Evidence-Based Dynamics in Rhinoplasty.

Rhinoplasty is a delicate surgical procedure that requires a thorough understanding of the dynamic interplay between the various structures of the nose. Any changes made to one part of the nose can have downstream effects on the overall harmony and appearance of the nose. For this reason, it is crucial for surgeons to be aware of these potential impacts in order to achieve predictable and aesthetically pleasing results. In this article, we aim to provide a summary of the current evidence-based conclusions on the dynamic influence of the radix, dorsum, tip, and ala during rhinoplasty. By understanding the complex relationships between these structures, surgeons can make informed decisions and achieve the best possible outcomes for their patients.

Chin Dysmorphology in the Primary Rhinoplasty Population: Prevalence, Objective Analysis, and Implications.

BACKGROUND: Chin flaws are far more common than recognized. Denial of genioplasty by parents or adult patients can present a surgical planning enigma, especially in patients with microgenia and chin deviation. This study aims to investigate the frequency of chin imperfections on patients seeking rhinoplasty, review the conundrum they generate, and offer management suggestions based on over 40 years of the senior author's experience. METHODS: This review included 108 consecutive patients presenting for primary rhinoplasty. Demographics, soft tissue cephalometrics, and surgical details were obtained. Exclusion criteria included prior orthognathic or isolated chin surgery, mandiblular trauma, or congenital craniofacial deformities. RESULTS: Of the 108 patients, 92 (85.2%) were female. Mean age was 30.8 years (SD±13, range 14-72). Ninety-seven (89.8%) patients exhibited some degree of objective chin dysmorphology. Fifteen (13.9%) had Class I deformities (macrogenia), 63 (58.3%) Class II (microgenia), and 14 (12.9%) Class III (combined macro and microgenia in the horizontal or vertical vectors). Forty-one (38%) patients had Class IV deformities (asymmetry). While all patients were offered the opportunity to correct chin flaws, only 11 (10.1%) underwent such procedures. Five (4.6%) patients had simultaneous osseous genioplasty (mean advancement 7.8mm, range 5-9mm); 7 (6.5%) received fat grafting to the chin (mean volume 4.4cc, range 1-9cc). CONCLUSIONS: A considerable proportion of primary rhinoplasty patients possess quantifiable chin dysmorphology on circumspect examination, high-resolution photographs and cephalometric analysis. Only a small number agree to surgical interventions that pursue full facial harmony. Potential reasons for these findings, patient aversion, and mitigation strategies will be discussed. 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 .

Frequency, Indications and Intraoperative Dynamics of Repositioning of the Lateral Crura of the Lower Lateral Cartilage: A 35-Year Experience.

BACKGROUND: Lower lateral cartilage repositioning (LLCR) is an effective technique that places the lateral crus in a newly created caudal pocket, and is utilized for a variety of indications including cephalic malposition, alar asymmetries and tip rotation/projection alteration. However, there is a relative sparsity in the literature regarding this procedure and the dynamic changes that it produces. In this study, we report our experience with LLCR in regard to its indications and related interplays. METHODS: Data from our institution were collected from the most recent 100 primary rhinoplasties, most recent 100 secondary rhinoplasties and all LLCRs performed. For each LLCR, patient demographics and concurrent surgical techniques were compiled. A descriptive analysis was performed for all cohorts, while Fischer's exact test was performed to compare the associations of categorical data for the respective sample sizes of the primary and secondary rhinoplasty cohorts. RESULTS: Overall, 127 patients underwent LLCR, with eleven (11%) LLCRs in the primary rhinoplasty cohort and twelve (12%) LLCRs in the secondary rhinoplasty cohort. The most common indication for LLCR was cephalic malposition, followed by over-projection and asymmetry of the lower lateral cartilages. Intraoperative observation of dynamic changes included invariable cephalic rotation of the tip, ability to precisely control the tip projection, drastic narrowing of the domal arch often minimizing the need for the transdomal suture, alar repositioning caudally, correction of alar retraction and more elegant tip definition. However, the external valve lost its strength on majority of LLCR patients, which required almost routine use of Gunter lateral crus strut. CONCLUSION: LLCR is a powerful and versatile tool that can be utilized in either primary or secondary rhinoplasty. Its transposition results in cephalic rotation of the tip, narrowing of the domal arch, caudal reposition of the alar rim and superior tip definition. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266.

