[3D printing in plastic surgery, an accessible tool: Technical note around a case of otopoiesis assisted by 3D model]. / L'impression 3D en chirurgie plastique, un outil accessible : note technique autour d'un cas d'otopoïèse assistée par modèle 3D.

3D printing has been used in the medical field since the beginning of the 21st century. Over the years, it has been democratized and has become an accessible tool at almost no cost, provided that a 3D printer is available. The surgeon can thus easily integrate it into his practice and techniques in the operating room, provided that he learns to use 3D image processing software. In order to illustrate the whole process, from the genesis and processing of the 3D image to its application in the operating room, we describe the case of a patient with a left auricle amputation, whose reconstruction was guided by a 3D model printed from his right ear.

[Impact of the number of pregnancies on the venous outflow of DIEP flap in breast reconstruction: A clinical and CT-scan study]. / Impact du nombre de grossesses sur la congestion veineuse dans les reconstructions mammaires par lambeau de DIEP : étude clinique et scannographique.

INTRODUCTION: The DIEP (deep inferior epigastric perforator) flap is the "gold standard" for breast reconstruction after cancer, giving better benefits on the quality of life. The most common complication is the venous congestion, because of the dominance of superficial venous outflow while the flap is drained by the deep epigastric vein. Pregnancy, by its physiological and vascular modifications, can reduce the risk of the venous congestion. Few studies explored the impact of pregnancy on the DIEP vascularization. MATERIAL AND METHODS: We studied the preoperative CT-scans of 104 patients who benefited reconstruction surgery by DIEP from January 2011 until March 2022. The patients were separated into 5 groups according to number of pregnancies. For each CT-scan, a concomitant vein of deep epigastric artery diameter/SIEV diameter ratio was performed on each side, to assess the relation between pregnancy and the reduction of venous complications. RESULTS: The results showed an increase of this ratio with the number of pregnancies. Patients with no pregnancy (G0) have the highest complication rate, with 41.7% of venous congestion case. On the other hand, in the group of four pregnancies or more (G4), the complication rate was significantly lower, at 10%, and none venous congestion was observed. These results suggest the beneficial effects of pregnancy on vascularization and especially on venous drainage in the DIEP flap. CONCLUSION: This study highlights the benefit effect of the number of pregnancies on the DIEP vascularization, especially for the reduction of the venous congestion risk. The ratio DIEV/SIEV may be a useful help to predict the risk of venous complications in nullparous patients. These results open to new studies to deepen the understanding of the physiological effects of the pregnancy on the breast reconstruction surgery.

[Ethical issues of gender reassignment surgery]. / Enjeux éthiques de la chirurgie de réassignation sexuelle.

Gender reassignment raises complex ethical issues. It questions gender identity and the right to self-determination. Some highlight the right to access the medical care necessary to live according to one's perceived gender. Others worry about the potential rush into major medical decisions, especially among minors. The need for a medical diagnosis of gender dysphoria can be seen as pathologizing. The requirement for surgery for marital status change, while not mandatory in many places, remains controversial. The balance between informed consent and access to treatment, as well as stigma and discrimination, contribute to the complexity of ethical issues. Finally, the issues surrounding the competence of health professionals, the quality of care and the integration of individual needs make these decisions particularly sensitive from an ethical point of view.

Efficacy and satisfaction of surgical treatment for hidradenitis suppurativa.

BACKGROUND: Surgery is a radical treatment for hidradenitis suppurativa (HS) and may be considered as the only one potentially curative. OBJECTIVES: To characterize HS recurrence in patients after surgery and assess the risk factors of recurrence. METHODS: We conducted a monocentric retrospective cohort study. All consecutive patients who had surgery (January 1, 2012 to March 31, 2017) were included. We estimated the rate of recurrence of HS lesions after surgery (<1 cm from the scar), and recurrence-associated factors were analysed by univariate then multivariate logistic regression, estimating odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: A total of 75 patients [median age 31.4 years (range 16-71); 36 females], corresponding to 115 interventions were included. The Hurley score at surgery was III for 70 (60%) patients. In total, 61/115 (53%) interventions involved wide excision and 50 (43%) limited local excision. The localizations were axillary folds (n = 46; 40%), buttocks (n = 15, 13%), genital area (n = 13; 11%), perineal area (n = 12; 10%) and inguinal folds (n = 18; 16%). We observed 11 (10%) complications and 40 (35%) recurrences. On multivariate analysis, probability of recurrence was associated with only one-stage surgical closure [OR 3.2 (95% CI 1.4-7.3), P = 0.005]. Overall, 44 (52%) patients were completely satisfied and 22 (26%) partially satisfied, and most (81%) considered the surgery the best treatment. CONCLUSIONS: Hidradenitis suppurativa recurrence in our study was 35% and associated with one-stage surgical closures, but two-thirds of patients were satisfied with surgical treatment and would recommend surgery.

