Hybrid Chin Advancement: Combining Fat and Sliced Cartilage Grafts for Chin Augmentation During Rhinoplasty.

BACKGROUND: Facial balance significantly impacts aesthetics, particularly in the middle and lower thirds. Patients with chin retrusion often benefit from sagittal plane chin advancement in rhinoplasty, enhancing surgical outcomes and satisfaction. OBJECTIVES: This article presents a method for analyzing chin deformities and discusses a hybrid treatment approach to harmonize facial features, complementing rhinoplasty. METHODS: The chin positions of patients treated by the senior author were assessed. A retrospective analysis included 49 patients with chin retrusion of 2.5-6 mm. Among them, 22 patients initially offered chin implants declined, leading to planned chin augmentation. Fat grafting was exclusively performed for 20 patients lacking sufficient cartilage. The "Hybrid Chin Advancement" technique involved supporting tissues beneath muscles with nasal septum cartilage and fat injections and tissues above muscles with fat injection alone. RESULTS: Pre- and postoperative Legan angle measurements and chin advancements were compared across three groups. While preoperative Legan angles were statistically similar, postoperative Legan angles and advancement changes were significantly higher in the implant group (p < 0.0001). Comparing hybrid chin advancement and fat grafting groups, postoperative Legan angles and advancement changes were significantly higher in the hybrid chin group (p < 0.0001). CONCLUSIONS: Fat grafting suffices for mild advancements (~ 2 mm), while the hybrid chin method is effective for moderate advancements (~ 4 mm). For advancements exceeding 6 mm, implants or osseous genioplasty are optimal. Our study's hybrid approach offers an easy, safe, and reliable method for achieving facial harmony in the lower two-thirds without compromising patient expectations. 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 .

Counter Autografting of Dorsal Septum in Crooked Nose.

INTRODUCTION: The nasal septum plays an important role in nasal form and function. In this study, we describe a novel, alternative septoplasty approach that results in an aesthetically acceptable dorsal profile and improves airway function in patients with a crooked nose. PATIENTS AND METHODS: This study enrolled 26 patients who presented with crooked noses between 2012 and 2017. All patients underwent open rhinoplasty under general anesthesia. During correction of the cartilaginous part, a dorsal strip from the deviated septum was prepared and inverted in a 180° fashion to exert a counter-force to correct the remaining septum and fixed by suturation. This maneuver allowed application of the maximum possible force in the opposite direction to reset the deviation by its own force. RESULTS: The approach was used successfully in 26 patients with severe nasal septal deviations in the caudal septum and dorsal angulation of the nasal shape. There was no case of hematoma, synechia, septal perforation, dorsal irregularity, or saddle deformity. Temporary nasal obstruction occurred in 4 patients but improved in all of them by the third postoperative month. One patient had a recurrence of the septal deviation, dorsal angulation, and persistent nasal obstruction, which were treated by revision nasal valve surgery 14 months postoperatively. There was no subsequent recurrence during the long-term follow-up. The improvement between the preoperative and postoperative 12-month deviation angle measurements, Nasal Obstruction and Septoplasty Effectiveness (NOSE) scores were significant (P < 0.05), Improvement in the NOSE score correlated strongly and significantly with deviation angle changes and patient satisfaction. CONCLUSION: Our counter-autografting technique in septoplasty is safe and effective in the correction of severe dorsal and/or caudal deviations, as long as the severely angulated cartilage septum remains in one piece after careful dissection. 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 .

Caudal Septal Support Versus Strut Graft in Achieving the Desired Lateral Profile in Rhinoplasty.

Nasal tip support is critical to achieve a lasting result in rhinoplasty. In this article, the authors compared the effects of strut grafts (SG) and caudal septum-based nasal tip supporting techniques (CSB-T) in terms of reaching the desired tip projection.Included in this study were 40 patients (24 women and 16 men) who underwent primary open rhinoplasty via transcolumellar incision between January and June 2012. To achieve a good nasal projection, SG and CSB-T were used for 15 and 25 of these patients, respectively.Certain anatomic landmarks were identified on preoperative, simulative, and 1-year follow-up photos. With these landmarks, certain angular and proportional values were calculated.In the SG, the authors found no statistically significant difference in between simulative goals and postoperative results regarding bending angle. Postoperative nasolabial angle (NLA), tip angle, subnasal-tip/subnasal-radix (SnT/SnR) ratios were significantly lower than the simulation values; radix angle and supratip index values were significantly higher.In the CSB-T group, the authors found no statistically significant difference in between preoperative values and postoperative results regarding NLA, tip angle, bending angle, (SnT/SnR) ratio values. Postoperative supratip index and radix angle measurements were found to be significantly higher than the simulation values.With these findings, the authors concluded that CSB-T support is superior than the SG for supporting the nasal tip in noses that also need shortening in caudal length. In noses that do not need caudal shortening, nasal tip projection can again be supported by the caudal septum by just forming a bridge between lower lateral cartilage and quadrangular septum using a wider SG that mimics septal extension grafts.

