A Systematic Review and Meta-Analysis of Complications Associated With Autogenous Diced Cartilage Wrapped in Fascia Used in Nasal Dorsum Augmentation.

BACKGROUND: Nasal dorsum augmentation is a highly challenging rhinoplastic procedure. Problems encountered in this surgery, such as residual humps, irregularities, and asymmetry, account for a significant number of revision rhinoplasties. OBJECTIVES: The aim of this meta-analysis was to assess complication rates and graft harvesting site morbidity and revision rates. METHODS: We carried out a systematic review of the literature for pertinent materials in PubMed/Medline and Google Scholar up to and including August 2020. In addition, the reference list of included studies was searched manually. The criteria used were those described in the PRISMA Declaration for performing systematic reviews. RESULTS: The initial search yielded 236 results. After 3 stages of screening, 16 papers (18 groups) were included in the systematic review and meta-analysis. Our results indicated that the total rates for the complications studied were as follows: graft resorption, 2.52%; insufficient augmentation, 3.93%; deviation (graft displacement), 1.77%; infection, 2.30%; irregularity, 1.36%; supra-tip depression, 1.13%; overcorrection, 3.06%; hematoma at recipient site, 1.36%; and visible bulging of the graft, 2.64%. The total rates for donor site hypertrophic scar and donor site hematoma were 2.64% and 3.58%, respectively. The rate of the revision surgery was 3.03%. CONCLUSIONS: Current findings suggest the overall complications and revision rates with the use of diced cartilage wrapped in fascia for dorsum augmentation were relatively low and this technique is a reliable treatment choice for patients with primary/secondary dorsum deficiencies. Further studies with larger sample sizes and long-term follow-ups, clearer definitions of complications, and objective measurements are warranted to draw reliable practical conclusions.

Esthetic Rhinoplasty in the Multiply Operated Nose.

PURPOSE: The present study assessed the most common deformities in often-revised noses and their predictable surgical treatments. PATIENTS AND METHODS: This retrospective case series was designed to review different aspects of patients with rhinoplasty who had more than 2 failed previous rhinoplasties. The main requests of patients, number of operations, and final surgical plan for management of these deformities were reviewed and analyzed. RESULTS: This study included 38 patients (27 women, and 11 men) who underwent multiple (2 to 10) unsuccessful rhinoplasties before being operated on by the author from 2011 to 2016. Pinch deformity (14 patients), breathing problems (13 patients), and irregularities were the most common complaints. The conchal cartilage (31 patients) and fascia (19 cases) were the most common graft donor sites in definitive treatments. CONCLUSION: The present study shows that multiple failed rhinoplasties can be properly corrected. Effective management of these patients is best started after a comprehensive preoperative assessment. Then, a conservative predictable approach can be used to overcome the flaws of previous surgeries.

Nasal Framework Osteotomy: An Innovative Approach to Manage an Extremely Long Nose With Meningoencephalocele.

Meningoencephlocele is a relatively rare deformity, usually characterized by penetration of brain or meningeal tissues through a defect in skull. This protruding tissue may affect facial structure and subtle to severe facial deformities may appear. Surgical treatments of these deformities are usually done by a team including a neurosurgeon and craniofacial surgeon. The conventional treatments includes several complicated operations to relocate herniating tissues, then correcting malformed facial structure. The nasal framework osteotomy, is an innovative approach that uses transfacial incisions to gain access to herniating tissue. Then, by completing the osteotomy around the nose, the entire nasal structure is lifted and transposed to it is original position. The authors believe that this technique may considerably reduce the complexity and risks of conventional approaches, while aesthetic demands are readily achieved at the same stage.

Treatment of mandibular angle fracture: Revision of the basic principles.

