A New Classification of Pollybeak Deformity and Its Treatment in Asian Rhinoplasty.

BACKGROUND: Supratip deformity, also known as pollybeak deformity, is a common complication of primary and secondary rhinoplasty, characterized by fullness in the supratip region. The correction of pollybeak deformity is a challenging procedure, and its management requires a thorough understanding of the pathogenic mechanism of pollybeak deformity. OBJECTIVES: This study aimed to evaluate the effectiveness of surgical methods for correcting pollybeak deformity in Asian rhinoplasty. METHODS: A retrospective chart review was conducted for 53 patients who underwent pollybeak correction between 2021 and 2022. A modified classification system for pollybeak deformity, the Supratip Fullness Rating Scale (SFRS), was developed to evaluate supratip fullness. The aesthetic outcomes of the patients were assessed by surgeons using the visual analog scale (VAS), and patient was self-assessed using the Rhinoplasty Outcome Evaluation (ROE) scale. RESULTS: The study demonstrated that our surgical method resulted in satisfactory outcomes, with a mean SFRS score change from 2.34[0.65] to 0.23[0.42], a decrease in VAS score from 7.47[1.73] to 1.79[1.67] and a high satisfaction rate of 77.36%, calculated by ROE score. No complications were reported. CONCLUSION: Our surgical method for correcting pollybeak deformity in Asian rhinoplasty can result in satisfactory outcomes, particularly in terms of aesthetic appearance, without any side effects. The use of the modified classification system (SFRS) can provide an objective evaluation of supratip fullness, thereby aiding in the management of this challenging complication. 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 .

Pollybeak deformity: how to avoid, how to cure.

We reviewed the Pollybeak deformity from prevention to treatment in all aspects. Research methods included searching online databases such as Google, Google Scholar, PubMed, and Proquest Central at King Saud University. We used terms like "Pollybeak deformity", "rhinoplasty", "etiology", and "treatment" to find related articles. Pollybeak deformity, an undesirable side effect of rhinoplasty, manifests as a dorsal nasal convexity resembling a parrot's beak. A dorsal hump that develops in the supratip region of the nose "pushes" the tip down, leading to under-rotation. Several factors may be at play here. When a surgeon fails to recognize the aberrant tip-supratip relationship that distinguishes this abnormality during the intraoperative evaluation of the nose, the result is a pollybeak. There is also the risk of pollybeak deformity, which the surgeon might be unable to predict. Supratip scar tissue is more common in people with thick skin and soft tissue envelopes. Medical intervention is only effective for soft-tissue pollybeaks when caught early. Injecting corticosteroids into the supratip dead space can alleviate edema and slow scar tissue formation. Surgical excision of scar tissue from the dorsum of the nose can repair the pollybeak deformity. Surgical correction of a supratip fullness that causes a disparity between the tip and supratip is known as a "pollybeak deformity". The appearance of the nose in some individuals with pollybeak deformity can resemble that of a bird, which can cause them to feel self-conscious and embarrassed. Therefore, treatment with medicine or surgery is required for these ailments.

The Management of Posttraumatic Nasal Deformities.

Nasal bone fractures are the most common fractures of the facial skeleton and are often accompanied by bony, cartilaginous, and soft tissue injuries. These injuries are often complex, and when untreated or inadequately treated, can lead to posttraumatic nasal deformity. The most common deformities are the crooked nose and the saddle nose. Both deformities may result in significant cosmetic and functional concerns. The treatment of these deformities can be complex, requiring careful evaluation of the nose and thoughtful planning to correct the cosmetic deformity and restore functional integrity. The rhinoplasty surgeon will benefit from having a large repertoire of techniques to achieve these repairs. In this article, we discuss the options and concepts for the management of nasal bone fractures as well as complicated posttraumatic nasal deformity. Level of evidence is not available.

Management of the Middle Vault.

Early reductive rhinoplasty techniques focused on hump reduction and tip plasty with minimal focus on treating or preserving the integrity and width of the middle vault. With time, rhinoplasty surgeons noted the aesthetic and functional complications of the deformities that may occur in the middle vault with reduction techniques and developed methods to treat and also avoid these complications. Thus, the importance of protecting the integrity of the middle third of the nose has been increasingly emphasized over the years. Primary deformities of the middle vault that result in nasal obstruction require attention of the rhinoplasty surgeon, as well as preservation of support structures of the middle vault and internal nasal valve to minimize secondary deformities and functional compromise after rhinoplasty surgery.

New classification system of contracted nose and its treatment algorithm.

