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.

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.

A 3-Level Impaction Technique for Dorsal Reshaping and Reduction Without Dorsal Soft Tissue Envelope Dissection.

BACKGROUND: Preservation rhinoplasty (PR) techniques are continuously evolving and many variations of established techniques have been proposed since Daniel coined this term in 2018. OBJECTIVES: The aim of this study was to describe indications for a new "3-level impaction" technique, allowing, in selected cases, a complete profile correction and dorsal reduction without dissection of the dorsal soft tissue envelope (STE). METHODS: Three hundred and fifty primary closed rhinoplasty cases were retrospectively studied from January 2018 and October 2019. Age, sex, race, technical details, surgical time, and complications were registered. Ninety-five dorsa were reduced and shaped without dissecting the dorsal STE by combining: (1) a swinging-door septoplasty with low septal strip resection, (2) endonasal bony cap mosaic osteotomies, and (3) let-down or push-down operation. RESULTS: All patients showed a dramatic change in profile height and shape without either dorsal STE dissection or bony cartilage dorsal tissue resection. Mosaic osteotomies converted the dorsal keystone area from S- to V-shaped dorsum, let-down-operation and low septal strip resection enabled impaction, and profile setting was achieved by quadrangular cartilage flap rotation. The average follow-up time was 14 months (range, 12-16 months). CONCLUSIONS: In selected patients, dorsum can be preserved without STE dissection. By combining multiple endonasal maneuvers it is possible to obtain a dramatic change without dissecting the STE, while simultaneously avoiding any dorsal tissue resection. This method offers a versatile technique in selected patients, which leads to fast recovery and natural results.

Cone-Beam Computed Tomography: A User-Friendly, Practical Roadmap to the Planning and Execution of Every Rhinoplasty-A 5-Year Review.

BACKGROUND: Cone-beam computed tomography has recently rapidly developed worldwide as a versatile and convenient alternative to traditional computed tomography for imaging of the maxillofacial region. However, most surgeons performing rhinoplasty are surprisingly unfamiliar with it, in both the plastic surgery and ear, nose, and throat communities. METHODS: The broad clinical experience of a single center over the past 5 years is reviewed. The many applications of cone-beam computed tomography to primary and secondary rhinoplasty are analyzed regarding septum, turbinates, nasal bones, skin thickness, and other issues. The importance of a paradigm shift from a two-dimensional to a three-dimensional approach in image reconstruction is demonstrated, together with the value of surface contour enhancement. RESULTS: Cone-beam computed tomography has a multitude of practical applications highly relevant to rhinoplasty. The surface image will strengthen aesthetic analysis, and the detailed preview of bony and functional anatomy will facilitate surgical planning. Cone-beam computed tomography serves as a roadmap to plan and execute rhinoplasties more predictably and efficiently. The availability of spatial views and accurate detail, together with the possibility of easy, accurate measuring, offers a plenitude of potential applications. CONCLUSIONS: Cone-beam computed tomography is a user-friendly, quick technique with abundant advantages in planning any rhinoplasty. It causes the patient no inconvenience and has very few, if any, drawbacks, with these being limited to radiation exposure and limited cost.

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.

Current Trends in Preservation Rhinoplasty.

Recently there has been a dramatic acceptance of the preservation principle in rhinoplasty surgery. Surgeons worldwide now preform preservation rhinoplasty, which has led to an expanding list of indications and techniques. Most rhinoplasty surgeons have accepted the fundamental principle that preservation is better than resection and that a natural result is superior to a fabricated or reconstructed structure, especially with regards to the nasal dorsum. Currently, the main emphasis is on defining the indications/contraindications, technical refinements, and minimizing complications. This paper provides an overview of the current trends in preservation rhinoplasty. In the 2 years following publication of the Editorial, "The Preservation Rhinoplasty: A New Rhinoplasty Revolution," 1 there has been a dramatic acceptance of the preservation principle. Numerous surgeons throughout the world are preforming preservation rhinoplasty, which has led to an expanding list of indications and techniques. The majority of rhinoplasty surgeons have accepted the fundamental principle that preservation is better than resection, and that a natural result is superior to a fabricated or reconstructed structure, especially as regards the nasal dorsum. Currently, the main emphasis is on defining the indications/contraindications, technical refinements, and minimizing complications. The present paper is an overview of the current trends in preservation rhinoplasty.

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.

Decision Making in Preservation Rhinoplasty: A 100 Case Series With One-Year Follow-Up.