Clitoral reduction: Technical note.

Clitoral hypertrophy is a rare genital malformation that can be congenital or acquired. In congenital forms, the most common cause is adrenal hyperplasia. The acquired forms are caused by endocrinological diseases, benign tumours or cysts. Idiopathic clitoral hypertrophies can be detected after the elimination of secondary causes. A complete assessment is needed to treat the origin of clitoridomegaly. The hypertrophy is often increased or unmasked during sexual arousal with the appearance of a true vulvar appendage in erection. It is often accompanied by a hypertrophy of the clitoral hood and can cause psychological suffering with an impact on the quality of sexual life. When the cause of clitoral hypertrophy is diagnosed, treated or stabilized, the plastic surgeon may be called upon for surgical correction. Reconstructive surgery in this area has evolved considerably since the historical clitoral amputations which led to the current technique of partial resection with sparing the dorsal neurovascular pedicle of the clitoris as described by Professor Paniel. We propose a modified conservative technique to treat clitoral hypertrophy and the clitoral hood and present two clinical cases: ventral reduction clitoridoplasty with preservation of the neurovascular pedicle associated with a chevron plasty of the clitoral hood and a lipofilling of the labia majora. The postoperative follow-up is simple with reports of great satisfaction from patients regarding their quality of life.

Immediate vaginal reconstruction following pelvic exenteration using the pedicled vertical Deep Inferior Epigastric Perforator (DIEP) flap: A technical note.

Immediate vaginal reconstruction is usually offered following pelvic exenteration for recurrent cervical cancer in women previously treated with radiotherapy or with severe radiation-induced fistulae. Introduction of muscle-sparing flaps, such as the pedicled vertical deep inferior epigastric perforator (DIEP) flap, provides viable tissues for vaginal reconstruction and is associated with reduced donor-site morbidity. This report describes the surgical technique, which is one of the procedures of choice for vaginal reconstruction. It is safe and beneficial, especially for women with gynecologic cancer who have undergone pelvic exenteration after failed radiation therapy.

Carbon dioxide laser treatment for vulvovaginal atrophy in women treated for breast cancer: Preliminary results of the feasibility EPIONE trial.

BACKGROUND AND OBJECTIVE: Quality of life preservation after anti-cancer therapy is a major challenge for breast cancer survivors. Approximately 42-70% of patients who receive systemic therapy for breast cancer, including endocrine therapy, will develop vulvovaginal atrophy (VVA). For these patients, the commonly proposed gel-based treatments for topical applications are restrictive. Recently, innovative, non-hormonal therapeutic approaches, such as laser therapy, have emerged. The purpose of this feasibility study is to investigate the safety and efficacy of CO2 laser therapy in women with a history of breast cancer. MATERIAL AND METHODS: This prospective monocentric study included 20 patients with vulvovaginal atrophy who were treated at Henri Mondor University Hospital between 2017 and 2018. We included patients with a vaginal health index (VHI) score<15 and a contraindication for hormone administration due to a history of breast cancer. Two carbon dioxide laser sessions were used. The treatment was delivered using the following settings: vaginal tightening, FinePulse (pulse width 0.9ms), and energy density of 11.5J/cm2 that allows coverage of 70% of the targeted vaginal area to be treated. All patients had their follow-up visit at one (M1), three (M3), and six (M6) months after the first treatment to evaluate efficacy of the treatment on vulvovaginal atrophy. Vaginal health index score and female sexual distress (FSD) score were used to assess treatment efficacy and its impact on sexual quality of life. A score≥11 was associated with sexual dysfunction. The vaginal health index and female sexual distress scores were evaluated at baseline, M1, M3, and M6 of follow-up. RESULTS: The mean age of the patients was 56.1±8.8 years (range, 27-69 years). Seventeen of the 20 patients had experienced menopause (mean menopausal age, 51.25±1.5 years). At inclusion, the mean vaginal health index and the female sexual distress scores were 10.58±1.71 and 21.36±15.10, respectively. Fourteen out of 20 patients (70%) had FSD scores≥11 at the baseline. At M1, the mean vaginal health index score increased significantly to 13.42±2.3 (P=0.03), which represented an improvement of 21% from the baseline. A persistent and significant improvement in the vaginal health index score was observed at M6, with the score increasing to 16.75±4.23 post-treatment (P<0.0001), representing a 34% improvement from the mean baseline score. The mean female sexual distress at M1 was 19.83±13.57, representing a 7% decrease compared to the baseline scores (P<0.01). At M3, the female sexual distress significantly decreased to 13.88±15.58, representing an improvement of 35% (P=0.006). It increased to 10.35±14.7 at M6, representing an improvement of 52% (P=0.001). At M3, 35% of the patients had a female sexual distress score>11, and at M6, only 15% had a female sexual distress score>11. No side effects were reported during follow-up. CONCLUSION: This pilot feasibility study showed that carbon dioxide laser treatment appears to be an effective and safe method to improve the trophicity and decrease vaginal mucosal dryness in women with vulvovaginal atrophy that developed after systemic breast cancer therapy.

