Utilization of Leech Therapy after Rhinoplasty.

BACKGROUND: The use of medicinal leeches in modern reconstructive surgery is well-described. Leech therapy after rhinoplasty has not been previously well-characterized. METHODS: The medical records of all patients who underwent open rhinoplasty by a single surgeon over a 4-year period were reviewed. Patient demographics, including age, sex, medical comorbidities, number of previous rhinoplasty surgeries, time to utilization of leech therapy, adjunct therapies used, resolution of skin changes, and smoking status, were recorded. Operative reports were reviewed for pertinent information, including number of tip grafts used, graft materials used, and placement of septal extension grafts or "unicorn" grafts. RESULTS: Between April of 2016 and March of 2020, 545 patients underwent rhinoplasty performed by the senior author (P.S.N.). Of these patients, 39 (7.2 percent) underwent leech therapy postoperatively. The mean age of included patients was 47.4 years. Of the patients who required leech therapy, 34 (87.2 percent) had undergone revision rhinoplasty. The mean number of previous rhinoplasties was 3.4. The mean number of tip grafts used was 2.6. Thirty-three patients (84.6 percent) had either a traditional septal extension graft or unicorn graft placed. Nine patients (23.1 percent) were former smokers. Complete resolution of skin color changes was seen in 38 patients (97.4 percent). There were no major complications after leech therapy. CONCLUSIONS: Leech therapy is a useful tool for the rhinoplasty surgeon, particularly in the setting of complex revision rhinoplasty, in patients who have undergone multiple previous nasal surgical procedures, or in patients who require significant cartilage grafting to reconstruct the nasal tip or lengthen the nose. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Outcomes of a Treatment Protocol for Compromised Nasal Skin in Primary and Revision Open Rhinoplasty.

Importance: This is the first study to review the incidence of nasal skin compromise after open rhinoplasty surgery and outcomes of treatment. Objectives: To determine whether risk of skin compromise after open rhinoplasty surgery can be predicted and whether our treatment protocol led to acceptable outcomes. Design, Setting, and Participants: This is a retrospective chart review of the senior author's private patients. In total, 384 rhinoplasty cases were reviewed and all cases with signs of vascular compromise requiring treatment were analyzed. Main Outcomes and Measures: Descriptive statistics were used to evaluate characteristics of patients who developed intra- and postoperative skin compromise, and unpaired two-tailed t-test was used to compare the characteristics of patients with and without compromised nasal skin when possible. Overall satisfaction results and complications in the skin compromise group were reported. Results: A total of 384 open rhinoplasties were performed by the senior author between October 1, 2015, and December 31, 2018. Of them, 109 were primary rhinoplasties and 275 were revision rhinoplasties. Of the 384 rhinoplasties, 27 (7%) had skin compromise leading to unplanned postoperative treatment. Two of the patients in the skin compromise group underwent primary surgeries (7.4%) and 25 underwent revision procedures (92.6%). Advanced age (p < 0.0001), prior or current history of smoking (p = 0.027), and greater number of prior rhinoplasty surgeries (p = 0.0002) were significantly correlated with risk of skin compromise. The average time to last follow-up in the skin compromise group was 392 days (range 15-1057 days). At their last follow-up, 12 patients had complete resolution of all signs of nasal skin compromise with no further treatment required (44.4%). The revision rate for patients experiencing skin compromise was 22.2%. One patient underwent revision surgery directly related to a complication of skin compromise and one is considering revision directly related to skin breakdown. Conclusions and Relevance: The rate of skin compromise after open rhinoplasty is low. Older patients and patients with more prior rhinoplasty surgeries may be at increased risk. Prompt treatment of compromised nasal blood supply after rhinoplasty surgery can salvage skin in most patients.

Treatment Protocol for Compromised Nasal Skin.

