Doxycycline Sclerodesis-"Rhinodesis"-for Enhanced Soft Tissue Adhesion in Rhinoplasty: A Preliminary Study.

The use of doxycycline as a sclerosing agent is well-established. Given the clinical efficacy of doxycycline sclerosant therapy, we embarked upon a study to evaluate the efficacy of small-volume liquified doxycycline particularly in thick skinned rhinoplasty patients to promote re-adhesion of the nasal skin-soft tissue envelope (SSTE) thereby minimizing surgical dead space and enhancing surface contour, to improve the eventual outcome of surgery.We present two clinical case series using rhinodesis. All patients were treated with the same rhinodesis protocol that included conventional splinting and taping. The first series consisted of 102 consecutive primary rhinoplasties with medium to thick nasal skin treated via open rhinoplasty. Doxycycline solution at a concentration of 20 mg/mL was applied beneath the skin flap using a 14-gauge angiocath inserted through small gaps in the marginal suture line following closure, retained for 2 to 3 minutes, and then expressed from the dead space. Firm manual compression of the SSTE was maintained for at least 1 additional minute, and the splint was then applied. The second series consisted of 25 thick-skinned primary rhinoplasties that were also treated with open rhinoplasty using the same rhinodesis protocol. However, the second group was evaluated with serial postoperative ultrasonography to characterize the soft-tissue response to rhinodesis, particularly within the tip and supra-tip regions.Results revealed enhanced skin adherence in nearly all patients when compared to traditional taping and splinting alone. Ultrasonic examination demonstrated enhanced adherence of the subcutaneous tissue to the nasal framework and suggests that rhinodesis is effective at minimizing dead space in majority of thick-skinned rhinoplasty patients. No complications were observed. Doxycycline can be used easily and safely to seal the surgical dead space post-rhinoplasty and minimize degradation of nasal contour with excellent outcome.

Advanced Preservation Rhinoplasty in the Era of Osteoplasty and Chondroplasty: How Have We Moved Beyond the Cottle Technique?

BACKGROUND: Over the last 10 years, many new papers on innovative strategies from different surgeons worldwide have elevated the philosophy of preservation rhinoplasty (PR) to a different level: advanced preservation rhinoplasty. OBJECTIVES: The goal of this article was to illustrate how 4 experienced surgeons approach important anatomical and functional issues related to PR. METHODS: M.G.F., A.M.K., B.S., and D.M.T. were asked about how they approach classical problems and relative contraindications for dorsal PR with different modern advanced preservation rhinoplasty techniques. RESULTS: The answers of each surgeon make clear a new reality in dorsal PR that did not exist in the recent past. These advances in dorsal PR techniques are due to many surgeons' contributions, leading this practice to a different level: advanced preservation rhinoplasty. CONCLUSIONS: Dorsal preservation is making a dramatic resurgence and is fueled by the many very talented surgeons who are demonstrating outstanding outcomes with preservation techniques. The authors believe that this trend will continue, and a mutual collaboration between structuralists and preservationists going forward will continue to advance rhinoplasty as a specialty.

Preservation Rhinoplasty: Open or Closed?

BACKGROUND: Preservation rhinoplasty (PR) is an evolving philosophy. OBJECTIVES: The open approach was initially utilized, but the author felt a closed approach might be of benefit in certain patients. METHODS: A total 162 primary rhinoplasty cases were studied retrospectively between May and November 2020. One hundred cases had at least 1 year of follow-up. Patients had follow-up at 1 week, 1 month, 3 months, and 1 year after surgery. Technical details were recorded, including dissection planes, preservation of the dorsum (DP) vs component reductions, surface vs foundational DP techniques, and open vs closed approach. RESULTS: One hundred patients had at least 1 year of follow-up. Fifty-six patients underwent an open approach and 44 a closed approach. Eighty-three patients had preservation of the dorsal soft tissue envelope. All patients who underwent a closed approach had preservation of the dorsal soft tissue envelope. Sixty-seven patients underwent DP, with 38 receiving surface techniques and 29 undergoing impaction techniques. Thirty-three patients underwent structural rhinoplasty with piezoelectric osteotomies and mid-vault reconstruction. All structural cases were performed employing an open approach. Four revision surgeries were necessary. CONCLUSIONS: Open and closed approaches have indications depending on the tip and dorsal deformities. A closed PR is favored with thin skin, minimal dorsal modification, osseocartilaginous preservation (foundation techniques), less complex tip deformities, and overprojected noses. An open PR is favored for extensive dorsal modification, S-shaped nasal bones, complex tip deformities, and tip augmentation. Structural dorsal rhinoplasty is always conducted open and preferred for complex dorsal deformities and severe septal deviations.

