Revision rhinoplasty: panel discussion, controversies, and techniques

Effect of Medical Ozone Therapy in Preventing Compromised Nasal Skin in Revision Rhinoplasty

BACKGROUND

Ozone is often used as an additive therapy for skin conditions like infectious diseases, wound healing, diabetic foot, and pressure ulcers. The viability of the nasal skin has crucial importance in revision rhinoplasty cases. The study investigates the potential benefits of medical ozone therapy in healing the nasal skin in multiple-operated cases.

METHODS

The study retrospectively examined 523 revision rhinoplasty patients operated by the first author from January 2017 to January 2024. Patients consenting to ozone therapy received 3 major autohemotherapy sessions post-surgery. Patients were divided into 2 groups: those with compromised nasal skin (infection, poor vascular supply) and those with normal healing. Age, gender, smoking, diabetes, previous surgeries, grafting materials, and techniques were considered.

RESULTS

Of the 523 patients, 12 (2.3%) experienced major skin complications like infection and necrosis, while 511 (97.7%) had no or minor issues, such as discoloration. In total, 301 patients accepted and received ozone therapy. Of the patients without major complications, 299 (58.3%) received ozone therapy, while 212 (41.7%) did not. Among the 12 with major complications, two (16.7%) received ozone therapy, and the remaining 10 (83.3%) did not. Ozone therapy recipients showed statistically fewer skin problems (p<0.05). Costal cartilage as tip and septal extension graft was linked to skin issues (p<0.05). No major adverse effects from ozone therapy were noted.

CONCLUSIONS

Our findings indicate that ozone therapy may be a safe and potentially effective option for patients undergoing revision rhinoplasty, especially those with compromised nasal skin. It appears to aid in skin healing and regeneration, possibly through enhancing oxygen delivery and modulation of the immune response. Ozone therapy is a promising adjunct treatment for managing skin complications in revision rhinoplasty patients.

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 .

Nonsurgical Correction of Surgical Rhinoplasty Complications with Hyaluronic Acid Fillers: A Retrospective Review of 2088 Cases

Background

Surgical rhinoplasty is a highly complex cosmetic procedure with significant revision rates. Unfortunately, surgical revision rhinoplasty is associated with many challenges. Nonsurgical correction of surgical rhinoplasty complications with injectable hyaluronic acid fillers is an alternative with less cost and downtime. In this article, we present the first author's experience with 2088 cases of nonsurgical revision rhinoplasty, including technical considerations, patient-reported outcomes, and adverse events.

Methods

A retrospective chart review was completed on patients 18 years and older who received nonsurgical rhinoplasty treatment between March 2018 and August 2022. Patient demographic data, and data on indications for treatment, volume of filler used, patient-reported satisfaction, and adverse events (including erythema, infection, vascular occlusion, and necrosis) were collected up to 1 year after the initial injection.

Results

A total of 2088 patient cases are included in this study. The most common indications for treatment included bridge collapse or asymmetry (49.0%), an under-projected tip (44.0%), and surface irregularity/scarring (35.4%). The mean volume of filler used at initial treatment was 0.49 mL (SD 0.19). Median patient satisfaction immediately after treatment was 9 (visual analog scale ranging from 1 to 10). The most common adverse event reported at the 2-week follow-up was erythema (36.4%). Three patients presented with skin necrosis (0.47%). All three of these were transient and self-resolving.

Conclusions

Nonsurgical correction of rhinoplasty complications with hyaluronic acid fillers can be a safe, minimally invasive option with high patient satisfaction and immediate and predictable results. This should be considered first line before surgical revision.

Decision-making in Nasal Dorsum Reconstruction in Revision Rhinoplasty

Background

The approach to revision rhinoplasty is a challenge that plastic surgeons often face. The objective of this communication is to describe a surgical algorithm for patients undergoing revision rhinoplasty based on the stability of the nasal dorsum.

Methods

The study included 18 patients, six men and 12 women, aged 19-54 years, who had previously undergone rhinoplasty and who visited our clinic to request a new procedure due to unsatisfactory results in those procedures. A surgical algorithm developed by the main author (N.A.) was followed for revision rhinoplasty, and then a validated rhinoplasty outcome evaluation questionnaire was applied 1 year after surgery to assess aesthetic outcomes.

