Rhinoplasty in Middle Eastern Patients.

Rhinoplasty in patients of Middle Eastern origin requires complete understanding of nasal morphology and an individualized approach to create a racially congruent and aesthetically pleasing outcome. In this article, common anatomic features and characteristics and detailed steps, surgical techniques, and operative maneuvers that can lead to predictable outcome in rhinoplasty of Middle Eastern patients are discussed.

Superior rhinoplasty outcomes with precise nasal osteotomy: an individualized approach for maintaining function and achieving aesthetic goals.

BACKGROUND: Although frequently performed in rhinoplasty, nasal osteotomies have been unpredictable in consistently controlling postoperative alterations in bony morphology in many patients. Consequently, a detailed algorithm for an individualized approach to osteotomy is needed to achieve superior aesthetic and functional outcomes. OBJECTIVES: The authors aimed to propose a component-oriented and individualized approach for nasal osteotomy in rhinoplasty. METHODS: Clinical outcomes were reviewed for 150 consecutive patients who underwent rhinoplasty. Type and frequency of specific osteotomy procedures and preoperative and postoperative photographs were examined. RESULTS: A total of 97 cases with at least 12 months of follow-up data were evaluated. In 92 of 97 patients (95%), a lateralized medial oblique osteotomy was performed; 70 (72%) required bilateral intermediate osteotomy, and 21 (22%) required unilateral osteotomy. Forty-one patients (42%) underwent bilateral base osteotomy and 24 (25%) underwent unilateral base osteotomy. No base osteotomy was performed in 32 patients (33%) who had aesthetically pleasing lateral wall width and no convexity of the posterior portion of the lateral bony wall. CONCLUSIONS: The osteocartilaginous vault is asymmetric in the majority of patients undergoing rhinoplasty. Anatomic variations in the height, length, and/or width of the bony vault can significantly influence its shape and symmetry. Various principles and techniques for nasal osteotomy increase predictability of outcomes while improving nasal aesthetics and function. LEVEL OF EVIDENCE 4: Therapeutic.

Dynamics of the alar rim graft.

BACKGROUND: The purpose of this study was to review the dynamics and frequency of the use of the alar rim graft. METHODS: The recorded intraoperative information for the purpose of rhinoplasty research was reviewed to investigate the frequency of the use of alar rim grafts. Intraoperative observations were also made while inserting the alar rim graft to identify the changes that occur in the structures that could be influenced by placement of this graft. The data were tabulated in an Excel file and analyzed. RESULTS: Of the 1427 patients who underwent nose reconstruction or rhinoplasty in this study, 565 (39.56 percent) received alar rim grafts. This included 73 primary nose reconstructions, 20 secondary nose reconstructions, two revision nose reconstructions, 304 primary rhinoplasties, 107 secondary rhinoplasties, 43 revision operations following primary rhinoplasties, and seven revision operations following secondary rhinoplasties. However, when 100 more recent consecutive cases were reviewed, 88 percent of primary rhinoplasty patients and 67 percent of secondary rhinoplasty patients received alar rim grafts. The observed dynamic changes after insertion of each graft included (1) correction of the concavity of the ala, (2) caudal advancement of the alar rim, (3) elongation of nostril, and (4) widening of the nostril. CONCLUSIONS: The majority of patients who undergo rhinoplasty would benefit from the alar rim graft, and this study demonstrates a steady increase in its use. Placement of an alar rim graft results in elongation of the short nostril, correction of the alar concavity, widening of the nostril, and slight caudal transposition of the alar rim.

Rhinoplasty and brow modification: a powerful combination.

BACKGROUND: Plastic surgeons have long recognized the importance of performing chin augmentation concurrent with a rhinoplasty to achieve facial balance. However, few surgeons consider the benefits of combining a rhinoplasty with brow modification to achieve a better aesthetic result. By increasing the size of the middle third of the face, the nose will automatically appear smaller. OBJECTIVE: The authors describe anatomical dissections that provided perspective on the facial anatomy of the areas being studied and report the results of concurrent browlift and rhinoplasty procedures in a retrospective series of patients. METHODS: The present study consisted of 2 parts: anatomical dissections and a retrospective chart review. The nose and central forehead area were dissected in 7 fresh cadavers at the time of autopsy to understand the anatomical relationship between the various muscles in the radix/glabellar region and to assess the muscle resection occurring in the clinical procedures. We also reviewed the charts of 24 patients who underwent combined rhinoplasty and brow modification with the senior author (R.K.D.) during a 2-year period (July 2010 to June 2012). Younger patients underwent a central browlift (CBL) with screw fixation, while older patients (ages 34-60 years) underwent full 5-incision endoscopic forehead lifting. RESULTS: The age range for patients in this series was 14 to 60 years. Two patients were men and 22 were women. There were 12 primary and 12 secondary procedures in the series; 13 patients underwent CBL and 11 had EFL. The mean follow-up was 18 months. One patient had a persistent fluid accumulation in the glabellar region, which required drainage. One patient requested additional refinement of her nasal tip. CONCLUSION: Modification of the central brow can dramatically change the aesthetic polygons of the nose/glabellar region. A CBL with radix/glabellar muscle excision is important in younger patients who need a well-defined nasion and older secondary patients who feel that the upper third of their nose is still heavy. A full EBL can enhance the facial appearance of older patients in whom a rhinoplasty alone would have a modest impact.