The Versatile Role of Fat Injection During Various Genioplasties.

BACKGROUND: Fat injection has become increasingly popular in aesthetic surgery, but there is a sparsity of literature regarding its role during genioplasty. In this study, we present the largest series of patients receiving fat injections to the chin for various indications. METHODS: Data were collected from January 2016 to December 2021 for patients who underwent chin fat injection for a variety of chin refinements. Patients with chin fat injection were divided into isolated genioplasty with fat injection (CF), combined facial and chin fat injection (CFC) and combined chin fat injection and osseous genioplasty (CFG). Complication rates and reoperations were compared using Fischer's exact test between each cohort. RESULTS: 181 patients were included in final analysis, with 14 patients in CF cohort, 130 patients in CFC cohort, 24 patients in CFG cohort, and 13 patients who underwent genioplasty alone. Repeat fat injections were required in 17 (9.4%) patients overall, which included 14 patients (10.8%) of CFC subcohort and three patients (12.5%) of CFG subcohort (p > 0.05). No patients who underwent genioplasty alone or CF required reoperation. There were no significant differences in complications between genioplasty alone group (0%) in comparison to CF (7.1%; p = 1.00), CFC (6.2%; p = .53), or CFG cohorts (7.7%; p = 1.00). CONCLUSION: Fat injection can safely correct minor chin deficiency or asymmetry, as either an isolated procedure or in combination with osteotomies. Additionally, fat injection enables advancement of the caudal segment to achieve superior outcomes by preventing unaesthetic deepening of labiomental groove which will not be advanced during sliding osteotomy. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Common Dorsal Flaws Following Preservation Rhinoplasty: A Systemic Analysis.

BACKGROUND: There has recently been a resurgence of interest in preservation rhinoplasty (PR) for dorsal hump elimination or dorsal projection reduction. However, no studies have scrutinized aesthetic outcomes to identify common pattern of flaws seen in published images to aid those with ardent enthusiasm for this technique to become aware of the frequency of these flaws and find ways to reduce imperfections. METHODS: A systematic literature review was performed using search terms ("preservation" OR "let down", "push down") AND "rhinoplasty" on PubMed, Cochrane, SCOPUS, and EMBASE databases for studies between January 2000 and December 2022. Patient images from these studies were analyzed by three reviewers (MWW, IAC, and BG) for dorsal flaws. Raw interrater agreement percentage and Krippendorff's alpha were calculated to determine interrater reliability. A descriptive and comparative analysis with Fisher's exact test was performed for the aggregate data. RESULTS: There were 59 patient images with 464 views from 24 studies included for final analysis. Optimal dorsal aesthetic lines (DAL) were noted in 12 patients (20.3%), while optimal profile was observed in 15 patients (25.4%) (p = 0.66). Combined ideal front and profile view of dorsum was not observed on any patients. The most common flaws were DAL irregularities (n = 45; 78.0%), dorsal deviation (n = 32, 54.2%), and residual hump (n = 25, 42.4%). There was excellent interrater agreement. CONCLUSIONS: While PR may have some advantages, it has shortcomings in outcomes, particularly dorsal irregularities, dorsal deviation, and residual humps. Awareness of these imperfections may compel those performing this procedure to modify their techniques and improve their results. 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 .

The Logical Sequence of Primary Open Rhinoplasty Founded on the Principles of Rhinoplasty Dynamics.

Rhinoplasty is a perplexing procedure due to the variety of complex interplays between anatomical structures of the nose and the maneuvers used to accomplish the intended objective. Although every rhinoplasty is individualized, having a systematic order and an algorithm is crucial to achieve the designed aesthetic goals and a superior outcome, considering the interactions between maneuvers. Otherwise, the accumulated, unanticipated effects will result in displeasing outcomes due to over or under correction. In this report, we describe the sequential steps of rhinoplasty based on knowledge that the senior author has garnered over four decades of experience and having studied the rhinoplasty dynamics continually. Furthermore, we explain the detailed reasoning for each maneuver based on surgical indications and the resulting interplays.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Exploring the Resurgence of the Preservation Rhinoplasty: A Systematic Literature Review.