Results

The questionnaire was applied to all participants, showing a significant increase in patient satisfaction. Before surgery, a minimum value of six and a maximum of 21 (mean of 12) were found. After revision rhinoplasty following the proposed surgical algorithm, a minimum value of 21 and a maximum of 30 (mean of 29) were found, and this difference was statistically significant (P < 0.001).

Conclusions

The surgical algorithm used for nasal dorsum reconstruction in patients undergoing revision rhinoplasty improved patient satisfaction and could be a feasible procedure to approach patients who have previously undergone rhinoplasty.

Advantages and Disadvantages of Reconstructive and Preservation Rhinoplasty: Surgical Techniques, Outcomes, and Future Directions

Reconstructive rhinoplasty, a specialized surgical procedure, aims to restore both the form and function of the nose, particularly after trauma, congenital defects, or prior surgeries. This review evaluates the advantages and disadvantages of various surgical techniques used in reconstructive and preservation rhinoplasty. The study focuses on the outcomes of commonly employed methods such as cartilage grafting, flap techniques, and alloplastic materials, assessing both functional and aesthetic results. Recent advancements, including 3D imaging, tissue engineering, and artificial intelligence, are discussed as potential future directions that could enhance surgical precision, safety, and patient care. The review systematically examines clinical studies from the past decade, highlighting the evolving landscape of rhinoplasty and its impact on patient outcomes.

Fresh Frozen, In-Alcohol, or Autologous Costal Cartilage? Analysis of Complications in Over 650 Revision Rhinoplasties

BACKGROUND

When there is insufficient autologous septal cartilage for graft sculpting in revision rhinoplasty, valid alternatives need to be found. Both autologous and homologous costal cartilage usage has been described in the literature. As there is no universally accepted consensus on cartilage choice, experience with different types of cartilage assumes significant importance in the rhinoplasty learning process.

OBJECTIVES

This multicenter prospective study outlined an overview of the authors' experience regarding short-term and long-term complications following revision rhinoplasty procedures in which either fresh frozen (FFCC), in-alcohol (IACC), or autologous costal cartilage (ACC) was used.

METHODS

A total of 671 patients undergoing revision rhinoplasty between June 2015 and September 2020 were divided into 3 groups according to the type of cartilage used (Group 1, 212 patients with FFCC; Group 2, 239 patients with IACC; Group 3, 202 patients with ACC). Sociodemographic and clinical characteristics and short- and long-term complications were described and discussed. A statistical analysis investigating a possible significance of the differences in complication rates was conducted.

RESULTS

The data obtained indicated a short-term general complication rate of 5.05%, and a long-term complication rate of 7.04%. A statistically significant difference was identified in cartilage warping rate between the homologous cartilages in comparison to ACC.

CONCLUSIONS

FFCC, IACC, and ACC can be safely used in revision rhinoplasty with no statistically significant differences regarding short- and long-term complication rates. Cartilage warping rate is significantly higher for ACC compared with FFCC and IACC.

LEVEL OF EVIDENCE: 2

Biological Changes of Autologous Auricular Cartilage in Rhinoplasty

Autologous auricular cartilage is used extensively as a good graft material in rhinoplasty. In this study, clinical specimens from patients who underwent revision rhinoplasty with auricular cartilage grafts were collected to compare the changes before and after auricular cartilage transplantation with the use of histologic, immunohistochemical, and quantitative assays. Patients who underwent revision rhinoplasty from 2018 to 2022 were analyzed. Fresh auricular cartilage left after surgery and auricular cartilage graft tissue were examined and compared. Compared with fresh auricular cartilage, local fibrosis was seen in the transplanted auricular cartilage with a slight decrease in elastic fibers, type II collagen, and extracellular matrix secretion. Quantitative assays showed a decrease in glycosaminoglycan, DNA, and total collagen content in the transplanted auricular cartilage tissue. The results of the study suggest that the histologic characteristics, cell functionality, and biochemical composition of the grafted cartilage changed to a certain extent after autologous auricular cartilage graft rhinoplasty. These results provide insights into the selection of graft/filler materials for rhinoplasty and what changes to expect.

