Aesthetic Science of Rhinoplasty: Three Principles.

Aesthetic science is a rapidly growing discipline that involves plastic surgery as much or more than other disciplines of science. Fortunately, how and why the human brain responds to the visual world is better understood now than ever before. Of necessity plastic surgery is a part of that aesthetic science movement because it deals directly with the application of aesthetic principles. Therefore, it behooves the surgeon to be familiar with the principles of aesthetic science so as to both delineate and attain the aesthetic goal at the same time any functional goal is part of the operation. There are three important principles for rhinoplasty: (1) symmetry, (2) continuity and (3) persistence. This study provides examples of how they apply in the preop, intraop and postop phase of performing aesthetic rhinoplasty. A firm understanding of these principles can then guide the surgeon through the difficult maze of decision making, operative planning and surgical execution that arguably makes aesthetic rhinoplasty the most difficult aesthetic operation in plastic 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 .

Current Practices in Dorsal Augmentation Rhinoplasty.

BACKGROUND: Dorsal augmentation rhinoplasty addresses the aesthetic and functional impairments caused by a deficient nasal dorsum. Augmentation rhinoplasty can be performed using a variety of different surgical techniques and grafting materials that all have distinct advantages and disadvantages. METHODS: Grafting materials have unique characteristics, uses, and safety profiles. A detailed overview of various grafting materials and their uses, risks, and benefits is provided. RESULTS: Autologous grafting materials include septal cartilage, auricular cartilage, and costal cartilage. These donor sites can provide various amounts of en bloc or diced cartilage. Alternatively, bone may be used when strong structural stability is required, and soft tissue may be used to fill mild to moderate defects. Homologous grafts (e.g., irradiated and nonirradiated rib) and acellular dermal matrices are alternatives to autologous graft with many similar advantages and no need for an additional surgical site. Lastly, alloplastic implants may be successfully used for dorsal augmentation if both patient and surgeon understand their associated risks. CONCLUSION: To perform successful dorsal augmentation, surgeons should be familiar with the wide variety of operative approaches and augmentation materials that are currently available and understand their risks, benefits, and uses.

Evidence-Based Medicine: Current Practices in Rhinoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Perform aesthetic and functional nasal analysis to guide septorhinoplasty. 2. Recognize common complications associated with rhinoplasty. 3. Select appropriate septorhinoplasty techniques to refine nasal aesthetics and treat nasal airway obstruction. 4. Identify factors leading to poor patient satisfaction following rhinoplasty. SUMMARY: Septorhinoplasty is among the most technically challenging procedures in the realm of plastic and reconstructive surgery. Moreover, it is a constantly evolving topic with extensive background literature. Surgeons must be comfortable with the traditional knowledge base and the current practices in the field. This article reviews the latest thinking on patient selection, functional indications, aesthetic analysis, and operative techniques in septorhinoplasty, with an emphasis on key cartilage grafting and tip suture techniques.

Primary Open Rhinoplasty.

Rhinoplasty is perhaps the most complex cosmetic surgery procedure performed today. It is characterized by an intricate interplay between form and function, with patient satisfaction being dependent not only on improvement of nasal appearance but also resolution of preexisting airway symptoms. The prerequisite for successful execution of this challenging procedure is a thorough understanding of nasal anatomy and physiology. Hence, a thorough preoperative evaluation is at least as important and the surgical skill in performing the operation. Establishing an accurate diagnosis through a comprehensive nasal analysis is obligatory. As to the surgical approach, much has been written about the advantages and disadvantages of closed vs open rhinoplasty. The more commonly chosen open approach has numerous advantages, including improved visualization without distortion, thus, enabling precise diagnosis and correction of deformities. While the surgical treatment of existing nasal deformities is tailored to the needs of the individual patient, the authors have noted a total of 10 essential components to form the foundation for successful technical execution of rhinoplasty. These include: (1) septoturbinotomy; (2) opening the nose; (3) humpectomy/spreader flaps; (4) tip-plasty; (5) supratip-plasty; (6) columellar strut; (7) dorsal augmentation; (8) nasal base reduction; (9) osteotomies; and (10) rim grafts. Postoperative, a variety of problems, such as edema, may be successfully addressed without surgical intervention. Diligent postoperative management is critical in ensuring a positive patient experience. Finally, a comprehensive understanding of possible postoperative complications, such as bleeding, ecchymosis, edema, and persistent or new iatrogenic deformity is mandatory prior to offering rhinoplasty to patients.

Surgical Management of Nasal Airway Obstruction.

The management and diagnosis of nasal airway obstruction requires an understanding of the form and function of the nose. Nasal airway obstruction can be structural, physiologic, or a combination of both. Anatomic causes of airway obstruction include septal deviation, internal nasal valve narrowing, external nasal valve collapse, and inferior turbinate hypertrophy. Thus, the management of nasal air obstruction must be selective and carefully considered. The goal of surgery is to address the deformity and not just enlarge the nasal cavity.

Management of the Nasal Dorsum: Construction and Maintenance of a Barrel Vault.

Rhinoplasty is not so much an art, but rather an architectural undertaking: a methodical approach to reconfiguring the nasal components to give a proportionate nose that both pleases the eye and satisfies functional requirements. The dorsum and dorsal esthetic lines are some of the most important components of the nose in terms of esthetics and function. The middle vault is the critical portion of the nose that will guide the management of the bony vault and the tip. The role of the spreader flap and its extension into the bony vault is stressed to re-create the barrel vaultlike nasal architecture.

Nasal Bone Osteotomies with Nonpowered Tools.

Controlling the shape of the nasal bones has long been a frustrating problem. Conventional osteotomies are associated with bleeding, loss of reduction, inability to achieve the desired alignment, improperly placed osteotomy sites, and spicule formation. A nonpowered osteotomy method empirically provided the safest and most controlled technique to achieve the desired anatomic result. The nasal bones should be thought of as 2 thin nasal plates that can be released from their medial and lateral attachments to become mobile units that can affect the dorsal width and bony base independently. There is a learning curve to osteotomies.

Desmopressin as a hemostatic agent to provide a dry intraoperative field in rhinoplasty.

BACKGROUND: Intraoperative bleeding during rhinoplasty makes it difficult to sculpt cartilages. Residual blood from a wet field can lead to induration, fibrosis, and definition loss. Recent studies with desmopressin (1-deamino-8-D-arginine vasopressin) to reduce blood loss in a variety of operations and minimize postoperative bleeding problems suggest using that drug routinely for elective rhinoplasty and not just for patients with coagulation issues. METHOD: Seventy-three consecutive rhinoplasty patients received desmopressin for the purpose of obtaining a dry operative field. The initial dose was 0.1 µg/kg. If the field was not as dry as desired, a second dose was given; if necessary, a third dose to a maximum of 0.3 µg/kg was given. All cases exhibited a satisfactorily dry field. There were no adverse effects. A retrospective comparison was made to 300 consecutive cases not receiving desmopressin. RESULTS: Thirty of the 73 patients received a starting dose of 0.1 µg/kg and nothing more. Fourteen received a second dose of 0.1 µg/kg because the field was not as dry as desired and 29 received a third dose of 0.1 µg/kg because the field was not as dry as desired. All 73 patients exhibited a satisfactorily dry field, in contrast to 9 percent in the group not receiving desmopressin. CONCLUSIONS: This study confirms the hemostatic effectiveness of desmopressin at lower than normally used doses in rhinoplasty. It also confirms its safety. It suggests its use in other procedures. A larger, carefully controlled study is indicated. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.