"Supratip Cross Flap: Reshaping the Nasal Tip and Improving the Nasal Vault Function."

The authors propose a novel flap for rhinoplasty: the supratip cross flap (SCF). It is a simple and effective method for avoiding and correcting alar contour deformities and external nasal valve (ENV) issues in rhinoplasty without grafts. In addition to its benefit for supratip break, the flap also allows a smooth and natural transition between the nasal dorsum and the nasal tip complex.

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

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

The Barn Doors Greenstick Fracture-A New 3D Geometry for Common Osteotomies in Rhinoplasty: The First 50 Patients with 1-Year Follow-up.

The "barn doors greenstick fracture" is a new concept that includes three contiguous greenstick fractures: one in the central compartment of the nasal dorsum (nasal bones) and two on the lateral walls of the bony nasal pyramid. The present study aimed to describe this new concept and to report the first esthetical and functional outcomes. This prospective, interventional, and longitudinal study was performed on 50 consecutive patients undergoing primary rhinoplasty by spare roof technique B. The validated Portuguese version of the Utrecht questionnaire (UQ) for outcome assessment in esthetic rhinoplasty was utilized. Each patient answered the questionnaire online before surgery and 3 and 12 months after surgery. In addition, a visual analog scale (VAS) was used to score nasal patency for both sides. The patients also answered three questions (yes or no): (1) "Do you feel any step on your nasal dorsum?" if yes: (2) "Is that step visible?" (3) "Does it bother you?"A statistically significant improvement in UQ scores postsurgery was found, demonstrating a high satisfaction index in this patient population. Additionally, the preoperative and postoperative mean functional VAS scores showed a significant and consistent improvement on both sides (right and left). Twelve months after surgery, a step at the nasal dorsum was felt by 10% of the patients, but it was visible just in 4%, which were two females with thin skin.The barn doors greenstick concept provides a new approach to achieve a real and sustainable smooth transition in the dorsal and lateral walls. The association of the two lateral greensticks and the already described subdorsal osteotomy allows a real greenstick segment in the most critical esthetic region of the bony vault-the root of the nasal pyramid.

Credit for Truly Novel Ideas? A Critical Approach to the Intellectual Authorship in Surgery.

The formation of new ideas and techniques in medicine and surgery is crucial to bettering the medical field and the quality of medical care. The transmission of these new ideas is a source of pride and recognition for physicians who devote their lives to patient care. The quality and integrity of the medical literature that results from seminal medical ideas are an essential but unregulated field. From time to time, there are discussions in the medical literature about the authorship of an idea/strategy/technique. In this digital era, where communication works at an unmeasurable speed, the authenticity of medical communication requires honesty and verification. The possibility of unreliable or false information exists, and the need to verify "new" information as accurate and honest is crucial. Rhythm, genuine, and fake (fair/unfair) information circulates at high speed, and suddenly everything one encounters is represented as "true and often represented as new." Regarding medical science and particularly surgery - we are overloaded daily with new techniques, new names, new strategies, and everything. Several questions regarding the authenticity of any publication or scientific communication exist. A critical approach is done in this article.

Validation of the European Portuguese Language Version of the Standardized Cosmesis and Health Nasal Outcomes Survey.

The Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) questionnaire is a tool developed to evaluate functional and aesthetic components of rhinoplasty. It is a reliable patient-reported outcome measure, not available in the European Portuguese language. Our goal was to translate and culturally adapt the SCHNOS questionnaire to the European Portuguese language. The questionnaire was forward and backward translated and culturally adapted to the European Portuguese language following international guidelines. The authors evaluated internal consistency, correlation, and reproducibility to determine the validity of the questionnaire. The final European Portuguese version of the SCHNOS was administered to 58 native European Portuguese speakers. Both the SCHNOS-O (obstructive) and SCHNOS-C (cosmetic) showed high internal consistency with Cronbach's α of 0.93 and 0.95, respectively. Also, for the entire SCHNOS, Cronbach's α was 0.96. All the items demonstrated good item-test and item-rest correlations with the differences between pre- and postestimates being nonsignificant. The translation, adaption, and validation of the SCHNOS into European Portuguese were successfully performed. This provides another tool to help evaluate the functional and aesthetic outcomes of rhinoplasty patients.

Surface Techniques in Dorsal Preservation.

Classical dorsal preservation rhinoplasty is typically done with impaction osteotomies (push/let down) and a low septal strip. These approaches are potentially highly destabilizing maneuvers in the architecture of the nasal pyramid. This is one of the reasons why these approaches did not have a popular acceptance in the 1960s and 1970s. More recently, the surgeon interested in preservation rhinoplasty has the possibility to do so with surface techniques with more control and, if needed, is easily converted to the standard structured techniques if the surgeon does not feel safe with the procedure.

Preservation Rhinoplasty in the Saddle Nose: The Reverse Spare Roof Technique.