Preoperative Simulation in Planning Rhinoplasty: Evaluation from Patients' and Surgeons' Perspectives.

Among aesthetic surgery procedures, rhinoplasty is one of the most common. Preoperative simulations have become increasingly commonplace through the recent years along with a controversy regarding their use. Although capable of building a solid rapport between the surgeon and the patient by visualizing the end result, it can also prove to be a liability for a surgeon who is not confident about delivering the result which has been put on screen. The objective of this study is to evaluate the outlook of the surgeons and patients on preoperative simulations. Plastic surgeons who perform rhinoplasty and individuals who consider rhinoplasty were surveyed via an online questionnaire system. Their opinions about the practice of simulation were questioned and they were asked to distinguish between simulated and actual postoperative results. Statistical analyses were performed using SPSS software. Major factors influencing the decision-making process of patients were the availability of preoperative simulation, being shown appealing results of the surgeon's previous work and a personal reference from a patient with an appealing result. Within the health care professionals, it has been observed that experienced surgeons are more confident about using simulations, while inexperienced ones are daunted by being bound with a visual contract (p < 0.05). However, it has been noted that the preference of withholding the simulation or providing a copy to the patient was similar in all experience levels (p > 0.05). In conclusion, our findings suggest that the patients' self-consciousness regarding preoperative simulations seem to grow faster than the surgeons' confidence in their use. Level of evidence is Level V.

Auto-Rim Flap Technique for Lateral Crura Caudal Excess Treatment.

BACKGROUND: There are many variables that influence nose tip harmony. Even in a rhinoplasty that appears successful in profile, one may see nostril asymmetries, alar retractions, or irregularities in the soft triangle, and patients express their dissatisfaction with these simple deformities. OBJECTIVES: In this study, we define the ratio of caudal and cephalic excess of the lower lateral cartilage. We evaluate whether it is possible to eliminate nostril asymmetries and alar retractions by means of supporting the facet polygon with the help of a lower lateral cartilage auto-rim flap, a technique we have developed in our rhinoplasties. METHODS: The auto-rim flap was used successively on 498 primary rhinoplasty patients on whom the same surgeon operated between May 2013 and June 2015, performing marginal incisions. RESULTS: Of the 498 patients in the series, only 1 of the first 10 required a revision due to tip asymmetry related to the auto-rim flap. A minimal nostril asymmetry that did not require intervention occurred in 10 patients. In none of the patients could an increased alar retraction be seen postoperatively. All patients exhibited alar cartilage in the anatomically correct position. CONCLUSIONS: With the auto-rim flap technique, a part of the caudal excess of the alar cartilage remains as a flap in the facet region; therefore, there is no need in the cephalic region to perform more of an excision than what is strictly necessary. LEVEL OF EVIDENCE: 4 Therapeutic.

Our Treatment Approaches in Severe Maxillofacial Injuries Occurring After Failed Suicide Attempts Using Long-Barreled Guns.

Maxillofacial traumas with long-barreled guns may sometimes cause catastrophic results by means of smashing in facial structures. In these patients, reconstruction strategies of both fragmented/lost soft and hard tissues still remain controversial. In their clinic, the authors treated 5 patients with severely injured face after failed suicide attempt between 2008 and 2013. In this study, the authors aimed to present their clinical experiences on these severely injured maxillofacial gunshot traumas and offer a treatment algorithm to gain a result as possible as satisfactory in terms of functionality and appearance.

Unintentional Complications After Uneventful Rhinoplasty Operations: Case Reports and a Review of the Literature.