Optimization of the Soft Tissue Envelope of the Nose in Rhinoplasty Utilizing Fat Transfer Combined with Platelet-Rich Fibrin.

A thin or damaged skin soft tissue envelope may cause concerns in primary and secondary rhinoplasty. During postoperative healing, unpredictable scarring and contraction may occur and lead to significant aesthetic and trophic sequelae. Besides a meticulous surgical technique, there are no reliable techniques to prevent long-term skin damage and shrinkage. Fat transfer with addition of platelet-rich fibrin (PRF) harbors the possibility of local soft tissue regeneration and skin rejuvenation through growth factors and mesenchymal stem cells. It may also facilitate the creation of a thin fat layer on the dorsum to prevent shrink-wrap forces and conceal small irregularities. The goal is to provide evidence for the feasibility, durability, and beneficial effect of diced macrofat transfer bonded with PRF on the nasal dorsum. We present the technique of fat transfer conjugated with PRF as a nasal dorsal graft. Clinical endpoints were the prevention of trophic disturbances and atrophy at a 1-year postoperative follow-up. We present the skin mobility test as a clinical indicator of a healthy soft tissue envelope. The presented case series consists of 107 rhinoplasties. Fat was harvested in the umbilical or costal region. PRF was created by centrifugation of autologous whole blood samples. Macrofat was diced, cleaned, and bonded with PRF. The compound transplants were transferred to the nasal dorsum. There were no perioperative complications or wound-healing issues. Mean follow-up was 14 months. Clinical inspection showed good skin quality and no signs of shrinkage, marked scarring, or color changes with positive skin mobility test in all patients. Survival of fat was confirmed by ultrasonography and magnetic resonance imaging. Diced macrofat transfer in conjunction with PRF to the nasal dorsum is a feasible and safe method. A beneficial effect on the soft tissue envelope is demonstrated as well as the prevention of shrink-wrap forces.

Expanding Indications for Dorsal Preservation Rhinoplasty With Cartilage Conversion Techniques.

BACKGROUND: Preservation rhinoplasty (PR) is a new and evolving philosophy in rhinoplasty surgery. As a surgeon becomes more experienced with preservation concepts, he/she begins to look for new ways to apply PR to an increasing percentage of primary cases. OBJECTIVES: This article presents a series of 100 primary rhinoplasties that underwent dorsal preservation with an emphasis on the cartilage-only dorsal preservation. METHODS: A total of 226 primary rhinoplasty cases were studied retrospectively between July 2017 and August 2018. One hundred cases of dorsal preservation were included in the study. Data was collected in all cases regarding age, gender, ethnicity, and technical details of the operation. These 100 cases fall into the following 3 categories: (1) dorsal preservation employing a subdorsal strip; (2) dorsal preservation utilizing a cartilage-only pushdown with separate bony pyramid modification; and (3) dorsal preservation employing a cartilage reduction method with separate bony pyramid modification. RESULTS: Fifty-seven patients underwent subdorsal strip technique, 39 underwent cartilage-only pushdown technique, and 4 underwent cartilage modification. The average lowering was 4.5 mm (range, 2-10 mm), 2.5 mm (range, 1-3.5 mm), and 2 mm (range, 1-2.5 mm) for the subdorsal strip, cartilage-only pushdown techniques, and cartilage modification technique, respectively. No patients required revision surgery of their dorsum. CONCLUSIONS: PR is a paradigm shift in rhinoplasty. With time, surgeons will find themselves asking in every situation whether they can preserve structures. Dorsal preservation is a reliable technique if patients are chosen properly. With bony cap modification, more dorsums can be preserved and dorsal aesthetics can be improved.

Decision Making in Preservation Rhinoplasty: A 100 Case Series With One-Year Follow-Up.

BACKGROUND: Preservation rhinoplasty (PR) is a new chapter in rhinoplasty history. The term was coined by Daniel in 2018 and represents a fundamental change in philosophy. OBJECTIVES: The aim of this study is to discuss a single-surgeon case series utilizing PR techniques. METHODS: One hundred fifty-three primary rhinoplasty cases were studied retrospectively between December 2016 and August 2017. One hundred cases had at least 1 year of follow-up. Technical details were recorded, including dissection plane, ligament preservation, tip support, lateral crural maneuvers, alar contour grafts, and preservation of the dorsum vs traditional reduction. These 100 cases can be categorized as either complete preservation rhinoplasty (PR-C) or partial preservation rhinoplasty (PR-P). RESULTS: All patients had open rhinoplasty and the average follow-up time was 13 months. All patients had preservation of the dorsal soft tissue envelope, and in 36 the entire soft tissue envelope and ligaments were preserved. Fifty-four had preservation of the alar cartilages. Thirty-one had dorsal preservation. The combinations include: PR-C (skin, dorsum, and alars): 24; PR-P (skin and dorsum): 2; PR-P (alars and dorsum): 2; and PR-P (skin and alars): 7. CONCLUSIONS: In most patients, the dorsal soft tissue envelope and nasal ligaments can be preserved. When possible, the lateral crura should be preserved and tensioning chosen over excision. Dorsal preservation is a versatile technique when proper patient selection is undertaken, and long-term issues with the middle vault and keystone area can be avoided. Some patients will benefit from total preservation where nothing is removed/disrupted and underlying structures are reshaped.Level of Evidence: 4.

Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery.

BACKGROUND: The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal skin and underlying soft tissue. OBJECTIVES: This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures. METHODS: Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi "skin pinch test" was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue. RESULTS: Patients determined to have thin, normal, and thick skin by the "skin pinch test" were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer. CONCLUSIONS: The "skin pinch test" is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively to treat patients with difficult soft tissue envelopes. LEVEL OF EVIDENCE 4.

Rhinoplasty: The Asymmetric Crooked Nose-An Overview.

There are three reasons why the asymmetric crooked nose is one of the greatest challenges in rhinoplasty surgery. First, the complexity of the problem is not appreciated by the patient nor understood by the surgeon. Patients often see the obvious deviation of the nose, but not the distinct differences between the right and left sides. Surgeons fail to understand and to emphasize to the patient that each component of the nose is asymmetric. Second, these deformities can be improved, but rarely made flawless. For this reason, patients are told that the result will be all "-er words," better, straighter, cuter, but no "t-words," there is no perfect nor straight. Most surgeons fail to realize that these cases represent asymmetric noses on asymmetric faces with the variable of ipsilateral and contralateral deviations. Third, these cases demand a wide range of sophisticated surgical techniques, some of which have a minimal margin of error. This article offers an in-depth look at analysis, preoperative planning, and surgical techniques available for dealing with the asymmetric crooked nose.

The Role of Piezoelectric Instrumentation in Rhinoplasty Surgery.

BACKGROUND: In rhinoplasty surgery, management of the bony vault and lateral walls is most often performed with mechanical instruments: saws, chisels, osteotomes, and rasps. Over the years, these instruments have been refined to minimize damage to the surrounding soft tissues and to maximize precision. OBJECTIVES: This article will present the evolution of the authors' current operative technique based on 185 clinical cases performed over an 19-month period using piezoelectric instrumentation (PEI). METHODS: A two-part study of cadaver dissections and clinical cases was performed using PEI. Evolution of the authors' clinical technique and the operative sequence were recorded. RESULTS: Thirty cadaver dissections and 185 clinical cases were performed using PEI, including 82 primary and 103 secondary cases. An extended subperiosteal dissection was developed to visualize all aspects of the open rhinoplasty including the osteotomies. Ultrasonic rhinosculpture (URS) was utilized in 95 patients to shape the bony vault without osteotomies. To date, 11 revisions (6%) have been performed. There were no cases of bone asymmetry, irregularity, or excessive narrowing requiring a revision. CONCLUSIONS: Based on the authors' experience, adoption of PEI is justified and offers more precise analysis and surgical execution with superior results in altering the osseocartilaginous vault. With extensive exposure, surgeons can make an accurate diagnosis of bony deformity and safely contour the bones to achieve narrowing and symmetry of the bony dorsum. Stable osteotomies can be performed under direct vision with precise mobilization and control. As a result of PEI, the upper third of the rhinoplasty operation is no longer shrouded in mystery. LEVEL OF EVIDENCE 4: Therapeutic.

The plunging tip: analysis and surgical treatment.

BACKGROUND: The plunging tip refers to a deformity in which the nasal tip plunges on smiling. OBJECTIVES: To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling. METHODS: Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose. RESULTS: Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip. CONCLUSIONS: This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation.

The osseocartilaginous vault of the nose: anatomy and surgical observations.