Saddle nose deformity (SND) is a pathological entity resulting from loss of dorsal height caused by a substantial decrease in the cartilaginous vault or bony vault, and it can occur after a variety of nasal pathological conditions.1 Most saddle nose deformities are secondary to surgery or trauma, but congenital causes do exist.1 Repair of saddle nose, therefore, represents one of the most challenging problems in nasal surgery, requiring long-term structural support while avoiding sacrifice of aesthetics.2 To achieve the desired results, various materials have been employed for nasal contour restoration. The most used grafts are autologous cartilages. Septal cartilage is ideal for reconstruction but often insufficient except in mild cases. Thus, conchal and costal cartilage grafts are the most used in moderate and severe nasal saddling. Augmentation rhinoplasty (AR) is a common procedure in Negroid and Asian patients due to their constitutional lack of dorsal projection. The purpose of this article is to introduce the reverse spare roof technique (rSRT) and its usefulness to correct SND and in AR. To the best of the author's knowledge, this is the first technique that applies the actual principles of preservation rhinoplasty in the correction of the SND and AR.

Spare Roof Technique Versus Component Dorsal Hump Reduction: A Randomized Prospective Study in 250 Primary Rhinoplasties, Aesthetic and Functional Outcomes.

BACKGROUND: Most Caucasian aesthetic rhinoplasty patients complain about having a noticeable hump in profile view. Taking the integrity of the middle vault into consideration, there are 2 ways to dehump a nose: the structured technique and the preservation technique. OBJECTIVES: The aim of this study was to compare the aesthetic and functional outcomes of 2 reduction rhinoplasty techniques. METHODS: We performed a prospective, randomized, interventional, and longitudinal study on 250 patients randomly divided into 2 groups: the component dorsal hump reduction group (CDRg) (n = 125) and the spare roof technique group (SRTg) (n = 125). We utilized the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty. Patients answered the questionnaire before the surgery, and at 3 and 12 months after surgery. In addition, we utilized a visual analog scale (VAS) to score nasal patency for each side. RESULTS: Analyses of the preoperative and postoperative aesthetic VAS scores showed a significant improvement in both groups, from 3.66 to 7.00 (at 3 months) to 7.35 (at 12 months) in the CDRg, and from 3.81 to 8.14 (at 3 months) to 8.45 (at 12 months) in the SRTg. Analyses of postoperative means of aesthetic VAS scores showed a significant improvement in both groups over time. However, aesthetic improvement was higher in the SRTg than in the CDRg at both 3 (P < 0.001) and 12 months (P < 0.001) postsurgery. Analyses of the mean functional VAS scores showed a significant improvement with both techniques, with a better result for the SRTg. CONCLUSIONS: The SRT is a reliable technique that can help deliver consistently better aesthetic and functional results than CDR for reduction rhinoplasty in Caucasian patients with a dorsal hump.

Dorsal Hump Reduction Based on the New Ethmoidal Point Classification: A Clinical and Radiological Study of the Keystone Area in 138 Patients.

BACKGROUND: Hump resection often requires reorganization of the keystone area. OBJECTIVES: The authors sought to describe the importance of the point where the perpendicular plate of ethmoid joins the septal cartilage (SC) and the nasal bones (NB) (Ethmoidal point [E-point]) for hump resection surgical planning. METHODS: Measurements from mid-sagittal slices in nasal computed tomography scans taken in adult Caucasian patients between January 2015 and December 2018 were compared between patients seeking primary rhinoplasty due to a nasal hump and patients not seeking rhinoplasty (control group). Patients with previous nasal surgery or trauma, genetic or congenital facial disorders, and high septal deviation were excluded. The length of overlap between NB and SC was compared between the 2 groups. The location of the E-point in relation to the beginning of the nasal hump in the cephalocaudal direction was documented in the patients seeking rhinoplasty. RESULTS: The study population included 138 patients, 69 seeking and 69 not seeking rhinoplasty (96 females). The mean age was 32.9 years (range, 18-55 years). The length of overlap between NB and SC was similar between both groups (11.7 ±â€…3.3 vs 10.8 ±â€…3.3; P = 0.235). The E-point was located before the beginning of the nasal hump in 97% (67/69) of nasal hump patients, and it could be found a mean distance of 2.3 (±2.3) mm cephalic to the latter. CONCLUSIONS: As a rule, the perpendicular plate of the ethmoid does not contribute to the nasal hump; therefore, only in exceptional cases should this be addressed while performing dorsal reduction.

Caucasian Mediterranean patients seeking rhinoplasty-Anthropometric measurements and prevalence of major deformities.