As the number of patients seeking surgical and nonsurgical rhinoplasty continues to increase, the risk of nasal skin compromise after surgery also has risen. Vascular insult to the nasal skin envelope can lead to permanent disfigurement that is nearly impossible to correct. Tissue loss often requires major reconstruction that yields suboptimal cosmetic results. This article discusses prevention, early recognition, and effective treatment that aim to mitigate skin necrosis and the resulting soft tissue destruction.

The More the Merrier? Should Antibiotics be Used for Rhinoplasty and Septorhinoplasty?-A Review.

BACKGROUND: With antimicrobial resistance a global threat, optimizing antibiotic usage across the surgical continuum is vital. The American Academy of Otolaryngology-Head and Neck Surgery Foundation recently published the first guidelines addressing management in rhinoplasty. The authors reviewed pertinent literature on the role of systemic antibiotics in rhinoplasty and septorhinoplasty. METHODS: The authors performed a MEDLINE search through PubMed using the key terms rhinoplasty, septorhinoplasty, infection, antimicrobials, and antibiotics. RESULTS: Ten studies met criteria. Studies evaluating antibiotics perioperatively showed similar infection and/or bacteremia rates (0-13.3%) in those receiving or not receiving antibiotics. No patients experienced significant local/systemic infections regardless of antibiotic use. In the 3 studies evaluating antibiotics postoperatively, antibiotics decreased the infection rate from 27% to 8% in complex revision cases. In a study evaluating postoperative antibiotics in noncomplex cases, there were no significant differences in infection rates between those receiving only a preoperative dose and those receiving preoperative in addition to 7 days of postoperative antibiotics, with the latter experiencing higher rates of antibiotic-related adverse events and costs. CONCLUSIONS: Peri- and postoperative antibiotics in noncomplex rhinoplasty and septorhinoplasty are not beneficial in decreasing infection risk. Antibiotics, with a first-generation cephalosporin such as cefazolin (non-ß-lactam, such as clindamycin, if ß-lactam allergy), should be considered in patients with comorbidities/undergoing complex surgery. If perioperative antibiotics are used, antibiotics should be administered within 1 hour of incision and discontinued within 24 hours of the operation. Further research is warranted to evaluate the optimal duration of postoperative antibiotics in complex cases.

Correction of the Lower Face and Neck.

Rejuvenation of the lower face and neck strives to reverse signs of aging while optimizing the patient's natural anatomy. Common features of an aesthetically pleasing lower face include a well-defined and appropriately balanced mandible and an acute cervicomental angle. Correction of the aging lower face and neck is accomplished through multiple surgical interventions, performed either alone or in combination. Determination of appropriate procedures is based on individual anatomic pathology. Intimate knowledge of facial anatomy and the complexity of the aging process is paramount to achieve a natural and aesthetic result. Thorough patient evaluation and counseling should precede any intervention. Specifically, the surgeon should be cognizant of the patient's skeletal structure, soft tissue distribution, muscular anatomy, and skin quality. Appropriate postoperative care and management of complications are vital to success.

Use of 5-Fluorouracil for Management of the Thick-Skinned Nose.

Patients with a thick nasal skin and soft tissue envelope can have unpredictable results and irregular scarring after rhinoplasty surgery. These patients typically have sebaceous tissue over the nasal tip and are particularly susceptible to soft tissue polly beak formation and excess scar tissue in the radix, tip, and septum. Targeted injections of 5-fluorouracil alone or mixed with low concentrations of steroid can be useful to prevent and treat excess postoperative scar tissue deposition. Ideally, four to six injections are performed every 1 to 4 weeks beginning 1 week postoperatively. The injections are most beneficial when performed within the first 3 months after surgery. Even a single injection may improve outcomes with minimal side effects.

Rhinoplasty in the African American Patient: Anatomic Considerations and Technical Pearls.

There are several anatomic considerations as well as variations in patients of African heritage. The goal of improvement in aesthetics and functionality must be in balance with racial preservation. Preoperative counseling must discuss patient expectations and surgical limitations based on patients' skin and cartilage. Dorsal augmentation, increased tip projection, and rotation are often needed. Understanding the thick, sebaceous skin often seen in African Americans assists in postoperative management of swelling.

Avoiding and managing complications in the periorbital area and midface.

The eyes play a central role in the perception of facial beauty. The goal of periorbital rejuvenation surgery is to restore youthful proportions and focus attention on the eyes. Blepharoplasty is the third most common cosmetic procedure performed today. Because of the attention placed on the periorbital region, preventing and managing complications is important. Obtaining a thorough preoperative history and physical examination can significantly reduce the incidence of many of the complications. This article focuses on the preoperative evaluation as it relates to preventable complications, followed by common intraoperative and postoperative complications and their management.

Microbiology and antibiotic prophylaxis in rhinoplasty: a review of 363 consecutive cases.

IMPORTANCE: A practical technique for reducing infectious complications from rhinoplasty would represent an important surgical advance. OBJECTIVES: To describe the microbial flora of patients undergoing septorhinoplasty and to evaluate the role of preoperative and postoperative antibiotic prophylaxis. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective medical record review of 363 consecutive adult patients who underwent preoperative nasal swab testing and rhinoplasty or septorhinoplasty in a single private practice: 279 women (76.9%) and 84 men (23.1%). The average patient age was 35.9 years (age range, 17-70 years). MAIN OUTCOMES AND MEASURES: Identification of endogenous nasal flora and pathogenic bacteria treated with culture-directed antibiotics; evaluation of comorbidities, perioperative infections, and antibiotic treatments. RESULTS: A total of 174 patients (47.9%) underwent primary rhinoplasty, and 189 (52%) underwent revision rhinoplasty. On preoperative nasal culture, 78.2% of patients had normal flora; 10.7% had Staphylococcus aureus; and 0.28% had methicillin-resistant S aureus (MRSA). In 7.4% of patients, fecal coliforms including Escherichia coli, Enterobacter species, and Citrobacter species were found. Age, sex, smoking, the use of oral contraceptives, or the presence of seasonal allergies did not significantly change the nasal flora or the postoperative infection rate. Patients with adult acne were found to have an increased incidence of colonization with fecal coliforms (43.8%; P < .001). Patients with diabetes were found to have an increased incidence of colonization with S aureus (66.7%; P = .002). The overall infection rate was 3.0% (11 of 363 patients), with 4.0% (7 of 174 patients) seen in primary septorhinoplasties and 2.1% (4 of 189 patients) seen in revision cases. Coliforms accounted for 5 cases (45.5%) of postoperative infections, while S aureus was responsible for 4 cases (36.4%), including 1 case of MRSA. CONCLUSIONS AND RELEVANCE: The results of this study suggest that risk factors alone may not reliably predict the subset of patients in whom antibiotic prophylaxis is indicated. Knowledge of the endogenous nasal flora and the microbiology of common pathogens in patients undergoing septorhinoplasty will help to further reduce the incidence of infectious complications. LEVEL OF EVIDENCE: 3.

Asian rhinoplasty.

Asian rhinoplasty is one of the most challenging ethnic rhinoplasties that plastic surgeons perform because of the thick skin and soft-tissue envelope. There are three goals: pleasing the patient, achieving an aesthetically appealing result, and preserving a natural look. Of these goals, the most arduous is to satisfy the patient, as many patients have unrealistic goals and may desire an extremely narrow Western nose. Furthermore, patients may bring in celebrity or model photographs and expect that outcome, even though it may not be suitable for their face or appear over-resected and pinched. The surgeon's most important task is to attempt to persuade the patient that this result is nonfunctional, esthetically unfit, and difficult to achieve with their skin. For ethnic surgery, a clear and thorough grasp of nasal anatomy, function, and surgical techniques is paramount. An extensive preoperative discussion, including expectations, outcomes, and a detailed list of potential complications with the patient can prevent physician-patient miscommunication. Before surgery, it is essential to review the office examination, previous operative summary, photographs, nasal analysis sheet, problem list, and plan before proceeding with the surgical treatment.

Evolution in techniques for endoscopic brow lift with deep temporal fixation only and lower blepharoplasty-transconjunctival fat repositioning.

As we become more confident with our surgical skills following our fellowship training, some of our approaches and techniques will be modified or changed. My primary evolutionary change involves procedures of the upper third of the face, primarily the brow lift and treatment of lower eyelid fat techniques. Traditional methods of forehead and brow rejuvenation, such as coronal, pretrichal, and direct brow lifts, have provided facial plastic surgeons with effective brow elevation for many years. In the past decade, the endoscopic brow lift has rapidly become accepted as part of the surgical armamentarium and is frequently the technique of choice. In general, the temporal dissection, temporal fixation, forehead subperiosteal or subgaleal dissection with release, and treatment to the brow depressor musculature have been standardized. Methods of bony fixation remain a controversial topic as there are numerous methods. We advocate deep temporal fixation only without bone fixation to achieve effective, long-term brow elevation. Traditionally, lower eyelid herniated fat is removed, which may cause a sunken or hollow lid appearance, especially in patients with a tear trough deformity (nasojugal groove). Lower eyelid transconjunctival fat repositioning, defined as the subperiosteal repositioning of the medial and central lower eyelid herniated orbital fat into the nasojugal fold, may prevent the surgical, hollow lower eyelid appearance while treating the herniated fat. Fat repositioning may be combined with an endoscopic subperiosteal midface-lift, transcutaneous skin pinch, and transconjunctival orbicularis oculi excision. This technique offers a powerful tool in the surgical armamentarium of the facial plastic surgeon.

Lower blepharoplasty: transconjunctival fat repositioning.

Traditionally, lower eyelid herniated fat is removed, which may cause a sunken or hollow lid appearance, especially in patients with a tear-trough deformity (nasojugal groove). Lower eyelid transconjunctival fat repositioning, defined as the subperiosteal repositioning of the medial and central lower eyelid herniated orbital fat into the nasojugal fold, may prevent the surgical hollow lower eyelid appearance while treating the herniated fat. Fat repositioning may be combined with an endoscopic subperiosteal midface-lift, transcutaneous skin pinch, and transconjunctival orbicularis oculi excision. This technique offers a powerful tool in the surgical armamentarium of the facial plastic surgeon.

Male revision rhinoplasty: pearls and surgical techniques.

Male revision rhinoplasty surgery is the most difficult and challenging procedure that facial plastic surgeons perform because males usually have thick nasal skin, which is more difficult to re-support and project the nasal tip, and often have high or unrealistic expectations. The primary etiology for the need for male revision rhinoplasty is a primary rhinoplasty with aggressive lower lateral cartilage reduction that causes tip ptosis and loss of projection. The goal to an aesthetically pleasing revision rhinoplasty is to re-create adequate tip projection and an intact strong tripod complex. Following tip reconstruction, the height and width of the dorsum should be set. For male revision nasal surgery, a clear and thorough knowledge of nasal anatomy, function, and surgical techniques is paramount. Having an extensive preoperative discussion including expectations, outcomes, and a detailed list of potential complications with the patient can prevent physician-patient mis-communication. Prior to surgery, review the examination, previous operative summary, photographs, nasal analysis sheet, problem list, and plan and then proceed with the surgical treatment.

Adjunctive applications for botulinum toxin in facial aesthetic surgery.

Botulinum toxin (Botox) has firmly established itself as one of the premier nonsurgical therapies. Recently, Botox is also being used as an adjuvant to many aesthetic procedures, both surgical and nonsurgical. This combined therapeutic use for Botox may not only create an added benefit toward facial rejuvenation but may create a synergistic one as well. This article examines such uses for Botox and reviews the current medical literature.