Rhinoplasty: congenital deficiencies of the alar cartilage.

BACKGROUND: Congenital deficiencies of the alar cartilages are rare and often visible at birth but can occasionally present later. OBJECTIVES: The authors review the anatomical development and discuss the incidence and treatment of congenital defects within the alar cartilages seen in rhinoplasty cases. METHODS: The charts of 869 consecutive patients who underwent open rhinoplasty were retrospectively reviewed, and 8 cases of congenital defects of the alar cartilage within the middle crura were identified. Intraoperative photographs were taken of the alar deformities, and each patient underwent surgical correction. To simplify analysis, a classification of the defects was developed. A division was a cleft in the continuity of the alar cartilage with the 2 ends separate. A gap was a true absence of cartilage ranging from 1 to 4 mm, which can be accurately assessed in unilateral cases. A segmental loss was a defect greater than 4 mm. RESULTS: The 8 cases of deformity could be classified as 4 divisions, 3 gaps, and 1 segmental loss. None of the patients had a history of prior nasal trauma or nasal surgery. Six patients were women and 2 patients were men. In all cases, adequate projection and stability were achieved with a columellar strut. Asymmetry was minimized through concealer or tip grafts. There were no complications. CONCLUSIONS: Surgeons performing rhinoplasty surgery will encounter and should be prepared to deal with unexpected congenital defects of the alar cartilage. These defects within the middle crura will require stabilization with a columellar strut and, often, coverage with a concealer tip graft. We speculate that the cause of these defects is a disruption of the hedgehog signals that may arrest the condensation or block the differentiation of the underlying neural crest cells.

Combination surgical excision and fractional carbon dioxide laser for treatment of rhinophyma.

Rhinophyma is a severe late complication of rosacea, which is characterized by progressive hyperplasia of sebaceous glands and connective tissue involving the lower two-thirds of the nose. It can be an emotionally devastating disorder, and serve as a medium for occult cancers and other health problems. Many surgical treatments have been advocated, as well as dermabrasion and laser therapy. In light of the problems faced with these individual therapy modalities, we advocate a combination therapy of surgical debulking and fractionated Carbon dioxide laser therapy. By excising the tissue first, we not only decreased the amount of time needed for the procedure, we were also able to preserve a histopathologic specimen that can be examined for occult cancers. After debulking, the fractionated carbon dioxide laser is then used to blend. By using fractionated carbon dioxide, we avoided the complications associated with non-fractionated carbon dioxide lasers, such as delayed healing times, hypopigmentation, hyperpigmentation, scarring, and persistent redness. We report our experience in two patients with rhinophyma who underwent a combination of surgical excision and fractional Co2 laser therapy for treatment. Pre- and postoperative protocols and treatment parameters are discussed. Both patients had excellent cosmetic and functional results and were followed for at least one year.

Primary rhinoplasty.

Rhinoplasty is generally considered to be one of the most challenging, complex, and exciting of all the plastic surgery procedures. In this article, the authors discuss key concepts related to patient evaluation and analysis, as well as techniques and maneuvers that reliably lead to favorable long-term results in rhinoplasty.

Current status of grafts and implants in rhinoplasty: Part II. Homologous grafts and allogenic implants.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the challenges in restoring volume and structural integrity in rhinoplasty. 2. Identify the appropriate uses of various homologous grafts and allogenic implants in reconstruction, including: (a) freeze-dried acellular allogenic cadaveric dermis grafts, (b) irradiated cartilage grafts, (c) hydroxyapatite mineral matrix, (d) silicone implants, (e) high-density polyethylene implants, (f) polytetrafluoroethylene implants, and (g) injectable filler materials. 3. Identify the advantages and disadvantages of each of these biomaterials. 4. Understand the specific techniques that may aid in the use these grafts or implants. SUMMARY: This review specifically addresses the use of homologous grafts and allogenic implants in rhinoplasty. It is important to stress that autologous materials remain the preferred graft material for use in rhinoplasty, owing to their high biocompatibility and low risk of infection and extrusion. However, concerns of donor-site morbidity, graft availability, and graft resorption have motivated the development and use of homologous and allogenic implants.

