Reconstructive Techniques for the Saddle Nose Deformity in Granulomatosis With Polyangiitis: A Systematic Review

Use of human acellular dermal matrix in rhinoplasty: a systematic review of the literature and meta-analysis

Alloplastic implants such as acellular dermal matrix (ADM) have been used for various aesthetic and reconstructive purposes since the 1990s. Rhinoplasty addresses both aesthetic and functional nasal impairments, often involving the adoption of grafting materials. Currently, autologous grafts, such as those using septal cartilage, are the gold standard. However, they pose the risk of donor site morbidity, technical challenges, and additional operative time. We review total complications, resorption/re-operation and success rates associated with the use of ADM in rhinoplasty. A literature search was conducted on PubMed, Prospero, DynaMed, DARE, EMBASE and COCHRANE databases. (Registry: CRD42023428019). A total of 462 patients from 15 studies were included, the mean (range) age was 30 (12-65) years, with a female-to-male ratio of 2:1. The most common indications for ADM were for cosmetic (35%, n = 163) and functional rhinoplasty (5%, n = 24). The most common type of ADM used was Alloderm (46%, n = 211). The most common indication for ADM was dorsal nasal augmentation (68%, n = 314). Eleven patients (2%) required revision surgery. The pooled success of ADM in rhinoplasty was 96% (95% CI 94 to 99, p = 0.93; I2 = 0%). 2% of patients developed postoperative complications and no statistically significant difference was seen in complications or success rates when comparing the different types of ADM. ADM in rhinoplasty was associated with fewer complications and re-operation rates, and similar if not less resorption compared to traditional autografts. Therefore, it can be a viable alternative to current autologous grafts in rhinoplasty surgery.

Considerations for Optimal Grafting in Rhinoplasty

A wide variety of grafting materials and techniques can be used to create functional and aesthetic changes in rhinoplasty. Choosing the optimal grafting approach is critical to achieving an optimal patient outcome. We present a review of autografts, allografts, and alloplasts used in primary and revision rhinoplasty and discuss factors that impact graft choice. Autologous grafts serve as the pillar for grafting material in rhinoplasty given their reliable long-term outcomes, low rates of infection, resorption, and extrusion, and ability to provide structural scaffolding as well as contour. Cadaveric allografts can be utilized as a source of grafting material in certain clinical scenarios including revision rhinoplasty and have been shown to be equally safe and effective as autologous grafts while avoiding donor-site morbidity. Alloplasts can prove useful in rhinoplasty in cases of iatrogenic nasal deformities or revision cases. Careful consideration of clinical scenario, patient factors, and outcome goals is necessary to choose the appropriate grafting approach to address functional and cosmetic outcomes.

Facial Rejuvenation in a Patient With Granulomatosis With Polyangiitis-Treatment Protocol for Compromised Skin Flap

Facial rejuvenation outcomes have not been well studied in patients with granulomatosis with polyangiitis (GP)-formerly Wegener granulomatosis. This report highlights a case of a 49-year-old female with a history of GP, presenting with facial aging and functional nasal concerns. The patient underwent facial rejuvenation and nasal reconstruction procedures, including primary open functional rhinoplasty, septal perforation repair with Alloderm, deep-plane rhytidectomy, platysmaplasty, nanofat grafting, and fractionated erbium laser to the face (sparing the nose and peri-incisional areas). Despite a routine operation, postoperative course was complicated by wound healing and vascular congestion issues related to her underlying autoimmune disease. This case highlights the risks associated with postsurgical healing in patients with GP undergoing esthetic surgery. To the best of our knowledge, this report is the first to discuss management considerations in a patient with GP undergoing facial rejuvenation surgery.

Rhinoplasty for Sinonasal Deformities in Granulomatosis with Polyangiitis: A Systematic Review and Meta-Analysis

BACKGROUND

Granulomatosis with polyangiitis (GPA) is a vasculitis that affects respiratory and kidney vessels. It primarily involves the nose and sinuses but can progress systemically. Granulomatosis with polyangiitis causes severe nasal deformities, impacting aesthetics and breathing. Literature focuses on rhinoplasty for saddle nose deformities in non-GPA patients, but its suitability for GPA patients remains uncertain.

AIM

Our study aims to assess the effectiveness and safety of rhinoplasty in GPA patients by analyzing the existing literature.

METHODS

Four databases were searched; 2 reviewers independently screened the retrieved references, then relevant data for our study were extracted. Categorical outcomes were analyzed using pooled proportions and 95% CI. Statistical heterogeneity was assessed using the I2 statistics χ 2 test with a P -value lower than 0.1 indicating heterogeneity.

RESULTS

In our systematic review and meta-analysis, we incorporated 16 studies encompassing 136 patients who underwent nasal reconstruction as part of their treatment for GPA. The collective findings indicate a favorable success rate for rhinoplasty, with a pooled ratio of 89% (95% CI: 84%, 95%). The rate of revision surgeries was relatively low, with a pooled rate of 19% (95% CI: 12%, 26%). Furthermore, rhinoplasty demonstrated comparatively lower rates of recurrence (pooled rate: 22%, 95% CI: 3%, 42%) and complications (pooled rate: 12%, 95% CI: 7%, 18%).

CONCLUSION

Rhinoplasty benefits GPA patients with saddle nose deformity and septal perforation with high success rates and low recurrence, revision, and complication outcomes. However, more research is needed for validation and refinement.

Reconstructive rhinoplasty using cadaver cartilage in relapsing polychondritis

Relapsing polychondritis is a rare autoimmune disorder of unknown cause characterized by recurrent inflammation of cartilage predominantly affecting the ears, nose, and upper airway. The bridge of the nose and surrounding tissue can collapse, producing a saddle nose deformity. Nasal reconstruction is often challenging in these patients due to impaired wound healing and graft take caused by autoimmune inflammatory disease and prolonged immunosuppressant treatment. Many different reconstruction techniques like autologous rib, fascia lata, and calvarial bone grafts have been used. Herein we report the use of a cadaver cartilage graft in a 55-year-old woman with relapsing polychondritis and saddle nose deformity. Because of the characteristic chondritis of her autoimmune condition, cadaver cartilage was selected because it is antigenically different from the patient's own cartilage, offering significant structural integrity for nasal reconstruction compared to other techniques.

Utilization of Leech Therapy after Rhinoplasty

BACKGROUND

The use of medicinal leeches in modern reconstructive surgery is well-described. Leech therapy after rhinoplasty has not been previously well-characterized.

METHODS

The medical records of all patients who underwent open rhinoplasty by a single surgeon over a 4-year period were reviewed. Patient demographics, including age, sex, medical comorbidities, number of previous rhinoplasty surgeries, time to utilization of leech therapy, adjunct therapies used, resolution of skin changes, and smoking status, were recorded. Operative reports were reviewed for pertinent information, including number of tip grafts used, graft materials used, and placement of septal extension grafts or "unicorn" grafts.

RESULTS

Between April of 2016 and March of 2020, 545 patients underwent rhinoplasty performed by the senior author (P.S.N.). Of these patients, 39 (7.2 percent) underwent leech therapy postoperatively. The mean age of included patients was 47.4 years. Of the patients who required leech therapy, 34 (87.2 percent) had undergone revision rhinoplasty. The mean number of previous rhinoplasties was 3.4. The mean number of tip grafts used was 2.6. Thirty-three patients (84.6 percent) had either a traditional septal extension graft or unicorn graft placed. Nine patients (23.1 percent) were former smokers. Complete resolution of skin color changes was seen in 38 patients (97.4 percent). There were no major complications after leech therapy.

CONCLUSIONS

Leech therapy is a useful tool for the rhinoplasty surgeon, particularly in the setting of complex revision rhinoplasty, in patients who have undergone multiple previous nasal surgical procedures, or in patients who require significant cartilage grafting to reconstruct the nasal tip or lengthen the nose.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Nasal reconstructive surgery for vasculitis affecting the nose: our two-centre international experience

PURPOSE

To recommend an international multidisciplinary medical and surgical algorithm of treatment in nasal vasculitis, which will create a more streamlined approach.

METHODS

A two-centre, international retrospective analysis of granulomatosis with polyangiitis (GPA) and levamisole-associated vasculitis (LAV) cases presenting between 2005 and 2019 was carried out. Demographic data, and surgical and medical treatment were recorded. Patients' signs and symptoms were analysed, and recommended treatment strategies outlined with key surgical procedures described.

RESULTS

Forty-one GPA patients and 11 LAV patients were included in the study with a mean age of 38.6 and 38.8 years, respectively. A stepwise surgical management approach with reconstructive options is described and includes: (1) examination under general anaesthesia, biopsy, and insertion of silastic nasal splints; (2) septal perforation repair (with caution); (3) mild-to-moderate saddle nose reconstruction with costal cartilage; (4) severe saddle nose reconstruction with osseocartilaginous rib grafts; (5) soft-tissue reconstruction techniques.

CONCLUSIONS

The management of nasal vasculitis is a particular challenge in facial plastic surgery. It requires a close collaborative approach with a physician skilled in the medical management of vasculitis. Surgery must be planned judiciously, with realistic patient expectations and only after a sustained period of remission. For more severe saddle deformities, the modified osseocartilaginous Andrews technique gives excellent long-term results.

The role of surgery in antineutrophil cytoplasmic antibody-associated vasculitides affecting the nose and sinuses: A systematic review

Background:

The ear, nose and throat region has been reported to be one of the commonest sites involved in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis diseases and often precedes the diagnosis of ANCA–associated vasculitis by many months. Although treatment for ANCA–associated vasculitis primarily requires systemic immunosuppressive therapy, there are specific indications for sinonasal surgery during the course of the disease process. The three major roles for surgery in sinonasal vasculitis are to aid diagnosis through biopsy, enable symptom relief and nasal reconstructive surgery consideration when in remission.

Purpose:

The aim of this systematic review is to provide an overview of the surgical procedures which can be performed in patients with ANCA–associated vasculitis presenting with sinonasal involvement.