BACKGROUND: The dorsal hump and dorsal aesthetic lines have been considered bony and cartilaginous structures. Knowledge of the anatomy of the osseocartilaginous vault is essential for obtaining aesthetically pleasing results of rhinoplasty. OBJECTIVES: The authors described the morphology, embryology, and clinical relevance of the nasal vault and the changes that occur in this area during rhinoplasty. METHODS: Dissections were performed on 15 fresh adult cadavers to examine the anatomy of the osseocartilaginous vault. Intraoperative endoscopic examination of the vault also was performed in 9 rhinoplasty patients before and after dorsal hump reduction. RESULTS: In the cadaver study, the average length of the dorsal keystone area, measured along the dorsal septum, was 8.9 mm, and the average width was 4.9 mm. No significant difference in length was observed between cadaver subgroups with straight or humped nasal profiles. The extent of lateral overlap of the nasal bones with the cephalic portion of the upper lateral cartilages varied. In rhinoplasty patients, the average length of the cartilaginous vault exposed during dorsal reduction was 7.6 mm. CONCLUSIONS: The aesthetic lines and profile of the nose before dorsal reduction are dictated by the cartilaginous vault. After reduction, the dorsal lines are determined by the bony vault edges. In routine rhinoplasty, reduction of dorsal height generally corresponds to removal of the dorsal cartilaginous septum.

Rhinoplasty: the nasal bones - anatomy and analysis.

BACKGROUND: The analysis of nasal anatomy, and especially the nasal bones including the osseocartilaginous vault, is significant for functional and aesthetic reasons. OBJECTIVES: The objective was to understand the anatomy of the nasal bones by establishing new descriptions, terms, and definitions because the existing parameters were insufficient. Adequate terminology was employed to harmonize the anthropometric and clinical measurements. METHODS: A two-part harvest technique consisting of resecting the specimen and then creating a replica of the skull was performed on 44 cadavers to obtain specific measurements. RESULTS: The nasal bones have an irregular, variable shape, and three distinct angles can be found along the dorsal profile line beginning with the nasion angle (NA), the dorsal profile angulation (DPA) and the kyphion angulation (KA). In 12% of cases, the caudal portion of the nasal bones was straight and without angulation resulting in a "V-shape" configuration. In 88% of cases, the caudal portion of the bone was angulated, which resulted in an "S-shape" nasal bone configuration. The intervening cephalic bone, nasion to sellion (N-S), represents the radix while the caudal bone, sellion to r (S-R), represents the bony dorsum. CONCLUSIONS: By standardizing and measuring existing nasal landmarks and understanding the different anatomic configurations of the nasal bones, rhinoplasty surgeons can better plan their operations within the radix and bony and osseocartilaginous vaults.

The plunging tip: illusion and reality.

BACKGROUND: The plunging tip is defined as a nasal deformity where the nasal tip descends or "plunges" during smiling. OBJECTIVE: The authors prospectively measure a series of 25 patients with a focus on the anatomic changes of the nose before and after the patient smiles. METHODS: Twenty-five women who presented for cosmetic primary rhinoplasty and complained of a plunging tip were included in the study. Three angles were measured on lateral view (tip angle, nasolabial angle, and columella inclination angle), along with changes in tip, subnasale, and alar crease. The Simon tip rotation angle (STRA) measured tip position in relation to the static tragus. The alar rim angle measured the angle of the alar rim at the nostril. Changes in static and smiling positions were compared. RESULTS: Tip, nasolabial, and the columella inclination angles decreased between static and smiling positions by 10.9, 11.8, and 11.9 degrees, respectively. Tip position dropped by 0.9 mm, while the subnasale and alar crease junction elevated by 1.3 and 3.7 mm, respectively. The STRA, an angle independent of alar base movement, decreased by less than 1 degree. The alar rim angle increased by 9.9 degrees. CONCLUSIONS: Our data demonstrate that the nasal tip changes its position less than 1 mm with a full smile. The concept of a "plunging tip" is an optical illusion. In reality, the alar crease and subnasale elevate and the alar rim straightens, while the tip position changes minimally. Objectively, the tip moves less than 1 mm and less than 1 degree using the STRA.

Rhinoplasty: the lateral crura-alar ring.