Short Nose Lengthening in Primary and Revision Rhinoplasty in Asians

BACKGROUND

Surgical techniques and graft materials are important factors for short nose lengthening in both primary and revision rhinoplasty in Asian patients. Other subunit of the nose need to be improved as well to achieve aesthetic perfection.

MATERIALS AND METHODS

A cohort of 98 patients who underwent primary and revision rhinoplasty for moderate to severe short nose deformity from January 1, 2019, to December 31, 2020, were enrolled. Nasal elongation was achieved via an open rhinoplasty approach using autologous costal cartilage exclusively for grafting. Aesthetic outcomes were evaluated by anthropometric measurement and satisfaction assessment from patients and physicians.

RESULTS

The mean duration of follow-up was 10.6 months. In both primary and revision cases, nasal length relative to preoperative measurements increased significantly, while nasal tip projection did not differ significantly. Columellar-facial angle and nasofrontal angle decreased significantly in both groups. Both physicians and patients reported improvement in aesthetic outcomes.

CONCLUSIONS

Aesthetic satisfaction was reported from both patients and physicians. Autologous costal cartilage is an ideal graft material that offers strong structural support. Caudal septal extension graft using autologous costal cartilage sandwiched by extended spreader grafts achieve satisfactory lengthening of the central compartment and also increase nasal tip projection and rotation.

Complications Associated with Autologous Costal Cartilage Used in Rhinoplasty: An Updated Meta-Analysis

OBJECTIVE

To estimate the complications using autologous costal cartilage as grafts in rhinoplasty objectively and systematically with newly published literature.

METHODS

The literature was searched systematically; included studies were published between July of 1990 and April of 2020. Meta-analysis was performed using a random-effects model.

RESULTS

Twenty studies involving 1648 patients were included for meta-analysis. The pooled rates of complications were 3.05% of warping (95% CI 1.36-5.19%), 1.2% of resorption (95% CI 0.26-2.56%), 1.45% of infection (95% CI 0.34-3.06%), and 1.53% of contour irregularity (95% CI 0.53-2.88%). The revision rate was 2.25% (95% CI 0.96-3.9%). Regarding of donor-site morbidities, the rate of hypertrophic chest scar was 2.08% (95% CI 0.31-4.83%), and the rate of pneumothorax was 0% (95% CI 0-0.46%). The pooled rates of complications were 9.06% (95% CI 6.13-12.43%) at the recipient site when complications at the recipient site did not include revision surgery, 1.47% (95% CI 0.17-3.56%) at the donor site, and 15.13% (95%CI 11.03-19.69%) overall. The recipient-site adverse event rate was 12.44% (95% CI 8.98-16.33%).

CONCLUSIONS

Warping was found the most common complication after rhinoplasty with autologous costal cartilage. Revision after rhinoplasty using autologous costal cartilage was increased in these years. Donor-site complications increased the complication rate after rhinoplasty using autologous rib cartilage by 22%.

LEVEL OF EVIDENCE III

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.

Endolift laser as new non-surgical technique for nose remodeling

BACKGROUND

In the last few years, facial rejuvenation has moved to less invasive or non-surgical techniques because their effects are visible immediately after the treatment, they have shorter recovery time and less pain and patients can go back to their normal life on the same day. Rhinoplasty is a cosmetic procedure that is very difficult to master. The main goal of rhinoplasty is anatomical preservation. One of novel technique for nose remodeling is laser therapy. In this study, the authors evaluate the efficacy of the endolift laser as a technique for nose remodeling.

METHODS

A total of eight patients were enrolled and were submitted to endolift laser therapy. The outcomes were measured by photography, three blind board-certified dermatologists assessment, and patients satisfaction.

RESULTS

Our results showed that endolift Laser as non-surgical nose remodeling technique is a safe and effective method. Clinical assessment of the physician showed a significant improvement at 6-months follow-up. Also, the patient satisfaction rate was higher in the enrolled participates. Also, no severe side effect was reported.

CONCLUSION

The endolift laser technique is practicable, effective, and safe method for non-surgical nose job and has no major complication.