[Peculiarities of botulinum toxin injections for the aesthetic treatment of men's face. A review of the literature]. / Particularités des injections de toxine botulique pour le traitement esthétique du visage chez l'homme. Une mise au point de la littérature.

INTRODUCTION: Botulinum toxin injections in aesthetic medicine are the most widely used products, ahead of hyaluronic acid, and aesthetic medicine is constantly increasing, including in the male population. The objective of this development was to show the specificities described in the literature concerning botulinum toxin injections in men. MATERIAL AND METHOD: A systematic literature search was carried out using the Pubmed search engine. Data were then collected to determine the specificities of botulinum toxin injections in men according to the morphology of the male face and the wishes of these patients. RESULTS: The studies conducted show that it is necessary to inject higher doses in men than in women to obtain a satisfactory result, due to a higher muscle mass. This adjustment gives the number of points to be performed per injection site, as well as the number of points to be performed, compared to the female population. CONCLUSION: Botulinum toxin injections for aesthetic purposes in men are different from those in women. Taking these particularities into account is essential to patient satisfaction.

Wound healing of cutaneous substance losses based on infectious, inflammatory and traumatic skin disorders: The experience of a center.

INTRODUCTION: There is no reference available concerning the standard healing time based on dermatological diseases responsible for cutaneous substance losses. The aim of our study was to assess the healing time after surgical debridement of necrotizing fasciitis (NF), hidradenitis suppurativa (HS) and skin necrosis due to trauma (SNT) based on multiples existing co-morbidities among these patients to provide surgeons with accurate scientific data in order to inform and educate patients and nurses who are practicing care under the supervision of the surgeon. MATERIALS AND METHODS: This was a retrospective study. The primary endpoint was the time for complete wound healing, which was calculated from the time of the last surgical procedure to the complete wound healing corresponding to the time of complete reepithelialization, when daily dressings were no longer needed. RESULTS: A total of 107 patients were included. The mean time for complete wound healing was 64.94±31.55 days in patients with NF, 45.70±21.40 days in patients with SNT and 75.02±26.41 days in patients with HS (SNT versus NF, P=0.004** and SNT versus HS, P<0.0001**). CONCLUSION: The mean time for complete wound healing was 64.94 days in patients with NF, 45.70 days in patients with SNT, 75.02 days in patients with HS. This study can be considered as a referential based on the experience of a reference centre for these 3 pathologies (NF, HS, and SNT) whose aim is to inform plastic surgeons in order to anticipate the management or educate the patient.

Skin-reducing oncoplasty: A new concept and classification in breast cancer surgery.

