Nasal Deviation and Facial Asymmetry in Patients Undergoing Rhinoplasty.

BACKGROUND: Existing literature conflicts on whether nasal deviation is primarily attributable to trauma or the result of asymmetric facial development. OBJECTIVES: Establish the prevalence of nasal trauma and facial asymmetry in patients undergoing rhinoplasty. Determine if a correlation exists between the laterality of facial asymmetry and nasal deviation. METHODS: Retrospective review of patients who underwent primary rhinoplasty with the senior author over a 12-month period. Patient charts were reviewed and clinical photographs were analyzed. RESULTS: 144 patients underwent rhinoplasty over the study period. 68 patients underwent revision rhinoplasty and were excluded. Of the 76 patients who underwent primary rhinoplasty, 9% reported prior nasal trauma, 68% had deviated nasal bones, 46% had deviated nasal tips, 70% had asymmetric midfaces, and 36% had deviated chins. In patients without prior trauma history, nasal bones were most commonly deviated towards the side of midface hypoplasia (53%, p=0.008). The nasal tip was most commonly deviated contralateral to the side of septal deviation (59%, p=0.001). There was no association between nasal bone and chin deviation. Nasal tip deviation was not associated with midface hypoplasia or chin deviation. CONCLUSIONS: Nasal deviation is primarily driven by asymmetric facial growth rather than the result of nasal trauma.

Change in Columellar-Philtral and Nasolabial Angles Over Time Following Rhinoplasty.

Preoperative analyses of the columellar-philtral and nasolabial angles (CPA and NLA) are important considerations for the rhinoplasty surgeon. This study aims to quantify and compare the degree of change in nasal tip rotation as measured by CPA and NLA over time following rhinoplasty and to identify surgical maneuvers or patient characteristics that may affect nasal tip rotation. Prospective analysis of CPA and NLA in 111 consecutive, consenting cosmetic, and/or functional rhinoplasty patients of the senior author over a 1-year time period was performed. Angles were analyzed before surgery, immediately after surgery, and at 1 week, 1 month, 6 months, and 1 year following surgery. Subgroup analyses based on surgical maneuvers and other covariates were performed. The greatest change to CPA and NLA in the upright position was 11.8 degrees (95% confidence interval [CI]: 9.8-13.7, p < 0.001) and 9.3 degrees (95% CI: 7.9-10.7, p < 0.001) of elevation 1 week after surgery, respectively. The mean CPA was not significantly different than preoperative measures 6 months after surgery; however, the NLA remained 4.94 degrees (95% CI: 2.1-8.4, p = 0.001) elevated. Females showed approximately 10 degrees more elevated CPA than males in pre- and postoperative time points; however, the NLA did not discriminate between sexes. Transfixion incisions appears to cause a significant decrease in postoperative NLA compared with patient who did not undergo transfixion incisions. Measurements for nasal tip rotation are variable and inconsistent throughout the literature. This study shows that rhinoplasty may have a greater effect on nasal tip rotation as measured by NLA and that the effects of NLA and CPA are independent, signifying that a standardized measurement for nasal tip rotation is warranted.

CUPID Lip Lift: Advanced Lip Design Using the Deep Plane Upper Lip Lift and Simplified Corner Lift.

BACKGROUND: Upper lip lift is achieved with a variety of techniques but many questions remain about the benefits and drawbacks of each technique. The CUPID deep plane or modified upper lip lift procedure has recently been introduced to help mitigate risk and optimize outcomes. OBJECTIVES: The aims of this study were: (1) to better characterize and simplify the complex and artistic decision-making process involved in upper lip lift and corner lip lift; (2) to present a mathematical guide to maintain the natural balance of the upper lip, optimizing muscle function, and to indicate when to add a corner lift; and (3) to elucidate design elements, aging, and future treatment considerations. METHODS: A PubMed (United States National Library of Medicine, Bethesda, MD) search was performed in October 2021 for all journal articles published on upper lip lift and corner lip lifts. The search covered from 1950 to the present day in all languages and without exclusion criteria. Outcomes and the evolution of deep plane upper lip lift design over the last 6 years were analyzed. RESULTS: By following the patterns demonstrated in over 2440 consecutive lip lifts, the authors have been better able to understand the nuances involved in proper design that will avoid acceleration of aging and exaggeration of appearance, and reduce the need for revision while maximizing results. CONCLUSIONS: Upper lip lift design is more complex than most practitioners realize. The mathematical concept described herein makes it possible to obtain more aesthetically pleasing and consistent outcomes. This novel approach to lip lift design enables the practitioner to improve lip balance, facial harmony, and tooth show, and obtain adequate exposure of the lateral vermillion.