BACKGROUND: Preservation rhinoplasty (PR) is a new chapter in rhinoplasty history. The term was coined by Daniel in 2018 and represents a fundamental change in philosophy. OBJECTIVES: The aim of this study is to discuss a single-surgeon case series utilizing PR techniques. METHODS: One hundred fifty-three primary rhinoplasty cases were studied retrospectively between December 2016 and August 2017. One hundred cases had at least 1 year of follow-up. Technical details were recorded, including dissection plane, ligament preservation, tip support, lateral crural maneuvers, alar contour grafts, and preservation of the dorsum vs traditional reduction. These 100 cases can be categorized as either complete preservation rhinoplasty (PR-C) or partial preservation rhinoplasty (PR-P). RESULTS: All patients had open rhinoplasty and the average follow-up time was 13 months. All patients had preservation of the dorsal soft tissue envelope, and in 36 the entire soft tissue envelope and ligaments were preserved. Fifty-four had preservation of the alar cartilages. Thirty-one had dorsal preservation. The combinations include: PR-C (skin, dorsum, and alars): 24; PR-P (skin and dorsum): 2; PR-P (alars and dorsum): 2; and PR-P (skin and alars): 7. CONCLUSIONS: In most patients, the dorsal soft tissue envelope and nasal ligaments can be preserved. When possible, the lateral crura should be preserved and tensioning chosen over excision. Dorsal preservation is a versatile technique when proper patient selection is undertaken, and long-term issues with the middle vault and keystone area can be avoided. Some patients will benefit from total preservation where nothing is removed/disrupted and underlying structures are reshaped.Level of Evidence: 4.

Dorsal Preservation: The Push Down Technique Reassessed.

Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author's current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author's operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (Less than 4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors' experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be "Can I keep the nasal dorsum intact?" Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a "not operated" aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty.

The Nasal Ligaments and Tip Support in Rhinoplasty: An Anatomical Study.

BACKGROUND: In 1971, Janeke and Wright1 published a now classic study on the support of the nasal tip in which they found four areas of anatomic support. These findings led to the "tripod concept" of tip support. Recently, surgeons have begun repairing and/or preserving the nasal ligaments as a method to control tip projection and rotation. Therefore, a reassessment of the nasal ligaments and tip support is warranted. OBJECTIVES: The present study was done to investigate the ligamentous and structural support of the nasal tip. Clinically, surgeons are aware of the role of the nasal ligaments and are beginning to utilize tip suture techniques to achieve greater tip refinement and long-term support. METHODS: Anatomic studies were conducted on 24 fresh cadavers at the time of autopsy. The two groups consisted of the following: (1) group 1 included dissection of 10 cadavers concentrated on the various ligaments of the nose; and (2) group 2 involved dissections of 14 cadavers analyzing the relationship between the alar domes and the anterior septal angle (ASA). RESULTS: Regarding the ligaments of the nose, we were able to consistently identify the following ligaments: (1) interdomal; (2) intercrural; (3) Pitanguy's midline; (4) pyriform; and (5) a scroll ligament complex consisting of the longitudinal and vertical scroll ligaments. We did not find two commonly accepted ligaments: (1) a "footplate ligament" from the footplate of the medial crus to the caudal septum; and (2) a "sesamoid ligament" attachment from the accessory cartilage to the pyriform aperture. Dissections done to study the relationship between the domes and ASA revealed that the domes projected an average of 5.7 mm (range, 2.2-9.6 mm) above the ASA and were longitudinally 5.5 mm (range, 2.9-9.5 mm) caudal to the ASA. Thus, there was no direct support from the ASA to the domes. CONCLUSIONS: It is our recommendation that surgeons should consider preservation of the nasal ligaments whenever possible and utilize them to manipulate tip projection, position, and rotation. Awareness of the relationship between the dome and the caudal septum will hopefully minimize problems with the tongue-in-groove operation.

Asian Cleft Rhinoplasty: The Open Structural Approach.

BACKGROUND: Asian cleft rhinoplasty is a unique procedure with specific challenges. OBJECTIVES: This paper presents our experience with the use of an open structural technique for Asian cleft rhinoplasty utilizing a complete autologous approach. METHODS: An open approach that reconstructs the malpositioned nasal cartilage was utilized. Centrally, the septocolumella graft fixed securely in the midline with extender spreader grafts was utilized to project and lengthen the nose. The dislocated lateral crura on the cleft side was completely detached from the accessory cartilages and mobilized off the vestibular lining. The deficient medial crura was lengthened with the lateral crural steal procedure. The resultant shortened lateral crura was then reconstructed with the lateral crural strut graft (LCSG). This gave the versatility needed to bring the tip cartilages into a more anatomic and symmetrical position. Tip suturing and grafting was performed and dorsal augmentation achieved through diced cartilage wrapped in deep temporal fascia. At closure, when indicated, a modified Tajima reverse-U excision of the vestibular lining was performed to correct the alar hooding on the cleft side. Alar base modifications were done as indicated. RESULTS: From January 2010 to December 2015, 35 Asian patients underwent open cleft rhinoplasty. There were 18 female patients and 17 male patients. Twenty-nine patients were unilateral cleft and 6 were bilateral cleft. The mean follow up was 23 months. All patients were highly satisfied with the functional and aesthetic improvement of the procedure. The complications and revision rates were low. CONCLUSIONS: The autologous open structural approach can predictably and consistently give excellent results for Asian cleft rhinoplasty. The result attainable is superior to results attainable before adopting this approach for our patients. LEVEL OF EVIDENCE: 4.

