The Key to a Straight Nose Is a Straight Septum: 10 Essential Steps.

SUMMARY: The deviated nose derives from underlying skeletal and soft-tissue deformities in the upper, middle, and/or lower third of the nose. Although deviation may stem from several intrinsic and extrinsic elements, the septum is most often the primary contributor. Attempts to straighten the nose without properly addressing the septum invariably result in a persistently deviated nose. The goal of this article is to review the 10 key steps for a reliable, methodical approach to correcting the deviated septum in primary rhinoplasty.

Five-Principle and Five-Step Liquid Rhinoplasty.

SUMMARY: Liquid rhinoplasty, otherwise known as nonsurgical or filler rhinoplasty, has earned increased attention for its ability to provide surgical rhinoplasty results at a fraction of the cost and without incising the skin. However, significant complications can arise, such as tissue necrosis, filler embolus, and vascular compromise if the procedure is performed without consideration of the principles and anatomy of the face and nose. As demonstrated in this article, a stepwise and patient-specific approach to performing liquid rhinoplasty will ensure safe, consistent, and desirable results.

Superiority of the Septal Extension Graft over the Columellar Strut Graft in Primary Rhinoplasty: Improved Long-Term Tip Stability.

BACKGROUND: Columellar strut grafts and septal extension grafts are commonly used support structures; however, their relative effectiveness remains debated. The purpose of this study was to compare the long-term stability of septal extension grafts to that of columellar strut grafts. METHODS: A retrospective review of all primary rhinoplasties performed by the senior author (R.J.R.) from 2016 to 2019 was performed. All adult patients undergoing primary open rhinoplasty with at least 1 year of follow-up were included. Revision cases and those in whom rib grafts were used were excluded. Standardized postoperative imaging was assessed at 2 months (early) and at 12 months (long-term) to measure projection/rotation change over time. Univariate and multivariable statistical comparisons were performed. RESULTS: The chart query yielded 133 patients. Of these, 40 patients were treated with a columellar strut and 37 patients were treated with a septal extension graft. Projection loss at 1 year was 4.7% for the columellar strut group compared with 0.2% for the septal extension graft group ( P < 0.0001). On multivariable logistic regression, there was a 5.1-fold increased risk of greater than 4% projection loss when using a columellar strut ( P < 0.005). Mean rotation loss for the columellar strut group was 4.9 degrees compared with 1.3 degrees for the septal extension graft group ( P < 0.0001). The independent effect of columellar strut use resulted in a 2.8-fold increased risk of rotation loss greater than or equal to 5 degrees ( P < 0.05). CONCLUSIONS: Septal extension grafts result in effectively no loss of projection and minimal loss in rotation. A small degree of projection and rotation loss can be expected with the use of a columellar strut alone. These long-term graft tendencies should be anticipated and accounted for appropriately. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Seven-Step, 7-Minute Chin Augmentation.

SUMMARY: Microgenia, or a recessed/weak chin, plays a significant role in facial disharmony. Although patients with severe microgenia, malocclusion, long-face syndrome, or other significant orthognathic problems are not suitable for chin augmentation alone, many people have mild to moderate microgenia that would benefit from implant-based chin augmentation. Assessment of the chin is included in any critical analysis of the face and plays a key role in the planning of all facial aesthetic procedures. The ideal chin is thought to extend to or just behind a vertical line dropped from the nasion or the upper lip vermilion on profile. The authors describe their efficient, safe seven-step approach to chin augmentation.

Modern Concepts in Nasal Deprojection.

SUMMARY: The overprojected nose, also known as a long nose, is a consequence of several interrelated factors. Standardized nasofacial assessment typically is approached through the anterior, lateral, and basal views. The senior author (R.J.R.) has developed an algorithmic approach to deprojection. The algorithm, presented in this article, allows for less aggressive methods to be followed while permitting a cartilage excision modality combined with construct supporting techniques when needed.

Rhinoplasty in the COVID-19 Era: Practice and Safety Considerations.

