Supracrural Ligament Graft in Rhinoplasty.

Irregularities of the nasal dorsum or tip are a potential risk after rhinoplasty. Patients with thin skin are considered to be at a higher risk of these irregularities. Different materials and grafts to address areas that may result in a contour irregularity postoperatively include diced or crushed cartilage, temporalis fascia, fascia lata, and AlloDerm. We describe a new graft, the supracrural ligament graft, which can be used to camouflage or add bulk during primary rhinoplasty. The graft is harvested easily during the initial exposure and does not require additional surgical sites or extra dissection. In this research, we described the use of the supracrural ligament graft in 49 patients. We found the average graft size to be 0.6 × 0.4 cm. The graft was used in the following locations: nasal tip (49%), radix (40%), and nasal dorsum (10%). No complications were seen using the graft in any of the 49 patients. In conclusion, the supracrural ligament graft is a safe, simple, and effective camouflage graft for commonly encountered irregularities in rhinoplasty. Common areas of use include the nasal dorsum and nasal tip. Routine harvest of this graft may obviate the need to use either additional grafting material or an additional surgical site to help camouflage areas of concern in thin skin patients.

Osteotomies-When, Why, and How?

An ideal nasal osteotomy should deliver precise, predictable, and reproducible cosmetic and functional results while minimizing soft-tissue trauma and postoperative complications. In addition to closing an open roof deformity after hump reduction, other common indications for osteotomies include the crooked nose and a wide bony vault. The literature has reported numerous and diverse osteotomy techniques as well as differences in timing of osteotomies. Each has its own merits and indications, and its proponents. In this article, we review the anatomy and nomenclature relating to osteotomies. We review the locations and paths of the osteotomies-lateral, intermediate, medial, and superior/transverse. We consider the percutaneous and endonasal approaches, as well as timing of osteotomies and other considerations. We also discuss technical considerations in the selection of instrumentation for osteotomies.

Surgical treatment of nasal obstruction in rhinoplasty.

Often, rhinoplasty patients present not just for aesthetic correction, but for improvement of their nasal breathing due to functional abnormalities or problems. Because the aesthetic and functional problems must be addressed together, an understanding of both the internal and external anatomy is essential. In this article, the authors review the differential diagnosis of nasal obstruction and the important components of a thorough examination. In this article, medical treatment options are not discussed, but just as an exacting aesthetic analysis leads to an appropriate cosmetic rhinoplasty plan, a thorough functional analysis will dictate the appropriate medical or surgical treatment.

Review and update on extracorporeal septoplasty.

PURPOSE OF REVIEW: To examine the recent literature on extracorporeal septoplasty. RECENT FINDINGS: The literature suggests that extracorporeal septoplasty is an effective approach for both functional and cosmetic treatment of moderate to severe deformities of the caudal and dorsal septum. The procedure can be performed via an endonasal or external approach based on the nature of the deformity and the experience of the surgeon, although recent literature highlights various advantages of an external approach. The use of polydioxanone foil as a scaffold for septal reconstruction is widely accepted, and can enhance the technical performance of this technique. Although reported complication rates are low, tip deprojection and rotation have been observed in cases where extracorporeal septoplasty is performed without simultaneous rhinoplasty. SUMMARY: Extracorporeal septoplasty is a useful technique in the armamentarium of surgeons addressing deviations of the dorsal and caudal septum.

Postoperative Opioid Use in Sinonasal Surgery.

OBJECTIVE: To survey patients following sinonasal surgery regarding postoperative pain and opioid use. STUDY DESIGN: Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids. SETTING: Four academic medical centers and 1 private practice institution. SUBJECTS: Consecutive adult patients undergoing sinonasal surgery. RESULTS: A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain ( R2 = 0.2, P < .01) but was not correlated with the use of acetaminophen ( R2 = 0.002, P = .48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers ( P < .001) and also required more postoperative opioids ( P = .02). CONCLUSIONS: An evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.

Review and update on postoperative opioid use after nasal and sinus surgery.

PURPOSE OF REVIEW: We examine the current literature on pain management after sinus and nasal surgery. The goal after surgery is to provide effective pain management without having too many 'leftovers', as leftover medications are an important source of opioids that are fueling the current prescription narcotic epidemic in the United States. There are more than 250 000 sinus operations and 260 000 septoplasties performed annually, and surgeons commonly prescribe a narcotic pain medication for postoperative pain management. RECENT FINDINGS: The literature suggests that an evidence-based approach may lead surgeons to prescribe significantly less narcotic pain medication for these procedures without affecting pain management. SUMMARY: An evidence-based approach to pain management can result in unchanged pain control and a significant positive impact on the narcotic abuse epidemic.

