The Dual-Plane Gluteal Augmentation: An Anatomical Demonstration of a New Pocket Design.

BACKGROUND: Fat grafting is the favored option for buttock augmentation by most surgeons, and buttock implants are mostly regarded as second choices. Accepted options for buttock implant pocket dissection are subfascial, intramuscular, and submuscular. To overcome the limitations of both intramuscular and submuscular pockets, and combine the benefits of both, the authors present a novel dual-plane pocket dissection. The dual-plane pocket involves a submuscular plane in the cranial half of the pocket and switching to an intramuscular plane in the caudal half. With this study, the authors describe their experience with this technique and analyze the dissection of the pocket on human cadavers. METHODS: The authors reviewed 82 consecutive composite gluteal augmentation cases from March of 2019 to November of 2019. In all cases, the implant was placed in the "dual plane." The clinical study was supplemented by 10 hemigluteal dissections in five cadavers following the surgical technique, with assessment of the anatomical components of the implant pocket created. RESULTS: Patients who underwent this technique showed excellent soft-tissue coverage over the implants. The main complications observed were seroma formation in five of 82 patients and temporary sciatic pain in four of the patients. The anatomical study confirmed double muscle coverage of both gluteus maximus and partial medius in the upper pocket pole and intramuscular gluteus maximus implant position in the lower pole. CONCLUSION: The authors present the dual-plane dissection technique as a valuable innovation to improve soft-tissue cover for the upper implant pole in buttock implant surgery.

Superficial and Deep Facial Anatomy and Its Implications for Rhytidectomy.

The relationship of the skin, the superficial and deep fat compartments, and the ligaments that connect these structures is key to performing any rhytidectomy. In order to successfully mobilize, elevate, and reposition the facial soft tissues, a detailed understanding of facial anatomy is required. This article details the anatomy of the midface and neck that is essential to understanding and performing the face-lift operation.

Rhinoplasty: A Sequential Approach to Managing the Bony Vault.

BACKGROUND: An important element of most rhinoplasty surgeries is the treatment of the nasal bones, which involves various combinations of osteotomies and hump removal. OBJECTIVES: The aim of this paper was to describe a rhinoplasty technique in which piezoelectric instruments (PEIs) are used to shape nasal bones, with the priority being to preserve the stability of these bones. In most clinical cases, nasal bones can be stabilized if rhinosculpture (RS) is applied broadly, both separately and in combination with different osteotomies, while preserving the nasal bridge. METHODS: A step-by-step algorithm was applied to achieve the required aesthetic results when working with PEIs on the bony pyramid, depending on the degree of asymmetry. We used the fully open approach in all clinical cases, which provided the greatest visual field when performing all the steps involved in treating the bony pyramid, thus fully exploiting all the possibilities and advantages of PEIs. RESULTS: We report our experience with 165 clinical cases performed over 18 months from December 2016 to July 2018. The patients were divided into 5 groups, depending on the algorithm selected to treat the bony pyramid. CONCLUSIONS: When working with the bony pyramid, our approach limits patient movement, thus ensuring stability of the side walls of the bones in both the short and the long term-a property that greatly improves the aesthetic results.

Dorsal Preservation: The Push Down Technique Reassessed.

Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author's current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author's operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (Less than 4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors' experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be "Can I keep the nasal dorsum intact?" Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a "not operated" aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty.

The Nasal Ligaments and Tip Support in Rhinoplasty: An Anatomical Study.

BACKGROUND: In 1971, Janeke and Wright1 published a now classic study on the support of the nasal tip in which they found four areas of anatomic support. These findings led to the "tripod concept" of tip support. Recently, surgeons have begun repairing and/or preserving the nasal ligaments as a method to control tip projection and rotation. Therefore, a reassessment of the nasal ligaments and tip support is warranted. OBJECTIVES: The present study was done to investigate the ligamentous and structural support of the nasal tip. Clinically, surgeons are aware of the role of the nasal ligaments and are beginning to utilize tip suture techniques to achieve greater tip refinement and long-term support. METHODS: Anatomic studies were conducted on 24 fresh cadavers at the time of autopsy. The two groups consisted of the following: (1) group 1 included dissection of 10 cadavers concentrated on the various ligaments of the nose; and (2) group 2 involved dissections of 14 cadavers analyzing the relationship between the alar domes and the anterior septal angle (ASA). RESULTS: Regarding the ligaments of the nose, we were able to consistently identify the following ligaments: (1) interdomal; (2) intercrural; (3) Pitanguy's midline; (4) pyriform; and (5) a scroll ligament complex consisting of the longitudinal and vertical scroll ligaments. We did not find two commonly accepted ligaments: (1) a "footplate ligament" from the footplate of the medial crus to the caudal septum; and (2) a "sesamoid ligament" attachment from the accessory cartilage to the pyriform aperture. Dissections done to study the relationship between the domes and ASA revealed that the domes projected an average of 5.7 mm (range, 2.2-9.6 mm) above the ASA and were longitudinally 5.5 mm (range, 2.9-9.5 mm) caudal to the ASA. Thus, there was no direct support from the ASA to the domes. CONCLUSIONS: It is our recommendation that surgeons should consider preservation of the nasal ligaments whenever possible and utilize them to manipulate tip projection, position, and rotation. Awareness of the relationship between the dome and the caudal septum will hopefully minimize problems with the tongue-in-groove operation.