INTRODUCTION: The underlying principles of preservation rhinoplasty (PR) center around maintaining the soft tissue envelope, dorsum, and alar cartilage through surgical manipulations and tip suture techniques. In particular, the let-down (LD) and push-down (PD) techniques have been described, although reports of indications and outcomes in the literature are sparse. METHODS: A systematic review of the literature was performed using search terms "preservation" OR "let down" OR "push down" AND "rhinoplasty" on PubMed, Cochrane, SCOPUS, and EMBASE databases. Patient demographic information, operative details, and surgical outcomes were recorded. Sub-cohorts for patients who underwent LD and PD techniques were analyzed utilizing Fischer's exact test for categorical variables and Student's t test for continuous variables. RESULTS: Overall, there were 5967 PR patients in 30 studies in the final analysis, with 307 patients in the PD cohort and 529 patients in the LD cohort. The Rhinoplasty Outcome Evaluation Questionnaire showed a significant increase of patient satisfaction after PR compared to before PR (62.13 vs 91.14; p < 0.001). There was a significantly lower rate of residual dorsal hump or recurrence of 1.3% (n = 4) in the PD when compared to 4.6% (n = 23) in LD cohorts (p = 0.02). The revision rate of PD (0%, n = 0) was also significantly lower than that of LD (5.0%, n = 25) (p < 0.001). CONCLUSION: Based on these published articles, it seems that preservation rhinoplasty is safe and efficacious procedure with improved dorsal aesthetic lines, reduced dorsal contour irregularities, and claimed excellent patient satisfaction. In particular, the PD technique has fewer reported complications and revisions than LD approach, although PD is often indicated in patients with smaller dorsal humps. 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 .

Economizing the Septal Cartilage for Grafts During Rhinoplasty, 40 Years' Experience.

BACKGROUND: During rhinoplasty, it is typically necessary to use cartilage to shape and support the final nasal construct to provide both form and function to the nose (Tanna et al. in Plast Reconstr Surg 141(1):137e-151e, 2018; Guyuron in Plast Reconstr Surg 105(6):2257-2259, 2000; Kim et al. in Ann Plast Surg 65(6):519-523, 2010). The septal cartilage is the ideal graft both for its ease of access and quality of cartilage. However, this graft is a limited resource, and economy of its use is important as to negate the need to harvest cartilage from the ear or rib. THE PURPOSE: 1. To share the senior author's 40 years' experience with the economy of septal cartilage. 2. To identify the areas of the septal cartilage most suitable for a particular graft. 3. To discuss the common grafts that are used in rhinoplasty. 4. To identify when other sources of cartilage are needed and where to best use those grafts. 5. To present option for preservation of the leftover septal cartilage. CONCLUSION: Overall consideration should focus on the size, thickness, and curvature of the graft contemplating the structural and functional needs of the rhinoplasty maneuvers. 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 .

Delayed Septal Perforation as a Complication of COVID-19: A Case Report.

BACKGROUND: There are increasing reports of the effects of SARS-CoV-2 on olfactory function, with a significant number of patients reporting anosmia as a symptom. However, our knowledge and understanding of the virus's complete impact on the nose remains poor. This report describes a unique patient case to demonstrate how COVID-19 may be associated with rhinoplasty complications such as septal perforation. CASE REPORT: This is a case report of a previously healthy patient who underwent septorhinoplasty in 2018. She had frequent follow-up including intranasal examinations without evidence of the septal perforation for the 2 years following her operation. In March 2020, the patient was noted to have symptoms suggestive of COVID-19, but testing was not recommended by the pediatrician. Soon after her symptoms resolved, she experienced a sudden onset of whistling and physical examination revealed a perforation in the septum which rapidly enlarged over the ensuing weeks. She tested positive for the COVID-19 antibody. After confirming that she no longer had an active infection via antigen testing, she underwent repair of her septal perforation without complications. CONCLUSION: This case report illustrates a septorhinoplasty complication that may be associated with COVID-19. Further study into this virus's impact on vascularity and wound healing, specifically in the nose, is recommended. 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.

The Prevalence of Blepharoptosis in Facial Rejuvenation Patient Population.