Biodynamics of mandibular angle fractures has been extensively discussed in the literature in search for the best way to fixate and expedite recovery of trauma patients. Pioneers like Michelet and Champy had the greatest impact on evolving of osteosynthesis in maxillofacial traumatology; they introduced their basic principles frequently used to describe the biomechanics of mandibular fixation. Their concept states when a physiologic load is applied on mandibular teeth a negative tension will be created at superior border and a positive pressure will appear at inferior border. These simple definitions are the basis for the advent of fixation modalities in mandibular angle fracture. This article sought to reassess these principals based on load location via finite elements method.

Dorsal Nasal Augmentation: Is the Composite Graft Consisting of Conchal Cartilage and Retroauricular Fascia an Effective Option?

PURPOSE: Augmentation of a deficient nasal dorsum remains a challenge in rhinoplasty. Different methods and materials have been described in the literature. The purpose of this study was to present the authors' experiences using a composite graft consisting of conchal cartilage and retroauricular fascia for dorsal augmentation. MATERIALS AND METHODS: Patients with moderate to severe dorsal deficiencies were included in this study. The postauricular sulcus was used to gain access to the auricular cartilage and the retroauricular fascia. If the dorsal deficiency was moderate, then 1 layer of conchal cartilage was used. In more severe deficiencies, the cartilage pieces were superimposed, and a multilayer conchal graft was used. To fix the cartilage segments to each other, 6-0 polydioxanone (PDS) suture was used. Then, the cartilage segment was fixed to the retroauricular fascia with 6-0 PDS suture. The nasal dorsum was undermined carefully to create adequate space for chondrofascial graft placement. After performing required maneuvers for solving the functional disorders, tip plasty, and the lateral nasal wall osteotomy, the prepared chondrofascial graft was placed in the dorsal pocket. RESULTS: Fourteen patients (5 men and 9 women) participated in this study. The average follow-up duration was 25.4 months (range, 16 to 42 months). The patients' age ranged from 14 to 54 years (average, 25.9 yr). Follow-up showed no cases of infection, hematoma, major graft resorption, asymmetric graft resorption, and displacement of grafts. No postoperative scars were visible at the donor sites. Mild to moderate ecchymosis occurred at the donor sites in 8 patients, which were solved after 10 days without any complications. In 3 male patients, slight graft resorption was noted. The esthetic results were not compromised in these patients, and revision surgery was not performed. CONCLUSION: This small series of cases with relatively adequate follow-up showed that a composite graft consisting of conchal cartilage and retroauricular fascia is a reliable technique for nasal dorsal augmentation in patients with moderate to severe dorsal deficiency.

Do the Size and Extension of the External Nasal Splint Have an Effect on the Osteotomy, Brow Lines, and Long-Term Results of Rhinoplasty: A Prospective Randomized Controlled Trial of 2 Methods.

PURPOSE: While performing a lateral nasal wall osteotomy during a rhinoplasty, an intentional fracture is produced and the fractured segments are medialized to narrow a wide nasal base. The purpose of this study was to investigate the effect of size, shape, and extension of the external nasal splint on the osteotomy, brow lines, and long-term results of rhinoplasty. MATERIALS AND METHODS: The authors designed a randomized prospective clinical trial. The study population was composed entirely of patients who were voluntarily referred to the authors' department from May 2012 to May 2013. They were randomly divided into 2 equal groups. The primary predictor variable was splint type. For group 1, the external splint was extended beyond the osteotomy lines laterally and covered the overlying skin of the frontal process of the maxillary bone. For group 2, the external splint was trimmed above the osteotomy lines. The primary outcome variables were the levels of satisfaction with the dorsal esthetic lines, brow lines, and distinct osteotomy lines at 12 months after the operation. Demographic variables were gender and age. Mann-Whitney U test, χ(2) test, and t test were used to analyze the data. Results with a P value less than .05 were considered significant. RESULTS: Forty healthy patients (American Society of Anesthesiologists status I and II; 18 men and 22 women; age range, 19 to 41 yr; mean, 31.4 yr) were selected. Although the level of satisfaction with the dorsal esthetic lines was higher in group 2, it was not significantly different from group 1 (P > .05). The levels of satisfaction with the brow lines and the distinct osteotomy lines were significantly higher in group 2 (P < .05). CONCLUSION: The results of this study showed that when a nasal splint is extended beyond the frontal process of the maxilla rather than the base of the nasal bones, positioning of the bones and long-term results are unpredictable.

Anesthetic efficacy of meperidine in teeth with symptomatic irreversible pulpitis.

Achieving adequate pulpal anesthesia in mandibular teeth is always a challenge. Supplementary injections and using drugs in combination are some methods implemented to overcome this hurdle. In this randomized clinical trial, use of meperidine in conjunction with lidocaine in intraligamentary injection did not exhibit significant improvement in anesthesia.

Carpentering in septorhinoplasty: a novel technique to straighten the deviated nasal septum.

Septal deviation presents a considerable challenge in septorhinoplasty because it leads to functional and esthetic problems. This deformity may displace the nasal tip, disturb nasal valve patency, and affect the final outcomes of septorhinoplasty. This report describes an innovative technique that can be used in patients with C-shaped deviation of the septum in a cephalocaudal direction. Because the procedure is similar to carpentering, it was named a "carpenter spreader graft." In this technique, the deviated dorsal cartilage is separated and displaced to a new straightened position.

Submental fat transfer: an approach to enhance soft tissue conditions in patients with submental lipomatosis after orthognathic surgery.

Soft tissue changes after orthognathic surgery and their effects on the esthetic appearance of the patient can be the most challenging and sometimes undesired parts of this procedure. Although the soft tissue profile is improved in many orthognathic surgeries, suboptimal soft tissue changes may necessitate some special interventions. To overcome these problems, the authors present a technique based on transferring the submental fat (in patients with submental lipomatosis) to the lips, paranasal areas, or other sites of the face instead of discarding it. According to this technique, in patients with submental lipomatosis, submental fat can be used not only to compensate some of the unpleasant soft tissue effects of orthognathic procedures (eg, thinning of the upper lip after mandibular setback), but also to improve pre-existing soft tissue problems, which may be worse after orthognathic surgeries (eg, a poor neck and chin profile). Although submental fat liposuction is a traditional technique to improve the neck and chin profile, the present technique is based on transferring the harvested fat to other sites of the face (lips, paranasal areas, etc) instead of discarding it.

Management of perforations of the nasal septum: can extracorporeal septoplasty be an effective option?

PURPOSE: Perforation of the nasal septum is a frustrating problem frequently reported in the literature. Surprisingly, in most reports, iatrogenic perforation during septoplasty and electrocautery are the leading causes of this complication. This article presents the management of septal perforations and the indications for an extracorporeal approach. MATERIALS AND METHODS: Fourteen patients with septal perforations were referred for treatment. Treatment was chosen based on defect size. Flaps, extracorporeal repair, or no treatment was used as indicated. RESULTS: Two of 14 perforations were small and were repaired by local flaps, 5 cases were treated by extracorporeal repair, and the 7 remaining cases required no surgical procedure. CONCLUSIONS: The extracorporeal technique, when indicated, can be used effectively for the repair of nasal septum perforations in selected cases.

Immediate effects of different steps of rhinoplasty on nasolabial angle and tip projection.

Nasolabial angle (NLA) and nasal tip projection (NTP) play an important role in aesthetic nose surgery. Little deviations can determine success and failure. The goal of this study was to analyze the immediate effect of different steps of open rhinoplasty on NLA and NTP. In this prospective single-blind study, 50 consecutive rhinoplasty cases were considered. The study consisted of 38 women and 12 men. The mean age was 28 years, ranging from 17 to 37 years. A standard life-size photograph was taken in each step of a classic open rhinoplasty during surgery. Nasolabial angle and NTP were measured and analyzed. Nasolabial angle: average increase after skeletonization (2.26 degrees), strut insertion (4 degrees), and tip spanning (0.17 degrees), whereas cephalic resection caused a decrease (1.9 degrees). Nasal tip projection: average increase after skeletonization (0.1 mm), strut insertion (0.31 mm), and tip spanning (0.84 mm), whereas cephalic resection caused a decrease (0.53 mm). Whereas strut insertion caused the highest mean increase in NLA, tip spanning was the most effective regarding change of NTP. Expectably cephalic resection was associated with decrease in NLA and NTP.

Lateral crural suspension flap: a novel technique to modify and stabilize the nasolabial angle.

The proper nasolabial angle is a determinant factor in achieving a pleasant result in esthetic rhinoplasty surgery. Nasal tip position depends on various interrelated elements. Its rotation should be analyzed by assessing the nasolabial angle. An increase in this angle results in an upward tilt of the base of the nose with a concomitant decrease in nasal length. Several methods have been advocated to improve this angle; unfortunately, these techniques have considerable limitations in modifying and stabilizing nasal tip rotation. The general principles for rotating the nasal tip include removing the factors that resist the rotation of the lower lateral cartilages, creating space to accommodate them, rotating the lower lateral cartilages into the desired position, and stabilizing the cartilages in the desired position. Resection of the cephalic margin of the lateral crura fulfills these goals. This report describes a straightforward and stable method that uses cephalic portions of the lower lateral crural cartilages as 2 flaps to suspend the nasal tip to the septum to modify and stabilize the nasolabial angle.

A simplified approach to the external lateral nasal osteotomy: a technical note.

Lateral osteotomy is usually performed to narrow a wide nasal base, widen a narrow nasal base, straighten deviated nasal bones, or close an (iatrogenic) open roof deformity. Based on the approach used, nasal osteotomy can be classified as external or internal. Although nasal osteotomy is an essential part of cosmetic rhinoplasty, it can be very difficult for young surgeons to perform external osteotomy. This article focuses on external osteotomy and its essential concepts. In addition, a new splint-guide method is introduced, which can help young surgeons perform external osteotomy in a very safe and predictable manner.

Tapia syndrome after repairing a fractured zygomatic complex: a case report and review of the literature.

Tapia syndrome is known as a rare complication of airway manipulation, which can occur after any type of surgery under endotracheal general anesthesia. This syndrome is characterized by neurologic deficits involving the hypoglossal (XII) and recurrent laryngeal branch of the vagal nerve (X) that result in the tongue muscle's unilateral paralysis associated with the vocal cord's unilateral palsy. This article describes the first case of Tapia syndrome, which occurred after repair of a fractured zygomatic complex. In this article, we discuss the diagnosis, possible causes, clinical manifestations, treatment methods, and preventive strategies as described in 10 case reports in the literature that have been attributed to manipulation of the airway.

Neck hairline incision for simultaneous harvesting of temporal and mastoid fasciae: a technical note.

Fasciae are known reservoirs of ideal graft material. The temporalis and mastoid fasciae are 2 of the most important graft reservoirs used by plastic surgeons, otolaryngologists, and oral and maxillofacial surgeons. The temporalis fascia is harvested predominantly by plastic surgeons, whereas otolaryngologists often prefer the mastoid fascia. In either case, graft harvesting might be accompanied by donor-site complications, such as hair loss, bleeding, hematoma, and scar formation, which can limit its application. To gain access to the temporal and mastoid fasciae simultaneously, the authors combined conventional techniques to develop a modified single-approach incision line that would minimize most donor-site complications.

Lateral crural transposition flap in tip correction: Tehran retrospective rhinoplasty experience.

PURPOSE: This study aims to review the authors' experience with the lower lateral crura (LLC) transposition flap in an attempt to highlight its advantages, indications, and limitations. MATERIALS AND METHODS: A retrospective study of 37 rhinoplasties (29 primary cases, 7 secondary cases, and 1 tertiary case) was performed. In all of these, an LLC transposition flap was used by inserting the cephalic portion of the LLCs into a subperichondrial pocket between the medial aspect of the remaining rim strip and the vestibular skin, based on the posterior pedicle. RESULTS: The most prevalent symptom among our patients was nasal external valve dysfunction. Concavity of the LLCs was very common. The LLC transposition flap can correct the LLC deformities with a high rate of patient satisfaction and no need for revision operations. CONCLUSIONS: The LLC transposition flap can overcome the common irregularities of the LLCs and could be applied to primary and secondary rhinoplasties, as well as ethnic noses.

Augmentation of the upper lip with temporalis fascia: a quantitative analysis.

BACKGROUND: Lip augmentation is a very common cosmetic procedure. A wide variety of materials have been used to enhance and contour the lips, including alloplastic and autogenous substances. OBJECTIVES: The authors describe their experience with augmentation of the upper lip using an autologous graft from the temporalis fascia. METHODS: Patients were enrolled prospectively. Upper-lip projection and vermilion show were measured preoperatively and 6 months postoperatively for 19 patients who were candidates for lip augmentation with temporalis fascia. RESULTS: Six months postoperatively, the mean values for upper-lip projection and lip vermilion were significantly greater than preoperative measurements. CONCLUSIONS: Augmentation of the upper lip with temporalis fascia appears to be safe and effective. Larger patient series, longer follow-up, and comparative studies are needed to corroborate these preliminary results. LEVEL OF EVIDENCE: 4.

Analysis of stress distribution on fixation of bilateral sagittal split ramus osteotomy with resorbable plates and screws using the finite-element method.

PURPOSE: To determine the most appropriate stress distribution in fixation with resorbable screws and plates after bilateral sagittal split ramus osteotomy using the finite-element method. MATERIALS AND METHODS: This experimental study was performed on simulated human mandibles using computer software. The osteotomy line was applied to the simulated model and experimental loads of 75, 135, and 600 N were exerted on the model in accordance with the vector of occlusal force. The distribution pattern of stress was assessed and compared in 8 fixation methods: 1 resorbable screw, 2 resorbable screws in a vertical pattern, 2 resorbable screws in a horizontal pattern, 3 resorbable screws in an L pattern, 3 resorbable screws in a backward-L pattern, 1 miniplate with 2 screws, 1 miniplate with 4 screws, and 2 parallel miniplates with 4 screws each. RESULTS: Among the simulated fixations, 2 parallel miniplates showed the greatest primary stability and the single screw and the 2-hole miniplate showed the least tolerance to posterior forces. CONCLUSIONS: This study showed the 2-miniplate/4-hole plate pattern was the strongest and the single-screw and 2-hole plate patterns were the weakest of fixations in this bilateral sagittal split ramus osteotomy model. The finite-element method showed that polymer-based resorbable screws and plates (polyglycolic acid and d,l-polylactide acid) provide satisfactory primary stability in this model.

Lip Lift Techniques in Smile Design.

The lips are the main aesthetic component of the facial lower third and simultaneously a substantial element for an ideally perceived smile. One of the most accepted and common procedures that is widely used to enhance the shape and contours of the upper lip is the lip lift. With a careful treatment plan and a professional surgery, a lip lift can reliably be used for the reduction of the philtrum height, enlargement of the upper vermilion, improvement of the dental show, restoration of facial aesthetic proportions, and creation of an enchanting smile.

Smile Management: A Discussion with the Masters.

Smile design is an ongoing challenge in both dentistry and facial cosmetics surgery. Herein, some very common smile design scenarios are shared with six world known masters. Each case will be reviewed by 2 cosmetic dentists, 2 periodontists, and 2 oral and maxillofacial surgeons. At the end, contributors will describe current advances and future prospects of this evolving field.