BACKGROUND AND OBJECTIVES: Breast-conserving surgery and skin-sparing mastectomy are nowadays widely accepted as the standard of care in selected patients with early breast cancer. After an accurate review of the literature, it appeared that no ordered list of the numerous techniques described for conservative breast surgery has been established so far. The aim of this study was to develop a simple classification of the different skin incision patterns that may be used in breast surgery. METHODS: A systematic review of the English literature was conducted using the PubMed database to identify all the articles reporting breast-conserving surgery and skin-sparring mastectomy techniques up to the 31st of December 2016. RESULTS: Among the 1426 titles identified, 230 were selected for review. Based on the reviewed papers, the skin-reducing oncoplasty incision pattern (SROIP) classification was elaborated. CONCLUSIONS: Breast cancer surgery should nowadays optimise aesthetic outcomes by improving the final breast shape, volume and scar location. This may be achieved using different procedures that we grouped together under the term skin-reducing oncoplasty (SRO). Depending on the breast cancer location, the SROIP classification helps in the choice of the best technique to be used.

Oral surgery in the European Union: challenges of diversity in training and practice.

INTRODUCTION: At the crossroads of medicine and dentistry, oral surgery with orthodontics are the only recognised dental specialties by the European Union. The goal of our study is to evaluate the current state of oral surgery in Europe from its teaching to its practice, the hypothesis being that a notable diversity persists despite European Union harmonisation process. MATERIALS AND METHODS: To understand the impact of this diversity applied to European Union freedom of movement and its ethical implications for the practice of oral surgery, English and French questionnaires were sent by email to universities and organisations delivering authorisation to practise in France, Germany, Spain, Sweden and United Kingdom chosen based upon inclusion and exclusion criteria. An analysis of documents on these organisations' official websites was also conducted. Demographic information was obtained from the aforementioned organisations. RESULTS: The profile of practising oral surgeons is different dependent on the country. The university and hospital trainings conform to European recommendations and span 3-4 years. European Board certification is not required. Continuing education is mandatory only in France, Germany and United Kingdom. As for curricula and scope of practice, no consensus can be derived. DISCUSSION: There is potential conflict of interest between European Union principles of freedom of movement and protection of all citizens, as member countries do not uniformly apply Directives and recommendations. A new survey of all European Union oral surgery programmes as well as organisations delivering authorisation to practise is necessary to implement across the board harmonisation of training and practice to insure patient safety in light of the migration of European Union practitioners.

[Hyaluronic acid rheology: Basics and clinical applications in facial rejuvenation]. / Rhéologie des acides hyaluroniques : principes fondamentaux et applications cliniques en rajeunissement facial.

Hyaluronic acid (HA) is the most widely used dermal filler to treat facial volume deficits and winkles specially for facial rejuvenation. Depending on various areas of the face, filler is exposed to two different forces (shear deformation and compression/stretching forces) resulting from intrinsec and external mechanical stress. The purpose of this technical note is to explain how rheology, which is the study of the flow and deformation of matter under strains, can be used in our clinical practice of facial volumization with fillers. Indeed, comprehension of the rheological properties of HA has become essential in selection of dermal filler targeted to the area of the face. Viscosity, elasticity and cohesivity are the main three properties to be taken into consideration in this selection. Aesthetic physicians and surgeons have to familiarize with those basics in order to select the HA with the right rheological properties to achieve a natural-looking and long-lasting outcome.

[How to make your own custom cutting guides for both mandibular and fibular stair step osteotomies?] / Ostéotomies fibulaires et mandibulaires en marche d'escalier. Comment réaliser ses propres guides de coupe pour les reconstructions maxillofaciales ?

INTRODUCTION: Using tailored cutting guides for osteocutaneous free fibula flap in complex mandibular reconstruction after cancer resection surgery constitutes a substantial improvement. Autonomously conceiving and manufacturing the cutting guides within a plastic surgery department with computer-aided design (CAD) and three-dimensional (3D) printing allows planning more complex osteotomies, such as stair-step osteotomies, in order to achieve more stable internal fixations. METHODS: For the past three years, we have been producing by ourselves patient-tailored cutting guides using CAD and 3D printing. Osteotomies were virtually planned, making the cutting lines more complex in order to optimize the internal fixation stability. We also printed reconstructed mandible templates and shaped the reconstruction plates on them. We recorded data including manufacturing techniques and surgical outcomes. RESULTS: Eleven consecutive patients were operated on for an oral cavity cancer. For each patient, we planned the fibular and mandibular stair-step osteotomies and we produced tailored cutting guides. In all patients, we achieved to get immediately stable internal fixations and in 10 patients, a complete bone consolidation after 6 months. CONCLUSION: Autonomously manufacturing surgical cutting guides for mandibular reconstruction by free fibula flap is a significant improvement, regarding ergonomics and precision. Planning stair-step osteotomies to perform complementary internal fixation increases contact surface and congruence between the bone segments, thus improving the reconstructed mandible stability.

