Rhinoplasty

Evaluation and Treatment of Nasal Valve Compromise in non-Caucasian Rhinoplasty

The number of non-Caucasian patients with nasal valve compromise seeking functional rhinoplasty is projected to increase in tandem with an increasingly diverse population in the United States. Gaining a deeper appreciation for the variances in nasal morphology amongst different ethnicities will help rhinoplasty surgeons perform accurate preoperative evaluations, optimize functional and esthetic outcomes, and maintain ethnic congruence with surgery.

Comparison on functional and esthetic outcomes between single and combined surgery to crooked nose deformities

BACKGROUND

Nose deviation deformities pose a complex cosmetic and functional problem. The most common surgical intervention to manage such deformities is septorhinoplasty, typically performed by a plastic surgeon or a rhinologist. This study investigated the effect of a combined operation by a plastic surgeon and rhinologist, comparing them with those operations performed singlehandedly by a plastic surgeon.

METHODS

From January 2017 to January 2022, 99 patients with deviated noses were treated. Fifty-nine underwent the combined operation, whereas 40 underwent surgery performed by a plastic surgeon. In the combined operation group, the rhinologist performed endonasal septoplasty and turbinoplasty, while the plastic surgeon performed open rhinoplasty, osteotomies, caudal septal deviation correction, camouflage procedure, esthetic enhancement, and dorsal augmentation. Subsequently, the rhinologist checked the airway and applied a nasal tamponade. Treatment outcomes were evaluated using the Rhinoplasty Health Inventory and Nasal Outcomes (RHINO) questionnaire and incidence of postoperative complications.

RESULTS

Of the 79 patients who responded to the RHINO questionnaire, 33 underwent an operation by a plastic surgeon, whereas 46 underwent the combined operation. All cases showed improved scores on the RHINO questionnaire postoperatively, with significantly higher scores in the combined group (p = 0.032). Furthermore, the combined group showed more significant improvements in function-related questions, despite longer total operation durations. The overall complication rate was 10.1%.

CONCLUSION

A combined surgical correction for deviated nose by a plastic surgeon and rhinologist could provide better subjective outcomes, especially in functional outcomes.

Assessment of Awareness, Source of Information, Motivational Factors, and Barriers for Rhinoplasty Among Young Females in Jordan: A Cross-Sectional Study

Rhinoplasty, or nose job surgery (NJS), alters the nose's size, shape, or structure. It can fix congenital abnormalities, enhance breathing, or improve nose attractiveness. Due to Jordan's high financial standing, cultural influences, and trained surgeons, rhinoplasty is the most prevalent cosmetic surgery in the USA and Jordan. Although reasonably safe, it can cause bleeding, infection, respiratory problems, and dissatisfaction. This cross-sectional study included Jordanian 20-24-year-old girls who completed a self-administered online questionnaire. A questionnaire was created by all study authors and assessed for internal reliability using Cronbach's α test. The participants (69%, 68.4%, 58%, and 54.1%) of the four groups strongly believe that functional abnormalities motivate surgery. Self-confidence, beauty standards, and new trends showed statistically significant differences. Groups 1 and 3 mostly strongly agreed (37.9%, 34.8%), Group 2 mostly agreed (47.4%), and Group 4 was neutral primarily (28.2%). This study evaluated postoperative issues awareness with the following variables: bruises and bleeding (89.2%), pain (73.2%), anesthesia complications (46.1%), inflammation (45%), stress due to with the outcome (42.8%), numbness and runny nose (41.7%), respiratory disorder and airway obstruction (38.2%), olfactory disturbance (38.2%), mismatch of the final nose appearance with other facial components (36%), remaining scar (30.4%), and allergy (19%). Rhinoplasty is becoming more popular due to various influences and motivations. It is still a surgical procedure with risks and complications, so the public should know its indications and risks.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 .

Turn Your Vision into Reality-AI-Powered Pre-operative Outcome Simulation in Rhinoplasty Surgery

BACKGROUND

The increasing demand and changing trends in rhinoplasty surgery emphasize the need for effective doctor-patient communication, for which Artificial Intelligence (AI) could be a valuable tool in managing patient expectations during pre-operative consultations.

OBJECTIVE

To develop an AI-based model to simulate realistic postoperative rhinoplasty outcomes.

METHODS

We trained a Generative Adversarial Network (GAN) using 3,030 rhinoplasty patients' pre- and postoperative images. One-hundred-one study participants were presented with 30 pre-rhinoplasty patient photographs followed by an image set consisting of the real postoperative versus the GAN-generated image and asked to identify the GAN-generated image.

RESULTS

The study sample (48 males, 53 females, mean age of 31.6 ± 9.0 years) correctly identified the GAN-generated images with an accuracy of 52.5 ± 14.3%. Male study participants were more likely to identify the AI-generated images compared with female study participants (55.4% versus 49.6%; p = 0.042).

CONCLUSION

We presented a GAN-based simulator for rhinoplasty outcomes which used pre-operative patient images to predict accurate representations that were not perceived as different from real postoperative outcomes.

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 .

Does Social Media Enhance Rhinoplasty Desire and its Recovery Period: A Saudi Retrospective Study

Rhinoplasty, which reconstructs the shape and size of the nose, is the most frequently performed cosmetic surgery procedure. Research indicates that social media is the leading influence motivating individuals to undergo rhinoplasty. Thus, we aimed to evaluate the effect of social media on the desire for rhinoplasty and to establish whether (and if so, how) social media enhances the recovery period after rhinoplasty. A retrospective study was conducted on 322 Saudi rhinoplasty patients through a questionnaire distributed online via specific rhinoplasty groups and accounts on different social media platforms containing rhinoplasty patients. The questionnaire included participants' demographic details, the factors behind undergoing the rhinoplasty and their belief about the effect of social media on their desire to undergo a rhinoplasty, and how social media affected their recovery period after undergoing rhinoplasty. The collected data were then analyzed statistically with SPSS. The associations of different variables were found using the Chi-square test. The study included 322 rhinoplasty patients with nearly equal gender distribution. The results indicate that social media highly (mean = 4.07 ± 1.07 out of 5.00, 81.4%) influenced participants' decision to undergo rhinoplasty, and it highly influenced the recovery period after surgery (mean = 3.59 ± 0.67 out of 5.00, 71.8%). A statistically significant association was observed between social media influence and participants' education level (p = 0.018) as well as place of residence (p = 0.002). Most participants reported following social media advice to deal with unforeseen post-rhinoplasty symptoms that may have arisen during the recovery phase, which is theorized as the mechanism driving shorter recovery times.

Implanted cartilaginous grafts following rhinoplasty: A retrospective histopathological study

To describe histopathological features of rhinoplasty-related implanted cartilages, 83 cartilages surgically removed from 42 patients (2 men and 40 women) with a median age of 28.0 years (range, 21-47 years) following correction/revision rhinoplasty were examined. These cartilages included 16 autologous costal cartilages (ACCs), 14 irradiated homologous costal cartilages (IHCCs), 24 autologous nasal cartilages (ANCs), 2 irradiated homologous nasal cartilages (IHNCs), 14 autologous ear cartilages (ECs) and 13 combined cartilaginous grafts. The median chondrocytic viability in ACCs (35.9%) was higher than that of IHCCs (0.0%) and ECs (21.4%) (both, P<0.001), and showed no significant differences compared with the viability in ANCs (41.3%) (P=0.455). The median organized rate of chondroid matrix in ACCs, IHCCs, ANCs and ECs was 2.5, 1.4, 0.9 and 2.0%, respectively, and there were no significant differences among them (P=0.909). The present study revealed not only enlarged chondrocytic lacunae, chondrocytic cloning and binucleated/trinucleated chondrocytes, but also a possible transition between chondrocytes and fibroblasts in 6 ACCs, 3 ANCs and 1 EC, lipomembranous fat necrosis (LFN)-like bodies in 15 ACCs, 14 IHCCs, 3 ANCs and 5 ECs, and chondrocytic vacuolar changes in 15 ACCs, 22 ANCs, 2 IHNCs and 16 ECs. A histological transition between LFN-like bodies and chondrocytic vacuoles was focally observed in 2 ACCs and 1 ANC. The present findings suggested that the stability of implanted cartilage did not depend on chondrocytic viability only. Viable chondrocytes preserve implanted chondroid matrix, but also may, in part, induce organization through their transformation into fibroblasts. LFN-like bodies are considered to be an underrecognized form of vacuolar change-related chondrocytic necrosis.

A Mortise and Tenon Framework Composed of Costal Cartilage and Expanded Polytetrafluoroethylene in Rhinoplasty for Asians: Application Ⅱ of Dai Exogenous Extension Stent Concept

BACKGROUND

The septum is often underdeveloped in East Asian populations, and traditional endogenous extension stents may not adequately fulfill the requirements for rhinoplasty. Herein, we present an innovative exogenous extension framework featuring a mortise and tenon structure specifically designed for East Asians.

METHODS

This framework comprises a mushroom-shaped rib cartilage component and a lancet-shaped expanded polytetrafluoroethylene (ePTFE) element, which are interconnected through a mortise and tenon design. The costal cartilage serves as a strut to support the nasal column and elevate the nasal tip. The ePTFE is utilized to augment the nasal dorsum and root, enhancing overall shape while being securely attached to the rib cartilage via the mortise and tenon structure. This configuration establishes a stable exogenous extension framework that also facilitates nose elongation. The safety and efficacy have been validated through over 10 years of clinical practice.

RESULTS

Over the past decade, we have performed this procedure in more than 500 cases without any complications, such as necrosis of the nasal column, ischemia of the nasal tip, or adverse graft appearances. Notable improvements in nasal morphology were observed across all patients. In addition, no postoperative restrictions on nasal ventilation were reported by any patient. Overall, patient satisfaction regarding surgical outcomes was exceptionally high.

CONCLUSIONS

This framework represents an advanced implementation of exogenous extension stent concept, which is particularly effective for East Asians since it does not require a well-developed nasal septum to provide support. In addition, it does not increase the risk of restricted nasal ventilation.

LEVEL OF EVIDENCE

Level IV.

Postrhinoplasty Depression: A Systematic Review

Background

Even though an increased number of patients indicate satisfaction with rhinoplasty outcomes, unexpected postoperative psychological reactions might occur. Postrhinoplasty depression is a type of adverse psychological response in relation to cosmetic surgery.

Methods

The present systematic review seeks to evaluate postoperative depression following successful rhinoplasty in patients who are psychologically stable.

Results

The findings on postrhinoplasty depression are a reminder to cosmetic surgeons that better surgery outcomes might not consistently generate happy and satisfied patients. Even though preoperative mental evaluations are considered important in the screening of patients to undergo rhinoplasty, the assessments might not often be predictive. Cosmetic surgeons should therefore be ready and willing to aid their patients in coping with the adverse psychological responses, including depression. Moreover, this systematic review seeks to enhance the comprehension of both the preoperative and postoperative psychology and mood changes in patients undergoing rhinoplasty.

Conclusions

Plastic surgeons are required to offer effective counseling services to their patients, ensuring effective and clear communication of their expectations, to aid in the decision on whether patients are apt candidates for rhinoplasty and to reduce the possibility of postrhinoplasty depression and anxiety.

Comparison of 1 Year Nasal Tip Projection Results of Triple Cartilage Combining Suture (Flexible Tongue-in-Groove) and Classical Tongue-in-Groove Techniques

Objectives: In the present study, we compared patient satisfaction with classical tongue-in-groove (TIG) technique and triple cartilage combining suture (TCCS; flexible tongue-in-groove) techniques applied to the nasal tip in rhinoplasty. Methods: In this retrospective study, 80 patients who underwent rhinoplasty operations with TIG or TCCS techniques applied to the tip region were included. There were 40 patients in both groups. All patients in groups 1 and 2 were evaluated by the criteria written below at preoperative, postoperative first month, and postoperative first year: (1) Rhinoplasty Outcomes Evaluation Questionnaire (ROE), (2) tip projection (cm), (3) nasal dorsum length (cm), (4) tip projection ratio (Goode), (5) nasofrontal angle, and (6) nasolabial angle. Results: The patients were followed up at 84.32 ± 19.38 months in the TIG group and 87.47 ± 18.01 months in the TCCS group. Our results showed that preoperative, postoperative first-month, and first-year tip projection (P = .013, P = .022, and P = .020, respectively), and nasal dorsum length values (P = .009, P = .020, and P = .020, respectively) of the TCCS group were significantly lower than those in the TIG group. There was a positive correlation between the postoperative first month and postoperative first year ROE scores. Lower preoperative tip projection ratio (Goode) values and higher nasolabial angle values were related to higher ROE scores showing patient satisfaction. Conclusion: For the patient satisfaction after tip rhinoplasty, lower projection ratio (Goode) and higher nasolabial angle values were related to ROE scores. Although there are no significant results, lower tip projection results in the TCCS group may be related to more patient satisfaction due to natural appearance.

Delayed Hematoma After Rhinoplasty in Young Adult With Hypertension

Rhinoplasty is one of the most commonly performed plastic surgical procedures. It has been reported that the overall incidence of complications is low, and hematoma is the most common complication. Recently, the authors experienced a young patient who developed nasal dorsal bleeding and hematoma formation 2 weeks after undergoing rhinoplasty. He had a history of hypertension and was on medication. Due to severe nasal dorsal swelling caused by bleeding and hematoma, the authors ultimately performed an open approach to control the bleeding and evacuate the hematoma. Herein, the authors report the case of a patient with delayed dorsal bleeding 2 weeks after rhinoplasty. The authors learned a lesson that although the patient was young and healthy, in patients with a history of hypertension, the possibility of delayed operative site bleeding should be considered.

Nasal Anthropometry: An Assessment Among the Akan and Ewe Ethnic Groups in Ghana

The distribution of nasal types has been reported to be influenced by climatic adaptation as the nose is involved in conditioning inhaled air. Previous studies have reported differential nasal types and dimensions among varying populations which is very beneficial in planning for rhinoplasty and in forensic identification. However, there is inadequate data on nasal types and dimensions of the various ethnic groups in the Ghanaian population. Since it is inappropriate to apply nasal dimensions of one ethnic group to another, the current study sought to assess the nasal types and dimensions of Akans and Ewes in the Ghanaian population. Nasal height, nasal length, nasal tip protrusion, morphological nose width, and anatomical nose width were measured from 202 participants (116 Akans and 86 Ewes) aged 18-27 years belonging to the Akan and Ewe ethnic groups. Nasal index was calculated, and the frequencies of the nasal types among the two ethnic groups were determined. Ewe significantly had greater nasal length and nasal tip protrusion than the Akans. For both ethnic groups, sexual dimorphism was observed in morphological nose width and anatomical nose width, with males having greater values than females. The platyrrhine (broad nose) nasal type was predominant among the Akan and Ewe ethnic groups. The average nasal dimensions of the Akan and Ewe ethnic groups for the Ghanaian population have been reported in the present study, which will be useful in rhinoplasty intended for individuals belonging to these ethnic groups and in identification.

Assessment of Harms Reporting Quality in Randomized Controlled Trials of Aesthetic Rhinoplasty: A Systematic Review

Background

Rhinoplasty is one of the most common aesthetic plastic surgery procedures. Complications can lead to both aesthetic and functional impairments. The Consolidated Standards of Reporting Trials (CONSORT) Harms statement was developed to promote improved reporting of harm across randomized controlled trials (RCTs).

Objectives

The aim of this systematic review is to assess harms reporting quality across RCTs on aesthetic rhinoplasty.

Methods

A literature search was conducted in Ovid MEDLINE and Embase databases (January 1, 2005 to August 4, 2023). RCTs which compared 2 or more interventions in rhinoplasty with primarily aesthetic indications and assessed patient-important outcomes were included. The reporting quality was assessed by following a 40-item checklist endorsed by the 2022 CONSORT Harms Extension update.

Results

A total of 58 RCTs met the inclusion criteria. Fifteen RCTs addressed harms of treatment in some capacity. Overall, the reporting quality across RCTs was poor, with a median CONSORT Harms score of 33% (range, 16%-83%). A reporting adherence of ≥50% was met by only 8 studies. There was no significant difference in reporting adherence between studies based on journal endorsement of CONSORT or industry vs nonindustry funding sources (P > .05). A high journal impact factor was significantly associated with a higher reporting quality (P = .044).

Conclusions

CONSORT Harms reporting adherence was poor across the majority of included RCTs. Future trials on aesthetic rhinoplasty should aim to follow the reporting recommendations endorsed by the CONSORT Harms statement to increase transparency and minimize heterogeneity in harms reporting across studies.

Level of Evidence 1

Is Piezosurgery Associated with Improved Patient Outcomes Compared to Conventional Osteotomy in Rhinoplasty? A Systematic Review and Meta-Analysis of RCTs

Background: Rhinoplasty is a common plastic surgery procedure with evolving surgical techniques. This systematic review and meta-analysis compares the outcomes of piezosurgery versus conventional osteotomy in rhinoplasty. Methods: A comprehensive search of six databases yielded 12 randomized controlled trials (RCTs) comparing piezosurgery (292 cases) to conventional osteotomy (338 cases) in rhinoplasty patients. The examined outcomes included postoperative edema, ecchymosis, complications, pain (using the Visual Analogue Scale-VAS), and operative time. Subgroup analyses were conducted based on the assessment timepoint, surgical approach, and outcome grade. The risk of bias was evaluated using the revised Cochrane tool. Results: Piezosurgery showed a significant reduction in the degree of postoperative edema (second and seventh postoperative days) and ecchymosis (second, fourth, and seventh postoperative days). The external approach in piezosurgery demonstrated greater benefits for both outcomes. Piezosurgery was associated with a significant reduction in overall complications, especially mucosal injuries, compared to conventional osteotomy, with no significant difference regarding postoperative hemorrhage. A significant reduction in pain scores and the need for analgesia was observed with piezosurgery. No significant difference was found in operative time. Conclusions: Piezosurgery offers significant benefits in patient outcomes, with similar operative time between both techniques. However, long-term investigations are still needed.

Structural Rhinoplasty as an Effective Surgical Approach for Frontonasal Dysplasia

Frontonasal dysplasia (FND), a rare congenital craniofacial disorder, primarily influences the development of midline craniofacial structures. A notable manifestation of this condition is nasal hypoplasia. This report details the treatment of a 19-year-old male patient diagnosed with FND accompanied by a severe case of nasal hypoplasia. The authors used structural rhinoplasty to achieve total nasal reconstruction. Albeit with some minor sequelae, the outcome of this surgery was markedly positive, enhancing both the cosmetic appearance and functional capacity of the nose. This case underscores the effectiveness of structural rhinoplasty as a feasible therapeutic approach for individuals suffering from FND and its associated nasal hypoplasia.

Clinical Practice Patterns and Evidence-Based Medicine in Rhinoplasty: A 10-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery (ABPS) has collected data on cosmetic surgery from member surgeons since 2003. These data offer valuable information on national trends in clinical practice.

OBJECTIVES

The present study was performed to analyze trends in rhinoplasty over the last decade.

METHODS

Tracer data were compared between two cohorts 2012-2016 (early cohort "EC") and 2017-2021 (recent cohort "RC"). Data included patient demographics and surgical techniques. Results were considered in the context of current EBM-based guidance in the plastic surgery literature.

RESULTS

Data from 730 rhinoplasties (270 EC and 460 RC) were analyzed. The median age was 30 years, and the most common patient concern was the nasal dorsum (79%). In the RC group, fewer patients voiced concerns about tip projection (58% vs 43%, p = 0.0002) and more complained of functional airway problems (38% vs 49%, p = 0.004). An open approach was most common (83%). Septoplasty (47% vs 52%, p = 0.005), caudal septum repositioning (14% vs 23%, p = 0.002), and tip rotation maneuvers (32% vs 49%, p < 0.0001) became more popular. There was also an increase in the use of spreader grafts (35% vs 45%, p = 0.01) and columellar strut grafts (42% vs 50%, p = 0.04), while there has been a decrease in alar base resection (17% vs 10%, p = 0.007) and non-cartilaginous dorsum/radix augmentation (9% vs 4%, p = 0.02).

CONCLUSIONS

ABPS tracer data provide an excellent resource for the objective assessment of procedures in plastic surgery. The present study is the first to highlight evolving trends in rhinoplasty over the last 10 years.

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 .

Anthropometry of the nose pre- and post-photogrammetric adjustments in a sample of Syrian medical students. A cross-sectional study

Background and Aims

The individual's perceived beauty, sense of identity, and general well-being are all influenced by the social implications of the esthetics of their facial appearance. One of the major indicators of one's facial beauty is anthropometric proportions. This study was conducted to measure and evaluate the anthropometric proportions in a Syrian population, and to determine their desired nasal shape.

Methods

A cross-sectional study was conducted on Syrian university students. Lateral and frontal pictures of the participants were taken using Canon EOS 250D from a standard distance of 100 cm. These pictures were analyzed, then nasal measurements were adjusted according to the participants' desire using Adobe Photoshop 2020. All anthropometric measurements were conducted on AutoCAD® 2019 software before and after the adjustments. Data was analyzed using the SPSS-25 using paired samples T test to compare the means.

Results

The study included 53 females and 47 males. The mean age was 22.25. The mean unadjusted nasofrontal angle, nasolabial angle, nasomental angle, nasofacial angle, nasal index, Byrd and Hobar ratio, and Powell-modified Baum ratio were 141.80, 102.18, 129.21, 34.60, 71.71, 0.62, and 3.08 in the rhinoplasty-negative participants, and 145.89, 102.03, 130.20, 32.44, 67.96, 0.64, and 3.06 in the rhinoplasty-positive participants, respectively. While the mean of the adjusted previously mentioned angles were 144.59, 106.32, 131.19, 31.15, 62.91, 0.60, and 3.19 in the rhinoplasty-negative participants, and 146.31, 102, 130.20, 31, 62.55, 0.62, and 3.08 in the rhinoplasty-positive participants, respectively.

Conclusion

In contrast to other populations, our study concluded that Syrians had unique anthropometric measurements and facial esthetics preferences. Moreover, the local plastic surgeons were able to identify most of the preferred nasal measurements for rhinoplasty in this ethnic group. It is advisable to use photogrammetry before rhinoplasty to identify the preferred nasal measurements of each individual to ensure the patient's satisfaction with the outcome of the surgery.

Level of Evidence

Level IV, cross-sectional study.

Harmonizing Beauty and Function: A Comprehensive Exploration of Patient Satisfaction in Rhinoplasty

Background

Rhinoplasty has become a globally prevalent esthetic procedure, necessitating precise facial analysis and comprehensive preoperative planning for favorable postoperative outcomes. We aimed to assess patient satisfaction levels concerning nasal appearance following rhinoplasty.

Methods

A case series interventional study was conducted involving 52 subjects referred to Rhinoplasty Clinics of Taleghani Hospital, Tehran, Iran from Mar 2021 to Mar 2022. Patients' satisfaction levels were evaluated using a concise checklist before and three months after surgery.

Results

The mean age of the patients was 29.23 ± 7.26 years, with 19 (36.5%) being male. Statistically significant improvements were observed in all assessed factors, including nasal obstruction, nasal size, hump presence, nasal bridge width, nasal tip bulbosity, nasal deviation, radix, nostril asymmetry, and tip ptosis (P < 0.001). These findings reveal a consistent pattern of patients' satisfaction levels predominantly shifting from moderate to low across various aspects of nasal appearance post-rhinoplasty.

Conclusion

The study demonstrated a significant enhancement in patients' satisfaction with their nasal appearance following rhinoplasty, indicated by statistically significant changes across all assessed factors. However, certain aspects exhibit more limited enhancement.

Radix's Importance for Plastic Surgeons: A Descriptive Cross-Sectional Study

Background

Considering the importance of the nose in the beauty of the face, accurate and systematic three-dimensional nasal analysis of the nose before the procedure is essential. The radix, and so the nasofrontal and nasofacial angles, play an essential role in forming an aesthetically pleasing nose because they influence the length and projection of the nose. We aimed to measure information about the pre-operative radix position in our region.

Method

Pre-operative images were taken from our cases in the profile view. A checklist including radix location and projection, nasofrontal angle, and nasofacial angle were extracted from these images.

Results

Overall, 200 (100 males and 100 females) cases were enrolled. Thirty-two male cases and 48 females had abnormal radix position. Radix projection were normal in only 36 male cases and 18 females. The mean nasofrontal angle in the male and female groups was 119.2 and 128.2 respectively. The mean nasofacial angle was 29.8 in the female groups and 32.6 in the male group.

Conclusion

The reality of the current society of Iranian patients can be very different from the predictions of surgeons and can be far away from the statistics mentioned in western books. We tried to notify surgeons to thoroughly examine the patients prior to surgical operation by measuring parameters such as projection and position of the radix and nasofrontal and nasofacial angles.

Beyond Alar Base Resection: Contouring of the Alar Rim and Base

SUMMARY

Alar base surgery is approached with hesitancy and is often avoided by many surgeons because of inexperience and a lack of understanding. However, with a thorough knowledge of the anatomy and dynamic nature of the lower third of the nose, alar base resection can achieve favorable and reproducible results. Beyond correcting alar flare, an appropriately diagnosed and performed alar base procedure serves to contour both the alar rim and the alar base. The following article presents a case series of 436 consecutive rhinoplasties from a single surgeon, 214 of which underwent alar base surgery. The outcomes demonstrate that the procedure is safe and yields desirable results without a single revision being required. As the third in a series of three articles on alar base surgery by the senior author (R.J.R.), this article unifies the management of the alar base. An intuitive approach to the classification and management of alar flare and the implications of alar base surgery on contouring of the alar base and alar rim is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

An Innovative Stent Consisting of Expanded Polytetrafluoroethylene and Ear Cartilage in Rhinoplasty For Asians: Application I of Dai's Exogenous Extension Stent Concept

BACKGROUND

Restricted ventilation is common after rhinoplasty with an endogenous extension stent. The authors proposed an exogenous extension stent concept for Asian rhinoplasty patients to avoid this problem. Herein, we introduce an innovative stent in rhinoplasty for Asians, which is an application of this concept.

METHODS

An L-shaped expanded polytetrafluoroethylene is hand-carved, and the long arm is placed at the nose back to improve the flatness of the nose, while the short arm supports the nasal column to raise the nose tip. The prosthesis does not occupy nasal volume and therefore theoretically does not affect nasal ventilation. The fan-shaped ear cartilage was placed at the nasal tip to prevent visualization of the nasal tip. The safety and effectiveness of this method were verified through 20 years of clinical practice. The difficulty of learning and popularizing the method was tested through the course of rhinoplasty among 22 plastic surgeons.

RESULTS

After 20 years of clinical practice, it was found that this stent could not only effectively improve the nasal dorsum and tip morphology, but also did not actually affect the nasal volume and thus did not affect the nasal ventilation of patients. Among the trainees in plastic surgery, we found that it was not difficult to learn this method of rhinoplasty and the trainees could complete the prosthesis carving well after standardized training.

CONCLUSION

This stent consisting of expanded polytetrafluoroethylene and ear cartilage is suitable in rhinoplasty for Asians with significant advantages, one of which is that it has no risk of resulting in restricted nasal ventilation.

LEVEL OF EVIDENCE

Level IV.

Refinements in Component Dorsal Reshaping in Primary Rhinoplasty

SUMMARY

Dorsal reduction and reshaping is an essential part of many rhinoplasty procedures. The steps of component dorsal reduction have been well established. The authors describe refinement of the dorsal reshaping process to improve the quality and consistency of results.

The Myrtiformis Muscle: Identification of a Forgotten Entity That Is Distinct From the Depressor Septi Nasi Muscle

INTRODUCTION

Nasal musculature anatomy is a topic that plastic surgeons pay attention to. However, the presence and role of the myrtiformis muscle (MM) remain controversial. To elucidate these aspects, an anatomy-based study was conducted.

MATERIALS AND METHODS

Seven midsagittally split and two total cadaver head's nasal bases, embalmed with modified Larssen solution (MLS), were dissected for MM anatomy. The features of this muscle were photographed, and a video of its function was recorded.

RESULTS

It was found that MM originates from the maxillary alveolar process and continues as two heads, one reaching the alar base with spicular fibrotendinous endings and the other extending to depressor septi nasi fibers. Owing to its bi-vectoral muscle fibers, MM is found to constrict the nares by simultaneously forcing the alar base and lowering the columella. It was also found that left-sided muscles were larger than right-sided muscles.

CONCLUSIONS

The MM is found to be a constrictor muscle of the nares in this study, contrary to recent observations.

Introducing a New Technique for Correcting Nasal Soft Tissue Triangle Deformity Using a Modified Fine Graft (Cartilage Graft) and Evaluating Its Effect on Deformity Correction: A Prospective Study

Background

The management of deformities of the nasal soft triangle (ST) is a difficult and very sensitive discussion in rhinoplasty. So far, the standard method for correcting these deformities has yet to be introduced. We aimed to introduce a new technique using modified fine graft (MMG) for correcting nasal ST triangle deformity and evaluate the effects of using this method.

Methods

This prospective study was conducted on 20 rhinoplasty candidates who underwent surgery at 15 Khordad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran between August 2021 to the February 2022 with the new technique of using an MMG to correct nasal ST triangle deformities. Follow-up was performed immediately after surgery, 3 and 6 months after surgery. Post-operative findings included ST deformity correction, graft exposure, graft visibility, recurrence rate, and the need for revision were evaluated by photography for all patients.

Results

The mean age of patients was 33.65± 11.047 years, 85% of the cases were female and 90% of surgeries were primal rhinoplasties. The ST triangle deformity was not corrected in 2 cases (10%). Both patients were women with primary rhinoplasty, and cartilage was removed from the septum in both. Graft exposure, recurrence, and visibility were not reported in any cases.

Conclusion

MFG was highly effective in correcting the deformity of the nasal ST triangle and did not cause serious complications in patients. This method is a suitable method with high efficiency for correcting nasal ST triangle deformity.

A Canadian Experience With Off-the-Shelf, Aseptically Processed, Costal Cartilage Segment Allografts in Complex Rhinoplasty

Background

Complex primary and secondary rhinoplasties usually necessitate grafting materials when native nasal cartilage is inadequate for reconstruction. Fresh frozen, aseptically processed, and nonterminally sterilized costal cartilage segment allografts (CCSAs) are a novel grafting material for such cases that avoid donor-site morbidity, improve operating efficiency, and mitigate the postoperative risks.

Objectives

To report the early experience using fresh frozen, aseptically processed, and nonterminally sterilized CCSAs used in complex primary and secondary rhinoplasties, in Canada.

Methods

We retrospectively reviewed 21 patients (17 female and 4 male patients) who underwent a primary or secondary rhinoplasty surgery using CCSAs from June 2019 to April 2022.

Results

The mean age was 39 years (range, 27-58 years), and the mean body mass index was 23.7 kg/m² (range, 24-40 kg/m²). Of the 21 procedures, 11 were primary (52.4%) and 10 were secondary (47.6%) rhinoplasties. The mean operative time was 185 min (range, 85-330 min), with a mean follow-up time of 15.0 months (range, 2.0-37.8 months). At follow-up, 19 patients (90.5%) reported being "very satisfied" with their aesthetic results, and only 2 (9.5%) underwent revision surgery. No serious complications were reported, and only 1 case showed evidence of graft resorption.

Conclusions

Based on early experience, this CCSA avoids donor-site morbidity and reduces operative time while maintaining a low complication rate, providing a viable alternative to the use of autologous costal cartilage when indicated in complex primary or secondary rhinoplasties with inadequate native nasal cartilage.

Level of Evidence 4

Functional Nasal Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) understand the functional significance of nasal anatomy as it relates to rhinoplasty and perform a comprehensive functional nasal assessment. (2) Identify the anatomical level of obstruction based on the authors' algorithmic approach and understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, external nasal valve collapse. (3) Understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, and external nasal valve collapse. (4) Appreciate the objective assessment tools for functional nasal surgery from a clinical and research perspective.

SUMMARY

The intent of functional rhinoplasty is to improve nasal airflow (and the perception thereof) by surgically correcting the anatomical sources of obstruction in the nasal airway. Cosmetic and functional rhinoplasty are not mutually exclusive entities, and the techniques that address one area, inevitably may affect the another. The rate of functional problems after cosmetic rhinoplasty range from 15 to 68 percent with nasal airway obstruction found to be the most common indication for secondary surgery. The objective of this CME article is to provide readers with an understanding of the (1) functional components of nasal anatomy, (2) clinical functional assessment, and (3) the current evidence supporting corrective maneuvers for each component.

Prevalence of Facial Asymmetry and Correction Methods for Rhinoplasty in Individuals with Deviated Nose: A Brief Review

Background:

Surgeons frequently perform rhinoplasty on individuals who have facial asymmetry. Patients’ discontent following rhinoplasty has been linked to facial asymmetry. On the other hand, correction of a deviated nose is a tough procedure, and it is not the same as septal deviation correction. Surgeons, who often perform rhinoplasty for deviated nose in people with asymmetrical faces, focus primarily on correcting nasal defects and overlook such facial asymmetry.

Aim:

We aimed to summarize and review the prevalence of facial asymmetry in patients subjected for rhinoplasty for deviated nose correction.

Methods:

A systematic search was conducted covering PubMed, Scopus, ISI, and Google Scholar using related key words and MeSH (Medical Subject Headings) terms from 2000 until November 2021 for English published articles.

Results:

The majority of subjects had more facial asymmetry such as chin deviation, nasal deviation, and face breadth. Facial asymmetry is typically found in patients undergoing rhinoplasty for a deviated nose, and its presence frequently results in the failure to achieve a straight-looking nose.

Conclusion:

Patients considering rhinoplasty frequently have facial asymmetries, and careful attention should be devoted to these elements in both surgical planning and patient counseling. In order to create facial harmony and apparent symmetry after rhinoplasty, it is critical to center the nose on the midglabellar to mid–bow Cupid’s line.

Controlling Nasal Tip Projection and Rotation with New Composite Septocolumellar Flap Approaches

BACKGROUND

Rhinoplasty is one of the most common and challenging surgeries in the field of aesthetic surgery. For obtaining an aesthetically pleasing nose, it is extremely important to control nasal tip projection and rotation as much as possible. Since the last decade, septocolumellar suture techniques have been most frequently used for modifying and controlling nasal tip rotation and projection and for obtaining a better columellar-labial angle during rhinoplasty. In the present study, the author has described 10 different approaches using composite septocolumellar flaps with the aim of obtaining better outcomes, such as the control of nasal tip projection and rotation, in addition to obtaining better tip refinement.

METHODS

The records of 68 patients were included in the present study based on the inclusion and exclusion criteria. Ten composite septocolumellar flap approaches were followed by the same surgeon.

RESULTS

The initial median Rhinoplasty Outcome Evaluation score was 60.5 points; the score increased to 92.5 points at 12 months after the surgery (p < 0.001). Satisfaction was excellent in 87.5 percent of the patients. The patients were also evaluated in terms of functionality. Their patency scores increased from 6.0 to 9.0 (out of 10) after a 12-month follow-up (p = 0.001).

CONCLUSIONS

The technique has the following advantages: control of nasal tip projection and rotation, fixation of mild deviations, and shortening of the nose with better aesthetic and functional outcomes. Furthermore, because the septocolumellar region is completely protected and remains solid, a dynamic nasal tip is obtained. Surgeons will be able to choose the most suitable approach when a composite septocolumellar flap is needed.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Preoperative Evaluation of the Rhinoplasty Patient

Requiring both high-level technical skills and artistic sense, rhinoplasty continues to be one of the most challenging procedures in plastic surgery despite its popularity. A thorough preoperative consultation of the rhinoplasty patient forms the foundation of a successful case. During the consultation, the physician should obtain a detailed medical and nasal history, understand the patient's areas of concern, conduct a nasal analysis, and evaluate the patient's candidacy for surgery. This article reviews the key functional, esthetic, and psychosocial considerations that should be taken into account during a preoperative consultation for a rhinoplasty patient.

Why Primary Rhinoplasty Fails

SUMMARY

Rhinoplasty remains one of the most challenging operations performed by plastic surgeons. The complexity lies in the ability to have a consistent and predictable aesthetic result. The unpredictability is mainly attributable to the interplay of manipulated internal structures and wound healing dynamics. In addition, setting realistic expectations with the patient is essential for achieving high postoperative patient satisfaction. An open rhinoplasty approach enables an accurate and in-depth evaluation and intervention. The authors provide a detailed analysis and discussion on why primary rhinoplasty fails, along with the surgical approach for preventing these failures.

Reduction Rhinoplasty Re-Endorsed: When Conservative and Measured

Reduction rhinoplasty has been widely criticised and dismissed due to the current preference for structural rhinoplasty. The criticism is related to airway compromise and secondary structural deformities, both early and late, due to overzealous resection. This two-year study attempted to prospectively assess the risk of airway and structural problems following reduction rhinoplasty in 30 consecutive patients. The findings showed no statistically significant difference either in the NOSE score (subjective sense of breathing) or in nasal valving (objective observations), at the 3-month follow-up. Subsequent 12-month telephone reviews revealed no change in the patients' functional or aesthetic outcomes. There was a 3% structural complication rate (requiring secondary surgery) and a 20% rate for further refining reduction surgery. The findings confirmed the author's impression that conservative, measured reduction rhinoplasty, performed with due consideration to preserving the nasal supportive framework, is a technique well worth endorsing with confidence to reduce the disproportionately large nose. Contemporary surgeons need not feel obliged to only use the more complex later-developed structural rhinoplasty techniques.

Perception of Risk Among Aesthetic Plastic Surgeons

BACKGROUND

With continuous innovation in plastic surgery, new procedures are constantly being introduced. A number of these procedures are generally safe but have the potential for rare yet serious complications. Many surgeons steer clear of these procedures due to safety concerns.

OBJECTIVES

The aim of this paper was to survey the membership of The Aesthetic Society to elicit perception of risk of several novel or less mainstream procedures.

METHODS

A 24-item survey was sent out to members of The Aesthetic Society. The survey focused on surgeon experience and attitude towards 3 procedures: filler rhinoplasty, gluteal augmentation with fat grafting, and submandibular gland excision.

RESULTS

In total, 189 completed surveys were returned. Of the responders, 50%, 49%, and 89% of surgeons said they do not perform filler rhinoplasty, gluteal augmentation with fat grafting, or submandibular gland excision in their practices, respectively. The majority of those who do not perform the procedures selected "danger to the patient" as the primary concern for each of the 3 procedures. Surgeons overwhelmingly reported not learning these procedures in training. Additionally, surgeons perceive the risks of more common procedures such as abdominoplasty and breast augmentation-mastopexy to be significantly lower and more acceptable than those of the studied procedures.

CONCLUSIONS

When comparing the perceived complication rates with data published in the literature, particularly when looking at rates of serious or life-threatening complications, plastic surgeons overestimate the risks of procedures with which they are less familiar. This perception of risk, accompanied by the lack of exposure to novel techniques in training, may contribute to surgeons avoiding these procedures.

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.

Predictive indicators for revisional surgery in nasal reconstruction after Mohs surgery

Background

Reconstruction of nasal lesions is complex due to the topography, mobile free margins and borders of anatomical subunits. Reconstructive challenges can lead to multiple revisional surgeries to achieve the final aesthetic result. This study aimed to evaluate risk factors and predictors of revisional surgery in patients undergoing reconstruction after Mohs micrographic surgery for nasal tumours.

Methods

This was a prospective cohort study from April 2, 2008 to February 26, 2019. The study population included all consecutive patients who underwent Mohs micrographic surgery for nasal skin cancer. Resection and reconstruction of nasal skin cancer was performed by the Mohs team.

Results

A total of 988 cases met our study inclusion criteria with 64 (6.5%) cases requiring unplanned surgical revision. Revision rates were highest in the ala (9.0%, p < 0.05) and complex anatomical subunits (16.7%, p < 0.0001). In contrast, revision rates for dorsum lesions were lowest (1.8%, p < 0.001). In terms of reconstructive modalities, local flaps resulted in significantly higher rates of revision when compared to grafts (relative risk, 2.37; 95% CI, 1.15–5.0; p < 0.01). In terms of histological diagnosis, squamous cell carcinoma had significantly higher revision rates when compared to basal cell carcinoma (p < 0.05).

Conclusions

To our knowledge, this is the first study to report the risk factors and predictors of revision surgery in patients undergoing MMS for nasal tumours. This study highlights that the reconstructive modality utilised affects the functional and cosmetic outcome of MMS. We note that ala complex subunit lesions, squamous cell carcinoma and flap reconstruction were associated with an increased risk of revision after Mohs reconstruction of nasal lesions.

Level of evidence: Level III, risk/prognostic; therapeutic study.

Trial registration number

(Ref: PLA-19-20_A03) 04/02/2020.

Systematic Surgical Approach to Alar Base Surgery in Rhinoplasty

In an era with smartphone photography and social media (specifically, "selfies"), basal view aesthetics is becoming increasingly important. Achieving balance between the nasal base and the remainder of the nose and face while preserving or restoring external valve function are essential to a successful rhinoplasty. Without a systematic approach to the nasal base, it is more difficult to achieve an ideal outcome from both aesthetic and functional standpoints. This article outlines an organized and systematic approach to the nasal base, beginning with comprehensive nasofacial analysis. The authors continue by describing idealized basal view aesthetics and provide a treatment algorithm for common deformities that include alar flaring and a wide nasal base. The authors attempt to provide a comprehensive approach to the treatment of the nasal base by discussing the implications of treating columellar deformities, tip positioning, or alar-columellar discrepancies on the overall aesthetics of the lower third of the nose. Furthermore, technical considerations are given for common surgical maneuvers addressing the alar base to help guide treatment and prevent complications such as poor scarring, notching, nostril asymmetry or stenosis (external valve obstruction), and alar deformities ("parenthesis" or "bowling pin"), to name a few.

Post-Rhinoplasty Acne, Frequency and Role Players

Introduction

Acne is a common complain among post rhinoplasty patients. While rhinoplasty is done for aesthetic reasons and acne expressively affects the individual’s appearance, we aimed to study its incidence and role players.

Materials and Methods:

A descriptive cross-sectional study was performed on 152 (143 females and 9 males) patients admitted for rhinoplasty during January 2016 to March 2017. Patients were examined by a dermatologist prior to surgery and 7, 30 and 90 days after rhinoplasty using the Global Acne Grading System and responded to a list of questions on the probable risk factors of acne. Psychological status was examined by the perceived stress scale-14 and the Hospital Anxiety and Depression Scale.

Results:

The patients' mean age was 28.9±3.82 yrs. Mild and moderate acne were observed in 21.7% (n=33) of the cases in the preoperative visit. The incidence of mild and moderate acne was 36.1%, 42.8% and 23% after 7, 30 and 90 days of surgery, respectively. One week after rhinoplasty, acne manifested in 14.9% of cases with no history of acne. Mean age significantly differed between those with and without post-surgical acne at all post-surgical visits (P> 0.001 and P=0.001 and P=0.015, respectively). Hospital anxiety and depression and perceived stress levels were significantly higher in patients who presented with acne on the first post-surgical visit compared to those with no acne presentations (P=0.04 and P=0.02, respectively).

Conclusion:

External psychological stress may be the main role player in post-rhinoplasty acne. Consultation or referral of patients to an experienced psychologist is highly recommended for a better outcome and fewer complications.

Assessment of functional and aesthetic outcomes in septorhinoplasty

PURPOSE

The aim of this study is to review the aesthetic and functional outcomes of septorhinoplasty using questionnaires that have never been collectively used, as well as surgeons' evaluation.

MATERIALS AND METHODS

Our study was conducted prospectively among 100 patients who underwent septorhinoplasty operation. We evaluated the effects of septorhinoplasty's functional and aesthetic outcomes on patients' emotional status using a combination of NOSE, ROE, DAS-24, and GBI questionnaires as well as surgeons' evaluations.

RESULTS

Our study did not detect any significant difference between preoperative and postoperative levels of patient satisfaction with regard to age, sex, and surgery type and the number of surgeries. Our study, on the other hand, revealed significantly higher postoperative GBI scores among patients with higher preoperative DAS-24 and NOSE scores. However, we showed no significant difference between the preoperative ROE score and postoperative GBI score CONCLUSION: This study demonstrated that septorhinoplasty can not only significantly alter a nose's functional and aesthetic appearance, but it can also boost patient satisfaction.

Catgut Versus Polypropylene Sutures for Transcolumellar Incision Closure in Open Rhinoplasty: A Retrospective Cohort Study

Background

Open rhinoplasty, including the transcolumellar approach, is commonly performed as it has fewer side effects and provides superior anatomical control to the surgeons compared to closed rhinoplasty. However, the postoperative scar outcomes, such as scar appearance, vary depending on the type of suture used in wound closure, and the optimal suture type is not firmly established.

Objective

To compare the impact of catgut versus polypropylene sutures on the postoperative transcolumellar scar outcomes and patient satisfaction following open rhinoplasty.

Methods

This retrospective cohort study, including 100 patients who underwent transcolumellar open rhinoplasty, was conducted at otolaryngology department of King Abdulaziz University Hospital, Riyadh, KSA. The patients were divided into two groups: the propylene suture group (group 1), which included 15 males and 35 females with a mean age of 31.5 years and underwent surgery using propylene sutures, and the catgut suture group (group 2), which included 10 males and 40 females with a mean age of 30.5 years and underwent surgery using catgut sutures. The postoperative transcolumellar scar outcomes, as determined by visual analogue scale (VAS) and Stony Brook Scar Evaluation Scale (SBSES) scores, and patient satisfaction, as assessed using a self-assessment scale, were compared between groups.

Results

The scars were unnoticeable in the majority of both groups: 88% in group 1 and 86% in group 2. The VAS and SBSES scores did not significantly differ between groups. Patients' satisfaction rates were also comparable and did not significantly differ between groups (p = 0.341).

Conclusion

Both catgut and polypropylene sutures lead to similar outcomes and patient satisfaction rates in terms of postoperative rhinoplasty transcolumellar scars. Thus, catgut may be the optimal suture for closing transcolumellar incisions following open rhinoplasty.

Treating Symptomatic Midvault Soft Tissue Collapse in Revision Rhinoplasty with a Nasal Wall Implant

Persistent nasal airway obstruction (NAO) due to midvault soft tissue collapse in patients following rhinoplasty or nasal surgery is a clinical challenge for surgeons. An absorbable lateral nasal wall implant is one option available to help treat midvault soft tissue collapse and to improve NAO symptoms. Previous studies have not investigated its use in complex revision functional rhinoplasty with respect to patient-reported outcomes. Data were collected on all patients with a history of previous nasal procedures who underwent Latera implant placement in conjunction with functional rhinoplasty from January to December 2018. The Nasal Obstructive Symptom Evaluation and Visual Analogue Scale were used to evaluate functional outcomes. Eight implants were placed in 6 revision functional rhinoplasty patients with midvault collapse. All patients responded to the survey. Mean follow-up was 16 ± 4 months. There were no implant-related adverse events. Mean Nasal Obstructive Symptom Evaluation score was 33 ± 33, and mean Visual Analogue Scale score was 20 ± 9. In total, 1 patient reported complete resolution of NAO, whereas 2 patients reported mild, 1 reported moderate, 1 reported severe, and 1 reported extreme symptoms. Four of the 6 patients reported nasal obstruction improvement, with all reporting improvement in midvault soft tissue collapse. Apart from being used in nasal valve collapse treatment, a lateral nasal wall implant is a potentially useful solution that may help surgeons improve patients’ NAO symptoms in complex functional rhinoplasty cases. However, in certain cases, a patient’s nasal obstructive symptoms may continue to be multifactorial.

Decision-Making in Middle Vault Reconstruction following Dorsal Hump Reduction in Primary Rhinoplasty

BACKGROUND

Dorsal hump reduction during open rhinoplasty disrupts the continuity between the upper lateral cartilages and the dorsal septum. Options to reconstitute the midvault include primary closure of the upper lateral cartilages to the dorsal aspect of the septum, placement of spreader grafts, and creation of spreader flaps. The authors sought to clarify from highly experienced rhinoplasty surgeons their decision-making rationale for midvault reconstruction, distilling down the group consensus into algorithmic guidelines.

METHODS

A panel of internationally recognized rhinoplasty surgeons participated in a two-part organized communication method. An introductory summit consisted of open discussions on various topics in midvault reconstruction. The summit transcription was analyzed by thematic content analysis to develop a survey encompassing clinical scenarios for primary rhinoplasty, which was then individually administered to each panelist. Data gathered from both parts were used to generate technical guidelines and a decision-making algorithm.

RESULTS

The panelists identified the following anatomical features as pertinent to their selection of midvault reconstruction method: size of the dorsal hump reduction, width of the midvault relative to the upper vault, presence of dorsal angulation, and presence of nasal obstructive symptoms. Individual panelist preference was gathered from the 24-scenario survey divided into either cosmetic or functional rhinoplasty cases.

CONCLUSIONS

Management of the midvault after dorsal hump reduction is important to establish proper aesthetic relationships and to provide functional integrity of the internal valve. Our authors present an algorithmic approach to decision-making based on the systematic analysis practiced by senior rhinoplasty surgeons.

Rhinoplasty Combined With Centrofacial Lipofilling to Optimize Facial Proportions

Background

The perceived appearance of the nose is influenced by its foundations (ie, malar areas, lip, and chin). The association of nasal hump and centrofacial volume deficiency is not uncommon.

Objectives

We evaluated and analyzed the role of centrofacial lipofilling simultaneously to rhinoplasty to sculpt facial proportions and shapes all in one procedure.

Methods

Volumes and placement of fat graft were determined preoperatively. Centrofacial microfat grafting was performed concomitantly to the rhinoplasty. Treated areas were malar, upper lip, pyriform aperture, and chin.

Results

From January 2016 to January 2019, concurrent lipofilling was performed in 23 rhinoplasties. Fat graft volumes ranged from 2 to 31 mL.

Conclusions

Centrofacial lipofilling is a simple and effective tool that can easily be associated with rhinoplasty techniques to optimize the results and may even influence the procedure towards a more conservative approach.

Level of Evidence: 4

3D photogrammetric analysis in hump nose correction based on nasal tip projection without dorsal augmentation in Asian rhinoplasty

INTRODUCTION

Hump nose in Asians should be managed differently in consideration of the lateral profile and the balance between the dorsal height and nasal tip projection. We suggest an alternative approach comprising mild rasping and nasal tip projection using a septal extension graft.

MATERIAL AND METHODS

In this retrospective study, patients who underwent hump nose correction with rhinoplasty between March 2012 and July 2015 were recruited. Instead of applying conventional dorsal augmentation after humpectomy, our approach involved only smooth dorsal contouring in limited cases. 15 patients were evaluated, with surgical outcomes demonstrated using three-dimensional photogrammetry.

RESULTS

Over the postoperative period, hump height decreased (pre 2.77 ± 2.07, post 0.31 ± 0.55, p = 0.001). Regarding the efficacy of tip projection, both nasal tip protrusion (pre 17.64 ± 4.82, post 20.46 ± 4.05, p = 0.001) and tip projection (pre 19.75 ± 4.26, post 21.83 ± 4.17, p = 0.023) were increased. The hump nose reduction ratio was 84.94% after 6 months and 76.47% after 1 year, whereas increases in nasal tip projection and dorsal augmentation were minimal, with ratios of 14.75% and 12.76%, respectively, after 6 months).

CONCLUSION

Therefore, creating a balance between the nasal tip and nasal dorsum in hump nose correction is more important than dorsal augmentation after hump resection in Asians.

Developing Consistency in Rhinoplasty

This invited Special Topic article outlines the authors' evolution and technique to optimize consistent results in rhinoplasty.

Assessment of Wellbeing and Anxiety-related Disorders in Those Seeking Rhinoplasty: A Crowdsourcing-based Study

BACKGROUND

Recently, it has been proposed that psychosocial concerns may motivate the demand for aesthetic rhinoplasty. Although successful operations often improve the quality of life and self-esteem symptoms in patients with sound mental health, they may actually result in unsatisfactory outcomes in those patients with significant depression, anxiety, or other severe psychological disorders. The purpose of this study was to assess the incidence of psychological disorders in patients seeking rhinoplasty.

METHODS

A prospective cross-sectional study of 298 random volunteers was conducted, with each participant completing a survey instrument that was administered through an internet crowd-sourcing service (Amazon Mechanical Turk). Participants were asked to complete a 10-item standardized SHNOS scale, and a 26-question PRIME-MD questionnaire in order to assess functional and aesthetic need for rhinoplasty, and the incidence of psychological disorders respectively.

RESULTS

38.95% of female participants reported a willingness to undergo aesthetic rhinoplasty, with a significantly lower number of men reporting the same (27.78%, P = 0.042). Adults between the ages of 18-24 (52.92%) were more willing to undergo aesthetic rhinoplasty, as compared to any other age group (P < 0.01). It was found that 57.84% of patients interested in surgery reported a psychological disorder as determined by the PRIME-MD questionnaire.

CONCLUSIONS

Those suffering from major depressive disorder, generalized anxiety disorder, or body dysmorphic disorder may seek aesthetic rhinoplasty as a solution. It is important that surgeons assess patient mental health prior to treatment in order to avoid unsuccessful outcomes secondary to psychosocial illness.

How Patient Decision-Making Characteristics Affect Satisfaction in Facial Plastic Surgery: A Prospective Pilot Study

BACKGROUND

The main objective of this study was to prospectively analyze which personality traits, clinical psychiatric states, and patient decision-making characteristics predict who will be less satisfied after facial plastic surgery.

METHODS

This prospective study enrolled 60 adult subjects into one of three groups: aesthetic, functional, and reconstructive facial plastic surgery procedures (n = 20 in each group) from November of 2011 to February of 2016. Self-report surveys of personality traits (i.e., NEO Personality Inventory-Revised), psychiatric state (i.e., Patient Health Questionnaire, Generalized Anxiety Disorder, Health Anxiety Inventory-Short Form), and decision-making characteristics (maximizer/satisficer survey) were given during the preoperative clinic visits. In postoperative follow-up, satisfaction questionnaires at 3, 6, and 12 months were administered. Data analysis examined associations between patient satisfaction, decision-making characteristics, and psychiatric variables.

RESULTS

Bivariate analyses showed that maximizer/satisficer decision-making style was significantly related to patient satisfaction scores in the year following surgery. This difference reached statistical significance at 6 months and remained a strong trend at 12 months. Patients who were less than extremely satisfied at both postoperative time points were more likely to portray the maximizer decision-making style. No other variables were associated with patient satisfaction at any time point. Maximizer/satisficer survey scores were not associated with self-reports of depression, anxiety, or illness anxiety. Mean scores on the maximizer/satisficer survey did not differ among the aesthetic, functional, and reconstructive groups.

CONCLUSIONS

The maximizer/satisficer survey captures an aspect of patient care not traditionally measured by standard clinical psychometric screening tools to help predict satisfaction. A short questionnaire targeting consumer decision-making may be a helpful tool for preoperative counseling.