Use of Computer Imaging in Rhinoplasty: A Survey of the Practices of Facial Plastic Surgeons.

OBJECTIVE: The objective of this study was to quantify the use of computer imaging by facial plastic surgeons. METHODS: AAFPRS Facial plastic surgeons were surveyed about their use of computer imaging during rhinoplasty consultations. The survey collected information about surgeon demographics, practice settings, practice patterns, and rates of computer imaging (CI) for primary and revision rhinoplasty. For those surgeons who used CI, additional information was also collected, which included who performed the imaging and whether the patient was given the morphed images after the consultation. RESULTS: A total of 238 out of 1200 (19.8%) facial plastic surgeons responded to the survey. Out of those who responded, 195 surgeons (83%) were board certified by the American Board of Facial Plastic and Reconstructive Surgeons (ABFPRS). The majority of respondents (150 surgeons, 63%) used CI during rhinoplasty consultation. Of the surgeons who use CI, 92% performed the image morphing themselves. Approximately two-thirds of surgeons who use CI gave their patient a printout of the morphed images after the consultation. CONCLUSIONS: Computer imaging (CI) is a frequently utilized tool for facial plastic surgeons during cosmetic consultations with patients. Based on these results of this study, it can be suggested that the majority of facial plastic surgeons who use CI do so for both primary and revision rhinoplasty. As more sophisticated systems become available, it is possible that utilization of CI modalities will increase. This provides the surgeon with further tools to use at his or her disposal during discussion of aesthetic surgery. 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 .

Dorsal Augmentation in Rhinoplasty: A Survey and Review.

Understanding the nuanced practices and grafting options of dorsal augmentation will improve outcomes and results in rhinoplasty. To better understand the practices of dorsal augmentation among our colleagues. To review the current literature regarding the indications, safety profiles, and outcomes of different materials used in dorsal augmentation. A PubMed search was performed to capture current articles containing reviews or large series regarding the safety and efficacy of various grafting materials used for dorsal augmentation. Of the many options available, autologous cartilage grafts maintain widespread use for dorsal augmentation and other techniques in rhinoplasty. Homologous cartilage grafts, namely irradiated rib, are a preferred alternative. Irradiated costal cartilage has been shown to have low complication rates and is unique in its abundance of supply, particularly in the revision rhinoplasty. Alloplastic implants, particularly silicone, are prevalent in Asian countries where they are a popular first-line choice. ePTFE has a favorable complication profile in primary rhinoplasty; however, caution is recommended when using ePTFE in revision cases. Porous polyethylene has a higher risk of associated complications than the other alloplastic implants listed, and therefore should be considered thoughtfully. Although cartilage is often the preferred graft for dorsal augmentation, there are many other autogenous, homologous, and alloplastic materials that have been shown to be safe and effective choices when applied in the proper setting.

Avoiding complications of the middle vault in rhinoplasty.

Functional and aesthetic abnormalities of the middle nasal vault are frequent reasons for seeking revision rhinoplasty. Complications in rhinoplasties are inevitable; understanding their etiology can help reduce their occurrence. We will examine the more common sequelae, likely causes, and predisposing factors as well as strategies for prevention.

An anatomic basis for revision rhinoplasty.

As the popularity of rhinoplasty has increased, so have the expectations of both patients and surgeons alike. Revision rhinoplasty has become an evolving field with unique challenges. One must first address the patient's specific concerns and emotional issues. To properly repair the inadequacies of a failed rhinoplasty, the surgeon must thoroughly analyze and understand the anatomic causes leading to why the patient needs revision surgery.

Surgical treatment of the nasolabial angle in balanced rhinoplasty.