[Identification of perforating vessels by augmented reality: Application for the deep inferior epigastric perforator flap]. / Repérage des vaisseaux perforants par réalité augmentée : application au lambeau perforant d'artère épigastrique inférieure profonde.

The augmented reality on smart glasses allows the surgeon to visualize three-dimensional virtual objects during surgery, superimposed in real time to the anatomy of the patient. This makes it possible to preserve the vision of the surgical field and to dispose of added computerized information without the need to use a physical surgical guide or a deported screen. TECHNIQUE: The three-dimensional objects that we used and visualized in augmented reality came from the reconstructions made from the CT-scans of the patients. These objects have been transferred through a dedicated application on stereoscopic smart glasses. The positioning and the stabilization of the virtual layers on the anatomy of the patients were obtained thanks to the recognition, by the glasses, of a tracker placed on the skin. We used this technology, in addition to the usual locating methods for preoperative planning and the selection of perforating vessels for 12 patients operated on a breast reconstruction, by perforating flap of deep lower epigastric artery. The "hands-free" smart glasses with two stereoscopic screens make it possible to provide the reconstructive surgeon with binocular visualization in the operative field of the vessels identified with the CT-scan.

Assessment Tools for Facial Rejuvenation Treatment: A Review.

BACKGROUND: In the field of cosmetic medicine, patient satisfaction is an important and common indicator used to measure the efficacy of the treatment. However, it is insufficient to prove objectively that the benefit of the specific factors involved in the cosmetic outcomes. The practitioner should be aware of these assessment tools, in particular in case of demanding or litigious patients. OBJECTIVE: The aim of this review was to establish a list and discuss the subjective and objective methods used to assess facial aesthetic rejuvenation treatments. METHODS: A systematic literature search was performed using the Pubmed search engine. Studies published over the last 5 years, i.e. between January 2010 and January 2015 were considered for review. The following keywords were used: "aesthetic treatment", "facial rejuvenation", and "subjective evaluation" or "objective evaluation". RESULTS: Of the 446 articles identified by the search strategy, 47 articles focused specifically on facial rejuvenation and on the efficacy of aesthetic medical treatments were retrieved for review. Thirty-seven articles used quantitative methods to assess aesthetic treatment outcomes and only 12 used subjective methods. The different assessment methods were listed according to the tools used and treatment indications. CONCLUSION: This review will help in choosing adequate methods to assess facial rejuvenation medical treatment. It is important to combine these tools adequately to improve the assessment. There is no current consensus on assess facial rejuvenation treatments but we noted that objective assessment methods seem helpful. NO LEVEL ASSIGNED: 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 .

Factors That May Enhance Longevity: A Literature Review and a Comprehensive Update for Aesthetic Surgeons.

INTRODUCTION: After surgery, the plastic surgeon is very often questioned about how to maintain the result and more frequently how to slow down the aging process. However, this type of knowledge is not commonly delivered during medical education or at least needs an update. This review could be used as a guide to help plastic surgeons to manage these frequent postoperative consultations. The aim of this literature review was to focus discussion on specific positive factors, identified to have a significant impact on human longevity. MATERIALS AND METHODS: A literature review was performed using the automated computerized PubMed search, with the keywords "human longevity." Only papers written in the English language were included. References were screened to identify further relevant articles. Experimental studies based on microorganisms and animals, works published in non-indexed journals, case reports, letters, and viewpoints were excluded. RESULTS: One hundred and twenty-four articles reporting factors influencing human longevity were analyzed for data extraction. A total of 59 articles reporting only positive factors were included. Fourteen factors seemed to have a positive impact on longevity: caloric restriction, active effort and sports, happiness, vitamins, vegetarian or Mediterranean diet, oriental practices, socioeconomic status, genetics, sexual activity, sleep, moderate wine consumption, religion, and education. CONCLUSION: While some factors with a positive impact on longevity are clearly identified and should be integrated in the postoperative process, further studies are still needed to be able to slow down the aging process. NO LEVEL ASSIGNED: 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 .

