Lateral Domal Translocation and Medial Crural Transection: A Reliable Method for Nasal Tip Deprojection.

SUMMARY: Nasal tip deprojection is a common goal in rhinoplasty. Several techniques have been described, many of which require destructive techniques that compromise the intrinsic integrity and morphology of the lateral crura. Through lateral translocation of the domes and shortening of the medial crura, nasal tip deprojection can be achieved without disrupting the integrity of the lateral crura. The domes are recreated lateral to the intrinsic domes with a standard transdomal suture, and excess length of the middle and medial crura is managed through transection and shortening of the medial crura. This technique preserves the morphology of the nasal base without altering the position of the medial crural footplates. Deprojection of 4 to 5 mm can be readily achieved with this technique.

A Simplified Approach to Nasal Tip Shaping: The Five-Suture Technique.

Techniques for nasal tip shaping have evolved from destructive to nondestructive techniques. These techniques have proven to be effective, yet they are often applied incrementally and require repeated intraoperative evaluation and manipulation to assess their efficacy. We describe a simple, effective, and reliable five-suture technique to achieve consistent results in tip shaping based on previously described ideals for nasal tip aesthetics.

Revisiting the Alar-Columellar Relationship: Classification and Correction.

The alar-columellar relationship has tremendous aesthetic significance in the lower one-third of the nose. Aberrancies in the alar-columellar relationship detract from nasal aesthetics, and are classified into six types: type I, hanging columella; type II, retracted ala; type III, combination of a hanging columella and retracted ala; type IV, hanging ala; type V, retracted columella, and type VI, combination of a hanging ala and retracted columella. This article describes the methods for proper evaluation and diagnosis of aberrancies in the alar-columellar relationship, and current strategies to restore the ideal alar-columellar relationship. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Primary Open Rhinoplasty.

LEARNING OBJECTIVES: After studying this article and viewing the videos, the participant should be able to: 1. Describe the operative technique necessary to perform open rhinoplasty. 2. Summarize the steps necessary in performing a component dorsal reduction. 3. Develop a surgical plan for nasal tip shaping and cephalic rotation of the nasal tip. 4. Identify the need for aesthetic improvement of the alar base, and perform successful alar base surgery. 5. Demonstrate consistency, safety, and predictability in rhinoplasty. SUMMARY: Rhinoplasty remains one of the most challenging procedures in plastic surgery, and continues to be one of the top five aesthetic surgical procedures, with over 223,000 performed in 2016. Rhinoplasty may be performed by means of the "open" or the "closed" approach, and each approach has its advantages and disadvantages. This article focuses on the open approach, and the principles and techniques necessary to achieve consistent and gratifying results. As with all plastic surgery procedures, successful rhinoplasty begins with a thorough clinical analysis, definition of the goals, meticulous preoperative planning, precise operative execution, vigilant postoperative management, and a critical analysis of one's results.

Nasal Analysis: Considerations for Ethnic Variation.

As the United States continues to be more ethnically and racially diverse, it is important for the rhinoplasty surgeon to have an appreciation and understanding of nasal variations that exist to plan for and execute ethnically congruent results. The nasal analysis is a critical component of the patient evaluation, which has been used as a tool by surgeons to identify deviations from anatomical norms or canons. In this article, the authors describe common nasal anatomical variations that exist between ethnic groups as a guide for nasal analysis. Understanding these variations will facilitate and help define important cultural aesthetics, which can be used to plan for rhinoplasties in a diverse patient population.

Tissue-Based Planning and Technique for Breast Augmentation with Anatomical Implants.

Breast augmentation with anatomical implants offers several potential advantages. Tissue-based planning is patient specific and essential in choosing the correct dimensions of an implant, thereby providing greater control in breast shape following augmentation. This video vignette demonstrates tissue-based planning in a patient with a constricted breast, allowing the surgeon to accurately choose the proper implant dimensions, which correct the constriction while providing aesthetic control of breast shape. Operative techniques of precise pocket formation, prospective hemostasis, and judging the aesthetic contour following implant insertion are demonstrated.

Long-Term Assessment of Perioral Rhytide Correction with Erbium: YAG Laser Resurfacing.

BACKGROUND: Use of nonsurgical skin rejuvenation has grown over the past two decades. This has led to an increase in ablative and nonablative resurfacing devices. Moderate to heavy perioral rhytides require an ablative laser to maximize results. Traditionally, this was performed with carbon dioxide lasers; however, more recently, erbium lasers have been used to target heavy rhytides. The purpose of this study was to assess long-term correction of perioral rhytides with the use of the senior author's (A.J.B.) erbium laser resurfacing technique. METHODS: A retrospective review of all patients who underwent perioral erbium laser resurfacing performed by the senior author from 2009 to 2016 with a minimum of 6-month follow-up was performed. Ten blinded nonphysicians and 10 blinded plastic surgeons evaluated the imaging based on a previously established standardized grading sheet, with gradation improvement from 1 to 8. The absolute and percentage improvement were evaluated, along with complications. RESULTS: Forty-five patients met inclusion criteria, with an average follow-up of 13 months. A statistically significant score improvement of 2.2 gradations was seen, in addition to a significant improvement (from 56 percent to 66 percent). Both the surgeon and nonphysician groups showed improvement, with no differences between the two groups. There were no cases of hypopigmentation at the 6-month postoperative visit. CONCLUSIONS: Erbium laser resurfacing is a powerful and safe tool for correcting perioral rhytides. It is effective in isolation or with other facial rejuvenation procedures. Erbium laser resurfacing is a useful adjunct in facial rejuvenation that can deliver exceptional results with few complications when performed within the proper guidelines. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Finesse in Face Lifting: The Role of Facial Fat Compartment Augmentation in Facial Rejuvenation.