Rhinoplasty: The Asymmetric Crooked Nose-An Overview.

There are three reasons why the asymmetric crooked nose is one of the greatest challenges in rhinoplasty surgery. First, the complexity of the problem is not appreciated by the patient nor understood by the surgeon. Patients often see the obvious deviation of the nose, but not the distinct differences between the right and left sides. Surgeons fail to understand and to emphasize to the patient that each component of the nose is asymmetric. Second, these deformities can be improved, but rarely made flawless. For this reason, patients are told that the result will be all "-er words," better, straighter, cuter, but no "t-words," there is no perfect nor straight. Most surgeons fail to realize that these cases represent asymmetric noses on asymmetric faces with the variable of ipsilateral and contralateral deviations. Third, these cases demand a wide range of sophisticated surgical techniques, some of which have a minimal margin of error. This article offers an in-depth look at analysis, preoperative planning, and surgical techniques available for dealing with the asymmetric crooked nose.

The Role of Piezoelectric Instrumentation in Rhinoplasty Surgery.

BACKGROUND: In rhinoplasty surgery, management of the bony vault and lateral walls is most often performed with mechanical instruments: saws, chisels, osteotomes, and rasps. Over the years, these instruments have been refined to minimize damage to the surrounding soft tissues and to maximize precision. OBJECTIVES: This article will present the evolution of the authors' current operative technique based on 185 clinical cases performed over an 19-month period using piezoelectric instrumentation (PEI). METHODS: A two-part study of cadaver dissections and clinical cases was performed using PEI. Evolution of the authors' clinical technique and the operative sequence were recorded. RESULTS: Thirty cadaver dissections and 185 clinical cases were performed using PEI, including 82 primary and 103 secondary cases. An extended subperiosteal dissection was developed to visualize all aspects of the open rhinoplasty including the osteotomies. Ultrasonic rhinosculpture (URS) was utilized in 95 patients to shape the bony vault without osteotomies. To date, 11 revisions (6%) have been performed. There were no cases of bone asymmetry, irregularity, or excessive narrowing requiring a revision. CONCLUSIONS: Based on the authors' experience, adoption of PEI is justified and offers more precise analysis and surgical execution with superior results in altering the osseocartilaginous vault. With extensive exposure, surgeons can make an accurate diagnosis of bony deformity and safely contour the bones to achieve narrowing and symmetry of the bony dorsum. Stable osteotomies can be performed under direct vision with precise mobilization and control. As a result of PEI, the upper third of the rhinoplasty operation is no longer shrouded in mystery. LEVEL OF EVIDENCE 4: Therapeutic.

Surface Aesthetics and Analysis.

Surface aesthetics of an attractive nose result from certain lines, shadows, and highlights with specific proportions and breakpoints. Analysis emphasizes geometric polygons as aesthetic subunits. Evaluation of the complete nasal surface aesthetics is achieved using geometric polygons to define the existing deformity and aesthetic goals. The relationship between the dome triangles, interdomal triangle, facet polygons, and infralobular polygon are integrated to form the "diamond shape" light reflection on the nasal tip. The principles of geometric polygons allow the surgeon to analyze the deformities of the nose, define an operative plan to achieve specific goals, and select the appropriate operative technique.

The plunging tip: analysis and surgical treatment.

BACKGROUND: The plunging tip refers to a deformity in which the nasal tip plunges on smiling. OBJECTIVES: To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling. METHODS: Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose. RESULTS: Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip. CONCLUSIONS: This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation.

The osseocartilaginous vault of the nose: anatomy and surgical observations.

BACKGROUND: The dorsal hump and dorsal aesthetic lines have been considered bony and cartilaginous structures. Knowledge of the anatomy of the osseocartilaginous vault is essential for obtaining aesthetically pleasing results of rhinoplasty. OBJECTIVES: The authors described the morphology, embryology, and clinical relevance of the nasal vault and the changes that occur in this area during rhinoplasty. METHODS: Dissections were performed on 15 fresh adult cadavers to examine the anatomy of the osseocartilaginous vault. Intraoperative endoscopic examination of the vault also was performed in 9 rhinoplasty patients before and after dorsal hump reduction. RESULTS: In the cadaver study, the average length of the dorsal keystone area, measured along the dorsal septum, was 8.9 mm, and the average width was 4.9 mm. No significant difference in length was observed between cadaver subgroups with straight or humped nasal profiles. The extent of lateral overlap of the nasal bones with the cephalic portion of the upper lateral cartilages varied. In rhinoplasty patients, the average length of the cartilaginous vault exposed during dorsal reduction was 7.6 mm. CONCLUSIONS: The aesthetic lines and profile of the nose before dorsal reduction are dictated by the cartilaginous vault. After reduction, the dorsal lines are determined by the bony vault edges. In routine rhinoplasty, reduction of dorsal height generally corresponds to removal of the dorsal cartilaginous septum.