Nasal basal cell carcinomas. Can we reduce surgical margins to 3mm with complete excision?

BACKGROUND: The purpose of this study was to evaluate the incomplete excision rate of nasal basal cell carcinomas (BCC) resected with different margins to demonstrate that 3-mm surgical margins could be used as safety margins to reduce esthetic consequences with a low risk of incomplete excision. METHODS: All patients with BCC of the nose excised from January 1st 2008 to December 31st 2011 were included. Data were analyzed and reviewed retrospectively. Tumors were treated with different surgical margins of excision: 3mm, 4mm, and 5mm. The primary outcome variable was the rate of incomplete excision. Other study variables were the histologic subtype, size, and recurrent lesions. RESULTS: Of the 132 patients, 115 were included corresponding on with 127 BCC. Median age was 75.5 (64-83) and sex ratio M:F=1.05. Of the 127 BCC, 80 were aggressive histologic subtype (63%), and 11 were recurrent (8.7%). The overall rate of incomplete excision was 17.3% (n=22). Of these 22, 17 (77.3%) were of an aggressive subtype. The incomplete excision rates within the groups were 12.5% (n=4), 22.2% (n=10), and 16% (n=8), respectively within the group with 3-, 4- and 5-mm surgical margins. No significant difference was observed between the groups (P=.519). The incomplete excision rate was not independently associated with the surgical margins, histologic subtype and recurrent type (P>.05). CONCLUSION: Three-millimeters margins could possibly be used to treat nasal BCC in chosen cases. Regarding the high rate of incomplete excision, reconstruction should be performed after receiving the pathologic report.

[One-staged surgical technique for scrotal calcinosis]. / Traitement chirurgical de la calcinose scrotale en un temps.

INTRODUCTION: Idiopathic calcinosis cutis is a rare condition involving the development of scrotal nodules in the skin and subcutaneous tissue. Although it is a benign disease, patient's quality of life can be importantly impaired. OBJECTIVE: We report herein our experience and surgical management of diffuse scrotal calcinosis. MATERIAL AND METHODS: From 2012 and 2015, 7 patients who suffered of diffuse scrotal calcinosis cutis were included in this study. We performed a one-staged resection of the lesions by an elliptic resection centered on the scrotal median raphe as a scrotal lift shape. Outcomes including sexual quality of life and patient's satisfaction were assessed with a questionnaire. RESULTS: No postoperative complication occurred. Aesthetic result was high and sexual quality of life was importantly improved. No recurrence was observed in a 2-year follow-up. DISCUSSION: This disease is a pathological condition of unknown origin and hence is idiopathic. Multi-staged resection of the nodules are often performed despite being a time-consuming and expensive approach. Our one-staged treatment increased the patient's quality of life and self-esteem. CONCLUSION: We present a one-staged treatment of scrotal calcinosis cutis that is simple and effective. Aesthetic and functional results were achieved. LEVEL OF EVIDENCE: 5.

Open rhinoplasty: influence of incisions, alar resection, and columellar strut on final appearance of the tip.

BACKGROUND: The aim of this study is to analyze scientifically the results of a rhinoplasty is a difficult task because of the multiplicity of surgical procedures and the subjective nature of the nose's beauty. Nevertheless, we wanted to evaluate open rhinoplasty by relying on objective and subjective criteria. METHODS: From 2004 to 2011, a total of 155 patients underwent open septorhinoplasty at our hospital. After excluding patients lost to follow-up and those who underwent orthognathic surgery, 55 patients were included in the study. The evaluation was based on the clinical record, the standardized photographs, and the consultation of control. We studied in particular the nasolabial angle (NLA), the Goode ratio (projection/length of nose), and patient satisfaction using the rhinoplasty outcome evaluation form. RESULTS: The columella-transalar incision tended to close the NLA (p = 0.001) and lowered the Goode ratio (p = 0.01), in contrast to the Réthi incision. The resection of the alar cartilages logically induced closure of the NLA (p = 0.02) and a decrease of nose projection (p = 0.001), whereas the use of a columellar strut induced a projection increase (p = 0.01). CONCLUSION: Despite the existence of unavoidable measures bias, we confirmed a number of assumptions that had never been demonstrated statistically. Furthermore, we found that the incision used could affect the final result of a rhinoplasty. LEVEL OF EVIDENCE IV: 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.