Credit for Truly Novel Ideas? A Critical Approach to the Intellectual Authorship in Surgery.

The formation of new ideas and techniques in medicine and surgery is crucial to bettering the medical field and the quality of medical care. The transmission of these new ideas is a source of pride and recognition for physicians who devote their lives to patient care. The quality and integrity of the medical literature that results from seminal medical ideas are an essential but unregulated field. From time to time, there are discussions in the medical literature about the authorship of an idea/strategy/technique. In this digital era, where communication works at an unmeasurable speed, the authenticity of medical communication requires honesty and verification. The possibility of unreliable or false information exists, and the need to verify "new" information as accurate and honest is crucial. Rhythm, genuine, and fake (fair/unfair) information circulates at high speed, and suddenly everything one encounters is represented as "true and often represented as new." Regarding medical science and particularly surgery - we are overloaded daily with new techniques, new names, new strategies, and everything. Several questions regarding the authenticity of any publication or scientific communication exist. A critical approach is done in this article.

Differences between Primary and Revision Rhinoplasty: Indications, Techniques, Grafts, and Outcomes.

BACKGROUND: The nose is at the center of the face and has essential functional and aesthetic properties. Over recent years, rhinoplasty has gained increasing popularity through the influence of "selfies" and social media. As a result, a growing demand for secondary correction has also emerged. Revision rhinoplasty is more complex than primary cases and often requires the use of extranasal grafting material. The authors sought to analyze the indications, techniques, and outcomes after primary and revision rhinoplasty. METHODS: A total of 245 patients (153 primary cases and 92 revisions) undergoing surgery at the authors' specialized clinic for facial plastic surgery were included. All patients were treated by an experienced facial plastic surgeon according to the authors' established clinic standards. A retrospective data analysis was performed to evaluate the differences between the groups regarding the indications, intraoperative techniques, and postoperative outcomes. RESULTS: Although more patients sought revision surgery for aesthetic reasons alone than isolated functional issues, almost two-thirds of the revision patients had functional and aesthetic problems in combination. Complex reconstructive techniques, extracorporeal septoplasties, and extranasal grafts were more commonly used in revision cases. The occurrence of another revision during the follow-up period was significantly higher after revision surgery compared to primary rhinoplasty cases (primary rhinoplasty, 10.5 percent; revision surgery, 23.9 percent; p = 0.006). CONCLUSIONS: There are differences between primary and revision rhinoplasty that must be appreciated by the treating surgeon. The patient should be informed about the increased complexity of the secondary procedure, the possible need for extranasal grafts, and the increased risk of a further revision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Rhinosurgery during and after the COVID-19 Pandemic: International Consensus Conference Statement on Preliminary Perioperative Safety Measures.

BACKGROUND: The coronavirus disease of 2019 (COVID-19) pandemic has widely affected rhinosurgery, given the high risk of contagion and the elective nature of the aesthetic procedure, generating many questions on how to ensure safety. The Science and Research Committee of the Rhinoplasty Society of Europe aimed at preparing consensus recommendations on safe rhinosurgery in general during the COVID-19 pandemic by appointing an international panel of experts also including delegates of The Rhinoplasty Society. METHODS: A Zoom meeting was performed with a panel of 14 international leading experts in rhinosurgery. During 3.5 hours, four categories of questions on preoperative safety measures in private practice and outpatient clinics, patient assessment before and during surgery, and legal issues were presented by four chairs and discussed by the expert group. Afterward, the panelists were requested to express an online, electronic vote on each category and question. The panel's recommendations were based on current evidence and expert opinions. The resulting report was circulated in an iterative open e-mail process until consensus was obtained. RESULTS: Consensus was obtained in several important points on how to safely restart performing rhinosurgery in general. Preliminary recommendations with different levels of agreement were prepared and condensed in a bundle of safety measures. CONCLUSION: The implementation of the panel's recommendations may improve safety of rhinoplasty by avoiding operating on nondetected COVID-19 patients and minimizing severe acute respiratory syndrome coronavirus 2 virus spread in outpatient clinics and operating rooms.

Caudal Extension Graft of the Lower Lateral Cartilage: Technique and Aesthetic and Functional Results.

Here we describe a new technique to deal with alar retraction, a highly undesirable imperfection of the nose. The procedure involves placing a caudal extension graft below the vestibular portion of the lower lateral cartilage (LLC) after its detachment from the vestibular skin. The graft is fixed to the cartilage and, subsequently, to the vestibular tissue. The present retrospective study included 20 patients, 11 females and 9 males, with a mean age of 28.90 years. Follow-up ranged from 1 to 18 months. Surgery improved alar notching to a smoother dome shape and nostril exposure was reduced in every patient. The caudal extension graft of the LLC contributed to rise in overall patient satisfaction, as revealed by the postoperative increase of the Rhinoplasty Outcomes Evaluation (ROE) mean score from 40.0 to 79.17 (p < 0.0001). It also contributed to and improved functional outcomes, as indicated by the decrease of the Nasal Obstruction Symptom Evaluation (NOSE) mean score from 52.75 to 13.25 (p = 0.0001). Sex did not affect the mean ROE and NOSE scores. Thus, increased patient satisfaction measured by the ROE is present in both sexes and at both age groups but it is better detected in the first year after surgery. Functional improvements analyzed with NOSE are best detected in patients aged ≥ 30 years and in follow-ups of 11 months. The caudal extension graft of the LLC technique described herein effectively and safely corrects alar retraction and the collapse of the nasal valve while filling the soft triangle.