BACKGROUND: Rhinoplasty surgeons routinely excise or incise the lateral crura despite nostril rim retraction, bossa, and collapse. Given recent emphasis on preserving the lateral crura, a review of the lateral crura's anatomy is warranted. OBJECTIVES: The authors quantify specific anatomical aspects of the lateral crura in cadavers and clinical patients. METHODS: This was a 2-part investigation, consisting of a prospective clinical measurement study of 40 consecutive rhinoplasty patients (all women) and 20 fresh cadaver dissections (13 males, 1 female). In the clinical phase, the alar cartilages were photographed intraoperatively and alar position (ie, orientation), axis, and width were measured. Cadaver dissections concentrated on parts of the lateral crura (alar cartilages and alar ring) that were inaccessible clinically. RESULTS: Average clinical patient age was 28 years (range, 14-51 years). Average cadaver age was 74 (range, 57-88 years). Clinically, the distance of the lateral crura from the mid-nostril point averaged 5.9 mm, and the cephalic orientation averaged 43.6 degrees. The most frequent configuration of the axis was smooth-straight in the horizontal axis and a cephalic border higher than the caudal border in the vertical axis. Maximal lateral crura width averaged 10.1 mm. In the cadavers, average lateral crural dimensions were 23.4 mm long, 6.4 mm wide at the domal notch, 11.1 mm wide at the so-designated turning point (TP), and 0.5 mm thickness. The accessory cartilage chain was present in all dissections. CONCLUSIONS: The lateral crura-alar ring was present in all dissections as a circular ring continuing around toward the anterior nasal spine but not abutting the pyriform. The lateral crura (1) begins at the domal notch and ends at the accessory cartilages, (2) exhibits a distinct TP from the caudal border, (3) has distinct horizontal and vertical vectors, and (4) should have a caudal border higher than the cephalic border. Alar malposition may be associated with position, orientation, or configuration.

Rhinoplasty: congenital deficiencies of the alar cartilage.

BACKGROUND: Congenital deficiencies of the alar cartilages are rare and often visible at birth but can occasionally present later. OBJECTIVES: The authors review the anatomical development and discuss the incidence and treatment of congenital defects within the alar cartilages seen in rhinoplasty cases. METHODS: The charts of 869 consecutive patients who underwent open rhinoplasty were retrospectively reviewed, and 8 cases of congenital defects of the alar cartilage within the middle crura were identified. Intraoperative photographs were taken of the alar deformities, and each patient underwent surgical correction. To simplify analysis, a classification of the defects was developed. A division was a cleft in the continuity of the alar cartilage with the 2 ends separate. A gap was a true absence of cartilage ranging from 1 to 4 mm, which can be accurately assessed in unilateral cases. A segmental loss was a defect greater than 4 mm. RESULTS: The 8 cases of deformity could be classified as 4 divisions, 3 gaps, and 1 segmental loss. None of the patients had a history of prior nasal trauma or nasal surgery. Six patients were women and 2 patients were men. In all cases, adequate projection and stability were achieved with a columellar strut. Asymmetry was minimized through concealer or tip grafts. There were no complications. CONCLUSIONS: Surgeons performing rhinoplasty surgery will encounter and should be prepared to deal with unexpected congenital defects of the alar cartilage. These defects within the middle crura will require stabilization with a columellar strut and, often, coverage with a concealer tip graft. We speculate that the cause of these defects is a disruption of the hedgehog signals that may arrest the condensation or block the differentiation of the underlying neural crest cells.

Immunological demyelination enhances nerve regeneration after acute transection injury in the adult rat sciatic nerve.

INTRODUCTION: Our recent experiments demonstrate that demyelination enhances peripheral nerve regeneration after contusion injury in the adult rat sciatic nerve. The role of demyelination in peripheral nerve regeneration in a sciatic nerve transection model has yet to be elucidated. We hypothesize that (1) axon regeneration within a region of injury increases after experimental, immunologic demyelination, and (2) regenerated axons are partially derived from the proximal motor axons. METHODS: Sciatic nerves of adult female Sprague-Dawley rats (n = 20) were injected with a demyelinating agent immediately after transection injury. The sciatic nerves were harvested 1 month (n = 5) and 2 months (n = 5) after surgery. In the control groups, the cut nerves were reapproximated without demyelination therapy. The lesion containing length of nerve was cut into 1-mm transverse blocks and processed to preserve orientation. Specimens were evaluated using structural and immunohistochemical analyses. RESULTS: A single epineural injection of complement proteins plus antibodies to galactocerebroside resulted in demyelination followed by Schwann cell remyelination. At 1 month, remyelination was clearly shown throughout the injured sciatic nerve segment. At 2 months, there was a statistically significant increase in peripheral nerve regeneration following demyelination therapy as evidenced by total axon count, axon density, and fiber diameter. CONCLUSION: This study demonstrates enhanced histomorphologic nerve regeneration in the rat sciatic nerve after local delivery of experimental, immunologic demyelination following transection injury. It highlights the utility of demyelination in peripheral nerve regeneration. This therapy may be applicable for tissue-engineered constructs, cell-based systems, and nerve transfers to improve outcomes in peripheral nervous system injuries.