BACKGROUND: Facial rejuvenation results, commonly seen in publications or national presentations, are fraught with uncorrected eyelid ptosis. This study was conducted to investigate the frequency of blepharoptosis in the rejuvenation population and to help increase awareness in recognizing this under corrected condition. METHODS: Fifty-nine consecutive patients being evaluated for facial rejuvenation were included in the study. Patients who had previous eyelid or forehead surgery, congenital abnormalities, or post-traumatic deformities were excluded. Standard preoperative photographs were obtained. Each photograph was analyzed to determine blepharoptosis by measuring the distance between the upper eyelid margin and the upper limbus in each eye using Adobe Photoshop. Patient age, gender, and race were reported. Ptosis was defined as more than 1.0 mm overlap between the upper eyelid margin and the upper limbus. RESULTS: Mean age was 63.7. Among 59 patients, 34 patients (57.6%) had blepharoptosis and 25 patients did not. Patients with blepharoptosis were likely to be older and male. CONCLUSION: Blepharoptosis becomes more common as patients age due to involution of eyelid and orbital tissue. It is commonly missed due to patient compensation by recruiting the frontalis muscle to lift the eyelids. It is imperative for the patient and the plastic surgeon to be aware of existing blepharoptosis and discuss expectations and formulate a comprehensive surgical plan. Awareness of the high prevalence of ptosis in the facial rejuvenation population allows plastic surgeons to provide better outcomes and higher patient satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Updated Dynamics of Rhinoplasty: A Review of the Literature and Comprehensive List of the Findings.

BACKGROUND: The cardinal reason accounting for the complexity of rhinoplasty is that each maneuver during this operation has both intended and unintended effects. The purpose of this report is to review the literature and update the dynamics of rhinoplasty. METHODS: PubMed searches were conducted for "rhinoplasty dynamics" as well for keywords associated with each specific rhinoplasty maneuver. Titles were evaluated for relevance, and duplicates were consolidated with years of publication 1991 to 2019. Article types include case series (retrospective and prospective), cohort studies, and review articles. RESULTS: Beginning with the radix, its reduction apparently elongates the nose and widens the intercanthal space, while radix augmentation creates the opposite illusions. In a similar manner, dorsal hump reduction widens both the nose and intercanthal space. Nasal tip dynamics focus on the aftermath of changes to tip projection, width, and rotational position. Resection of the upper lateral cartilages can cephalically rotate the tip and reduce tip width. Manipulation of the footplates of the medial crura primarily influences the columella but can also affect tip projection. Placement of a columellar strut firmly establishes tip position. Placement of alar rim grafts advances the ala caudally, widens the nostrils, and elongates the short nostril. Alar base reduction can create the illusion of increased tip projection. Augmentation and reduction in the anterior nasal spine influence tip projection, upper lip length, and the nasolabial angle. CONCLUSIONS: As rhinoplasty techniques continue to evolve, surgeons undertaking this operation must continue to reassess the dynamics of various maneuvers. 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.

Fat Injection: A Systematic Review of Injection Volumes by Facial Subunit.

BACKGROUND: Fat grafting to the aging face has become an integral component of esthetic surgery. However, the amount of fat to inject to each area of the face is not standardized and has been based mainly on the surgeon's experience. The purpose of this study was to perform a systematic review of injected fat volume to different facial zones. METHODS: A systematic review of the literature was performed through a MEDLINE search using keywords "facial," "fat grafting," "lipofilling," "Coleman technique," "autologous fat transfer," and "structural fat grafting." Articles were then sorted by facial subunit and analyzed for: author(s), year of publication, study design, sample size, donor site, fat preparation technique, average and range of volume injected, time to follow-up, percentage of volume retention, and complications. Descriptive statistics were performed. RESULTS: Nineteen articles involving a total of 510 patients were included. Rhytidectomy was the most common procedure performed concurrently with fat injection. The mean volume of fat injected to the forehead is 6.5 mL (range 4.0-10.0 mL); to the glabellar region 1.4 mL (range 1.0-4.0 mL); to the temple 5.9 mL per side (range 2.0-10.0 mL); to the eyebrow 5.5 mL per side; to the upper eyelid 1.7 mL per side (range 1.5-2.5 mL); to the tear trough 0.65 mL per side (range 0.3-1.0 mL); to the infraorbital area (infraorbital rim to lower lid/cheek junction) 1.4 mL per side (range 0.9-3.0 mL); to the midface 1.4 mL per side (range 1.0-4.0 mL); to the nasolabial fold 2.8 mL per side (range 1.0-7.5 mL); to the mandibular area 11.5 mL per side (range 4.0-27.0 mL); and to the chin 6.7 mL (range 1.0-20.0 mL). CONCLUSIONS: Data on exactly how much fat to inject to each area of the face in facial fat grafting are currently limited and vary widely based on different methods and anatomical terms used. This review offers the ranges and the averages for the injected volume in each zone. 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 .