40 Years of Total Extracorporeal Septal Reconstruction: The Past, Present, and Future.

BACKGROUND: Even today, severe septal deformities are a challenging problem for any rhinoplasty surgeon. Standard techniques are often not able to achieve satisfactory long-term results regarding function or aesthetic form. In such severe cases, a partial or total extracorporeal septal reconstruction may be used, as these techniques provide reliable and lasting results. METHODS: The aim of this work is to present the authors' experience with the technique of total extracorporeal septal reconstruction and its development to today's standard and to prove its effectiveness in the long-term follow-up. RESULTS: This article presents 40 years of clinical experience in this field and describes the technical changes that have evolved. Low complication rates, safe techniques, and favorable long-term outcomes of the total extracorporeal septal reconstruction show the benefits of this technique. CONCLUSION: The indication for a total extracorporeal septal reconstruction has been limited by the development of less complex surgical procedures, but it still represents the best technique to achieve long-term functional and aesthetic results in patients with very complex septal deformities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

How to Reduce the Probability of a Pollybeak Deformity in Primary Rhinoplasty: A Single-Center Experience.

Being a very common and highly stigmatizing deformity following primary rhinoplasty, a pollybeak deformity should be avoided during any primary rhinoplasty, especially in patients with thick nasal skin. Two surgical techniques used in the authors' department to decrease the probability of its development in at-risk patients are described in this article: the authors' modification of the supratip suture initially described by Guyuron, and a direct excision of excessive skin that the authors term supratip excision, reserved for rare cases with massive skin excess. In addition, a brief overview of the results of the authors' case series of 74 patients treated with the supratip suture technique, and 21 patients treated with the supratip excision technique over a 5-year period, is given. In the authors' experience, very good aesthetic results are achieved using either of the two techniques in selected cases.

Bony Fixation of the Nasal Framework.

The importance of a straight and stable central framework is beyond dispute. Many authors allude to technical aspects how to achieve the above-mentioned requirements. Far less is said about the contact zones of the framework and how to achieve a long-lasting and solid fixation. In the authors' patient group, they found the need to work on the septum/the central framework in approximately 84% of the cases. In 61% of the patients, the authors had to operate on the fixation point. Of course, there is a great variety of anatomical findings. So the required techniques differ immensely. The surgeon must be prepared for all kinds of different situations. Especially the dorsal fixation and the anchoring on the maxilla without having a standard anterior nasal spine can be a great challenge. In their daily routine, suture techniques (e.g., the transcutaneous transosseous cerclage suture) have become the authors' working horse for these complex fixation situations.

Invited Commentary: Outcome of In Situ Septoplasty and Extracorporeal Subtotal Septal Reconstruction in Crooked Noses: A Randomized Self-Controlled Study.

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 .

Free Diced Cartilage: A New Application of Diced Cartilage Grafts in Primary and Secondary Rhinoplasty.

BACKGROUND: Irregularities or deformities of the nasal dorsum after hump reduction account for a significant number of revision rhinoplasties. The authors therefore developed a technique of meticulously dicing and exactly placing free diced cartilage grafts, harvested from septum, rib, or ear cartilage. The cartilage paste is used for smoothening, augmentation, or camouflaging of the nasal dorsum in primary or revision rhinoplasties. METHODS: A retrospective analysis of multisurgeon consecutive open approach rhinoplasties from January to December of 2014 was conducted at a single center. The authors compared the outcome of three different techniques to augment or cover the nasal dorsum after an observation period of 7 months. In group I, 325 patients with free diced cartilage grafts as the only onlay were included. In group II, consisting of 73 patients, the dorsal onlay was either fascia alone or in combination with free diced cartilage grafts. Forty-eight patients in group III received a dorsal augmentation with the classic diced cartilage in fascia technique. RESULTS: Four hundred forty-six patients undergoing primary and secondary rhinoplasties in which one of the above-mentioned diced cartilage techniques was used were included in the study. The authors found revision rates for dorsal irregularities within the 7-month postoperative observation period of 5.2, 8.2, and 25 percent for groups I, II, and III, respectively. CONCLUSION: The authors' findings strongly support their clinical experience that the free diced cartilage graft technique presents an effective and easily reproducible method for camouflage and augmentation in aesthetic and reconstructive rhinoplasty.

Refining the Nasal Dorsum with Free Diced Cartilage.

Refining the nasal dorsum has become a major challenge in modern rhinoplasty as irregularities of the nasal dorsum account for a significant number of revision surgeries. In our department, free diced cartilage is now routinely applied for smoothening of the nasal dorsum. In this retrospective study, the outcomes with regard to irregularities or contour deficits of the nasal dorsum of 431 rhinoplasty cases operated by a single surgeon between July 2013 and June 2015, using free diced cartilage, are compared with 327 cases operated by the same surgeon between January 2007 and December 2008, before the introduction of the free diced cartilage technique. A decrease in early revision surgeries (i.e., revision within the 2-year period evaluated) due to dorsal irregularities or contour deficits is seen. Being a quick, easy, and highly cost-effective procedure, we feel that free diced cartilage is currently the ideal technique for refinements of the nasal dorsum.

Nasal Reconstruction: Extending the Limits.

Reconstructing the 3-dimensional structure of the nose requires the maintenance of its aesthetic form and function. Restoration of the correct dimension, projection, skin quality, symmetrical contour, and function remains problematic. Consequently, modern approaches of nasal reconstruction aim at rebuilding the units rather than just covering the defect. However, revising or redoing a failed or insufficient reconstruction remains very challenging and requires experience and creativity. Here, we present a very particular case with a male patient, who underwent 37 operations elsewhere and presented with a failed nasal reconstruction. We describe and illustrate the complex steps of the nasal rereconstruction, including the reconstruction of the forehead donor site, surgical delay procedures for lining, and the coverage with a third paramedian forehead flap.

New Suturing Techniques to Reconstruct the Keystone Area in Extracorporeal Septoplasty.

BACKGROUND: Severe septal deformations require adequate treatment to restore shape and function using extracorporeal septoplasty. Because it has been criticized for being technically demanding to execute and has increased risk for aesthetic complications, the authors have developed two new suture techniques for refixation of the neoseptum. METHODS: A retrospective analysis of multisurgeon consecutive extracorporeal septoplasties performed from January of 2014 to December of 2014 was conducted at a single institution using the criss-cross or transcutaneous transosseous cerclage suture (group 1) compared with fixation at the upper lateral cartilages only (group 2). RESULTS: One hundred ten extracorporeal septoplasties were performed in 110 patients over 12 months. Group 1 consisted of 58 patients (53 percent), whether receiving the criss-cross [12 patients (21 percent)] or the transcutaneous transosseous cerclage suture [46 patients (79 percent)], and group 2 consisted of 52 patients (47 percent). The median follow-up was 11 months (range, 6 to 16 months). Operative revision because of complications at the dorsum or the keystone area had to be performed in no case in group 1 and in five cases (9.6 percent) in group 2, resulting in a statistically significant difference between the two groups (p = 0.0212). There were no complications such as bleeding or infection observed in any of the 110 cases. CONCLUSIONS: To facilitate and to reduce the complication rate after extracorporeal septoplasty, the authors have developed the criss-cross and transcutaneous transosseous cerclage suture to overcome the important and technically demanding reimplantation of the neoseptum. Thus, the authors believe that these new operative techniques are safe and reproducible procedures that may take a permanent place among extracorporeal septoplasty procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-Term Comparison of Rib and Ear Cartilage Grafts in Autologous and Allogenic Fascia Lata: An Experimental Study in a White Rabbit Model.

BACKGROUND: Diced cartilage in fascia has become the graft material of choice for dorsal grafts in rhinoplasty. Allogenic fascia lata has not yet been investigated as an isolated fascial graft or as a combined graft with ear and rib cartilage, especially in comparison with autologous fascia and over a long implantation period. METHODS: Ten different grafts were built from either autologous or allogenic fascia lata alone or as diced cartilage in fascia grafts with diced costal or ear cartilage and implanted into the dorsal skin of 15 rabbits. After 3 or 9 months, the grafts were explanted and analyzed histologically. Chondrocytes and cartilage matrix characteristics, including calcification, ossification, formation of bone marrow, fibrosis ingrowth and fibrotic transformation, the presence of immune reactions, vascular ingrowth, regenerative capacity, and capsule formation, were examined in a semiquantitative manner. RESULTS: All grafts were vital and without inflammatory response. The cartilage showed regular nuclei, a normal matrix, and regenerative capacity. A higher grade of calcification and ossification was observed in the fascia/cartilage grafts than in isolated cartilage grafts, and was more pronounced for costal cartilage. Both types of fascia were shown to be equally stable and without degradation. There were no significant differences in the diced cartilage in fascia grafts built with autologous compared to allogenic fascia. CONCLUSIONS: This study shows the equivalency of diced cartilage in fascia grafts and isolated fascial grafts using allogenic fascia lata compared to autologous fascia. The type of cartilage used accounts for different long-term characteristics of diced cartilage in fascia grafts.