OBJECTIVE: To describe the average values of the nasal anthropometric measurements of Caucasian Mediterranean patients seeking rhinoplasty and evaluate the major nasal deformities. DESIGN: Prospective, observational and cross-sectional study. SETTING: Centro Hospitalar do Porto. PARTICIPANTS: A 100 Caucasian Mediterranean patients seeking rhinoplasty. OUTCOMES: Standardized photography was used to obtain nasal anthropometric measurements and to evaluate the major nasal defects. Data regarding age, gender, skin type and Fitzpatrick scale were also collected. RESULTS: There was a statistically significant difference in the means values of palpebral fissure, intercanthal width, upper lip height, nasal root width, morphological nose width, nose height, nasal tip projection and nasofrontal-hump and nasofrontal-supratip angles between females and males. The major nasal deformity was dorsal hump (78.0%), followed by rinomegalia (53.0%) and boxy bulbous tip (47.0%). CONCLUSION: The present study shows statistically significant gender differences between anthropometric nasal measurements and the mean values are greater than standard values obtained on general population. This might be one of the reasons why Caucasian Mediterranean patients seek aesthetical rhinoplasty. On both genders, dorsal hump, rinomegalia and boxy bulbous tip were the major nasal defects. This emphasize the importance of rhinoplasty techniques designed to reconstruct nasal dorsum and nasal tip on Caucasian Mediterranean patients. To the best of our knowledge, our study is the first study of digital anthropometric nasal analysis and evaluation of major nasal defects specifically in Caucasian Mediterranean patients who applied for rhinoplasty. With this results, we provide a reference material for the evaluation of the Caucasian and Mediterranean patient when planning a cosmetic nasal surgery.

Spare roof technique in reduction rhinoplasty: Prospective study of the first one hundred patients.

OBJECTIVE: Assess the aesthetic and functional outcomes of the first 100 patients who underwent reduction rhinoplasty with the spare roof technique (SRT). METHODS: Prospective, interventional, and longitudinal study performed on consecutive patients undergoing primary rhinoplasty by SRT. All the surgical procedures were performed by the surgeon who first described this technique. The validated Portuguese version of the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty was used. Patients completed the questionnaire presurgery and again 3 and 12 months postsurgery. In addition, a visual analogue scale (VAS) was used to score nasal patency for both sides. RESULTS: The study population included 100 Caucasian Mediterranean patients (33 males; 67 females). Mean age at surgery was 32.8 years. Analysis of the preoperative and postoperative mean aesthetic VAS scores showed a significant improvement from 3.67 to 8.1 (P < 0.001) and 8.44 (P < 0.001), respectively, 3 and 12 months postsurgery. Analysis of the five aesthetic Likert scale questions all showed a highly significant improvement after rhinoplasty. The mean preoperative aesthetic sum score was 13.9, which improved to 8.26 and 7.08, respectively, 3 and 12 months postsurgery (P < 0.001), indicating a significant improvement of subjective body image in relation to nasal appearance. Analysis of the preoperative and postoperative mean functional VAS score showed a significant improvement on both sides. CONCLUSION: This prospective statistical study confirms that SRT significantly improved patient quality of life regarding nose function and appearance. It is a reliable technique that can help deliver consistently good results in reduction rhinoplasty in Caucasian patients with dorsal hump seeking rhinoplasty. LEVEL OF EVIDENCE: 2 Laryngoscope, 129:2702-2706, 2019.

Rhinoplasty-Do Patients and Surgeons See the Same? A Double-Blind Study with 100 Randomized Patients.

One of the key points of a successful rhinoplasty is communication between the patient and surgeon. The surgeon needs to get a clear understanding of the patient's motivation for surgery and expectations of the procedure. This information is mandatory in formulating an optimal surgical plan and managing realistic expectations of the procedures. Ideally, surgeons and patients see, discuss, and quantify the same nasal defects. In reality, the subjective nature of perceiving aesthetics can cause variability of inter-rating nasal appearance. Therefore, one might question how well surgeons understand their patients. Do they see what patients see? The aim of this study is to assess the level of agreement on the evaluation of nasal appearance between patients, surgeons, and nonphysicians observers, and try to find predictive factors that cause high interobserver variability. This prospective, observational, and cross-sectional study was performed on a total of 100 randomized patients undergoing rhinoplasty. All patients were photographed before surgery and asked to rate the appearance of their nose on a 10 cm visual analogue scale (VAS) with 0 indicating very ugly and 10 indicating very nice. Subsequently, the photographs of each patient were, independently, rated by two panels: one constituted by two rhinoplasty surgeons and the other by four nonmedical raters. Both panels included European raters from the north (The Netherlands) and south (Portugal). Data regarding age, gender, skin type, and major nasal deformity were also collected. The authors found that there is no statistical agreement between the aesthetical evaluation of the nose between patients and surgeons or patients and nonmedical raters. Based exclusively on the VAS for subjective evaluation of nasal appearance, the authors' findings show that surgeons and patients do not "see the same" and generally, the score attributed by the surgeon is more favorable (almost 1 point higher) than the auto-assessment's score. This is important to realize when communicating about nasal appearance before rhinoplasty.

Spare Roof Technique: A Middle Third New Technique.

To our knowledge, the spare roof technique (SRT) is the first technique that is based on a complete skeletonization/preservation of the upper lateral cartilages. This technique is used to keep the natural roof of the nose's middle third, while dehumping and/or correcting the crooked septum. From January 2014 till March 2015, a total of 40 rhinoplasties were performed through the SRT: 28 reduction rhinoplasties, 6 complex crooked noses (with extracorporeal septoplasty), and 6 mixed cases. The SRT is an excellent middle third technique. The natural roof was kept and fitted the accurate new position in almost all cases with no surgical complexity. It is an easy technique with many applications and it is also very useful in the classical humpectomy of the Caucasian nose and correction of the crooked nose.