Current status of grafts and implants in rhinoplasty: part I. Autologous grafts.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the challenges in restoring volume and structural integrity in rhinoplasty. 2. Identify the appropriate uses of various autografts in aesthetic and reconstructive rhinoplasty (septal cartilage, auricular cartilage, costal cartilage, calvarial and nasal bone, and olecranon process of the ulna). 3. Identify the advantages and disadvantages of each of these autografts. SUMMARY: This review specifically addresses the use of autologous grafts in rhinoplasty. Autologous materials remain the preferred graft material for use in rhinoplasty because of their high biocompatibility and low risk of infection and extrusion. However, these advantages should be counterbalanced with the concerns of donor-site morbidity, graft availability, and graft resorption.

An algorithm for treatment of the drooping nose.

UNLABELLED: Nasal tip ptosis ("drooping" or long nose) occurs when the tip of the nose is more caudal than what is deemed ideal. Intrinsic factors, such as elongated or caudally-rotated lower lateral cartilages, can lead to nasal tip ptosis. Extrinsic factors, such as elongated upper lateral cartilages or excessive caudal anterior septum and heavy nasal skin, can push the nasal tip caudally and lead to drooping of the nasal tip. The loss of maxillary or nasal spine support may enhance the potential for tip ptosis. In addition, a hyperactive depressor nasi septi could, as a result of continuous pull on the tip, result in tip ptosis. Aging or previous nasal procedures (such as the Goldman-type tip surgery) where the continuity of the lateral and medial crura of the lower lateral cartilages have been violated may cause a weakening of the tip-supporting mechanisms and de-rotation of the nasal tip. Correction of this deformity is challenging and rewarding; it can resolve both the cosmetic deformity and nasal obstruction symptoms related to this entity. The goal of this article is to present our current principles of diagnosis and treatment of nasal tip ptosis, as well as to introduce and algorithm of preferred methods and techniques for its reliable and stable correction. RESULTS: Correction of the nasal tip ptosis requires accurate diagnosis, a recognition of the interplay between various anatomic components, specific strategy planning, and a correction of anatomic abnormalities.

Treating facial soft tissue deficiency: fat grafting and adipose-derived stem cell tissue engineering.

The authors outline the limitations of fat grafting. They then describe the currently available fat culturing technique and explain how options incorporating adipose-derived stem cell technologies and growth factors will provide new modalities in treating facial soft tissue deficiency.

Omental transposition flap for salvage of ventricular assist devices.

BACKGROUND: The use of ventricular assist devices for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. Ventricular assist devices improve the longevity and the quality of life for these patients. In addition, they serve as a bridge to cardiac allograft transplantation until a donor heart is found. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Clinical infection and sepsis can critically threaten these patients with ventricular assist devices. Infection can delay immediate transplantation and potentially require the removal of the device for definitive treatment of the problem. METHODS: Patients who underwent insertion of a ventricular assist device at the University of Pittsburgh Medical Center were identified through accessing the medical records archives of the hospital. Review of patients' medical records was conducted to obtain patient demographics, preoperative diagnosis and disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, infectious organism identified, timing of omental flap procedure after the initial insertion, duration of ventricular assist device support before cardiac transplantation, and patient follow-up. RESULTS: There were 76 patients who underwent a ventricular assist device insertion procedure during the 4-year period between January of 2000 and January of 2004. Of the 76 patients who received a device, 11 (14 percent) had evidence of clinical infection secondary to insertion. Two of these 11 patients died before surgical intervention, four had their devices explanted, and the remaining five underwent omental flap transposition with bilateral pectoralis major advancement flaps in surgically addressing their infections. Of the five patients with infections who received omental transposition flaps, two went on to undergo successful transplantation, two continue to await cardiac allograft transplantation, and one died as a result of an unknown cause. CONCLUSIONS: The authors present their experience with five patients who received omental transposition flaps to cover infected ventricular assist device pumps and the associated tubing in large, open sternoabdominal wounds. Treatment included the direct application of an omental transposition flap over the infected device with use of a bilateral pectoralis advancement flap to aid in complete sternal and skin closure of the sternal wound defect. In each of these cases, the use of the omental flap was followed by resolution of the mediastinal infection. In addition, the treatment with an omental flap prevented the removal of infected devices in patients who were otherwise pump dependent during their waiting periods for transplantation. The use of omental transposition flaps can be an effective technique in salvaging infected ventricular assist devices and preserving this valuable device for patients awaiting a cardiac transplant.