INTRODUCTION: No surgical procedure is free of complications; however, some of these complications are unintentional. Plastic surgeons may be unfamiliar with certain complications after rhinoplasty operations. In this study, we aimed to present four unintentional complications that have occurred in our patients and review the literature related to these complications. MATERIALS AND METHODS: In this study, we conducted a review of 1400 patients who were operated on from 2007 to 2015. The medical recordings of all patients were investigated. Four patients with unintentional complications after rhinoplasty operations are presented and the related literature was reviewed. CASES: Cases 1 and 2: These patients included a 26-year-old woman and a 30-year-old man who developed herpes simplex virus (HSV) infections after a primary septorhinoplasty. Case 3: This was a 25-year-old woman who developed periorbital emphysema after a primary rhinoplasty operation. Case 4: This was a 22-year-old woman who developed a second-degree burn on the nasal dorsum. All patients healed without sequel or scars. DISCUSSION: Many unexpected complications have been reported in the literature. Some of these complications include bleeding disorders, allergic reactions, dermatitis, visual loss, gastric bleeding, benign paroxysmal positional vertigo, false aneurysm after rhinoplasty, pneumocephalus, Tapia's syndrome, cavernous sinus syndrome, and skin reactions to prolene. CONCLUSION: Meticulous patient histories, consistent surgical routines, careful radiologic examinations, and frequent patient visits can help surgeons control these types of complications. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 Effect of Epigallocatechin Gallate on Flap Viability of Rat Perforator Abdominal Flaps.

Background Epigallocatechin gallate (EGCG) is a substance abundant in green tea. In this study, the effects of EGCG on perforator flap viability were investigated. Methods A total of 40 rats were assigned to four groups of 10 each. In each subject, a 4 × 6 cm abdominal skin flap was raised and adapted back onto its place. In the control group, no further procedures were taken. In the flap group, 40 mg/kg/d EGCG was injected into the flap. In the gavage group, 100 mg/kg/d EGCG was given through a feeding tube. In the intraperitoneal group, 50 mg/kg/d EGCG was injected intraperitoneally. On the 7th postoperative day, flaps were photographed and the viable areas were measured and compared via a one-way analysis of variance. Results The ratios of viable and contracted flap area were 9.15/12.01, 4.59/16.46, 11.56/11.20, and 11.65/10.77 cm(2) for the control, flap group, gavage group, and intraperitoneal group, respectively. While the flap group yielded the worst results in the sense of flap contraction and viability (p < 0.001), the gavage and intraperitoneal groups were significantly better than those of the control group (p = 0.03). Histologically, epidermal, papillary dermal, and capillary tissue volumes were evaluated. In comparison to the control group, the flap group yielded significantly increased epidermal and dermal volumes (p = 0.03), however, these values were significantly decreased (p = 0.04) in the gavage and intraperitoneal groups. Capillary volumes were significantly decreased in EGCG treatment groups (p < 0.01). Conclusion Our experiment has shown that oral and intraperitoneal administration of EGCG increases the perforator flap viability when compared with controls, while direct injection decreases the viability.

The effect of twisting on single and double based perforator flap viability: an experimental study in rats.

In this study, the histological and vital effects of rotation on multiple and single based perforator flaps were evaluated. A 6 cm × 6 cm abdominal perforator flap model was used on 80 male rats; half of these received a single-pedicled flap, and the other half double-pedicled. The flaps of control subgroups were raised and sutured without rotation. In rotation subgroups 90-, 180-, 270-degree rotations were performed, and rotation effects on flap viability and histological changes were analyzed. Among single- and double-pedicled perforator flaps, respectively, mean survival area was 12.59 cm(2) and 27.84 cm(2) in non-rotated subgroups, 12.49 cm(2) and 17.06 cm(2) in 90-degree rotation subgroups, 5.96 cm(2) and 9.96 cm(2) in 180-degree rotation subgroups, and 1.45 cm(2) and 1.70 cm(2) in 270-degree rotation subgroups. While survival areas of double- and single-pedicled perforator flaps with the same rotation degree showed no statistically significant difference, non-rotated double-pedicled perforator flaps had a statistically larger survival area compared to single-pedicled perforator flap (P = 0.001). In the single-pedicled flap group, there were no statistical differences between survival flap areas of the non-rotated subgroup and the 90- and 180-degree rotation subgroups (P > 0.05), but the non-rotated subgroup had a statistically larger survival area compared to the 270-degree rotation subgroup (P = 0.003). In double-pedicled perforator flap group, the control subgroup had a statistically larger flap survival area compared to 90-degree, 180-degree, and 270-degree rotation subgroups (P = 0.004, P = 0.002, P = 0.001). Degenerative histological changes gradually increased in correlation with the rotation angle in both single- and double-pedicled groups. When double- and single-pedicled groups were compared; degenerative histology score displayed no statistical difference between control subgroups and rotated subgroups (P > 0.05). In this rat abdominal propeller perforator flap model, we found that double perforators without pedicle rotation could support larger flap survival when compared to the single pedicle. However, double perforators did not cause an increase of survival area when pedicles were rotated. In the single-pedicled perforator flap, the flap survival area did not significantly decrease until 180-degree pedicle rotation. In the double-pedicled perforator flap, the flap survival area decreased when the degree of rotation increased. The degenerative changes increased in correlation with the rotation degree in both single- and double-pedicled perforator flaps.

Are grafts necessary in rhinoplasty? Cartilage flaps with cartilage-saving rhinoplasty concept.

BACKGROUND: Cartilage grafts are used routinely in rhinoplasty, but are they necessary? Can we support the normal anatomy by preserving and transposing the adjacent tissues? In this study we hypothesize that during rhinoplasty, cartilage flaps can give adequate support and may decrease the need for cartilage grafts. METHODS: Included in this study were 147 patients who underwent an open rhinoplasty technique under general anesthesia between January 2010 and May 2012. Mean operative time was 73 min (range=44-120 min). After dissection and septoplasty (if needed), we performed dorsal bone and septal reductions. Following reduction, upper lateral cartilage superior segments were preserved and turned inward as cartilage flaps to replace the spreader grafts. Lower lateral cartilage cranial parts were not excised and were slid over the caudal part to replace the alar strut grafts. Cartilage from the caudal nasal septum was not excised; instead, lower lateral cartilages were cephaloposteriorly displaced with a tongue-in-groove technique to support the nasal tip. RESULTS: Mean follow-up time was 19.6 months (6-30 months). All patients but 12 were satisfied or completely satisfied with the results. Among the 12 unsatisfied patients, four complained of a one-sided inverted-V deformity (secondary spreader grafts were added), three had supratip deformity (secondary additional dorsal septal excisions), two demanded extra tip definition (secondary tipoplasty), two were unhappy with the bone symmetry (secondary osteotomies), and one complained of hanging columella (secondary excision from the caudal septum). CONCLUSIONS: Cartilage flaps have some advantages over cartilage grafts. First, graft harvest is not needed in the former; second, because flaps are a part of the normal anatomy, they provide a good tissue match, making fixation easier. However, the tongue-in-groove technique cannot be used in patients who do not need caudal excision, and cartilage flaps can be inadequate in some patients who may need additional grafts. EBM LEVEL 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 .

A rare complication of rhinoplasty: periorbital emphysema.

UNLABELLED: Subcutaneous emphysema is a clinical entity that may be associated with trauma. Rhinoplasty is not an atraumatic procedure. This report presents a case of acute periorbital emphysema after cosmetic rhinoplasty. 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 .

Would you be a face transplant donor? A survey of the Turkish population about face allotransplantation.

With the technical advancement in face allotransplantation, we decided to survey the Turkish population to gain perspective into their thoughts and reactions toward face transplantation. A questionnaire was given to 1000 volunteers, regarding data about demographics, educational status, religious, and behavioral preferences. Their attitudes about donating their faces, knowledge about the pros and cons of this procedure, and personal desire for face transplantation if needed were inquired.The results of the survey demonstrated that knowing more about the procedure increases its acceptance but even so, the majority would rather undergo multiple operations with self-tissues before getting a facial transplantation (FT). When the risks of immunosuppression were exposed, less people agreed to FT, thinking it was not worth the risks.The cultural, ethnical, religious, and social background of different societies may influence the way FT is perceived and accepted. As this procedure is thought to challenge many ethical, physiological, and social points of views, we believe that it is important for a surgical team to have insight into their population's perception and general thoughts concerning the issue.

The effect of learning curve on flap selection, re-exploration, and salvage rates in free flaps; A retrospective analysis of 155 cases.

The purpose of this study is to report our experience and learning curve in avoiding complications at both the recipient and donor sites as well in choosing the best flap for different anatomic locations. For this purpose 155 free flaps done between October 2005 and August 2012 were retrospectively examined. Patient demographics, flap types, etiology, re-exploration indications, timing of the re-explorations, and salvage rates were documented. In the first 60 cases, our re-exploration rate was 26.7% (16 flaps), and the rate decreased to 15.0% for the second 60 flaps (9 flaps). In correlation with this decrease, in the last 35 cases, only three flaps were re-explored (8.6%). This decrease in re-exploration rates over time was statistically significant (P = 0.021). Re-exploration rates for axial and perforator flaps were 14.6% and 22.7%, respectively. Salvage rates were 76.9% in axial flaps and 53.3% in perforator flaps. The total success rate for axial flaps was 95.5% and for perforator flaps was 89.4%. Besides, re-exploration rates were higher with lower salvage rates in perforator flaps compared to axial flaps causing lower overall success rates in the former group. The mean time of re-explorations was 21.4 hours. Salvage rates were significantly higher in re-explorations done within the first 12 hours after the initial surgery than in re-explorations done after 12 hours (83.3% vs. 47.3%) (P = 0.040). We can conclude that axial flaps have a steeper learning curve and are safer options for the inexperienced reconstructive micro-surgeons until they have adequate experience with the perforator dissection.