Revision Rhinoplasty: With Introduction of a Novel Preoperative Assessment Classification System

Revision rhinoplasty presents several complex surgical challenges. Proper patient selection for revision rhinoplasty, along with thorough preoperative examination and surgical planning, is key to achieving ideal outcomes. Along with achieving a high level of understanding of primary rhinoplasty techniques, surgeons performing revision rhinoplasty must understand and diagnose deformities created by the primary surgery. A systematic approach to diagnosing rhinoplasty deformities assists in forming a suitable surgical plan. A classification system based on nasal analysis, described here, may be used to differentiate the degree of difficulty of the surgery as well as assist in surgical planning. Surgeons have a multitude of options available in their armamentarium for addressing common nasal deformities encountered during revisional surgery, and a stepwise surgical approach may facilitate the creation of an optimal aesthetic and functional result.

Role of Fresh Frozen Cartilage in Revision Rhinoplasty

BACKGROUND

Correction of secondary nasal deformities frequently requires cartilage to build the framework of the nose. Traditionally, autologous costal cartilage has been used because of the paucity of the septal cartilage. Because of associated donor-site complications and increased operating time, irradiated allografts have been used. These grafts have a higher rate of resorption and infection. Thus, the authors have used fresh frozen, nonirradiated, cadaveric rib cartilage as donor cartilage to avoid these shortcomings, and they present their early experience.

METHODS

The operative data of 50 patients who underwent secondary rhinoplasty performed by the senior author between 2014 and 2017 were analyzed. The outcomes of the rhinoplasty were evaluated by preoperative and postoperative photographs by four blinded plastic surgeons, and the results were tabulated using the Independent Rhinoplasty Outcome Score.

RESULTS

Fifty patients were followed up over an average period of 3.35 months (range, 1 to 18 months). There was only one complication (infection, 2 percent), which did not need revision surgery. There was no warping or extrusion in this cohort.

CONCLUSIONS

The authors believe that fresh frozen, nonirradiated cartilage allografts are an evolving source of donor cartilage grafts for revision rhinoplasty because they are associated with lower complication rates. However, further long-term studies with an increased sample size are necessary to prove that fresh frozen cartilage grafts are better than other sources.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Suture techniques and cartilage grafts in nasal tip surgery: An algorithm in primary and secondary rhinoplasty

OBJECTIVE

In most primary and secondary rhinoplasties, the adjustment of the nasal tip in terms of position, projection, and configuration is mandatory. Usually, this is one of the most challenging parts of the operation. The aim of this study was to present a step-by-step algorithm that evaluates popular techniques for a predictable outcome.

PATIENTS AND METHODS

A single-surgeon retrospective review of primary and secondary rhinoplasty patients was undertaken for nasal tip refinement. An overview of popular and clinically relevant suture techniques and cartilage grafts is provided, in particular, concerning the position, projection, and rotation. On the basis of clinical examples, we will present different indications, the latest operative treatment options, and long-term results.

RESULTS

Between 2013 and 2018, we devised an algorithm based on 322 patients. Ninety patients (28%) were admitted for primary rhinoplasties and 232 patients for secondary rhinoplasties (72%). Our patients reported overall high satisfaction rates, and no further revisions were required.

CONCLUSIONS

Preoperative analyses and the knowledge of different suture techniques and cartilage grafts for nasal tip surgery are crucial factors for a successful postoperative outcome.

Postrhinoplasty fibrotic syndrome

BACKGROUND

Over the years there have been numerous anecdotal reports of nasal tip enlargement and loss of tip definition post rhinoplasty. Subsequent revisionary procedures not only failed to reduce the tip size but aggravated the problem causing an even larger and less defined nasal tip. The final result was often worse than the preop condition and uncorrectable.

METHOD/RESULTS

Six patients who demonstrated an aggravation of the postop result with subsequent revisionary or secondary surgeries were evaluated to find common causes or circumstances. All patients had 1) worsening of nasal tip result with subsequent procedures, e. g., nasal tip enlargement and/or loss of tip definition with subsequent procedures 2) exhibited substantial postop edema at one or more surgeries and 3) extensive subcutaneous fibrous tissue noted at revisionary procedures.

CONCLUSIONS

The nasal scenario described is referred to as postrhinoplasty fibrotic syndrome. It is recommended that if revision surgery is necessary by a surgeon, the scale of the surgery should be smaller than that of the primary operation. If yet another revision is necessary that surgery should be of an even smaller scale than the prior surgery. Augmentation rather than reduction rhinoplasty is clearly a better approach. With the surgical philosophy of smaller and/or less surgery with each revision (should it be necessary) the irreversible condition of postrhinoplasty fibrotic syndrome should be avoidable.

Introduction of a Less Invasive Revision Rhinoplasty Using Closed Nasal Chondrotome

Rhinoplasty is the most common aesthetic surgical procedure in Iran. Dorsal bony and cartilaginous structures of the nose play an important role in nasal esthetics and function. Manipulation of nasal dorsum is one of the cardinal procedures during rhinoplasty operation. Some cases of primary rhinoplasty lead to various post-operative nasal imperfections. One of the most common imperfections is dorsal nasal spur which can cause dorsal irregularities. The accurate rate of imperfections relates to some factors like the surgeon’s experience and his/her precision, and appropriate post-operative patient care. Alomost 15%of revision or secondary surgical manipulations are acceptable for an experienced plastic surgeon. Most of the revision rhinoplasties are due to minor deformities in nasal dorsum like cartilaginous spur or mild focal depression. We have introduced an innovative device “Closed Nasal Chondrotome” that can ease the procedure for treating of minor nasal dorsal deformities. we propose the use of closed nasal chondrotome for mild dorsal spurs and have presented the effectiveness of this device in one patient. This simple but very effective instrument can be an alternative for a revision rhinoplasty procedure in the operating room to an outpatient procedure with local anesthesia. This method has been used in one patient with the satisfactory result, permitting corrections of minor cartilaginous excess deformities, with a less invasive procedure.

Functional and Aesthetic Factors Associated with Revision of Rhinoplasty

Background

Surgical revision rate of rhinoplasty is from 5% to 15% in literature. The aims of our study were to define the rate and the predictive factors for surgical revision of rhinoplasty.

Methods

We have realized a single-center case/control study including 62 patients who underwent surgical revision among 732 patients who underwent closed rhinoplasty between 2005 and 2015. Data of each rhinoplasty were collected from medical records and photographs. Statistical analyses were used.

Results

The surgical revision rate was 8.6%. After multivariate analysis, 4 factors were statistically significant and independently associated with surgical revision: "preexisting respiratory functional disorder" [odds ratio OR = 3.30; 95% CI (1.47-7.76); P = 0.004], "wide nasal bone and side walls" [OR = 3.94; 95% CI (1.49-11.25); P = 0.007], "deviated nasal bone and side walls" [OR = 2.68; 95% CI [1.14-6.58]; P = 0.02] and the use of camouflage grafts [OR = 0.26; 95% CI [0.07-0.89]; P = 0.04].

Conclusions

Closed rhinoplasties have similar revision rate to open techniques. Revision surgeries are justified by functional or aesthetic disorders. The interests of this study are to better inform patients and to adapt operative management. We provide here some recommendations with focus on the keys to successful rhinoplasty surgery.

Non-surgical rhinoplasty using filler, Botox, and thread remodeling: Retro analysis of 332 cases

BACKGROUND

Non-surgical nasal job has been practiced and published with doubtful concerns about efficiency and safety among physicians and aesthetic surgeons.

AIM

of the work to share our experiences in non-surgical rhinoplasty using filler, Botox, and thread with presentation of aesthetic and complication outcome.

PATIENT AND METHODS

Retrospective analysis of the aesthetic and complication outcomes and techniques for non-surgical remodeling rhinoplasty using fillers, Botox, and PDO absorbable threads in 332 cases.

RESULTS

Non-surgical nasal remodeling provides temporary correction of small nasal deformities with achieved satisfactory aesthetic outcome and very low incidence of complications.

CONCLUSION

Non-surgical nasal remodeling with injection precautions could work efficiently and safely in outpatient clinic with good temporary results up to 6 months.

Use of Costal Perichondrium as an Interpositional Graft for Septal Perforation Closure

Importance

Closure of septal perforations remains a technically difficult procedure to perform.

Objective

To assess the use of costal perichondrium as an interpositional graft to enhance closure of septal perforations using bilateral mucosal flaps and the effectiveness of the procedure.

Design, Setting, and Participants

This case series included all 51 consecutive patients presenting with septal perforations from January 1, 2006, to August 31, 2014, at a single institution. Mean (SD) follow-up was 19 (18) months. Patients with subtotal perforations did not have their perforations closed but underwent rhinoplasty with improved form and function. All patients underwent evaluation for changes in postoperative symptoms.

Interventions

Bipedicled mucoperichondrial flaps with placement of costal perichondrium between the repaired flaps.

Main Outcomes and Measures

Success rate of septal perforation closures and the clinical impact of the success of closure as experienced by the patient using the validated Nasal Obstruction Symptom Evaluation (NOSE) questionnaire (range, 0-20; higher scores indicate greater obstruction).

Results

Of the 51 patients (14 male; 37 female; median age, 42.6 [range, 17-69] years), 44 underwent attempted closure of the perforation at the time of the procedure. Closure was successful in 42 of the 44 patients (95%).Two patients had persistent perforations, one of which was subsequently closed in a secondary procedure. Twenty-six of 51 patients with septal perforations completed preoperative and postoperative NOSE questionnaires. The mean (SD) preoperative and postoperative NOSE scores were 12.6 (4.2; range, 6-20) and 3.4 (3.8; range, 0-12), respectively (P < .001). A mean (SD) improvement of 9.0 (3.9) points in the NOSE score was observed from patients after closure of their septal perforation, and 10 patients reported no symptoms (NOSE score, 0).

Conclusions and Relevance

Costal perichondrium is an effective interpositional graft to be used in conjunction with the bilateral mucoperichondrial flaps for closure of septal perforations. Costal perichondrium may be used to aid in closure rates of septal perforations.

Level of Evidence

4.

Primary Open Rhinoplasty

Rhinoplasty is perhaps the most complex cosmetic surgery procedure performed today. It is characterized by an intricate interplay between form and function, with patient satisfaction being dependent not only on improvement of nasal appearance but also resolution of preexisting airway symptoms. The prerequisite for successful execution of this challenging procedure is a thorough understanding of nasal anatomy and physiology. Hence, a thorough preoperative evaluation is at least as important and the surgical skill in performing the operation. Establishing an accurate diagnosis through a comprehensive nasal analysis is obligatory. As to the surgical approach, much has been written about the advantages and disadvantages of closed vs open rhinoplasty. The more commonly chosen open approach has numerous advantages, including improved visualization without distortion, thus, enabling precise diagnosis and correction of deformities. While the surgical treatment of existing nasal deformities is tailored to the needs of the individual patient, the authors have noted a total of 10 essential components to form the foundation for successful technical execution of rhinoplasty. These include: (1) septoturbinotomy; (2) opening the nose; (3) humpectomy/spreader flaps; (4) tip-plasty; (5) supratip-plasty; (6) columellar strut; (7) dorsal augmentation; (8) nasal base reduction; (9) osteotomies; and (10) rim grafts. Postoperative, a variety of problems, such as edema, may be successfully addressed without surgical intervention. Diligent postoperative management is critical in ensuring a positive patient experience. Finally, a comprehensive understanding of possible postoperative complications, such as bleeding, ecchymosis, edema, and persistent or new iatrogenic deformity is mandatory prior to offering rhinoplasty to patients.

Controversies in Revision Rhinoplasty

Revision rhinoplasty is a complex operation with many variables that may influence the final esthetic and functional outcome of the procedure. Cartilage forms the structural framework of the lower two-thirds of nose and is essential for long-term support and maintenance of a patent nasal airway. The use of autologous cartilage grafting is the primary source of this material, limited by donor site quantity, quality, and harvest morbidity. Alloplastic materials, solid and injectable, are often used for augmentation purposes and may have devastating consequences. This article discusses past and current treatment concepts for various nasal deformities using available autologous grafting techniques.

Revision Rhinoplasty

Revision rhinoplasty is one of the most challenging operations the facial plastic surgeon performs given the complex 3-dimensional anatomy of the nose and the psychological impact it has on patients. The intricate interplay of cartilages, bone, and soft tissue in the nose gives it its aesthetic and function. Facial harmony and attractiveness depends greatly on the nose given its central position in the face. In the following article, the authors review common motivations and anatomic findings for patients seeking revision rhinoplasty based on the senior author's 30-year experience with rhinoplasty and a review of the literature.