Nasal analysis and surgical planning are crucial for a successful, aesthetically pleasing rhinoplasty. One of the key parameters for evaluation is the nasolabial angle. The nasal spine, caudal septum, and medial crura of the lower lateral cartilages provide the framework for this area. Alteration of these structures, as well as nasal tip rotation and projection, may affect the resultant nasolabial angle, length of the upper lip, and overall harmony of the nose. Fullness at the nasolabial junction caused by a pushing philtrum may also result in an unbalanced appearance. The literature is replete with methods for categorizing the nasal tip and with recommendations for surgical treatment. Treatment of the caudal septum and nasal spine is often an afterthought that is left up to the aesthetic judgment of the surgeon. To make this a more systematic decision, in 1990 we devised a classification for analysis and treatment of this area. This study included the length of the nose, the nasolabial angle, and the presence of a pushing philtrum, with suggested treatment to allow proper tip placement and to provide aesthetic balance to the nose. The only modification was in the order of presentation of nasal types. Since that publication, the senior author has consistently followed these guidelines and has found them to be a reliable tool in creating a harmonious result in rhinoplasty.

Nasal valve reconstruction: experience in 53 consecutive patients.

OBJECTIVES: To determine the cause of nasal valve obstruction in a series of patients requiring surgical correction, to evaluate the efficacy of our surgical techniques, and to assess the cosmetic effect of nasal valve repair. METHODS: Retrospective review of 53 consecutive cases involving adult patients who underwent nasal valve reconstruction over an 8-year period. The preoperative symptom severity, cause of nasal valve obstruction, preoperative photographs, anatomical findings at the time of surgery, and reconstructive techniques were reviewed. Postoperative photographs and resolution of symptoms were analyzed. RESULTS: The most common cause of nasal valve obstruction was previous rhinoplasty (79%), followed by nasal trauma (15%) and congenital anomaly (6%). Spreader grafts were used in 42 patients (79%), and alar batten grafts were used in 19 patients (36%). The patients received a minimum of 1 year of follow-up. All 12 patients with external valve dysfunction showed improvement after surgery. Thirteen (93%) of the 14 patients with concomitant external and internal valve dysfunction had improvement in nasal obstruction after treatment. Twenty-four (89%) of 27 patients with internal nasal valve dysfunction reported improvement in nasal obstruction. Spreader grafts caused a widening of the middle third of the nose. Alar batten grafts resulted in effacement of deep alar creases and a widening of the nasal tip. CONCLUSIONS: We have found that surgical correction of nasal valve obstruction is extremely effective in improving subjective nasal obstruction. Success of this procedure is predicated by correct diagnosis and appropriate surgical technique.

Rhinoplasty: panel discussion.

Should one use an open or closed rhinoplasty approach? How appropriate is the endonasal approach in modern-day rhinoplasty? Should the tip lobule be divided or preserved? Are alloplastic implants inferior to autologous implants? Does release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid one-third nasal pinching in reduction rhinoplasty? Over past 5 years, how have rhinoplasty techniques and approaches evolved?

Axial computed tomography evaluation of the internal nasal valve correlates with clinical valve narrowing and patient complaint.

BACKGROUND: The objective of this work was to explore the utility of axial computed tomography (CT) imaging to objectively define a narrow internal nasal valve, and compare those findings with clinical examination and patient complaint. METHODS: Retrospective review from a single facial plastic surgery center. We reviewed 40 consecutive patients evaluated for either sinusitis or nasal airway obstruction for which a CT scan was obtained at a single radiology institution. Thirty-six complete office records were examined for the presence of clinical internal valve narrowing and complaints of nasal obstruction. In total, 72 internal nasal valves were analyzed using axial plane CT and measurements were compared to clinical findings and presence of airway obstruction. RESULTS: Measured valve areas for clinically normal internal nasal valves averaged 0.47 cm(2) vs 0.28 cm(2) for clinically narrow valves, a decrease of 40.4%. In unobstructed nasal airways the valve area averaged 0.51 cm(2) vs 0.38 cm(2) in obstructed airways, a difference of 25.5%. A radiographically measured valve area of <0.30 cm(2) suggests clinical narrowing with a sensitivity of 71.4%, specificity of 88.9%, positive predictive value of 62.5%, and negative predictive value of 92.3%. CONCLUSION: Using standard axial CT imaging we describe an objective method of radiographically evaluating the nasal valve, demonstrating strong correlation with physical examination and patient complaint. Additionally, radiographic valve areas can be used to screen for clinically narrow nasal valves with good sensitivity and specificity, providing a novel straightforward method for nasal valve assessment.

Radix grafts in cosmetic rhinoplasty: lessons from an 8-year review.

We describe our experience with radix augmentation during cosmetic rhinoplasty over an 8-year period using both autologous and synthetic grafts and provide insight into maximizing success. We discuss various surgical considerations, including patient selection, graft materials, and dealing with complications. We focus on our operative technique and provide patient examples.

Functional and aesthetic concerns of patients seeking revision rhinoplasty.

OBJECTIVES: To assess the subjective aesthetic and functional concerns of patients seeking revision rhinoplasty and to compare them with objective deformities found on evaluation by the surgeon. METHODS: This prospective study used a questionnaire to systematically target the aesthetic and functional concerns of 104 consecutive patients seeking revision rhinoplasty. Analysis of the subjective data revealed the frequency of each concern, which was then compared with objective deformities found on evaluation by the surgeon. RESULTS: The most common patient and surgeon aesthetic concerns were (1) tip asymmetry, (2) crooked middle third of the nose, and (3) upper third irregularity. A mean of 79% of patient concerns were also reported by the surgeon. Of the 64 patients describing subjective nasal obstruction, 60 (94%) had objective physical findings related to obstruction. The 3 most troublesome patient concerns were (1) tip asymmetry, (2) difficulty breathing or nasal blockage, and (3) crooked middle third of the nose. CONCLUSIONS: Tip asymmetry was the most common deformity noted. Symptomatic nasal obstruction was the second most frequent reason for seeking revision rhinoplasty. Differences in patient and surgeon findings were largely due to differences in assessment skills and should be addressed by thorough explanation of nasal aesthetics.

Incidence of alarplasty in primary and revision rhinoplasty in a private practice setting.

OBJECTIVE: To evaluate the incidence of alarplasty in primary and revision rhinoplasty during a 3-year period. METHODS: We conducted a retrospective medical record review of patients undergoing primary and revision rhinoplasty between January 1, 2004, and December 31, 2006. Patients were divided into the following categories: primary or revision rhinoplasty, alarplasty, and ethnicity. The incidence of alarplasty was calculated and compared for primary vs revision rhinoplasty and for ethnicity. Statistically significant differences were confirmed using the chi(2) test. RESULTS: A total of 168 patients underwent rhinoplasty with minimum follow-up of 6 months; 116 patients had primary rhinoplasty and 52 revision rhinoplasty. All alarplasties were bilateral. Of 50 alarplasties performed, 35 were in the primary group and 15 in the revision group. The incidence of alarplasty was 30.2% in the primary group and 28.8% in the revision group. Nonwhite patients had a higher overall incidence of alarplasty (63.0%) than did white patients (25.4%). Each ethnic category identified had a higher incidence of alarplasty than the white group. CONCLUSIONS: Alarplasty is an important technique in rhinoplasty. The high incidence of alarplasty in revision rhinoplasty procedures suggests that alarplasty is underused by many surgeons currently performing rhinoplasty. One should consider alarplasty for all patients' noses, not just those of nonwhite ethnic rhinoplasty patients.

Surgical treatment of the nasolabial angle in balanced rhinoplasty.

Aesthetic rhinoplasty is a complex surgical procedure that contains numerous components; when performed harmoniously, it should yield a successful, balanced result. The process begins with a comprehensive nasal analysis and surgical planning. Many surgeons concentrate on altering the nasal dorsum and nasal tip but may ignore potential contributions to overall appearance from the caudal nasal septum and nasal spine. One of the key parameters for evaluation and aesthetic treatment of the nose is the nasolabial angle. The nasal spine, caudal septum, and the medial crura of the lower lateral cartilages provide the framework for this area. Alteration of these structures, as well as nasal tip rotation and projection, may affect the resultant nasolabial angle, length of the upper lip, and overall harmony of the nose. Fullness at the nasolabial junction by a pushing philtrum may also result in an unbalanced appearance. The literature is replete with methods for categorizing the nasal tip and recommended surgical treatments. Treatment of the caudal septum and the nasal spine is often an afterthought that is left to the aesthetic judgment of the surgeon. A chart-with recommended treatment for the caudal septum and nasal spine following appropriate profile analysis-is included in the interest of a more systematic process. The chart takes account of the length of the nose, nasolabial angle, and possible presence of a pushing philtrum with suggested treatments to allow for proper tip placement and aesthetic balance to the nose. Adherence to this process provides a valuable tool for assuring a harmonious result in rhinoplasty.