The Super-High SMAS Facelift Technique with Tailor Tack Plication.

BACKGROUND: Super-high superficial musculoaponeurotic system (SMAS) suspension and tailor tack plication are powerful facelift tools used in cases of primary facial rhytidectomy. TECHNIQUE: Thorough pre-operative patient screening and counseling are completed in an outpatient cosmetic surgery center. A super-high SMAS flap is developed by undermining and incising along a line extending from the tragus to lateral canthus and dissecting the SMAS sufficiently to induce movement of the lateral nose and the oral commissure with traction on the SMAS. The SMAS is suspended from the deep temporal fascia using 4-0 Mersilene sutures. Tailor tack sutures are placed strategically in the SMAS caudal to the malar bone to eliminate any residual laxity in the SMAS close to the oral commissures and the cheek area. This is repeated until the laxity of the SMAS is completely eliminated. The orbicularis muscle is conservatively suspended laterally from the deep temporal fascia, facial volume is restored with fat grafting, the neck is contoured, if necessary, and the vest-over-pants platysma overlap technique is commonly utilized. Concomitant forehead rejuvenation, blepharoplasty, and laser resurfacing are extremely common. RESULTS: Of the 72 cases of primary rhytidectomy performed by the senior author on consecutive patients included in the study, there were 64 (89%) female and 8 (11%) male patients. The average age of the patient at the time of primary facelift was 58 years old. Fifteen out of 72 (21%) patients received one dose of desmopressin (DDAVP) injection during the surgery, and one patient received DDAVP the day after surgery to maintain hemostasis. There was no incidence of facial nerve injury. Of those 72 cases, 3 (4%) developed minor hematomas that were resolved by aspiration. There were no expanding hematomas that required surgery. Of the 26 patients whose satisfaction was documented, 24 were very satisfied. Two patients expressed their dissatisfaction with the results, and one of these patients underwent a revision operation by the senior author. The other patient was mainly not pleased with the recovery duration. CONCLUSION: An alteration in the SMAS elevation and suspension is described with strategic submalar plication, providing a powerful technique for primary facial rhytidectomy that offers reliable and significant malar lift, orbicularis suspension, improvement in jowls, and repositioning of the oral commissure. The technical details are demonstrated through complete video segments along with many nuances that make delivery of optimal and natural outcomes possible, while maintaining the normal anatomy. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Cartilage Warp Prevention Suture.

BACKGROUND: Costal cartilage graft warping can challenge rhinoplasty surgeons and compromise outcomes. We propose a technique, the "warp control suture," for eliminating cartilage warp and examine outcomes in a pilot group. METHODS: The warp control suture is performed in the following manner: Harvested cartilage is cut to the desired shape and immersed in saline to induce warping. A 4-0 or 5-0 PDS suture, depending the thickness of the cartilage, is passed from convex to concave then concave to convex side several times about 5-6 mm apart, finally tying the suture on the convex side with sufficient tension to straighten the cartilage. First an ex vivo experiment was performed in 10 specimens from 10 different patients. Excess cartilage was sutured and returned to saline for a minimum of 15 min and then assessed for warping compared to cartilage cut in the identical shape also soaked in saline. Then, charts of nine subsequent patients who received the warp control suture on 16 cartilage grafts by the senior author (BG) were retrospectively reviewed. Inclusion of study subjects required at least 6 months of follow-up with standard rhinoplasty photographs. Postoperative complications and evidence of warping were recorded. RESULTS: In the ex vivo experiment, none of the 10 segments demonstrated warping after replacement in saline, whereas all the matching segments demonstrated significant additional warping. Clinically, no postoperative warping was observed in any of the nine patients at least 6 months postoperatively. One case of minor infection was observed in an area away from the graft and treated with antibiotics. No warping or other complications were noted. CONCLUSION: The warp control suture technique presented here effectively straightens warped cartilage graft and prevents additional warping. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Horizontal Forehead Lines: A Reflection of Eyelid Ptosis or Blepharodermachalasia.

