cosmetic procedures has increased dramatically over the past few years, in part fueled by the prevalence of cosmetic 'makeover shows', increased media coverage on television and easy accessibility to the Internet. This growing social acceptance of aesthetic surgery has caused an increasing number of women and men to undergo elective noninvasive and invasive procedures to enhance their appearance. As the number of patients interested in cosmetic surgery increases and the number of physicians performing these procedures increases, the risk of complications invariably also rises. An article focusing on the prevention of complications in facial plastic surgery, therefore, is clearly appropriate in the current era. RECENT FINDINGS: One of the recurring themes in the literature is preventing complications before they occur. Proper patient selection, a thorough understanding of the anatomy and adhering to proper techniques are some of the methods mentioned to avoid unfavorable outcomes. SUMMARY: The literature is replete with articles that focus on the newest techniques for facial rejuvenation. Only through careful analysis of the pitfalls of cosmetic procedures, however, can the facial plastic surgeon adopt principles to help prevent complications.

Deep plane face-lift.

The deep plane face-lift is a safe and reliable technique for treatment of the aging face. It affords improvement in the lower face and midface. The use of fibrin glue in the face-lift has improved the healing and recovery of patients.

The extended columellar strut-tip graft.

The extended columellar strut-tip graft is a structural unit used in endonasal rhinoplasty that combines the attributes of the columellar strut and the tip graft. It is used to provide projection and contour to the nasal tip. Our goal with this study was to evaluate a 15-year experience with 155 patients who underwent rhinoplasty with the extended columellar strut-tip graft. Of these, 110 underwent secondary rhinoplasty, and 45 underwent primary rhinoplasty. There were 6 patients in the secondary rhinoplasty group who experienced complications: in 3, the graft became visible postoperatively, and 3 patients had graft placement asymmetry. These 6 patients underwent surgery in the initial years of graft development. One patient with graft edge visibility and 1 patient with graft asymmetry underwent revision surgery with satisfactory results. The extended columella strut-tip graft is a reliable method to provide nasal tip projection and contour. The successful use of the graft requires precise diagnosis and surgical technique.

Long-term results of lower-lid suspension blepharoplasty: a 30-year experience.

BACKGROUND: Muscle suspension blepharoplasty remains a reliable method to tighten the loose skin and muscle of the lower eyelid. OBJECTIVE: To evaluate the 30-year experience of the senior author (N.J.P.) with the skin-muscle suspension technique for lower-lid blepharoplasty. PATIENTS AND METHODS: Of 4395 patients who underwent lower-lid blepharoplasty, 3988 had muscle suspension blepahroplasty performed with adequate follow-up. RESULTS: Results of the 30-year review showed that most patients were very satisfied with the procedure. There were 67 complications (2 hematomas, 1 poor scar, 24 cases of scleral show <1 mm, and 40 cases of chemosis). Chemosis resolved in 2 to 8 weeks, and there were no cases of ectropion, scleral show greater than 1 mm, dry eye, or vision loss. Revision surgery was needed in 41 patients, all of whom were satisfied after the secondary procedure. CONCLUSION: Despite the recent drift toward orbital fat preservation for lower-lid blepharoplasty, conventional lower-lid muscle suspension offers the surgeon a reliable method to tighten the loose skin and muscle of the lower eyelid and give the patient a more attractive, youthful appearance.

The underprojecting nasal tip: an endonasal approach.

The consistent ability to gain and maintain nasal tip projection in the under projected nose is the trump card of the successful facial plastic surgeon. The underprojected nose is the nemesis that causes most of the disappointment in rhinoplasty for the patient and the surgeon. It is imperative that the surgeon recognize the many variations that constitute the underprojected nose, and this recognition must be made long before it is encountered in the operating room. The diagnosis of under projecting nasal tip is made by observation and by palpation. Several broad categories of nasal tips can be thought of as the underprojecting nasal tip family.

Correction of the soft tissue pollybeak using triamcinolone injection.

OBJECTIVE: To describe the technique for correction of the soft tissue pollybeak deformity using intralesional injection of triamcinolone acetonide. METHODS: We discuss our philosophy, regimen, and technique for treatment of the soft tissue pollybeak using triamcinolone injection. We include results from a series of 173 patients who underwent rhinoplasty performed by one of us (N.J.P.). RESULTS: Triamcinolone was injected at 1 week after surgery in 127 patients (73%). A second injection was performed in 92 (72%) of the 127 patients at 4 weeks after surgery. One hundred eight (85%) of the 127 patients had an acceptable result, as judged by the surgeon, with good supratip definition. Nineteen (15%) of the 127 patients had a less than optimal result, with residual supratip fullness, as judged by the surgeon. There were no complications caused by triamcinolone injection. CONCLUSIONS: Because revision surgery is difficult and may be associated with complications, intralesional triamcinolone injection is the first-line treatment for the soft tissue pollybeak deformities caused by subdermal scarring. Should intralesional steroid injection fail to satisfactorily treat the deformity, revision rhinoplasty can subsequently be performed.

Blepharoplasty update.

The author's current perspective of blepharoplasty is a product of a 30-year evolution in treating the aging eyelid. A review of the literature highlighting the most recent techniques can provide the reader with state of the art thinking by many authors on the subject. Some-times, however, a single surgeon's lifetime experience with a surgical procedure also can be insightful. The article details the author's experience with blepharoplasty.