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 .

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.

Mattress sutures to remove unwanted convexity and concavity of the nasal tip: 12-year follow-up.

Nasal tip bulbosity, or convexity, has been one of the most difficult problems to correct during rhinoplasty. Excision of cartilage from the cephalic part of the lateral crus has helped. However, complete correction of the deformity is not always possible with this maneuver alone. Suture techniques have also helped to improve outcomes. Twelve years ago, the lateral crus mattress suture was introduced as a way of converting the lateral crus to a flat, straight segment with resultant correction of the convexity. Since then, this suture technique has been employed in most primary and some secondary rhinoplasties and has stood the test of time. We report our experience with this technique, including a slight modification to facilitate its application when the cartilage is unusually narrow or when the original technique is difficult to complete. In addition, the suture technique for the less concave lateral crura is redescribed. It, too, has withstood the test of time.

The beneficial effects of postrhinoplasty taping: fact or fiction?

BACKGROUND: Initial patient perceptions of rhinoplasty results are complicated by early postoperative edema, ecchymosis, and distortion. Anecdotal evidence suggests that taping the nose immediately upon splint removal aids with the patient's psychological adjustment to his or her new appearance. OBJECTIVES: The authors attempt to assess the overall impact of taping after splint removal on patient well-being while providing statistical validation regarding the utility of this intervention. METHODS: The authors evaluated the reaction of 24 postoperative rhinoplasty patients on the day of splint removal by photographing them and noting their verbal responses. Those patients who were obviously happy received no taping and were dismissed from the study. The remainder of the patients received flesh-colored tape (3M, St Paul, Minnesota) and their subsequent reactions were noted and photographed. RESULTS: Of 24 consecutive patients, 16 received tape. Fifteen of those taped initially displayed a flat affect (group A), while 1 was clearly unhappy (group B). The remaining 8 patients were obviously happy (group C) and were excluded from taping. Thirteen (86%) of those in group A displayed immediate subjective improvement after taping (χ(2) = 12.8; P < .001). The lone patient in group B continued to be unhappy and required ongoing reassurance. CONCLUSIONS: Application of tape immediately upon splint removal after rhinoplasty improves initial patient perceptions. Taping can provide a simple and risk-free intervention for patients who do not express immediate satisfaction.

Supratip-plasty: a completely cartilaginous tip complex to maintain nasal tip width.

BACKGROUND: Following primary rhinoplasty, the nasal tip may become wider on front view, possibly due to splaying of the lateral crura. OBJECTIVES: The authors describe a technique, the "supratip-plasty," to create an all-cartilaginous supratip that resists splaying and postoperative broadening of the nasal tip complex. METHODS: Thirteen consecutive primary rhinoplasty patients (10 women; 3 men) with broad nasal tips received a supratip-plasty (which preserved the cephalic part of the lateral crus, reducing it in size and securing it to the dorsal septum, resulting in a completely cartilaginous tip framework) and were followed for 11 to 17 months. Since the frontal tip width (TW) is relative to the frontal nasal base width (NBW), the TW/NBW ratio was contrasted to that of 19 unoperated aesthetically pleasing nasal tips. RESULTS: Of the 13 cases, all but 1 were considered to have a good result. The preoperative mean TW/NBW ratio was 0.68. The postoperative mean was 0.53, compared with 0.48 in the unoperated aesthetic tip group. No tip revisions were necessary; however, 2 patients did require revisionary surgery for nontip problems. CONCLUSIONS: Preserving a cephalic island of lateral crus, trimming it to fit the new supratip contour following suture tip-plasty, and securing it to the septum provides a completely cartilaginous nasal tip framework that tends not to widen postoperatively.

Septoturbinotomy.

The inferior turbinates are a principal cause of nasal airway obstruction. To some extent, the bony septum (the perpendicular plate of the ethmoid) also, on occasion, contributes to that airflow obstruction. There are many excellent methods to resect or ablate the turbinates, including submucous resection and cauterization. However, some have been associated with bleeding, crusting, and the development of synechiae. In this Featured Operative Technique article, we propose 2 mechanical means to expand the nasal vault: (1) the insertion of a large and long speculum that outfractures the turbinates and also centralizes the bony septum when the handles are compressed and (2) the insertion of a large clamp, which is expanded (in reverse "nutcracker" fashion) to achieve a similar result. Mechanical dilation (expansion) of the nasal vault with the speculum or large clamp substantially improves vault diameter such that further work on the turbinates in the form of turbinectomy is seldom necessary. The nasal vault is not necessarily expanded to the maximal diameter that could be achieved with resection procedures but need not be to achieve satisfactory air flow. Septoturbinotomy is a quick and simple way to deal with inferior turbinate hypertrophy. It is a minimally invasive procedure that improves the airway in virtually all cases, such that turbinectomy is seldom employed. It can be used prophylactically on all rhinoplasty cases requiring lateral osteotomy, which potentially shrinks the nasal vault slightly.

Rhinoplasty sizers.

Templates and sizers are used as tools to assist in the design and construction of both structural and artistic works. These templates and sizers are used frequently in the field of aesthetic and reconstructive surgery. The use of a template to assist with construction of cartilage grafts in rhinoplasty allows the surgeon to sculpt by replicating the template model. Templates and sizers are useful and advantageous tools in the rhinoplasty operation.

Physical Time Within Human Time.

A possible solution is offered to help resolve the "two times problem" regarding the veridical and illusory nature of time. First it is recognized that the flow (passage) of time is part of a wider array of temporal experiences referred to as manifest time, all of which need to be reconciled. Then, an information gathering and utilizing system (IGUS) model is used as a basis for a view of manifest time. The model IGUS robot of Hartle that solves the "unique present" debate is enhanced with veridical and (corresponding) illusory components of not only the flow of time but also the larger entity of manifest time, providing a dualistic IGUS robot that represents all of the important temporal experiences. Based upon a variety of prior experiments, that view suggests that the veridical system is a reflection of accepted spacetime cosmologies and through natural selection begets the illusory system for functional purposes. Thus, there are not two opposing times, one outside and one inside the cranium. There is just one fundamental physical time which the brain developed, now possesses and is itself sufficient for adaption but then enhances. The illusory system is intended to provide a more satisfying experience of physical time, and better adaptive behavior. Future experiments to verify that view are provided. With a complete veridical system of temporal experiences there may be less need to reify certain temporal experiences so that the two times problem is less of a problem and more of a phenomenon.

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.