Intermediate crural overlay in rhinoplasty: a deprojection technique that shortens the medial leg of the tripod without lengthening the nose.

OBJECTIVE: To review the indications for, surgical techniques of, and results of intermediate crural overlay of the alar cartilages in rhinoplasty. DESIGN: Prospective study of patients undergoing intermediate crural overlay of the lower lateral cartilages. The setting was a facial plastic surgery private practice. Patients included 10 primary rhinoplasty patients and 1 revision rhinoplasty patient who underwent intermediate crural overlay of the lower lateral cartilages. The main outcome measures were postoperative photographs and patient records, which were reviewed for tip projection and rotation, preservation of the double break, bossae, and knuckling. RESULTS: Intermediate crural overlay decreased projection in all 11 patients and increased the nasolabial angle in 7 patients. One patient had no change in the nasolabial angle, and 3 patients had counterrotation of 1 degrees , 3 degrees , and 4 degrees . A postoperative physical examination revealed that no patient had developed bossae, tip asymmetries, or knuckling. In addition, the double break was maintained in all the study patients. CONCLUSIONS: Intermedial crural overlay is a reliable technique for achieving tip deprojection. Overall, the nasolabial angle is maintained (although in 3 patients, clinically insignificant counterrotation did occur). In addition, the length of the intermediate crura is reduced, but the double break is preserved. In the group of patients with thin skin and tip overprojection secondary to overdevelopment of the lower lateral cartilages, intermediate crural overlay achieves tip deprojection while controlling the nasolabial angle and preserving the natural curvature of the dome.

Reducing complications in rhinoplasty.

The dedicated rhinoplasty surgeon continues to acquire throughout his or her career an increasingly detailed understanding of the anatomy and the problems that occur related to rhinoplasty and a growing armamentarium of techniques to achieve improvement or correction. This article out-lines the authors' approach and discusses selected technical problems and approaches to reducing their occurrence. Focusing on the two essential goals-making the patient happy and making this the patient's only nasal surgery-primary rhinoplasty can be a uniquely rewarding experience for the patient and the surgeon.

Revolutionary advances in medical waste management. The Sanitec system.

It is the purpose of this collective review to provide a detailed outline of a revolutionary medical waste disposal system that should be used in all medical centers in the world to prevent pollution of our planet from medical waste. The Sanitec medical waste disposal system consists of the following seven components: (1) an all-weather steel enclosure of the waste management system, allowing it to be used inside or outside of the hospital center; (2) an automatic mechanical lift-and-load system that protects the workers from devastating back injuries; (3) a sophisticated shredding system designed for medical waste; (4) a series of air filters including the High Efficiency Particulate Air (HEPA) filter; (5) microwave disinfection of the medical waste material; (6) a waste compactor or dumpster; and (7) an onboard microprocessor. It must be emphasized that this waste management system can be used either inside or outside the hospital. From start to finish, the Sanitec Microwave Disinfection system is designed to provide process and engineering controls that assure complete disinfection and destruction, while minimizing the operator's exposure to risk. There are numerous technologic benefits to the Sanitec systems, including environmental, operational, physical, and disinfection efficiency as well as waste residue disinfection. Wastes treated through the Sanitec system are thoroughly disinfected, unrecognizable, and reduced in volume by approximately 80% (saving valuable landfill space and reducing hauling requirements and costs). They are acceptable in any municipal solid waste program. Sanitec's Zero Pollution Advantage is augmented by a complete range of services, including installation, startup, testing, training, maintenance, and repair, over the life of this system. The Sanitec waste management system has essentially been designed to provide the best overall solution to the customer, when that customer actually looks at the total cost of dealing with the medical waste issue. The Sanitec system is the right choice for healthcare and medical waste professionals around the world.

Multimodality approach to sinus and nasal disorders: results of treatment as determined by a patient survey.

Patients with sinus and nasal disorders whose symptoms persist despite primary care may benefit from a referral to a dedicated nose and sinus center where all treatment modalities are available. The essential principle of a multimodality approach is that medical therapy, allergy treatment, and surgery are all important and useful tools. While various medical and surgical treatments of sinus and nasal disorders have been well described in the literature, overall assessments of comprehensive treatment are uncommon. For more than 7 years, the office practice of the senior author (D.G.B.) has been dedicated to the treatment of sinus and nasal disorders. In an effort to assess the results of the multimodality approach to therapy delivered there, we mailed questionnaires to 1,800 patients who had been treated at this practice over a 3-year period. Responses from 222 of these patients revealed that patients required less medication following treatment with a multimodality approach and that they expressed a high degree of satisfaction with the comprehensive care they received. In addition, most patients with asthma experienced relief of their asthma symptoms following treatment for sinonasal disease. We conclude that a stepwise, multimodality, specialty-center approach to treatment is beneficial for patients with persistent sinonasal disorders.

Analysis in otoplasty.

The normal auricle has a well-recognized shape, and significant deviation from "normal" is immediately evident. In particular, prominent ears are readily apparent and are a relatively frequent cause of patient concern. Correction of the outstanding ear requires a careful understanding of the discrete elements that compose the normal ear. Careful anatomic analysis to determine the precise cause allows appropriate preoperative planning for the correction of a protruding ear.

Open and Closed Rhinoplasty.

Most surgeons recognize the broad utility of both endonasal and external rhinoplasty approaches. Most understand that there are situations when a given approach offers advantages and may be considered preferable. In this article, the anatomy, incisions, and approaches that are available to the surgeon are reviewed. General indications are discussed for the external and endonasal approaches. The pros and cons of each approach are discussed, and further thoughts on the decision-making process are provided.

The extended columellar strut-tip graft.

The extended columellar strut-tip graft is a structural unit used in endonasal rhinoplasty that combines the attributes of the columellar strut and the tip graft. It is used to provide projection and contour to the nasal tip. Our goal with this study was to evaluate a 15-year experience with 155 patients who underwent rhinoplasty with the extended columellar strut-tip graft. Of these, 110 underwent secondary rhinoplasty, and 45 underwent primary rhinoplasty. There were 6 patients in the secondary rhinoplasty group who experienced complications: in 3, the graft became visible postoperatively, and 3 patients had graft placement asymmetry. These 6 patients underwent surgery in the initial years of graft development. One patient with graft edge visibility and 1 patient with graft asymmetry underwent revision surgery with satisfactory results. The extended columella strut-tip graft is a reliable method to provide nasal tip projection and contour. The successful use of the graft requires precise diagnosis and surgical technique.

A dedicated specialty center for nose and sinus care: an organized approach.

A specialty center focusing on a single, widespread medical problem and housing all treatment modalities is a revolutionary approach to medical treatment. Sinusitis, the most common chronic illness in the United States, is ideally suited to this approach. By housing the most advanced options for patients in a highly specialized treatment facility, attention is focused on the patient's problem, and treatment may be improved. In this article, an overview of the specialty center approach to sinus and nasal disorders is provided. State-of-the-art medical treatment, allergy evaluation and treatment, and surgical technology, including powered instrumentation and computerized image-guided surgery, are all employed in the treatment of functional nasal problems and cosmetic nasal requests. A subspecialty training program will allow for replication of this model for sinus and nasal care nationally. The Becker Nose and Sinus Center, LLC, is the first specialty center in New Jersey focused on diagnosing and treating patients who suffer from nasal and sinus disorders. The Nose and Sinus Center houses some of the most advanced options for patients in nose and sinus care in a highly specialized treatment facility and is a model for this organized approach to sinus and nasal care.

Devastating injuries in healthcare workers: description of the crisis and legislative solution to the epidemic of back injury from patient lifting.

The purpose of this report is to describe a crisis in healthcare, disabling back injuries in US healthcare workers. In addition, outlined is the proven solution of safe, mechanized, patient lifting, which has been shown to prevent these injuries. A "Safe Patient Handling--No Manual Lift" policy must be immediately instituted throughout this country. Such a policy is essential to halt hazardous manual patient lifting, which promotes needless disability and loss of healthcare workers, pain and risk of severe injury to patients, and tremendous waste of financial resources to employers and workers' compensation insurance carriers. Healthcare workers consistently rank among top occupations with disabling back injuries, primarily from manually lifting patients. Back injury may be the single largest contributor to the nursing shortage. Reported injuries to certified nursing assistants are three to four times that of registered nurses. A national healthcare policy for "Safe Patient Handling--No Manual Lift" is urgently needed to address this crisis. Body mechanics training is ineffective in prevention of back injury with patient lifting. Mandated use of mechanical patient lift equipment has proven to prevent most back injury to nursing personnel and reduce pain and injury to patients associated with manual lifting. With the national epidemic of morbid obesity in our country, innovative devices are available for use in emergency medical systems and hospitals for patient lifting and transfer without injury to hospital personnel. The US healthcare industry has not voluntarily taken measures necessary to reduce patient handling injury by use of mechanical lift devices. US healthcare workers who suffer disabling work-related back injuries are limited to the fixed, and often inadequate, relief which they may obtain from workers' compensation. Under workers' compensation law, healthcare workers injured lifting patients may not sue their employer for not providing mechanical lift equipment. Discarding healthcare workers disabled by preventable back injuries is an abuse which legislators must remedy. In addition, Medicare reimbursement policies must also be updated to allow the disabled community to purchase electrically operated overhead ceiling lifts. The US lags far behind countries with legislated manual handling regulations and "No Lifting" nursing policies. England and Australia have had "No Lifting" nursing policies in place since 1996 and 1998, respectively. The National Occupational Research Agenda (NORA) recognized a model in 2003 for reduction of back injuries to nursing staff in US healthcare facilities. Also in 2003, the American Nurses Association called for elimination of manual patient handling because it is unsafe and causes musculoskeletal injuries to nurses. The first state legislation for safe patient handling passed both houses in California but was vetoed by the Governor in September 2004. California and other states are preparing to (re)introduce legislation in January 2005. A national, industry-specific policy is essential to quell the outflow of nursing personnel to disability from manual patient lifting.

Rhinoplasty.

Rhinoplasty--surgery to reshape the nose--is a common procedure for both cosmetic and functional requests. In this article, the author provides an overview of rhinoplasty, with special emphasis on the surgical anatomy and preoperative analysis of appearance. A review of some of the surgical techniques at the disposal of the rhinoplasty surgeon is also provided and illustrated with patient examples.

Treatment of sinus and nasal disorders in the 21st century.

In the modern history of the surgical treatment of sinus and nasal problems, there have been three revolutionary changes. The first was the introduction and refinement of endoscopic techniques in the 1980s. The second important development in the modern history of rhinology was the introduction of powered instrumentation in the 1990s. Now in the 21st Century we see a third turning point, which is the use of intraoperative image guidance in endoscopic sinus surgery. These three advances are being integrated to provide a new level of care for problems of the nose and sinuses and are the subject of this special section. In the first articles, the author provides an overview of sinusitis and reviews many of the medical treatments available for the management of sinusitis. When anatomic abnormalities of the nose and sinuses contribute to sinusitis, and when medical therapy has failed, these anatomic or structural abnormalities can be surgically corrected. In the article entitled "Minimally Invasive Approach to Endoscopic Sinus Surgery," we review this modern approach to the sinuses and discuss recent advances. We also provide an overview of rhinoplasty--surgery to reshape the nose--with special emphasis on the surgical anatomy and preoperative analysis of appearance. We conclude by reviewing some of the more common adjunctive cosmetic procedures performed with surgery of the nose and sinuses.

Medical treatment of sinusitis.

Treatment of sinusitis is aimed at eliminating causative factors and controlling the inflammatory and infectious components. Ideal management includes preventative measures, including the use of specific medications in proper dose and duration. In this article, we review many of the medical treatments available for the management of sinusitis.

Adjunctive cosmetic procedures during rhinoplasty and sinus surgery.

A number of patients undergoing nasal surgery such as endoscopic sinus surgery and rhinoplasty request whether facial cosmetic procedures can be performed at the same time. This report outlines some of the more common adjunctive procedures.

Sinusitis.

Sinusitis is one of the most common health care complaints in the United States. Approximately one in eight people in the US will have sinusitis at one time in their lives. Until recently, sinusitis has been an undertreated disease. The drastic negative effect of sinusitis on patients' quality of life has been generally underappreciated and unrecognized. Recent studies show that patients score the effects of chronic sinus disease in areas such as bodily pain and social functioning as more debilitating than diseases such as angina, congestive heart failure, emphysema, chronic bronchitis, and lower back pain, to name a few. In the past, many patients were told they would just have to "live with" their sinus problem. However, there have been enormous advances in the past 15 years in the ability to diagnose and treat these problems. This is largely because of technological advances in nasal endoscopy and X-ray imaging. Also, the development of newer, more powerful medications and significant advances in surgical treatment have played a major role in improved patient care. In this article, we provide an overview of sinusitis. We describe the modern definition of sinusitis and the normal physiology of the sinuses. We discuss the causes of sinusitis with attention to the role of allergies, acid reflux, and other related disorders. Finally, we review the current approach to the diagnosis of sinusitis.