The osseocartilaginous vault of the nose: anatomy and surgical observations.

BACKGROUND: The dorsal hump and dorsal aesthetic lines have been considered bony and cartilaginous structures. Knowledge of the anatomy of the osseocartilaginous vault is essential for obtaining aesthetically pleasing results of rhinoplasty. OBJECTIVES: The authors described the morphology, embryology, and clinical relevance of the nasal vault and the changes that occur in this area during rhinoplasty. METHODS: Dissections were performed on 15 fresh adult cadavers to examine the anatomy of the osseocartilaginous vault. Intraoperative endoscopic examination of the vault also was performed in 9 rhinoplasty patients before and after dorsal hump reduction. RESULTS: In the cadaver study, the average length of the dorsal keystone area, measured along the dorsal septum, was 8.9 mm, and the average width was 4.9 mm. No significant difference in length was observed between cadaver subgroups with straight or humped nasal profiles. The extent of lateral overlap of the nasal bones with the cephalic portion of the upper lateral cartilages varied. In rhinoplasty patients, the average length of the cartilaginous vault exposed during dorsal reduction was 7.6 mm. CONCLUSIONS: The aesthetic lines and profile of the nose before dorsal reduction are dictated by the cartilaginous vault. After reduction, the dorsal lines are determined by the bony vault edges. In routine rhinoplasty, reduction of dorsal height generally corresponds to removal of the dorsal cartilaginous septum.

Rhinoplasty: the lateral crura-alar ring.

BACKGROUND: Rhinoplasty surgeons routinely excise or incise the lateral crura despite nostril rim retraction, bossa, and collapse. Given recent emphasis on preserving the lateral crura, a review of the lateral crura's anatomy is warranted. OBJECTIVES: The authors quantify specific anatomical aspects of the lateral crura in cadavers and clinical patients. METHODS: This was a 2-part investigation, consisting of a prospective clinical measurement study of 40 consecutive rhinoplasty patients (all women) and 20 fresh cadaver dissections (13 males, 1 female). In the clinical phase, the alar cartilages were photographed intraoperatively and alar position (ie, orientation), axis, and width were measured. Cadaver dissections concentrated on parts of the lateral crura (alar cartilages and alar ring) that were inaccessible clinically. RESULTS: Average clinical patient age was 28 years (range, 14-51 years). Average cadaver age was 74 (range, 57-88 years). Clinically, the distance of the lateral crura from the mid-nostril point averaged 5.9 mm, and the cephalic orientation averaged 43.6 degrees. The most frequent configuration of the axis was smooth-straight in the horizontal axis and a cephalic border higher than the caudal border in the vertical axis. Maximal lateral crura width averaged 10.1 mm. In the cadavers, average lateral crural dimensions were 23.4 mm long, 6.4 mm wide at the domal notch, 11.1 mm wide at the so-designated turning point (TP), and 0.5 mm thickness. The accessory cartilage chain was present in all dissections. CONCLUSIONS: The lateral crura-alar ring was present in all dissections as a circular ring continuing around toward the anterior nasal spine but not abutting the pyriform. The lateral crura (1) begins at the domal notch and ends at the accessory cartilages, (2) exhibits a distinct TP from the caudal border, (3) has distinct horizontal and vertical vectors, and (4) should have a caudal border higher than the cephalic border. Alar malposition may be associated with position, orientation, or configuration.

Three-dimensional simulation of the nasoalveolar cleft defect.

This study describes the planning process for a three-dimensional (3D) model of a nasoalveolar bone graft in patients with unilateral cleft lip and palate. A 3D reconstruction of the alveolar cleft based on cone-beam computed tomography was performed in 10 patients. Graft models were planned using a 3D planning software (iPlan ENT 3.0, Brainlab, Feldkirchen, Germany) and printed using a 3D printer (Objet30 Pro, Objet Ltd., Rehovot, Israel). A reproducible, step-by-step planning method was established, which is manual rather than automatic. Still, the 3D visualization and a life-size graft template could be useful during secondary alveolar osteoplasty.

The lower nasal base: an anatomical study.

Currently, most rhinoplasty surgeons focus their analysis and operative techniques on the upper nasal base, with its alar cartilages. They tend to minimize the lower nasal base, composed of the columellar base, nostril sills, and alar lobules. The requisite operative techniques are often considered ancillary techniques. In this article, the authors describe anatomical composition of the columellar base, nostril sill, and alar lobule; discuss the presence of a distinct lower nasal base; and reevaluate the nasal musculature and the nasal superficial muscular aponeurotic system in an anatomical cadaver model. They also discuss the results of both a detailed literature review (for articles related to the levator labii superioris alaeque nasalis, orbicularis oris, depressor septi nasalis, myrtiformis, and dilator naris) and the results of their own dissection of 45 fresh cadavers.