One-stage reanimation of the paralyzed face using the rectus abdominis neurovascular free flap.

BACKGROUND: Functional free muscle transfer for the surgical correction of long-standing facial paralysis has gained validity over the past three decades. These traditionally multistep reconstructions often achieve clinical success, but at the cost of significant morbidity and lengthy recovery periods. To address this dilemma, the authors propose reconstruction using the rectus abdominis and accompanying intercostal nerve in a one-stage neurovascular free flap reanimation procedure. METHODS: Between 1998 and 2001, five patients with long-standing unilateral facial paralysis at the University of Pittsburgh Facial Nerve Center underwent reanimation using the authors' protocol. Preoperative and postoperative assessments included clinical evaluation using the Facial Grading System and electromyography. The patients were followed for a mean of 16 months. RESULTS: At the final postoperative visit, all five patients demonstrated improved levator electromyographic potential, with a median 67 percent improvement. All five patients further demonstrated an increase in zygomaticus electromyographic potential, with a median 225 percent improvement. All five patients demonstrated increased Facial Grading System score at most recent follow-up. CONCLUSIONS: The one-step reanimation using free rectus abdominis neurovascular free flap demonstrated a consistent positive outcome in electromyographic and clinical assessments. The additional benefits of reduced recovery time and anatomical reliability of the flap render the authors' method preferable to other traditional methods of surgical reanimation of the paralyzed face.

Correcting the saddlebag deformity in the massive weight loss patient.

Skin redundancy of the trunk and thigh is treated by a circumferential abdominoplasty and a lower body lift. Despite preservation and tight approximation of the subcutaneous facial system, the authors have failed to adequately correct severe saddlebag deformity and midthigh laxity in the massive weight loss patient. The technique used in the last nine of the senior author's 43 lower body lifts was modified by fully abducting each operated thigh on a side utility table, before closure in the prone position. This maneuver permits an increase in width of skin excision and causes the lateral thigh skin to be taut upon leg adduction. This is a retrospective review of the senior surgeon's experience over a 3-year period. Postoperative follow-up of the nine-patient cohort ranged from 8 to 12 months. A standardized set of six-view preoperative and postoperative photographs was available for each patient. A regional grading system was developed to assign points for deformity seen in preoperative and postoperative photographs. To compare the effect of the new technique on the correction of hip/lateral thigh deformities, the authors used this same grading system to analyze 10 other lower body lift patients treated by the same surgeon without full thigh abduction who had six sets of standardized photographs. A deformity severity score was determined for each anatomic region by four trained observers blinded to the surgical technique. The nonparametric Mann-Whitney U test using exact p values was used to compare preoperative and percentage change in deformity severity score from preoperative to postoperative scores relative to preoperative scores for each anatomical region among subjects in each treatment group. The nonparametric Wilcoxon signed rank test using exact p values was used to evaluate the change in deformity severity score from preoperative to postoperative values. The change in technique resulted in an observable symmetrical correction of the severe saddlebag deformity and better contour to the distal lateral thighs. All evaluated patients were satisfied with the lateral thigh skin contour. The grading system revealed that patients treated with or without intraoperative thigh abduction had similar preoperative deformity severity scores for each anatomic region (p > 0.05). Postoperatively, all subjects showed improvement in scores for all treated regions. However, patients closed during full thigh abduction had significantly lower deformity severity scores for the hip/thigh complex when compared with patients treated without full thigh abduction (p < 0.05). Complications in these 19 patients consisted of one 6-cm superficial skin layer dehiscence due to a broken polyester suture that healed spontaneously. There were three seromas that responded to a short series of aspirations or catheter drainage. There were no infections. Distal abdominal flap tip skin necrosis in four patients responded to outpatient débridement and healed secondarily. A new grading system for body contour deformities was successfully utilized to judge differences in the quality of trunk and thigh deformity and outcome in 19 patients with adequate photographic records. Tight suture closure in full thigh abduction in the prone position results in improved treatment of significant saddlebag deformity and midthigh skin laxity in the massive weight loss patient. The essential principles are meticulous planning, careful isolation, tight closure of the lateral trunk and thigh subcutaneous fascial system, and artistic contouring of remaining tissues. Dehiscence, undesirable scarring, and seromas were minor issues in the entire group of 43 patients.