BACKGROUND: In his facial aesthetics practice, the senior author (B.G.) observed that many patients presenting with horizontal forehead lines also demonstrated upper eyelid ptosis or enough blepharodermachalasia to require compensation. This study was conducted to investigate this observation. METHODS: Photographs of patients presenting for facial rejuvenation were retrospectively reviewed for the presence of forehead lines, ptosis, brow ptosis, and blepharodermatochalasia. Patient age, gender, and race were reported. Only patients over age 50 were included. Patients who had previous eyelid or forehead surgery, congenital abnormalities, or post-traumatic deformities were excluded. Ptosis was defined as more than 1.5-mm overlap between the upper eyelid and the iris. Patients were divided into two groups based on presence of forehead lines for comparative analysis. RESULTS: One hundred sixty patients, including 100 patients with and 60 patients without horizontal forehead lines, were included. Patients with forehead lines were likely to be older (age 61.56 ± 8.93 vs. 58.58 ± 7.59; P = 0.0337), male (36 vs. 11.67%; P = 0.0008), have ptosis (90 vs. 76.67%; P = 0.0377), and have blepharodermatochalasis (20 vs. 5%; P = 0.0097). All 28 patients with unilateral forehead lines (17 left, 11 right) had ipsilateral ptosis. CONCLUSIONS: Ptosis and blepharodermatochalasis may result in the development of horizontal forehead lines through compensatory frontalis activation. Whenever horizontal forehead rhytids are noted, it is imperative to search for ptosis or blepharodermachalasia in repose. Otherwise, forehead rejuvenation may fail to eliminate these compensatory forehead lines, and chemodenervation may have significant adverse effects on the visual field by forcibly blocking frontalis compensation. 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 .

Neck Contouring Without Rhytidectomy in the Presence of Excess Skin.

BACKGROUND: Patients with severe neck skin laxity due to excess submental adipose tissue have required either standard rhytidectomy or direct excision of neck skin with Z-plasty and submental lipectomy. Our recent experiences with four patients who declined cervicofacial rhytidectomy demonstrate that submental lipectomy and platysmarrhaphy appear to obtain sufficient improvement. METHODS: The submental area, submandibular area, and lateral neck are injected with local anesthetic. An incision is made in the submental area anterior to the existing crease, and the incision is taken through the subcutaneous tissue to the underlying fat. The skin is undermined in the deep subcutaneous plane. The lateral fat that cannot be visualized directly is suctioned using a number 2 cannula. Supra-platysmal and subplatysmal excess fat are excised under direct vision. The anterior bellies of the digastric muscle are excised partially or completely to obtain a flat contour if necessary. The submaxillary gland is partially or totally removed as indicated. The platysmarrhaphy is performed, and a TLS drain is placed in position and brought out through the left post-auricular sulcus using the attached trocar. The submental incision is then closed without skin excision. RESULT: Non-excisional surgical neck rejuvenation was performed on four patients with significant skin laxity. There was adequate improvement in the cervicomental angle and neck profile contour in all patients, indicating that significant improvement may be achieved without skin excision. CONCLUSION: Patients with excess skin can achieve acceptable results with submental lipectomy and platysmarrhaphy without rhytidectomy or direct excision of neck skin. 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 .

The Incidence of Psychiatric Medication Use and Its Effect on Intraoperative Bleeding in Facial Cosmetic Patients.

PURPOSE: Psychiatric medications, particularly the selective serotonin reuptake inhibitors, have been associated with increased surgical bleeding. This study aims to compare intraoperative surgical bleeding between cosmetic surgery patients who are and are not taking psychiatric medications. METHODS: The charts of 392 consecutive patients who underwent cosmetic facial surgery at the senior author's practice were reviewed. Independent variables included self-reported psychiatric history, psychiatric diagnoses, and psychiatric medications as documented in the preoperative history and physical examination. The primary endpoint was administration of desmopressin (DDAVP), our proxy for increased surgical bleeding. Significant predictors of these endpoints were determined via Chi-squared testing. RESULTS: One hundred and seventeen patients had a psychiatric diagnosis (30%), and 129 patients were taking some class of psychiatric medication (33%). Seventy-two patients received DDAVP (18%). A psychiatric diagnosis did not predict DDAVP administration (14.3% for patients with a psychiatric diagnosis vs. 20.88% for those without, p = 0.14). The use of a psychiatric medication was not associated with DDAVP administration (14.7 vs. 21%, p = 0.14). Male gender significantly predicted DDAVP administration (27.8 vs. 16.9% for females, p = 0.04). CONCLUSION: The use of psychiatric medications does not predict increased intraoperative surgical bleeding. This is useful given the prevalence of psychiatric medication use among this patient population and obviates the need for discontinuation of these medications, which otherwise could be consequential. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Interface Between Cosmetic and Migraine Surgery.

