The Limits of Evidence in Rhinoplasty.

The broad trend toward minimally invasive methods in most surgical fields is contrasted by rhinoplasty: Extended open approaches, an increasing number of grafting techniques, donor site depletion, and extensive osteotomies seem to indicate a trend away from minimally invasive methodology for this particular procedure. This article intends to analyze which factors are involved in this and related developments in rhinoplasty.Evidence-based methodology sets the standards for scientific analysis. For rhinoplasty, however, limitations of established scientific methodology are identified. These include the relative lack of objective outcome measures and the impact of various systematic biases on reported results. These biases include operator dependence, interdependence of techniques, biased selection of outcome parameters, and orthodox treatment bias. Upon critical review, the importance of systematic biases may outweigh the impact of evidence-based study in rhinoplasty. Results should therefore be interpreted with caution. Strategies are suggested to identify and mitigate the impact of biases and to improve reporting and outcome analyses in rhinoplasty.

Narrowing and Operated Appearance of the Middle Nasal Third after Hump Resection without Middle Vault Reconstruction.

BACKGROUND: Little is known about the incidence of narrowing and an operated appearance of the dorsum after hump resections if the dorsum is not reconstructed with spreader grafts or spreader flaps. METHODS: Patients who had undergone a composite hump resection (n = 22) or a component hump resection (n = 25) were interviewed and photographed with a minimum follow-up of 12 months. Four expert rhinoplasty surgeons and four laypersons rated the appearance of the middle third of the dorsum on the preoperative and postoperative en face photographs. The quartile of the most surgical appearing outcomes was analyzed regarding potentially preventive surgical maneuvers. RESULTS: No patient was dissatisfied with the frontal view of the nose. Agreement between expert and lay raters (Kendall's coefficient of concordance) was 0.51 (p < 0.01) and 0.34 (p = 0.06) for appearance and 0.55 (p < 0.01) and 0.46 (p < 0.01) for width, respectively. Expert raters found that a surgical appearance of the dorsum had both increased and decreased after surgery, with an average increase of 0.27 ± 1.05 and 0.21 ± 1.18 points on a five-point Likert scale for composite and component resection, respectively. Pearson correlation between the degree of dorsal lowering and surgical appearance on the anterior view was 0.31 (p = 0.026). Reconstruction of the middle third could potentially have improved the outcome in 15 percent of the patients. CONCLUSIONS: Lowering of the dorsum without middle vault reconstruction on average increased an operated appearance to a small degree that was not noted by the patients. This effect was similar for composite and component hump resections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The "Segmental SMAS Model": A Didactic Concept of Face and Neck Lift Anatomy.

Profound understanding of the surgical anatomy of the face and neck is the key to successful face lift surgery. The "Segmental SMAS Model" presented herein is the result of a decade-long effort in teaching fellows a logical and coherent anatomic model of face lift anatomy. The superficial musculo-aponeurotic system (SMAS) consists of segments with distinct surgical characteristics. These are determined by the presence of a deep gliding plane and/or adhesion through fibrous insertions. In this article, we define SMAS segments that are profoundly heterogeneous in their behavior and have surgical implications on the maneuvers required for a deep plane face lift. The present model introduces several novel interpretations of the surgical anatomy of the face and neck lift procedure and hopes to convey a better understanding of face lift anatomy to training surgeons.

Minimally invasive techniques in rhinoplasty.

PURPOSE OF REVIEW: To present criteria of minimally invasive surgery, which include minimal and hidden incision lines, reduced injury to tissue and application of endoscopic techniques, when feasible; to analyze techniques in rhinoplasty for their minimally invasive character - in light of recent publications; and to discuss the techniques that best meet the criteria of minimally invasive surgery. RECENT FINDINGS: The nose consists of about 60 percent soft tissue and 40 percent skeletal elements. Surgery causes injury to both tissue types through various mechanisms, including mechanical traction, separation, incision, heat, desiccation, and others. Multiple aspects including extent of approach and degree of tissue undermining determine the minimally invasive character of techniques and maneuvers in rhinoplasty. SUMMARY: A single incision endonasal approach, the subperichondrial and subperiosteal septal plane, the supraperichondrial plane over the cartilaginous dorsum, the subperiosteal plane over the bony dorsum, limited dorsal undermining with endoscopic visualization when feasible, conventional straight lateral osteotomy or percutaneous curved lateral osteotomy; percutaneous transverse osteotomy; conventional straight paramedian osteotomy; piezo and drill paramedian ostectomy; dorsal uncapping osteotomy; conventional rasp gross dorsal contouring; piezo or drill fine dorsal contouring; (cartilaginous) middle vault 'let down'; and minimal access subperiosteal turbinate bone resection were found to best fulfil the criteria of minimally invasive surgery. A classification system for the degree of minimally invasiveness of rhinoplasty techniques is proposed as a basis for discussion.

Finesse in Caucasian Endonasal Rhinoplasty: The S.O.F.T. Concept.

The nasal anatomy of Caucasian people includes thin skin, limited soft tissue volume, a high dorsum, strong cartilaginous framework, and narrow elliptical nasal inlets. A smooth dorsal contour, a well-defined tip, a naturally soft-feeling tip, and a functionally patent nasal valve constitute key objectives for Caucasian rhinoplasty. The author's focus on minimal-impact surgery has resulted in multiple novel techniques, embedded in a coherent algorithmic concept termed the S.O.F.T. (surgery and ongoing care free of trauma) concept. The foundation is the endonasal operation for the entire spectrum of primary and secondary deformities and maximal preservation of anatomic structures.

The Use of Botulinum Toxin Type A in the Healing of Thyroidectomy Wounds: A Randomized, Prospective, Placebo-Controlled Study.

BACKGROUND: Recent research has indicated that botulinum toxin type A may have an inhibitory effect on the formation of fibroblasts and thus possibly decreases the severity of scar formation. Therefore, a trial was designed to assess the effects of botulinum toxin type A on scar formation after thyroid surgery. METHODS: A double-blind, randomized, controlled trial was designed. All patients underwent a preoperative survey to assess scar history. All patients underwent a total thyroidectomy, hemithyroidectomy, or parathyroidectomy through a standardized incision. At the conclusion of the case, one half of the incision was injected with botulinum toxin type A, and the other half was injected with saline (placebo). The scars were then evaluated at 4 weeks, 6 months, and 1 year postoperatively using subjective scar analysis scales. RESULTS: A total of 40 patients were enrolled. There was no significant difference in scarring at any of the time points between the botulinum toxin type A-treated and placebo sides of the incision. A subgroup analysis was performed that examined the effects of botulinum toxin type A on those with a severe scar history. This demonstrated a significant decrease in scarring at 6 months postoperatively on the botulinum toxin type A-treated side. CONCLUSIONS: This study indicates that botulinum toxin type A administration immediately after surgical closure of a thyroid incision does not demonstrate a difference in scar outcomes compared with the control side. However, there was less scarring in subjects who had a severe scar history. This study found opposite results to a similarly designed study. Further study is required to determine the optimal use of botulinum toxin type A for wound healing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Nuances in component nasal hump reduction.

IMPORTANCE: Nasal hump reduction is a frequent manoeuvre in rhinoplasty. Over the last years, composite hump reduction has been advocated in favour of component hump reduction. The latter allows a more controlled and stepwise approach in reducing the nasal dorsum by deprojecting the cartilaginous dorsum separately from the bony dorsum. This approach also preserves the upper lateral cartilages (ULCs) and their mucosa. OBJECTIVE: To analyse the intricacies of the anatomic transition zone between the ULCs, the rhinion and the nasal bones as they pertain to component hump reduction. METHOD: Anatomical dissections with five fresh cadaveric heads were performed in this study. The cephalic extension of the ULCs beneath the nasal bones was modified and measured after component hump reduction on both sides of the rhinion. RESULTS: Central detachment of the ULCs from the bony dorsum and their release from the medial undersurface of the nasal bones allows for complete preservation of the ULCs. This is achieved by inferior-medial rotation of the cephalic ends of the ULCs against the septum. If not released completely during hump reduction, a substantial loss of the ULCs may be the consequence. CONCLUSIONS: The described manoeuvre allows the preservation of the cephalic components of the ULCs underneath the bony dorsum during component hump reduction. The result is a smoother transition line at the keystone area and along the entire bony-cartilaginous dorsum with a straighter aesthetic dorsal profile and oblique view. The present findings allowed us to present an operative algorithm with implementation into clinical practice.