Much of facial aging can be attributed to volume deflation and tissue laxity. Successful surgical rejuvenation can be achieved through volume restoration with autologous fat grafting of the facial fat compartments. In conjunction with volume restoration, correction of tissue laxity and recontouring of the face and neck can be achieved. Current strategies for surgical correction of the face and neck involve superficial musculoaponeurotic system manipulation, medial platysma plication, and lateral platysma tightening through the lateral platysma window. These combined techniques facilitate optimal results in facial rejuvenation.

Cephalic Rotation of the Nasal Tip.

The position of the nasal tip holds important aesthetic significance. Cephalic rotation of the nasal tip is a frequent motivating factor for patients seeking rhinoplasty. The position of the nasal tip is a complex interplay of the size, morphology, and position of several anatomical components of the lower one-third of the nose. Cephalic rotation can be achieved by means of six different methods. The indirect methods promote passive cephalic rotation and include cephalic trim of the lower lateral cartilages, caudal trim of the upper lateral cartilages, and caudal septal trim. Direct methods involve precise repositioning of the domes and include shortening the lateral crura, lateral domal relocation, and the tip rotation suture. Used alone or in combination, these techniques and their subtle variations represent comprehensive and effective methods to achieve cephalic rotation of the nasal tip.

Autologous Fat Grafting to the Chin: A Useful Adjunct in Complete Aesthetic Facial Rejuvenation.

The chin makes up the central unit of the face and neck, and is a significant factor in facial harmony and aesthetics. Historically, correction of microgenia required surgical intervention with a sliding genioplasty, or placement of a permanent implant. However, these techniques require more extensive surgical intervention, prolonged downtime, with higher costs and complications. Furthermore, chin rhytides and descent of chin fat lead to an aged appearance of the chin and lower face that is difficult to correct with a chin implant alone. Autologous fat grafting in facial rejuvenation has expanded in its application and can serve as an effective technique to correct and enhance chin aesthetics, including lateral chin hollowing, asymmetry, mild microgenia, and correction of deep labiomental sulcus or a bifid chin. This article and accompanying video demonstrate the authors' technique for chin augmentation and refinement with autologous fat.

Refinements in Upper Blepharoplasty: The Five-Step Technique.

Periorbital tissues are a keystone in facial beauty and a representation of youth. The aesthetically pleasing and youthful upper eyelids are full, with a defined tarsal upper lid crease and with smooth, taut pretarsal and preseptal skin. The upper blepharoplasty is a critical component of any facial rejuvenation procedure. This five-step procedure provides key steps in the correction of upper lid age-related changes and provides a reliable and reproducible method of achieving excellent results. Furthermore, the addition of fractionated fat restores volume and youthfulness of the upper lid, and also improves the skin quality of the upper lid.

An Update on the Safety and Efficacy of Outpatient Plastic Surgery: A Review of 26,032 Consecutive Cases.

BACKGROUND: Outpatient surgery offers many advantages, including cost-containment, privacy, and convenience. However, patient safety must take precedence over these benefits. Limited well-designed studies exist in the plastic surgery literature on patient safety in the outpatient setting, particularly those that identify risk factors for adverse outcomes. METHODS: A retrospective review was performed on 26,032 consecutive cases completed by board-certified plastic surgeons at an accredited outpatient surgical center between 1995 and 2017. All cases were reviewed for potential morbidity and mortality events, and variables were analyzed to determine potential risk factors for postoperative complications and inpatient admission. RESULTS: A total of 26,032 cases were performed over a 23-year period. There were a total of 203 complications (0.78 percent). Compared with the control population, the 12 patients (0.05 percent) that sustained venous thromboembolic events demonstrated higher body mass indexes (p < 0.01), greater lipoaspirate amounts (p = 0.04), longer operative times (p < 0.01), and were more likely to have undergone a combined procedure (p < 0.01). In addition, the 22 patients (0.08 percent) that were transferred to inpatient facilities demonstrated greater body mass index (p < 0.01) and longer operative times (p = 0.01). CONCLUSIONS: Plastic surgery is safe to perform in an accredited outpatient facility for a majority of patients. According to the authors' data, postoperative monitoring in a nursing facility should be considered for the following high-risk patients: those with a body mass index greater than 30 kg/m, operative times greater than 4 hours, lipoaspirate volumes greater than 3 liters, and those undergoing combined procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Infratip Lobule Butterfly Graft: Balancing the Transition from the Tip Lobule to the Alar Lobule.

The nasal alae and the soft-tissue triangles are delicate structures, the contours of which are largely dependent on soft tissue and the indirect influence of the lower lateral cartilages. Creating appropriate and continuous contour from the tip lobule to the alar lobule can be challenging. The alar contour graft is one reliable method of achieving predictable contour. However, alar contour grafts of ideal length may be scarce. The butterfly graft is a simple, reliable, and predictable method of providing support in the region of the soft triangle, and spans the region between the tip lobule and alar lobule, thereby balancing the transition between these regions.

The Keystone: Consistency in Restoring the Aesthetic Dorsum in Rhinoplasty.

The keystone represents the union of six distinct anatomical structures between the bony vault and the cartilaginous midvault. In reshaping the nasal dorsum, the individual components of the nose respond variably as the fusion points of the keystone are released. In restoring the nasal dorsum, meticulous effort is made to equalize the width between the bony vault and the cartilaginous midvault. Techniques used for width equalization will yield gratifying long-term results and avoid common pitfalls such as the inverted-V deformity.