BACKGROUND: The nasal contracture after rhinoplasty is one of the most severe complications in East Asian patients. The classification and treatment algorithm of nasal contracture have not yet been established. This study aimed to develop a new classification system and treatment algorithm of contracted noses in East Asian patients to improve treatment outcomes. METHODS: A retrospective study was conducted with 62 patients with nasal contracture who underwent a revision rhinoplasty between March 2017 and March 2021. The authors classified the 62 patients into 3 groups based on the classification system. All patients underwent rhinoplasty designed according to the corresponding classification. The patients were followed up after surgery, and the rhinoplasty outcomes evaluation (ROE) was used to evaluate their satisfaction rate. RESULTS: A total of 59 female patients and 3 male patients (mean age, 29.45 ± 7.73 years) were included in this study. Forty-five cases presented mild nasal contracture (72.58%), 11 presented moderate nasal contracture (17.74%), and 6 presented severe nasal contracture (9.68%). There were statistically significant differences in the number of prior rhinoplasty procedures, infection history, and preoperative ROE scores among the three groups, with no differences in sex ratio, age, kinds of initial implant materials, and postoperative ROE scores. Almost all patients achieved satisfactory outcomes after the revision surgery designed by different classifications. CONCLUSION: The authors have established a new classification system and treatment algorithm for contracted noses based on the change in pathological anatomy of nose, which is effective for guiding the treatment of contracted noses with good results.

Efficacy of Nostril Supportive Splint Treatment for Nasal Septum Deformities after Le Fort I Osteotomy.

This retrospective study aimed to evaluate the efficacy of support splint treatment for deformities and deviations of the nasal septum after Le Fort I osteotomy (LFI). Patients were divided into two groups: the retainer group wore a nasal support splint immediately after LFI for 7 days, and the no retainer group did not wear a nasal support splint. Evaluation was performed by measuring the ratio of the difference between the left and right sides of the nasal cavity area (ratio of nasal cavity) and the angle of the nasal septum using three computed tomography frontal images (anterior, middle, and posterior) before and one year postoperatively. Sixty patients were included and divided into two groups, the retainer and no retainer group (n=30 each). Regarding the ratio of nasal cavity on middle images at one year postoperatively, the retainer and no retainer groups differed significantly (0.79±0.13 and 0.67±0.24, respectively; P =0.012). The angle of the nasal septum on anterior images at one year postoperatively was 164.8±11.7° in the retainer group and 156.9±13.5° in the no retainer group, showing a significant difference ( P =0.019). This study suggests that support splint treatment after LFI is effective in preventing post-LFI nasal septal deformation or deviation.

Application of a Modified Costal Cartilaginous Framework in Correction of Severe Saddle Nose Deformity.

BACKGROUND: Insufficient support of the nasal septum due to congenital or secondary deficiency leads to severe saddle nose deformity, which presents an unpleasant appearance. OBJECTIVES: The purpose of this study is to present our approach to constructing a costal cartilaginous framework with autologous costal cartilage for correction of severe saddle nose deformities. METHODS: A retrospective analysis was conducted of patients who underwent correction of severe saddle nose deformity (type 2 to type 4) by a senior surgeon from January 2018 to January 2022. Preoperative and postoperative measurements were conducted to evaluate the surgical outcomes. RESULTS: A total of 41 patients ages 15 to 50 years completed the study. The average follow-up time was 20.6 months. No short-term complications were observed. Revisional operations were performed on 3 patients. All patients were satisfied with the aesthetic results. Analysis of objective measurements showed that the nasofrontal angle, columellar-labial angle, and tip projection improved significantly in type 2 cases, the nasofrontal angle and tip projection improved significantly in type 3 cases, and tip projection improved significantly in type 4 cases. CONCLUSIONS: Application of this modified costal cartilaginous framework, which consists of a fairly stable foundation layer and an aesthetic contour layer of block costal cartilage, has achieved satisfactory results over the long term.

The Key to a Straight Nose Is a Straight Septum: 10 Essential Steps.

SUMMARY: The deviated nose derives from underlying skeletal and soft-tissue deformities in the upper, middle, and/or lower third of the nose. Although deviation may stem from several intrinsic and extrinsic elements, the septum is most often the primary contributor. Attempts to straighten the nose without properly addressing the septum invariably result in a persistently deviated nose. The goal of this article is to review the 10 key steps for a reliable, methodical approach to correcting the deviated septum in primary rhinoplasty.

Transection of Pitanguy's Midline Ligament to Avoid Supratip Depression in Closed-Approach, Low-Septal-Resection Dorsal Preservation Rhinoplasty.