Fluorescein sodium-guided surgery of parotid gland tumors as a technical advance.

BACKGROUND: Complete tumor removal and preservation of the facial nerve are essential in parotid gland surgery. A technical adjunct that potentially enhances the contrast between the facial nerve and the adherent tumor tissue and allows to identify residual tumor tissue could be Fluorescein Sodium. METHODS: Retrospective chart analysis on 7 patients with benign parotid gland lesions that were operated using Fluorescein Sodium intravenously and the application of the YELLOW 560 nm filter of the operating microscope. Safety and feasibility were evaluated. RESULTS: All tumors showed fluorescence and the rating ´contrast-enhancing´ was assigned in all cases. In 2 patients, satellite nodules were identified and resected meaning that the fluorescence staining of the tumor margins was significantly better than under white light. CONCLUSION: The use of Fluorescein Sodium in parotidectomy is promising. In two cases residual tumor was detected that would have been left behind under white light. Further research in parotid gland surgery and other head and neck tumor procedures is warranted.

Technique in Cleft Rhinoplasty: The Foundation Graft.

Secondary cleft rhinoplasty represents a particular surgical challenge. The authors have identified the deficit in skeletal projection of the cleft-sided piriform rim as an important contributor to the pathology. A graft is described to augment the piriform crest on the cleft side. This foundation graft is suture fixated to the piriform crest after complete release of all soft tissue attachments to the alar base. The foundation graft is articulated with a long alar strut graft, which allows for powerful projection of the cleft-sided nasal tip. An advancement flap of vestibular skin is described to correct the vestibular stenosis. A transplant of diced cartilage in fascia is added to augment maxillary soft tissue volume. Subjective and objective measures of form and function are presented in a retrospective series of five cases, illustrating the efficacy of the techniques described.

A Co-Culture Model of Fibroblasts and Adipose Tissue-Derived Stem Cells Reveals New Insights into Impaired Wound Healing After Radiotherapy.

External radiation seems to be associated with increased amounts of cytokines and other cellular modulators. Impaired microcirculation and fibrosis are examples of typical long term damage caused by radiotherapy. Adipose tissue-derived stem cells (ASC) are discussed to enhance wound healing, but their role in wounds due to radiotherapy is poorly understood. Normal human fibroblasts (NHF) and ASCs were co-cultured and external radiation with doses from 2-12 Gray (Gy) was delivered. Cell proliferation and mRNA levels of matrix metalloproteinases (MMP1, MMP2 and MMP13) were determined 48 h after irradiation of the co-cultures by qPCR. Additionally, tissue inhibitors of matrix metalloproteinases (TIMP1, TIMP2) were determined by enzyme-linked immunosorbent assay (ELISA). There was a reduction of cell proliferation after external radiation in mono-cultures of NHFs and ASCs compared to controls without irradiation. The co-culture of ASCs and NHFs showed reduced impairment of cell proliferation after external radiation. Gene expression of MMP1 and MMP13 was reduced after external irradiation in NHF. MMP2 expression of irradiated NHFs was increased. In the co-culture setting, MMP1 and MMP2 gene expression levels were upregulated. TIMP1 and TIMP2 protein expression was increased after irradiation in NHFs and their co-cultures with ASCs. ASCs seem to stimulate cell proliferation of NHFs and modulate relevant soluble mediators as well as proteinases after external radiation.

Safety Approach to Otoplasty: A Surgical Algorithm.

An algorithm was developed through an evolution of refinements in surgical technique with the goal to minimize risk and morbidity in otoplasty. Key principles were avoidance of cartilage incisions and transections and the use of multiple surgical techniques to distribute the "surgical load" evenly among these techniques. The present retrospective study was designed to test safety and efficacy of the concept in 100 consecutive patients and to discuss the results in light of the literature. Data detailing the surgery, preoperative, and postoperative period were extracted from the record and during patient interviews. Patients were contacted to complete a questionnaire to rate the postoperative pain and their satisfaction with the final outcome on a 6-point visual analog scale (VAS). An expert and a lay panel assessed preoperative and postoperative frontal-view photographs, using the same VAS. Pain in the postoperative was rated as minor (pain level VAS average score, 2.33) and patients' satisfaction was excellent (satisfaction level VAS average score, 1.82). The assessment by the panels of expert and lay evaluators paralleled these outcomes with a postoperative average VAS score of 1.69 and 1.87, respectively. Cartilage incision and transection can be effectively avoided in otoplasty. Even distribution of the surgical load among multiple techniques avoids the problems associated with "overload" of a single technique. The innovative technique of cortical mastoid drill-out is described. High satisfaction with the results, excellent patient comfort, and a favorable safety profile are associated with the present algorithm.

Minimally invasive surgery of the anterior skull base: transorbital approaches.

Minimally invasive approaches are becoming increasingly popular to access the anterior skull base. With interdisciplinary cooperation, in particular endonasal endoscopic approaches have seen an impressive expansion of indications over the past decades. The more recently described transorbital approaches represent minimally invasive alternatives with a differing spectrum of access corridors. The purpose of the present paper is to discuss transorbital approaches to the anterior skull base in the light of the current literature. The transorbital approaches allow excellent exposure of areas that are difficult to reach like the anterior and posterior wall of the frontal sinus; working angles may be more favorable and the paranasal sinus system can be preserved while exposing the skull base. Because of their minimal morbidity and the cosmetically excellent results, the transorbital approaches represent an important addition to established endonasal endoscopic and open approaches to the anterior skull base. Their execution requires an interdisciplinary team approach.

Orbital compartment: effects of emergent canthotomy and cantholysis.

The objective of this study was to determine the effect of orbital decompression procedures on the intraocular pressure (IOP). The orbital compartment syndrome represents an emergency situation. Due to the elevated IOP vision loss may ensue. Several maneuvers including lateral canthotomy are discussed to reduce the IOP. Eight orbits were studied in a fresh frozen cadaveric model (4 specimens). Intraorbital volume was determined by CT volumetry. An orbital compartment syndrome was simulated by injecting viscous material into the orbit. Injected volumes were documented and lateral canthotomy, cantholysis, inferior and superior septolysis were performed. IOP and exophthalmometric measurements were obtained after each intervention. Controlled elevation of IOP was achieved in all specimens. IOP was partially reduced after performing a lateral canthotomy in eight orbits. IOP was significantly and sufficiently decreased under 20 mmHg by inferior cantholysis in seven orbits. An additional superior cantholysis was necessary in two orbits to achieve a complete decompression. Inferior or superior septolysis were not needed to further reduce the IOP. Lateral canthotomy must be followed by an inferior cantholysis to successfully decompress an orbital compartment syndrome in the majority of cases. Occasionally, superior cantholysis may generate additional benefit. Additional inferior and superior septolysis were not shown to provide a beneficial effect when performed after canthotomy and cantholysis.

The stairstep graft: an alternative technique in nasal valve surgery.

IMPORTANCE: The stairstep graft is a novel method to modify the lateral anchoring point of lateral grafts for nasal valve correction. OBSERVATIONS: Eight consecutive patients with a diagnosis of nasal valve collapse were included in the study. The novel method of stairstep grafts was performed to reinforce the lateral crus and to widen the nasal valve. Postoperative evaluations were performed by using questionnaires and photographs. After a minimum follow-up of 3 months, all patients reported an improvement of nasal airway postoperatively. Persistent normalization of the preoperatively narrow alar base was noted. CONCLUSIONS AND RELEVANCE: The stairstep graft introduces a new concept in nasal valve surgery by lateralization of the lateral anchoring point for the alar strut graft (or other lateral functional grafts). The concept seems logical, enhances an existing technique, and may be performed through a minimally invasive approach, and the potential for untoward effects seems to be low.

Endoscopic forehead approach for minimally invasive benign tumor excisions.