This article describes connections between migraine surgery and cosmetic surgery including technical overlap, benefits for patients, and why every plastic surgeon may consider screening cosmetic surgery patients for migraine headache (MH). Contemporary migraine surgery began by an observation made following forehead rejuvenation, and the connection has continued. The prevalence of MH among females in the USA is 26%, and females account for 91% of cosmetic surgery procedures and 81-91% of migraine surgery procedures, which suggests substantial overlap between both patient populations. At the same time, recent reports show an overall increase in cosmetic facial procedures. Surgical techniques between some of the most commonly performed facial surgeries and migraine surgery overlap, creating opportunity for consolidation. In particular, forehead lift, blepharoplasty, septo-rhinoplasty, and rhytidectomy can easily be part of the migraine surgery, depending on the migraine trigger sites. Patients could benefit from simultaneous improvement in MH symptoms and rejuvenation of the face. Simple tools such as the Migraine Headache Index could be used to screen cosmetic surgery patients for MH. Similarity between patient populations, demand for both facial and MH procedures, and technical overlap suggest great incentive for plastic surgeons to combine both. 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 .

An Effective Algorithm for Management of Noses with Thick Skin.

BACKGROUND: Thicker nasal skin blunts the definition of the underlying osseocartilaginous frame and the delicate topography of the nose posing additional challenges in producing desirable tip definition. Despite the recognized challenge in this patient population, there is a paucity of literature on how to overcome this problem. PURPOSE: The goal of this article is to provide a systematic algorithm to manage patients with thick nasal skin. METHOD: Approach to the thick nasal skin patient begins with an evaluation of the etiology of their skin thickness. Skin thickness secondary to sebaceous overactivity is diminished with the use of retinoic acid derivatives, lasers or isotretinoin (Accutane), commonly under the advice of the dermatologist. Rhinoplasty maneuvers include open technique, raising a healthy and reasonably thick skin flap overlying the tip, removing the remaining fat overlying and between the domes, creating a firm cartilaginous frame and eliminating dead space using the supratip suture reported by the senior author, and trimming redundant nasal skin envelope when indicated. CONCLUSION: This systematic approach has been greatly effective in achieving often predictable and aesthetically pleasing rhinoplasty results. 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 .

Effects of the Rhinoplasty Maneuvers on Upper Lip Position and Incisor Show.

BACKGROUND: Smiling involves dynamic movements that include nasal tip descent and upper lip ascent. The effect of rhinoplasty on upper lip position is poorly described. METHODS: One hundred charts were reviewed in reverse chronologic order. Inclusion criteria were receiving one of the rhinoplasty maneuvers of interest, at least 6 months of follow-up, and pre- and postoperative photographs by a professional medical photographer with matching maximum smile extent and size. Maxillary incisor show was measured as the vertical distance between the caudal border of the upper lip and the caudal-most aspect of maxillary central incisors. Pre- and postoperative maxillary incisor show was compared by open versus closed approach and rhinoplasty maneuver with and without controlling for depressor septi nasi (DSN) release. RESULTS: Sixty-one females and fifteen males with a mean age of 39 years and mean follow-up of 16 months were included. No significant differences were seen between open versus closed approaches (p > 0.05). A decrease in postoperative maxillary incisor show was observed following columella strut, extended spreader graft, and DSN release (p < 0.05). No significant change in maxillary incisor show was seen after nasal spine graft, maxillary augmentation, tip rotation suture, shield graft, columella retraction, or tip suspension suture (p > 0.05). Patients undergoing footplate approximation and alar base resection had a significant decrease in maxillary incisor show (p < 0.05), but this significance was lost upon controlling for DSN release (p > 0.05). CONCLUSION: Certain caudal rhinoplasty maneuvers may result in decreased maxillary incisor show, particularly when the DSN muscles are involved. Examination of upper lip position and patient discussion is important for maximizing outcome. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .