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.

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.

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.

What are some tips and pearls for preserving and improving nasal function when performing a cosmetic rhinoplasty?

PURPOSE OF REVIEW: Understanding nasal form and function is critical in performing successful cosmetic rhinoplasty. Careful evaluation of the patient's nasal airway with identification of areas of existing or potential obstruction is important in avoiding potential pitfalls that may compromise nasal function following rhinoplasty. This article will review surgical techniques that can be utilized to preserve and improve nasal function during cosmetic rhinoplasty. RECENT FINDINGS: Recent literature on nasal functionality focuses on the management of the internal and external nasal valve as well as the nasal septum during rhinoplasty. SUMMARY: Successful cosmetic rhinoplasty requires a thorough preoperative analysis of both aesthetic and functional characteristics of the nose. Close attention should be paid to the internal and external nasal valves and nasal septum before and during surgery to preserve and improve nasal function following cosmetic rhinoplasty.

Quantifying osteotome sharpness: comparing the major manufacturers.

OBJECTIVE: (1) To develop a method for quantification of osteotome sharpness in a rhinoplasty model, using artificial bone; (2) to demonstrate changes in osteotome sharpness over multiple uses; and (3) to compare osteotomes from different manufacturers in terms of sharpness and cost. STUDY DESIGN: Prospective surgical model. SETTING: Academic hospital and engineering research facility. METHODS: Osteotomes were used to make 4-cm cuts through 4-mm wedges of artificial bone. Sharpness was assessed at baseline and following 1, 4, 7, and 10 uses by measuring the load required to cut a #2 Prolene suture. Changes in sharpness from baseline were measured over time, and comparison of manufacturers was performed using analysis of variance (ANOVA). Cost per use was computed for each osteotome. RESULTS: Five osteotomes were tested (Biomet, Black & Black, Miltex, NexEdge, Storz). At baseline, the Storz osteotome was sharpest (1.74 lb, P < .001), followed by Miltex and Biomet (2.50 lb, 2.68 lb) and NexEdge and Black & Black (3.48 lb, 3.40 lb). All osteotomes except NexEdge (P = .098) demonstrated significant decreases in sharpness over time (P = .02 to P < .001), although relative changes and absolute sharpness varied greatly. ANOVA demonstrated Storz to be significantly sharper at all time points (P < .001). Storz and Miltex were superior in cost-per-use analysis. CONCLUSION: Sharp osteotomes are important in cosmetic and functional rhinoplasty. Instruments may appear the same but can be quite dissimilar in efficacy and cost. Indeed, relative efficacy has not been previously tested. Quantitative analysis performance and cost-effectiveness analyses are reported here and can assist the surgeon in selection and maintenance of instruments.

Quantifying the sharpness of osteotomes for dorsal hump reduction.

OBJECTIVE: To assess the relative sharpness of osteotomes after multiple uses, routine maintenance, and sharpening. METHODS: This prospective clinical study and mechanical model quantified the relative sharpness of identical osteotomes at baseline; after 3, 6, and 9 uses; and after sharpening techniques compared with osteotomes from hospital central supply. The Instron universal tester developed a force-displacement curve as the osteotome blade cut a standardized suture. Force required to cut the suture is inversely proportional to osteotome sharpness. RESULTS: For osteotomes 1, 2, and 3, dullness occurred after 9 uses (4.836 lb; P < .001), 6 uses (4.431 lb; P < .005), and 3 uses (4.093 lb; P < .02), respectively. Osteotome 1 was professionally sharpened after 9 uses and retested (3.156 lb); results were similar to those for an osteotome used 6 times (3.160 lb). Additional sharpening showed significantly poorer performance (7.737 lb; P < .001 at baseline and after 9 uses). Osteotome 3 was hand sharpened after 6 uses and retested (7.750 lb; baseline P < .001). Two osteotomes from central supply required almost twice the cutting force relative to the senior author's osteotomes. CONCLUSIONS: Although osteotome performance decreased significantly over time, professional sharpening only achieved results similar to an osteotome used 3 to 6 times. Further resharpening seems detrimental to performance. Surgeons may want to consider osteotomes disposable instruments.

Anatomy, physiology, and general concepts in nasal reconstruction.

Nasal reconstruction provides a challenging task for any facial plastic surgeon. In performing reconstructive surgery on the nose, one must balance both the functional aspects of the nasal airway with the aesthetic responsibilities of being the central fixture of the face. Before performing surgery, the surgeon must grasp the importance of the anatomic nasal relationships and subunits, the physiology of the skin, the flaps or grafts used to reconstruct these areas, and the basic steps in wound healing. Accurate preoperative planning and analysis of the nasal defect are also vital to producing both an aesthetic and functional nose.

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.

A patient seeking aesthetic revision rhinoplasty and correction of nasal obstruction.

Thorough evaluation of a patient presenting with nasal obstruction, including nasal endoscopy and a CT scan when indicated, is recommended to guide proper diagnosis and treatment. The rhinoplasty surgeon should be aware of the differential diagnosis of nasal obstruction and should proceed with thorough evaluation or refer the patient for appropriate complete evaluation.

Domal stabilization suture in tip rhinoplasty.

OBJECTIVE: To investigate use of the domal stabilization suture as a complementary suture modification technique for refining and securing the nasal tip. METHODS: A single permanent or absorbable suture is placed via an open or cartilage delivery approach. The suture is placed along the cephalic borders of the domes at the medial third of the lateral crura bilaterally just posterior to the junction of the intermediate and lateral crura as a final step in tip rhinoplasty. RESULTS: The domal stabilization suture provided a means to help maintain dome symmetry in the setting of variable healing and scarring forces with no complications and no effect on tip rotation or projection. CONCLUSION: Use of the domal stabilization suture enables correction of subtle changes in mild tip asymmetry and irregularities in domal height and provides subtle narrowing of the interdomal distance.

Five techniques that i cannot live without in revision rhinoplasty.

Revision rhinoplasty is an art and a science. Consistent success requires well developed judgment, vision and accumulated knowledge, and experience. For this article the senior author was asked to select five surgical techniques; pearls from his revision practice that warrant highlighting. The authors discuss hump reduction under direct visualization, powered rasp, diagnostic nasal endoscopy and endoscopic septoplasty, computer imaging, and composite grafting.

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.

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.

Website for rhinoplasty and facial plastic surgery.

The Internet has become an important avenue for facial plastic surgeons to make potential patients aware of their practice. It is important for the facial plastic surgeon to understand how the Internet is used by patients and how it can complement a physician's practice. The website unavoidably has a marketing aspect. Although there are no statistics available, certainly a substantial number of patients use the Internet as a primary source for both learning about cosmetic surgical procedures and also to locate a physician. A practice website can provide potential patients with important logistical information; it also provides an opportunity to educate the potential patient about the surgical procedures provided. A website can be an important aspect of the overall practice image. An increasing number of individuals visit the website of their physician or potential physician, so it is important that attention is given to this aspect of a practice.