BACKGROUND: Supratip depression is a common complication after preservation rhinoplasty. OBJECTIVES: This aim of this paper was to present a simple surgical maneuver to prevent supratip depression. METHODS: Thirty-six patients who underwent closed-approach, low-septal-resection dorsal preservation rhinoplasty between January and June 2021 were included in this retrospective study. Depending on the operation performed on Pitanguy's midline ligament, the patients were divided into 2 groups as follows: (1) a group in which Pitanguy's midline ligament was transected (transection group); and (2) a group in which Pitanguy's midline ligament was preserved (preservation group). Standardized postoperative 6-month lateral-view photographs were scanned for the presence of supratip depression or pollybeak deformity. The Rhinoplasty Outcome Evaluation (ROE) scale was applied at 6 months. RESULTS: Supratip depression was observed in 4 patients in the preservation group (n = 16), but was not observed in any of the patients in the transection group (n = 20; P < 0.05). There was no pollybeak deformity in either group. With respect to the Rhinoplasty Outcome Evaluation scores and number of satisfied patients, no statistically significant difference was found between the transection and preservation groups (P > 0.05). CONCLUSIONS: Transecting Pitanguy's midline ligament reduces the likelihood of supratip depression and does not affect the likelihood of pollybeak deformity in closed-approach, low-septal-resection dorsal preservation rhinoplasty.

Impact of the Location of Nasal Septal Deviation on the Nasal Airflow and Air Conditioning Characteristics.

The location of nasal septal deviation (NSD) directly impacts nasal physiology. The objective is to examine, using computational fluid dynamics (CFD), the difference in the airflow and air conditioning characteristics according to the location of NSD. Twenty patients with septal deviation were divided into two: 10 caudal septal deviation (CSD) and 10 posterior septal deviation (PSD). Physiological variables were compared and numerical models for nasal cavity were created with CT scans. Cases with CSD had distinctive features including restricted airflow partition, larger nasal resistance, and decreased surface heat flux in the more obstructed side (MOS), and lower humidity and air temperature in the lesser obstructed side (LOS). Physiological differences were observed according to the location of septal deviation, CSD cases exhibit significantly more asymmetric airflow characteristics and air conditioning capacity between LOS and MOS.

Nasal Reconstruction in Granulomatosis with Polyangiitis: A Two Decade Review.

Background: Granulomatosis with polyangiitis (GPA) leads to progressive destruction of the nasal tissues resulting varying degrees of saddle deformity and nasal obstruction. Reconstructive techniques are numerous, but there are no large series reporting their results. Objective: This study sought to measure complications and outcomes after rhinoplasty for GPA. Methods: We conducted a retrospective review of 42 patients with GPA who underwent nasal reconstruction of saddle nose deformity between 2005 and 2019 using primarily costal cartilage and soft tissue grafts. Results: Thirty-six patients met the criteria for inclusion. All were followed for a minimum of 12 months. Six patients required revision surgery due to infection or GPA flare ups. Five patients had complications. All patients were given a questionnaire at 12 months to rate their degree of satisfaction with their appearance and breathing. Conclusion: The findings of this study suggest that the use of strong cartilage grafts and the timing of surgery result in improvement in breathing and appearance after rhinoplasty in patients with GPA. Clinical Trial Registration number: REB # 21-125.

Simple method of saddle nose correction: A double-layer dermofat graft: case report.

INTRODUCTION: Saddle nose deformities are typically reconstructed with cartilage grafts; however, conchal cartilage grafts are and associated with a risk of damage to the posterior auricular ligament and insufficient amounts, and costal cartilage grafts require invasive surgery under general anesthesia. We proposed a double-layer dermofat graft as an alternative to these methods. PATIENT CONCERNS: Two patients with type IV saddle nose deformity underwent reconstruction with nasal augmentation with a double-layer dermofat graft harvested from the gluteal sulcus. DIAGNOSIS: After operation, photogrammetric analysis demonstrated an improvement in the dorsal depression area, which corresponded to the angle between the sellion, most depressed point, and pronasale. Rhinoplasty Outcome Evaluation questionnaire was assessed. INTERVENTIONS: The graft was divided into 2 sections; the first section was implanted transversely into the depressed nasal framework, and the second section was inserted vertically from the nasion to the supratip break for augmentation. OUTCOMES: Both patients reported high satisfaction with the Rhinoplasty Outcome Evaluation questionnaire. The mean preoperative angle between the sellion, most depressed point, and pronasale was 157.8°, and the mean postoperative angle at 6 months was 176.9°. CONCLUSION: The simple method double-layer dermofat graft technique demonstrated excellent outcomes in saddle nose deformity correction, did not require cartilage, and was easily performed under local anesthesia.

Nasal Septal Mucocele Causing Saddle Nose Deformity.

Nasal septal mucoceles are a rare occurance, and reports in the current literature are limited. We describe the case of a 73-year-old woman who developed a nasal septal mucocele several days after an episode of angioedema. The lesion was treated with 2 rounds of needle aspiration with antibiotics and the application of silastic splints. There was no recurrence after 1 month, though the patient developed a saddle nose deformity. She ultimately underwent reconstruction with a diced-cartilage dorsal augmentation graft with fibrin glue. We review the learning points of this case and summarize existing literature on this disease.

A New Approach for Alar Grafting Technique to Support Soft Triangle.

Rhinoplasty is 1 of the leading surgical procedures among all aesthetic and plastic surgeries. Grafting is an important part of both primary and revision rhinoplasties. The grafts are used for improving the functional and as well as aesthetical deformities of the nose. The choice of a graft is important for long term results in rhinoplasty operations. In present research, the author aimed to present a new approach for alar grafting in a special patient group for providing better cosmetic and functional outcomes. The patients who received rhinoplasty, who had a retraction in the soft triangle region, who had a wide alar base and who gave permission for sharing their photos for medical purposes were included in the study. According to inclusion and exclusion criteria 21 patients were included in the study. All patients included in the study completed the Rhinoplasty Outcome Evaluation (ROE) before operation and at their 1-year follow-up appointment. Twelve months after surgery, the ROE scores ranged between 90 and 100 points. The median score increased from 56.8 to 91.5 points (P < 0.001). Patient satisfaction was excellent in 100% of the included cases according to ROE scale. Physical examination and assessment of postoperative photographs demonstrated that there were no asymmetry or functional problems in all participants. This new alar graft approach has advantages such as; because the alar graft was obtained from the similar tissue, the accordance of the graft will be much more compared with other tissues. Another advantage is not making an intervention to septum, rib or auricle and this advantage can bring more suitability for both patients and as well as surgeons. LEVEL OF EVIDENCE: Level III, therapeutic study.

Upper Margin of the Forehead Flap and Its Correlation With Aesthetic Results in Nasal Reconstruction in Fitzpatrick Skin Type III and IV Chinese.

BACKGROUND: The forehead flap is one of the most commonly used methods for nose reconstruction. OBJECTIVE: To determine the ideal upper margin of the flap in nasal reconstruction and its correlation with aesthetic results. METHODS: From April 2013 to September 2017, 40 patients underwent nasal reconstruction involving the dorsum with a forehead flap. The authors hypothesized 5fdifferent levels as the position to place the upper margin of the forehead flap: (1) glabella, (2) level of the upper eyelid, (3) intercanthal line, (4) horizontal line between the keystone and intercanthal line, and (5) the keystone. Then they photoshopped the upper margins of the forehead flap at 5 different levels and designed a questionnaire. Nasal reconstructive plastic surgeons, medical practitioners, and people without medical backgrounds chose the most aesthetically pleasing photograph for every patient. RESULTS: The questionnaire showed that the most aesthetically pleasing positions were located at glabella (n = 0), level of upper eyelid (n = 9), intercanthal line (n = 24), the line between keystone and intercanthal line (n = 6), and keystone (n = 1). CONCLUSION: The authors suggest placing the upper margin of the forehead flap at the level of the intercanthal line in nasal reconstruction involving the dorsum to achieve the best aesthetic results.

Expanded Role of Alar Contour Grafts.

SUMMARY: Alar rim deformities are among the most common problems affecting patients undergoing both primary and secondary rhinoplasty. They can be caused by several factors such as congenital hypoplasia or malpositioning of the lateral crura, and from acquired surgical weakening during rhinoplasty. Even though altering the structure of the lower lateral cartilage complex can help prevent and correct alar rim deformities, this may not always allow for sufficient control of the alar rim. Alar contour grafts have been proven efficacious not just in the treatment of specific rim deformities but also in their prevention. In this article, the authors present four types of alar contour grafts and discuss their expanded role in the prevention and treatment of alar rim deformities.

Fine Details That Improve Nasal Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify common negative outcomes that arise with conventional nasal reconstruction. 2. Understand the technical refinements that help avoid and reduce negative outcomes in nasal reconstruction. 3. Learn about the utility of regional axial island flaps for nasal reconstruction, in particular, the lateral nasal artery flap. SUMMARY: Nasal reconstruction has been a preoccupation of surgeons dating to before 600 bc. The nose is the central focal point of the face and a key identifying facial feature, and surgery to the nose can prove to be challenging to even the most experienced surgeon. The objective of this CME article is to outline the most commonly used surgical options for each nasal aesthetic subunit, and the specific complications observed for each. The best surgical options and technical refinements are highlighted, and principles that may help restore the nose are outlined.