Preoperative rhinoplasty: evaluation and analysis.

In reality, the process of surgery is initiated at the moment patient and surgeon first meet. Patients arrive as candidates for surgery for a wide variety of reasons; motivational factors must be searched out and thoroughly evaluated by the surgeon. No completely accurate checklist exists to compute the psychologic makeup of individuals who seek facial plastic surgery. Before surgery is contemplated, significant education of patients is essential. This article examines the evaluative and analytical process of preoperative preparation for elective surgery.

Targeted solutions in submentoplasty.

Obtaining superior aesthetic results in the cervical-mental region requires accurately diagnosing the underlying anatomic abnormality. We have designed a comprehensive classification scheme based on diagnostic and surgical methods from a facial plastic surgical practice with 30 years of experience. Patients can be classified into the suggested system to determine the optimal rejuvenation technique.

A 3-year multi-institutional experience with the liposhaver.

OBJECTIVE: To report a 3-year multi-institutional clinical experience with the liposhaver in facial plastic surgery. DESIGN: Nonrandomized, nonblinded, multi-institutional evaluation of the liposhaver in a clinical setting. INTERVENTIONS: Seventy-two patients who presented for facial plastic surgical procedures underwent surgery with the liposhaver. Seventy-six liposhaving procedures and 74 concomitant procedures were performed. Standardized preoperative and postoperative photographs were obtained. OUTCOME MEASURE: Subjective evaluation by the surgeons who performed the procedures. RESULTS: The liposhaver was used successfully in all cases. The fat was cleanly shaved and the contour results were even, without dimpling or significant asymmetry. Operative time was comparable to that of conventional liposuction. There were no cases of facial nerve injury and no evidence of increased bleeding intraoperatively. Two male patients had small postoperative hematomas in the immediate postoperative period that were successfully treated with conservative measures. An additional patient developed a small hematoma on postoperative day 5 that was effectively treated with needle aspiration and a pressure dressing. CONCLUSION: This 3-year multi-institutional report suggests that the liposhaver continues to offer a precise alternative to conventional liposuction.

The contoured auricular projection graft for nasal tip projection.

In all rhinoplasty surgery, the universal need exists to increase, decrease, or preserve existing tip projection. When proper tip projection is lacking, a variety of techniques are useful for improving projection. We describe a valuable technique for tip projection, particularly useful and indicated in the Asian rhinoplasty, African American rhinoplasty, and in certain revision rhinoplasties. In the past 15 years, the senior author (M.E.T.) has used the contoured auricular projection graft in selected patients for achieving satisfactory tip projection in patients with blunted tips. The aesthetic outcomes have been predictable, pleasing, and reliable for the long term. Precision pocket preparation for auricular conchal cartilage graft placement is key to symmetry and projection of the final outcome. The results yielded a rounded nasal tip that may be more natural-appearing in Asians, African Americans, and selected patients with revision rhinoplasty. The contoured auricular projection graft provides a highly useful graft for the nasal tip.

Standardized photography in facial plastic surgery: pearls and pitfalls.

Photographic images in facial plastic surgery play a critical role in photodocumentation, patient education, preoperative planning, and self-education. Consistent, uniform, high-quality photography allows the best opportunity for critical self-assessment and self-education. The purpose of this article is to review important elements in the production of standardized, uniform photographs with a 35-mm camera or with a digital camera. Equipment, lighting and background, film selection, and a standardized photographic technique are detailed. Principles of intraoperative photography are also reviewed.

Clinical study of alar anatomy and surgery of the alar base.

OBJECTIVES: To analyze and quantify specific aspects of alar base anatomy and to identify anatomic configurations that may be correlated with specific surgical manipulations. DESIGN: Analysis in a population of patients presenting for aesthetic nasal surgery. SETTING: Facial plastic surgery practice. PATIENTS: The photographic slides of 120 white patients who presented for consultation were reviewed. INTERVENTIONS: On the base view of photographic slides, observations were made on the width of the alar base, recurvature of the alar base, thickness of the alar lobule, thickness of the alar wall, and flare of the alar wall. On the lateral view, observations were made on the vertical insertion of the ala on the face (cephalic, normal, or caudal), contour of alar rim in profile (gentle S-shape or straight), size of alar lobule (small, normal, or large), and alar-columellar relationship, with special attention to the presence of alar hooding. MAIN OUTCOME MEASURES: A spreadsheet program was used to analyze the incidence of each configuration and any association between various features of the alar base. RESULTS: Anatomic diversity exists that requires a careful individual analysis for each patient. A planned surgical intervention must fit the patient's unique anatomy. Distinctive configurations of recurvature, vertical insertion, and other aspects of the alar base were observed, with special implications for the surgeon's approach. CONCLUSIONS: Anatomic diversity requires a thorough preoperative examination followed by selection of an approach that addresses the specific anatomic findings. The choice of the best alar reduction and sculpture technique ultimately relies on a precise analysis of the anatomic configuration of the patient's alar base.

Use of alar batten grafts for correction of nasal valve collapse.

OBJECTIVE: To determine the efficacy of alar batten grafts for the correction of internal and external nasal valve collapse. DESIGN: In this retrospective study, a questionnaire was used to ask patients to rate their nasal breathing before and after application of alar batten grafts. SETTING: Private practice and academic tertiary referral medical center. PATIENTS: The questionnaire was given to 63 patients who underwent application of alar batten grafts between 1980 and 1995. Forty-six patients (73%) responded and were included in the study. INTERVENTION: Alar batten grafts were applied into a precise pocket via a limited endonasal incision or via the external rhinoplasty approach. The grafts consisted of curved septal cartilage or auricular cartilage and were applied to the site of maximal lateral nasal wall collapse. The convex surface of the cartilage was oriented laterally to allow maximal lateralization of the collapsed portion of the lateral nasal wall. In most cases, alar batten grafts were applied caudal to the existing lateral crura and extended from the lateral one third of the lateral crura to the piriform aperture. OUTCOME MEASURES: The degree of nasal airway obstruction was determined by subjective scoring on a scale from 1 (no obstruction) to 5 (complete obstruction) before and after surgery. The patency of the internal airway was also assessed on physical examination. RESULTS: The results of the study revealed that all but 1 of the 46 patients experienced an improvement in their nasal airway obstruction. The mean improvement in nasal airway obstruction was 2.5 on a scale of 5. Patients that had the least improvement had intranasal scarring in the region of the internal nasal valve, loss of vestibular skin, or excessive narrowing at the piriform aperture. Physical examination revealed a significant increase in the size of the aperture at the internal or external nasal valve after the application of the alar batten grafts. There was minimal postoperative fullness in the supraalar region, where the alar batten grafts were applied. With time, this fullness decreased, leaving little evidence of the graft and an overall improvement in the aesthetic result. CONCLUSIONS: Alar batten grafts are effective for long-term correction of internal and external nasal valve collapse that is not complicated by intranasal scarring in the region of the nasal valve, loss of vestibular skin, or excessive narrowing at the piriform aperture.

Powered instrumentation for dorsal reduction.

We describe the use of powered instrumentation for precise modification of the bony nasal dorsum. Specific modifications were made to design a drill specifically for the bony nasal dorsum. This drill has a protective sheath that covers all but the active part of the drill, protecting the skin-soft tissue envelope, and it also has suction at the resection site. In some cases an osteotome is used to reduce the hump and the drill is used to achieve additional reduction and to smooth the exposed edges under direct vision. In other cases the entire bony hump is reduced using the drill. The nasal dorsum drill offers a precise alternative to the rasp. The precision of the drill is highlighted in cases in which limited reduction is needed, as in cases of a single or several spicules requiring reduction and smoothing after osteotomy, or a single 4 mm raised area requiring limited reduction. The design of rasps makes it difficult to work on these focal areas without unnecessarily rasping surrounding areas, whereas the drill may be used to reduce the entire hump, to smooth the edges after osteotomy, or in a more precise and limited fashion when indicated. The drill may be less traumatic to the skin-soft tissue envelope because it does not rely on the potentially bruising back and forth motion typical of rasping. The nasal dorsum drill may decrease the incidence of bony dorsal irregularities after rhinoplasty.

The liposhaver in facial plastic surgery. A multi-institutional experience.

OBJECTIVE: To report a multi-institutional clinical experience with the liposhaver in facial plastic surgery. DESIGN: Nonrandomized, nonblinded, multi-institutional evaluation of the liposhaver in a clinical setting in patients presenting for cosmetic facial liposuction. INTERVENTIONS: Cosmetic facial surgery with the liposhaver was performed in 19 patients (21 procedures) who underwent submental lipectomy, facelift with defatting beneath the facelift flap, and/or correction of deep nasolabial folds. Standardized preoperative and postoperative photographs were obtained. Fat obtained from the abdomen of 1 patient was also studied histologically. This fat was excised sharply and was then liposhaved at varying oscillation speeds. OUTCOME MEASURES: Subjective evaluation by the operating surgeons. RESULTS: The liposhaver was used successfully in all cases. The fat was cleanly shaved and the contour results were even, without dimpling or asymmetry. Operative time was comparable to that for conventional liposuction. Preferred cannula sizes and settings were determined. There were no cases of facial nerve injury, no evidence of increased bleeding intraoperatively, and no hematomas in the immediate postoperative period. One patient developed a small hematoma on postoperative day 5 that was effectively treated with needle aspiration and a pressure dressing. Histologic evaluation of liposhaved abdominal fat showed normal fat cells and well-preserved architecture. CONCLUSIONS: The liposhaver offers a precise alterative to conventional liposuction. It may be less traumatic because it requires low suction pressures and does not rely on the potentially bruising, vigorous, back-and-forth motion for fat extraction typical of conventional liposuction.

Illusions in rhinoplasty.

In both primary and secondary rhinoplasty, favorable illusion may be created by cartilage grafting of various nasal anatomic components, as well as rearranging components in relationship to one another. Recognizing which patients will benefit from the procedures described herein can lead the rhinoplasty surgeon to improved long-term outcomes.

Variable histotoxicity of histoacryl when used in a subcutaneous site: an experimental study.

Histoacryl (butyl-2-cyanoacrylate) is one of the least histotoxic cyanoacrylate derivatives and is used as a tissue adhesive. Clinical applications primarily include skin closure (blepharoplasty incisions, etc.). In a recent study, we demonstrated that Histoacryl elicits minimal histotoxicity when used to glue bone grafts to rabbit-ear cartilage. Acute inflammation was limited to areas where Histoacryl escaped from between the bone graft and ear cartilage to contact well-vascularized soft tissue. In this study, Histoacryl was applied between bone graft and cartilage in one rabbit ear and adjacent to well-vascularized soft tissue with no graft in the opposite ear. Histologic analysis revealed minimal if any inflammation when small amounts of glue was used in the nonvascular region between bone graft and cartilage. However, subcutaneous implantation contacting well-vascularized soft tissue resulted in increased acute inflammation and prolonged foreign-body giant-cell response. Further studies are required to rule out any long-term problems associated with subcutaneous implantation of Histoacryl.

Aesthetic surgery of the face.

A large variety of safe and effective surgical procedures to achieve rejuvenation is currently available. If surgery is carefully and properly performed, with an emphasis on a conservative approach, lasting and gratifying results may be realized. Great care must be taken to select appropriate and highly motivated individuals for such procedures, from the standpoint of both psychologic maturity and ideal anatomic configurations. Furthermore, patients seeking aesthetic surgery are generally healthy and well, unlike patients who seek medical care for disease; surgeons must exercise extraordinary care to ensure that rejuventation surgery does not result in an unwell patient. Clearly, the ideal outcome is represented by a patient happy and gratified by his improvement and a surgeon proud of his resultant achievement.

Histotoxicity of cyanoacrylate tissue adhesives. A comparative study.

Cyanoacrylate derivatives have been used as surgical adhesives for many years. Shorter-chain derivatives (methyl- and ethyl-cyanoacrylate) have proved to be histotoxic. Longer-chain derivatives (butyl- and isobutyl-cyanoacrylate) are much less histotoxic. Many surgeons continue to use ethyl-2-cyanoacrylate (Krazy Glue) despite the availability of a less toxic derivative, butyl-2-cyanoacrylate (Histoacryl). In this study, the histotoxicity and bone graft-cartilage binding ability of Krazy Glue and Histoacryl were compared. Bone grafts harvested from the anterior wall of the maxillary sinus were placed in a subcutaneous pocket and glued to auricular cartilage in the rabbit. Krazy Glue and Histoacryl were used in opposite ears, harvesting specimens at 1, 2, 4, 12, 24, and 48 weeks. The Krazy Glue-treated ears developed seromas with histologic evidence of acute inflammation, tissue necrosis, and chronic foreign body giant cell reaction. The Histoacryl-treated ears showed mild acute inflammation and mild foreign body giant cell reaction. The Krazy Glue was completely degraded within 12 months, while some Histoacryl was still present at 1 year. Histoacryl had minimal histotoxic effect and good bone graft-cartilage binding ability, whereas Krazy Glue demonstrated severe histotoxicity.