Materials and methods:

A systematic literature search was performed for scientific articles on MEDLINE (PubMed Advanced MEDLINE Search) and EMBASE. The search included all articles up to April 2020.

Conclusion:

Surgical intervention during the active phase of ANCA–associated vasculitis disease can improve the patient’s symptoms and enable histological diagnosis. The surgical decision to manage the nose requires a multidisciplinary approach involving the vasculitis specialist and the ear, nose and throat surgeon. Nasal reconstruction can be performed to restore form and function but only when the disease is in remission so as to maximise success and minimise complications.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Osseocartilaginous Rib Graft L-Strut for Nasal Framework Reconstruction

BACKGROUND

In the setting of major nasal framework reconstruction, it is critical to create a stable, warp-resistant L-strut to resist the contractile forces of healing to achieve a durable outcome.

OBJECTIVES

The authors sought to demonstrate the effectiveness of the osseocartilaginous rib graft for nasal framework reconstruction.

METHODS

Retrospective analysis was performed of all patients who underwent osseocartilaginous rib graft for L-strut reconstruction from 2007 to 2017 at a tertiary care hospital. Only patients with severe framework-only defects (Type IV, Daniel Classification) or total/subtotal nasal defects (Type V, Daniel Classification) were included. Primary outcome measures were: (1) maintenance of projection; (2) graft warping; and (3) graft resorption.

RESULTS

Twenty-six patients aged an average of 54.6 years underwent nasal framework reconstruction with an osseocartilaginous rib graft L-strut. Eighteen patients had framework-only deformities (Daniel Type IV) and 8 had total or subtotal nasal deformities (Daniel Type V). Twelve patients underwent reconstruction for autoimmune mediated deformity, 10 for malignancy, 3 for traumatic injury, and 1 for an iatrogenic deformity. Average follow-up was 21 months. There was no observed warping of the L-strut construct, and all but 2 patients demonstrated total maintenance of projection. Resorption of the caudal cartilage graft was identified as the etiology of partial loss of projection in 2 patients.

CONCLUSIONS

The osseocartilaginous rib graft L-strut provides a stable, warp-resistant construct for patients lacking major dorsal and caudal support, which may be applied to reconstruction of defects due to malignancy, autoimmune, traumatic, or iatrogenic etiologies.

LEVEL OF EVIDENCE: 4

Rib cartilage in Asian rhinoplasty: new trends

PURPOSE OF REVIEW

Costal cartilage has many advantages over other grafting materials because of its large quantity and high biocompatibility. As a result, it has been considered as a good option for Asian rhinoplasty. However, costal cartilage is difficult to use and is associated with a high complication rate. To avoid the disadvantages and complications of costal cartilage graft, several techniques have been proposed in the literature. This review addresses the conventional uses of costal cartilage in Asian rhinoplasty and recent updates.

RECENT FINDINGS

Different techniques have been reported for Asian rhinoplasty using costal cartilage. Solid-block costal cartilage and diced cartilage with or without wrapping materials are widely used for dorsal augmentation. Many different grafting techniques for the tip and septal reconstruction have been reported by numerous surgeons. When using costal cartilage graft, surgeons should pay attention to both graft complications, such as warping or infection, and donor-site morbidity. Several strategies have recently been developed to avoid these complications.

SUMMARY

This article summarises grafting options for Asian rhinoplasty using costal cartilage and possible complications. This information may assist with proper selection of appropriate techniques for harvesting, carving and grafting costal cartilage.

Clinical implication of chronic paranasal sinusitis for the classification of microscopic polyangiitis

BACKGROUND

Chronic paranasal sinusitis (CPS) has been known as a surrogate marker for granulomatosis with polyangiitis (GPA). We investigated whether CPS at diagnosis may have an influence on the classification and outcomes of microscopic polyangiitis (MPA).

METHODS

We retrospectively reviewed the medical records of 106 immunosuppressive drug-naïve patients with MPA. We compared variables at diagnosis of MPA patients with CPS with either MPA patients without CPS or 29 GPA patients with CPS. We applied the algorithm for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) proposed by the European Medicine Agency to 22 MPA patients with CPS and reclassify them. Death, relapse and end-stage renal disease were assessed as the poor outcomes.

RESULTS

Except for ENT manifestations, only pulmonary manifestation was more frequently observed in MPA patients with CPS than those without (77.3% vs 47.6%). No proteinase 3-ANCA was detected in all MPA patients with CPS. Meanwhile, general (63.6% vs 27.6%) and renal manifestations (81.8% vs 44.8%) more often developed in MPA patients with CPS than GPA patients with CPS. Of 22 MPA patients with CPS, 21 patients underwent biopsies. When CPS was not considered as a surrogate marker for GPA, all patients with CPS were reclassified as MPA. Ground glass opacity and reticulation on high-resolution computed tomography and renal vasculitis were helpful clues supporting the classification of MPA in patients with CPS. CPS at diagnosis was not associated with the outcomes of MPA.

CONCLUSION

CPS might not be a sufficient surrogate marker for GPA in the classification of AAV.