IMPORTANCE: Direct transcutaneous resection has been a widely accepted standard for the removal of benign forehead lesions. In recent years, the endoscopic approach has become more prevalent because of its noninvasiveness. To date, only a few studies with limited case numbers have reported on this technique. We report our findings from one of the largest cohorts of patients undergoing tumor resection of the forehead via the endoscopic approach. OBJECTIVES: To evaluate results of the endoscopic forehead approach for benign tumor excisions, to give a more nuanced insight into this procedure, and to discuss technical pearls and potential pitfalls from our experience. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, retrospective case study at 2 university centers and 1 private practice among 36 patients aged 18 to 72 years (mean age, 44 years) who underwent the endoscopic forehead approach for benign tumor resections. MAIN OUTCOMES AND MEASURES: Symptoms at presentation, surgical procedure and duration, type of lesions, intraoperative and postoperative complications, recurrences, and patient satisfaction. RESULTS: In total, 34 patients had an asymptomatic forehead mass, while 2 patients reported discomfort and headache. Among all patients, complete tumor excision was achieved endoscopically. The mean operative time was 36 minutes. Histopathological examination revealed 18 lipomas, 13 osteomas, 2 dermoid cysts, and 1 bone fragment after previous rhinoplasty. In 2 patients, no specimen was submitted. No hematomas, infections, scalp numbness, contour irregularities, temporal branch paralysis, or tumor recurrences occurred. One patient had a prolonged area of alopecia, which resolved on its own. All patients attested to a high satisfaction rate. CONCLUSIONS AND RELEVANCE: The endoscopic approach offers excellent aesthetic results and allows for safe tumor removal. It has proven to be an effective and minimally invasive alternative to the conventional open approach. LEVEL OF EVIDENCE: 4.

Correcting the lobule in otoplasty using the fillet technique.

IMPORTANCE: Correction of the protruded lobule in otoplasty continues to represent an important challenge. The lack of skeletal elements within the lobule makes a controlled lobule repositioning less predictable. OBJECTIVE To present a new surgical technique for lobule correction in otoplasty. DESIGN, SETTING, AND PARTICIPANTS: Human cadaver studies were performed for detailed anatomical analysis of lobule deformities. In addition, we evaluated a novel algorithmic approach to correction of the lobule in 12 consecutive patients. INTERVENTIONS/EXPOSURES: Otoplasty with surgical correction of lobule using the fillet technique. MAIN OUTCOMES AND MEASURES: The surgical outcome in the 12 most recent consecutive patients with at least 3 months of follow-up was assessed retrospectively. The postsurgical results were independently reviewed by a panel of noninvolved experts. RESULTS: The 3 major anatomic components of lobular deformities are the axial angular protrusion, the coronal angular protrusion, and the inherent shape. The fillet technique described in the present report addressed all 3 aspects in an effective way. Clinical data analysis revealed no immediate or long-term complications associated with this new surgical method. The patients' subjective rating and the panel's objective rating revealed "good" to "very good" postoperative results. CONCLUSIONS AND RELEVANCE: This newly described fillet technique represents a safe and efficient method to correct protruded ear lobules in otoplasty. It allows precise and predictable positioning of the lobule with an excellent safety profile. LEVEL OF EVIDENCE: 4.

Effects of botulinum toxin A on patient-specific keloid fibroblasts in vitro.

OBJECTIVES/HYPOTHESIS: To test whether therapeutic effects of botulinum toxin A on patient- specific keloid tissue can be reproduced on the cellular level. Specifically, effects on cell proliferation and expression of growth factors and cytokines relevant for wound healing were to be tested. STUDY DESIGN: Experimental study including patient specific cell cultures of keloids. METHODS: Patient-specific keloid tissue was tested in a cell culture model for effects of botulinum toxin incubation on cell proliferation and expression of the following cytokines and growth factors: IL-6 (interleukin-6), VEGF (vascular endothelial growth factor), TGF-ß (transforming growth factor-ß). RESULTS: None of the tested parameters of human keloid tissue were affected by botulinum toxin A incubation. CONCLUSION: The present study does not add evidence to suggest a significant therapeutic role of botulinum toxin injections for the treatment of keloids. LEVEL OF EVIDENCE: N/A.