Heterotopic ossification in orbital roof, frontal sinus, and ethmoidal cells leading to hypoglobus and upward-gaze deficit.

Heterotopic ossification (HO) of facial sinuses is very rare. In this article, we present an extensive HO case covering the right frontal sinus, superior ethmoidal cells, and upper orbital rim and roof. This mass was leading to a hypoglobus and upward-gaze deficit due to mass effect. With an upper eyelid incision, mass over the upper orbital rim and roof was excised by an osteotome. Histopathologic examination was compatible with HO. On the postoperative 18-month follow-up, hypoglobus and upward-gaze deficit have significantly regressed. There were no relapses or enlargement over the operative field or the primary mass seen on computed tomography scans.

Extended spreader graft placement before lateral nasal osteotomy.

UNLABELLED: The extended spreader graft technique in septorhinoplasty is presented. The procedure involves applying spreader grafts before lateral osteotomies to support the whole osteocartilaginous vault. This study enrolled 51 patients who had undergone open septorhinoplasty between January 2010 and March 2012. The dorsal width ratio (DWR) was calculated for each patient by dividing the keystone width score by the intercanthal width score. The preoperative DWR scores classified 32 of the 51 noses as normal, six noses as narrow, and 13 noses as wide. All the patients with a nose classified as narrow preoperatively had a nose with a normal width postoperatively. All but one patient who had a normal preoperative DWR score also had a normal DWR score postoperatively. Of the 13 patients who had a wide nose preoperatively, seven were classified in the normal-width group postoperatively. Although the remaining six patients had a positive DWR score change (DWR closer to 0.50), they still were in the wide-nose group postoperatively. All but three patients were satisfied with their cosmetic and aesthetic results. Inverted-V or open-roof deformities were not observed. For all 18 patients in the normal nasal width group preoperatively (18/32), the nasal dorsum seemed wide after lateral osteotomies due to the spacing effect of the graft. As a result of medializing the bones, the caudal end of the graft became palpable. Although the graft position was checked perioperatively, at the postoperative 6-month follow-up assessment, three patients had palpable cartilages in the keystone area, one of which needed a surgical revision. Extended spreader grafts applied before lateral nasal osteotomies can support the entire nasal dorsum, including the bony vault. This spacing effect could be highly advantageous for both narrow and wide noses. In narrow noses, these grafts prevent further narrowing of the osteocartilaginous vault and support the dorsal aesthetic lines. In wide noses, extended spreader grafts fill the bone gap before lateral osteotomy and help to prevent open-roof deformity. In addition, fixing the upper lateral cartilages before lateral osteotomies might further prevent bone collapses, even after premature fractures. In normal-width noses, after completion of the lateral osteotomies, the bone gap usually does not persist, and nasal bones push the cranial end of the spreader graft dorsally. Therefore, in normal-width noses, extending the graft along the bony gap is not necessary, and the use of extended spreader grafts is not preferred. 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 .

Effects of different surgical techniques on cephalic index and intracranial volume in isolated bilateral coronal synostosis model.

BACKGROUND: Bilateral coronal synostosis (brachycephaly) is the most common single-suture synostosis that may lead to functional deficits such as mental retardation. This increases the importance of volume gain during surgery. This study was designed to understand the differences in volume gain, cranial index (CI), and aesthetic outcomes when additional osteotomies or rotations are applied on the frontoparietal segment. METHODS: Acrylic brachycephaly models were prepared. Frontoparietal osteotomy was standard in all models. Frontoparietal segment was fixed: to the same position in surgical control model, after 1.2-cm advancement in advancement model, after 180-degree rotation without advancement in rotation model, after 180-degree rotation plus a horizontal osteotomy and 1.2-cm advancement in rotation plus angled advancement model, and after a horizontal osteotomy without rotation and 1.2-cm advancement and in angled advancement model. RESULTS: Intracranial volume changes (in milliliters) and CIs were as follows between groups: control group, 828/94.1; surgical control group, 830/93.8; advancement model, 900/84.5; rotation model, 834/89.1; rotation plus angled advancement model, 897/82.7; angled advancement model, 902/81.8. CONCLUSIONS: Advancement of the frontoparietal segment is the keystone of surgery in brachycephaly treatment. Making an additional horizontal osteotomy can angle this segment and may supply additional volume gain. Rotation of the frontoparietal segment does not provide additional volume or CI gain but increase better aesthetic outcomes.