Invited Discussion on: Matched Cohort Comparison of Dorsal Preservation and Conventional Hump Resection Rhinoplasty.

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 .

Skin Contour Sutures in Rhinoplasty.

BACKGROUND: The skin-soft tissue envelope (STE) is a critical component of rhinoplasty and can have a significant impact on the final result. Skin contour sutures (SCSs) can be used to prevent potential complications related to skin detachment and to improve rhinoplasty results. OBJECTIVES: The aim of this study was to assess the efficiency of SCSs for nasal skin approximation. METHODS: SCSs involve the use of external sutures to stabilize the STE flap based on the principle that the pressure of the sutures helps to approximate the STE to the underlying nasal skeleton. The first study group demonstrated the utilization of SCSs in 459 consecutive rhinoplasty cases between December 2016 and April 2022 which were retrospectively reviewed. The second study group consisted of 30 patients with thick skin who had insertion of SCSs with ultrasonic evaluation both preoperatively and postoperatively. RESULTS: The average postoperative follow-up period in the first study group was 41 months (range, 12-64 months). Any suture site that was visible after removal of the suture disappeared completely after 6 weeks in most patients. No complications were reported. In the second group the ultrasound data indicated that STE healing was faster as its thickness returns to its preoperative state earlier in the healing process when SCSs were used. CONCLUSIONS: SCSs appear to help to decrease severe nasal edema, hematomas, loss of tip definition, fibrosis, and pollybeak deformity, thereby improving the results and predictability of rhinoplasty surgery.

The Dual-Plane Gluteal Augmentation: An Anatomical Demonstration of a New Pocket Design.

BACKGROUND: Fat grafting is the favored option for buttock augmentation by most surgeons, and buttock implants are mostly regarded as second choices. Accepted options for buttock implant pocket dissection are subfascial, intramuscular, and submuscular. To overcome the limitations of both intramuscular and submuscular pockets, and combine the benefits of both, the authors present a novel dual-plane pocket dissection. The dual-plane pocket involves a submuscular plane in the cranial half of the pocket and switching to an intramuscular plane in the caudal half. With this study, the authors describe their experience with this technique and analyze the dissection of the pocket on human cadavers. METHODS: The authors reviewed 82 consecutive composite gluteal augmentation cases from March of 2019 to November of 2019. In all cases, the implant was placed in the "dual plane." The clinical study was supplemented by 10 hemigluteal dissections in five cadavers following the surgical technique, with assessment of the anatomical components of the implant pocket created. RESULTS: Patients who underwent this technique showed excellent soft-tissue coverage over the implants. The main complications observed were seroma formation in five of 82 patients and temporary sciatic pain in four of the patients. The anatomical study confirmed double muscle coverage of both gluteus maximus and partial medius in the upper pocket pole and intramuscular gluteus maximus implant position in the lower pole. CONCLUSION: The authors present the dual-plane dissection technique as a valuable innovation to improve soft-tissue cover for the upper implant pole in buttock implant surgery.

Composite Dorsal Augmentation.

BACKGROUND: Dorsal augmentation is one of the most challenging procedures in rhinoplasty. Solid grafts and diced fascia graft (DC-F) have been employed for this purpose with varying success. Warping, irregularities, and variability of final height are some of the potential pitfalls. OBJECTIVES: The aim of this study was to assess the efficiency of the authors' approach combining multiple grafts for nasal dorsal augmentation. They described a technique employing composite dorsal augmentation that is a combination of a foundation layer utilizing high spreader grafts plus a dorsal gap graft combined with a contour layer of 3 possible types of fascia or DC-F grafts. The combination of the 2 layers for the nasal dorsum can be varied to achieve the required height to correct the patient's deformity and achieve the desired aesthetic goals. METHODS: Fifty-one patients who underwent dorsal augmentation with composite technique between 2017 and 2020 were retrospectively reviewed. A step-by-step algorithm was applied to achieve the required dorsal height. RESULTS: The patients were divided into 3 groups according to the type of contour graft: double-layer fascia graft, segmental DC-F, or narrow thin full-length DC-F. Smooth continuity and increased projection of the nasal dorsum were achieved in all patients. CONCLUSIONS: Composite dorsal augmentation is an effective technique for dorsal augmentations requiring 4 mm or more of height increase. This technique allows to achieve dorsal augmentation employing a combination of grafts from a single donor site together with camouflaging dorsal irregularities and highlighting dorsal aesthetic lines. This algorithm allows optimization of patients' aesthetic profile.

Rhinoplasty: Aesthetic Augmentation With Improvement of Dorsal Aesthetic Lines.

BACKGROUND: Camouflage of nasal dorsum, aesthetic augmentation, and highlighting the dorsal aesthetic lines are essential elements in modern rhinoplasty. Numerous techniques have been utilized, including deep temporal fascia, rectus abdominis fascia, and diced cartilage in fascia (DC-F). Despite their widespread adoption, technical challenges remain, especially when utilized for aesthetic purposes. OBJECTIVES: This paper details the utilization of fascia and DC-F for aesthetic dorsal refinement in primary and secondary cases. One of the main goals was to achieve ideal dorsal aesthetic dorsal lines rather than just volume augmentation. METHODS: The authors employed grafts from the deep temporalis fascia and rectus abdominis fascia in 4 configurations: (1) single layer, (2) double layer, (3) full-length DC-F, and (4) partially filled segmental DC-F grafts. Technical refinements included careful determination of dimensions and meticulously suturing to the dorsum at appropriately 10 points to prevent graft displacement. RESULTS: The authors report their experience with 146 clinical cases over 35 months from January 2017 to December 2019. The patients were divided for 4 groups depending on which type of graft was utilized. CONCLUSIONS: Autogenous deep temporal fascia, rectus abdominis fascia, and DC-F were utilized to camouflage dorsal irregularities, highlight dorsal aesthetic lines, and aesthetically augment either the entire nasal dorsum or its individual parts. Optimization of cutting, stitching, filling the graft, and careful fixation of these grafts on the nasal dorsum significantly increases the predictability of these techniques and minimizes problems.

Rhinoplasty Dissection Planes (Subcutaneous, Sub-SMAS, Supra-perichondral, and Sub-perichondral) and Soft Tissues Management.

Rhinoplasty as an operation is akin to a game of chess, where every maneuver will influence the eventual outcome. Undoubtedly, more than one approach to the nasal soft tissues envelop can produce beautiful and safe results as will be described in the paper namely, the subcutaneous, sub-superficial musculoaponeurotic system, supra- and sub-perichondral planes. For different justifiable reasons surgeons have their preferences, regarding dissection planes on the tip, middle and upper thirds, and regarding the manipulation of the soft tissue layers and nasal ligaments. The concept of the nasal layers and the presence of relevant ligamentous structures and how to restore them in an anatomical fashion, will help to understand the logic behind various approaches.

Circumlateral Vertical Augmentation Mastopexy for the Correction of Ptosis and Hypoplasia of the Lower Medial Quadrant in Tuberous Breast Deformity.

BACKGROUND: Type I tuberous breast deformity (according to Grolleau's classification) is characterized by the hypoplasia of the lower medial quadrant of the mammary gland and ptosis of the lower lateral quadrant. This results in an aesthetic imbalance in the breast that has an unnatural and unattractive appearance. The study aims to propose a surgical technique ensuring the successful correction of hypoplasia of the lower medial gland quadrant combined with ptosis. The essence of the technique is augmentation mastopexy with circumlateral vertical access. In the presence of pronounced ptosis of the breast, it is combined with the horizontal component and rotation of the gland flap. METHODS: The participants in the study were 26 patients (51 breasts) who were treated for type I tuberous breast deformity from 2015 to 2020. The average age of the patients was 34 years (within the range of 27-42 years). Patients from Group I were treated using the technique of circumlateral vertical mastopexy, and patients from Group II using circumlateral vertical augmentation mastopexy with a horizontal component. RESULTS: The average follow-up period was 36 months (9-60 months). Treatment was aimed to correct tuberous breast deformations of type I (according to Grolleau) combined with varying degrees of ptosis. The complication rate for all patients in this study was 5.4%-1 patient (1.8%) had a hematoma, 1 (1.8%) had postoperative implant malposition, and 1 (1.8%) had visibility and palpability of the implant edges. CONCLUSIONS: Circumlateral vertical access can be applied for augmentation mastopexy in patients who wish to simultaneously correct ptosis and type I tuberous breast deformity and perform breast augmentation. LEVEL OF EVIDENCE IV: 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 .

Rhinoplasty: A Sequential Approach to Managing the Bony Vault.

BACKGROUND: An important element of most rhinoplasty surgeries is the treatment of the nasal bones, which involves various combinations of osteotomies and hump removal. OBJECTIVES: The aim of this paper was to describe a rhinoplasty technique in which piezoelectric instruments (PEIs) are used to shape nasal bones, with the priority being to preserve the stability of these bones. In most clinical cases, nasal bones can be stabilized if rhinosculpture (RS) is applied broadly, both separately and in combination with different osteotomies, while preserving the nasal bridge. METHODS: A step-by-step algorithm was applied to achieve the required aesthetic results when working with PEIs on the bony pyramid, depending on the degree of asymmetry. We used the fully open approach in all clinical cases, which provided the greatest visual field when performing all the steps involved in treating the bony pyramid, thus fully exploiting all the possibilities and advantages of PEIs. RESULTS: We report our experience with 165 clinical cases performed over 18 months from December 2016 to July 2018. The patients were divided into 5 groups, depending on the algorithm selected to treat the bony pyramid. CONCLUSIONS: When working with the bony pyramid, our approach limits patient movement, thus ensuring stability of the side walls of the bones in both the short and the long term-a property that greatly improves the aesthetic results.

Tuberous Breast Deformity Correction: 12-year Experience.

BACKGROUND: This article shows our 12-year experience in application of the technique of breast parenchyma modification with simultaneous augmentation on the tuberous breast. We undertook the study, and with the results of this study we can say that tuberous breast deformation is a common pathology that is caused not only by a thickening of the superficial fascia but also by breast parenchyma fibrosis. When traditional techniques without parenchyma modification are used during the surgery, it is often that patients come back to treat complications. METHODS: A total of 208 patients (414 breasts) with tuberous breast deformation treated from 2005 to 2017 were included. The mean patient age was 31 years (range, 22-53 years). A periareolar approach, vertical and horizontal glandular scoring, dual-plane pocket creation, and anatomic implants were used in all cases. RESULTS: The mean follow-up was 36 months (range, 3-144 months). Deformities of the types I-IV by Von Heimburg were corrected. The global complication rate for all patients in this study was 8.9%-1.4% had capsular contracture, 1.5% had postoperative malposition, 2% had "double bubble" , 2% had rippling, 2% had areola and nipple sensitivity disorder. CONCLUSION: The authors' experience demonstrates that the described one-stage approach combining mammary gland parenchyma modification (glandular scoring) with dual-plane pocket and anatomic implants provides satisfactory results for treatment of tubular breast deformity with minimal complications and other effects that require repeated treatment. LEVEL OF EVIDENCE IV: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .