Nuances in component nasal hump reduction.

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

Facial aesthetic surgical goals in patients of different cultures.

The purpose of facial aesthetic surgery is to improve the patient's psychological well-being. To achieve this, the surgeon must understand the patient's body image and their aesthetic and psychological expectations. These factors must be judged in the context of their cultural background. The patient's cultural values must also be understood to optimize the doctor-patient relationship.

Refining the nasal tip-an anatomical approach.

Surgical strategies to refine the nasal tip should be conceived to address the lobule rather than just the domal extremity of this aesthetic region. The goal should be to create normal, stable anatomy. The anatomy of the tip cartilages is complex. Surgical strategies must consider the size, shape, position, and orientation of each crus including their relationships with the ipsilateral and contralateral crura of both lower lateral cartilage rings. Every surgical step has the potential for unintended as well as intended change. We favor as a first step fixation of the medial and lobular segments of the middle crura. The domes and lateral crura can then be addressed on a stable base. Suture placement must be precise with excess tightening avoided to prevent nonanatomical twists of the tip cartilage ring in part or whole. Consideration must be given to structural grafts to brace the crura and to correct convex lateral crura. These grafts should be incorporated within or deep to the tip cartilage framework to minimize visibility. It is the, contour, position, and orientation of the caudal margins of the middle and lateral crura which we think are a key component in achieving natural tip refinement.

Current approaches to septal saddle nose reconstruction using autografts.

PURPOSE OF REVIEW: To describe the contemporary techniques used for septal saddle nose and, based on these, present our approaches for correction of a spectrum of deformity severities. RECENT FINDINGS: A review of different techniques currently in practice. These reflect greater emphasis on nasal structural framework repair rather than disguise and the use of autografts rather than allografts. SUMMARY: We present our classification of septal saddle deformity, demonstrating that this condition requires a flexible surgical approach with different techniques required depending on the extent of the defect.

Special considerations in northern European primary aesthetic rhinoplasty.

Primary aesthetic rhinoplasty in Northern European females presents particular challenges and pitfalls that the rhinoplasty surgeon needs to be aware of. The authors completed a prospective study of 57 consecutive female patients of Northern European descent who underwent primary aesthetic rhinoplasty, with a minimum of 18 months follow-up. The anatomic features and operative techniques used are presented. Pitfalls that make classical steps of reduction rhinoplasty inappropriate are discussed and illustrated by case reports. Attention is drawn to (1) the dorsal hump with an overprojected tip, (2) the enlarged anterior nasal spine and/or posterior septal angle and strong depressor septi nasi muscle, (3) the dorsal hump tension nose, and (4) the bulbous nasal tip with lateral crus recurvature. The authors emphasize the need to maintain structure in the nose to secure middle third and tip support while achieving a balance between dorsal projection and tip position. The limitations and risks of each surgical step versus their potential benefit must be balanced. The surgeon must diligently manage patient expectation and in this population explain that achieving a better nasal shape may take precedence over size reduction.

Reconstruction of the nasal septum using perforated and unperforated polydioxanone foil.

OBJECTIVE: To present our experience of reconstruction of the nasal septum using perforated and unperforated foils, particularly with respect to functional and aesthetic sequelae. METHODS: A retrospective medical record review of a prospectively conducted case series was undertaken of all consecutive patients who underwent septal reconstruction using polydioxanone foil in a 4-year period. Procedures included septorhinoplasty and isolated septoplasty via external and endonasal approaches using corporeal and extracorporeal techniques. The polydioxanone foils were in battens or sheets. RESULTS: Fifty patients underwent septal reconstruction using unperforated (first 26 patients) or perforated (next 24 patients) polydioxanone foil. Median total postoperative follow-up was 51.5 months (range, 34-60 months) for unperforated foil and 20.5 months (range, 12-31 months) for perforated foil. All the patients were reviewed for assessment of appearance and function. Forty-three patients had satisfactory results, needing no further treatment. Three patients required minor septal or tip revision surgery. Four patients experienced moderate saddling of the dorsum (all involved unperforated polydioxanone foil) and underwent successful revision surgery using auricular cartilage grafts. CONCLUSIONS: Synthetic materials are a useful alternative to autologous tissues during reconstruction of the nasal septum. To our knowledge, we present the largest single-center series of septal reconstructions using unperforated and perforated polydioxanone foils-shown to be useful in the correction of complex septal deformity. However, the unperforated form seems to be associated with a significant risk of postoperative saddling, and we warn against its use in this context. No such complications were observed with the use of thin, 0.15-mm perforated polydioxanone foil, which we exclusively recommend for this application. The use of this implant warrants further evaluation.

Surgeon radiation exposure in ESS with balloon catheters.

OBJECTIVE: Less invasive instruments such as balloon catheters are available for sino-ostial dilation during endoscopic sinus surgery (ESS). Currently, balloon catheter position is confirmed under fluoroscopic visualization. Radiation exposure has been an area of concern. This study was initiated to determine surgeon radiation exposure when fluoroscopy is used during ESS with balloon catheters. STUDY DESIGN: A multi-center, prospective evaluation of surgeon radiation exposure was conducted. SUBJECTS AND METHODS: For three months, 14 sinus surgeons wore dosimeters to record radiation exposure while using C-arm fluoroscopy during balloon catheter-aided sinus surgery. One dosimeter was placed at collar level (chest), outside the lead apron and another dosimeter was placed on a finger (extremity). These dosimeters were sent for readings. Deep, eye, and shallow radiation dose for each surgeon was calculated. RESULTS: Thirteen chest badges recorded annualized averages of 191.08, 193.54, and 187.69 mrems for deep, eye, and shallow exposure respectively. Eleven ring badges recorded 584.00 mrems. CONCLUSIONS: A recent publication reported low levels of surgeon radiation exposure during ESS with balloon catheters. This study validates radiation exposure among experienced surgeons is well below the annual occupational radiation exposure limit of 50,000 mrem. With vigilant technique and education, fluoroscopy reliance can be minimized.

Assessment of predictive prognostic factors for functional endoscopic sinus surgery in a 5-year prospective outcome study.

BACKGROUND: Among numerous studies in the literature regarding prognostic factors that might determine outcome in functional endoscopic sinus surgery (FESS), very few have dealt with assessment of their predictive potential regarding outcome, and none have tried to find out the extent of such a prediction. We have developed a composite model to find out the predictive values of various prognostic factors, using an outcome measure based on the need for postoperative medical intervention. METHODS: One hundred nine patients were recruited for FESS and followed up at regular intervals for 5 years. Ten prognostic factors were identified and were correlated with prospectively recorded outcome measures. A discriminant analysis using SPSS software was performed to identify the prognostic factors that could "predict" the outcome. RESULTS: CT scan scores and polyp scores were the strongest predictors. Using our model, the probability to predict correctly the need for postoperative systemic medication was found to be 81.7%. CONCLUSION: We have generated a model to predict the outcome of FESS, with a 5-year follow-up. CT scan scores and polyp scores were found to be the strongest predictors of the need for postoperative systemic medication.

Infections and foreign bodies in the ear, nose and throat.

Infections of the ear, nose and throat are common and may threaten life. Intracranial complications may arise from infections of the ear and paranasal sinuses. Orbital complications (loss of vision) may arise from infection of the paranasal sinus. Respiratory embarrassment may result from infections of the upper aerodiogestive tract. The clinical presentation, implications and management of foreign bodies in the ear, nose and throat depend on the nature of the foreign body and the site at which it becomes lodged.

Functional endoscopic sinus surgery: 5 year follow up and results of a prospective, randomised, stratified, double-blind, placebo controlled study of postoperative fluticasone propionate aqueous nasal spray.

One hundred nine patients with chronic rhinosinusitis underwent functional endoscopic sinus surgery. Seventy seven patients had polyposis. The population was studied prospectively for 5 years postoperatively. Seventy two patients attended the 5 year follow-up visit. At 1, 2, 3, 4 and 5 years of follow-up all outcome measures except olfactory detection thresholds (visual analogue scores, endoscopic findings, nasal mucociliary clearance times, total nasal volumes) were significantly improved compared to preoperative baseline values. Olfactory detection thresholds were significantly improved at 1 and 2 years postoperation. Patient symptom scores were improved in a greater percentage of patients than more objective outcome measures. Thirty eight patients required a total of 88 postoperative rescue medication courses with prednisolone and antibiotic. Twelve patients failed the study as they required at least 1 rescue medication course a month for 2 consecutive months. We demonstrated an 89% 5 year "survival" rate with regards to the risk of failure. The patients were also entered into a randomised, stratified, prospective, double-blind, placebo controlled study of fluticasone propionate aqueous nasal spray 200 mcg twice daily, commencing 6 weeks after FESS, with a 5 year follow-up. The change in overall visual analogue score was significantly better in the FPANS group at 5 years. The changes in endoscopic oedema and polyp scores and in total nasal volumes were significantly better in the FPANS group at 4 years but not 5 years. Last value carried forward analysis demonstrated that changes in endoscopic polyp score and in total nasal volume was significantly better in the FPANS group at 5 years. Significantly more prednisolone rescue medication courses were prescribed in the placebo group. Of the 12 patients who failed the study, 10 were in the placebo group. This difference nearly achieved significance.

Acute and chronic infections of the ear, nose and throat.

The article focuses on infections that present with external signs, require surgery and carry the risk of life-threatening complications. This contribution looks at the infections of the ear, nose, oral cavity and neck.

Assessing outcome in aesthetic rhinoplasty.

In the measurement of outcome, rhinoplasty surgery suffers from the lack of easily calculable data such as recurrence rates or survival figures, which are inherent in other branches of the speciality and surgical practice in general. We have reviewed methods utilized for the assessment of outcome following aesthetic rhinoplasty, and have developed an instrument by which a pre- and postoperative assessment of nasal and facial appearance can be made from standard frontal, lateral, basal and oblique photographs, the Rhinoplasty Assessment Scale (Photographic) (RASP). It is our intention that this will act as a template for methodical and standardized photographic assessment of the nose prior to rhinoplasty. This will highlight the changes required and provide a quantitative measure of nasal aesthetics, which will be complimentary to existing measures of subjective patient benefit.