SUMMARY: The COVID-19 pandemic has required changes in health care practices to decrease the risk of disease transmission during the provision of medical care. The risk of transmission is high in procedures involving the nasopharyngeal and oropharyngeal tissues. This article describes simple preventative strategies at a single institution to minimize the risk of disease transmission during rhinoplasty procedures. In particular, the utility of povidone-iodine in prophylaxis during the perioperative period is discussed.

Jawline Refinement in Face Lifting: The Five Zones and the Five-Step Technique✰.

Facial aging changes due to increased skin laxity as well as soft tissue atrophy and decent lead to blunting and distortion of previously well-defined zones of the face and neck. A critical component of re-establishing a youthful appearance during facelift and neck lift surgery is restoring a well-defined mandibular contour. Key principles of jawline refinement include the addition of volume to deficient areas and removal of volume in areas of unwanted fullness to re-establish facial harmony in the lower face and neck. In this article, we describe a novel classification of jawline zones and discuss our stepwise surgical approach to aid in the systematic evaluation and surgical treatment of the jawline.

Minimally Invasive Approach to Skin Tightening of the Face and Body: Systematic Review of Monopolar and Bipolar Radiofrequency Devices.

BACKGROUND: Radiofrequency treatment is a relatively new and increasingly popular option for patients desiring skin tightening and an improvement in facial or body contour without undergoing an excisional surgical procedure. A systematic review of the literature was performed to investigate the safety and efficacy of monopolar and bipolar radiofrequency devices for facial and body rejuvenation. METHODS: A computerized search of the MEDLINE database was performed for clinical studies investigating the use of monopolar and bipolar radiofrequency devices in facial and body rejuvenation. Data on the type of device, treated areas, number of patients, number of treatments, follow-up, complications, and outcomes were collected. RESULTS: The systematic review was performed in September of 2020. A total of 207 articles examined the use of radiofrequency technology for cosmetic purposes, and 23 articles remained after all inclusion and exclusion criteria were considered. Nine articles evaluated monopolar devices and five articles evaluated bipolar devices for treatment of the face. Three articles evaluated monopolar devices and six articles evaluated bipolar devices for treatment of various body areas. CONCLUSION: There is clinical evidence that monopolar and bipolar radiofrequency devices produce measurable improvement in skin laxity of the face and body with an acceptable complication profile. The majority of reported complications are minor and transient in nature; major complication rates are higher with the use of monopolar devices than with the use of bipolar devices.

Personal Evolution in Rhinoplasty Tip Shaping: Beyond the Tripod Concept.

SUMMARY: Introduced over 50 years ago, the "tripod concept" has long been the foundation of our understanding of tip dynamics in rhinoplasty. Modern approaches to rhinoplasty have built on these principles and seen the evolution of several operative techniques to address tip aesthetics. This article and accompanying case video detail our algorithmic approach to tip shaping, based on the use of complete lower lateral cartilage reshaping and tensioning, clarified use of medial crural transection and overlap, with stabilization on a fixed-floating septal extension graft, and deliberate management of the soft-tissue envelope. The intraoperative sequencing, key technical considerations, relevant classification schemes, and global decision-making processes are reviewed. .

Technique for Minimally Invasive Face and Neck Contouring with Bipolar Radiofrequency Devices.

SUMMARY: Radiofrequency devices have grown in popularity as minimally invasive options for the treatment of skin laxity in the face and neck. These treatments are often combined with liposuction procedures to provide enhanced tissue contraction alongside the reduction in adiposity. Proper patient selection and intraoperative technique are crucial to achieving the desired outcomes in a safe manner. In this article, the authors discuss their indications and technique for the treatment of the face and neck with bipolar radiofrequency devices.

Fresh Frozen Rib Cartilage Grafts in Revision Rhinoplasty: A 9-Year Experience.

BACKGROUND: Revision rhinoplasty is undoubtedly one of the most challenging procedures in facial plastic surgery. The complexity is compounded when there is a paucity of native septal cartilage to perform the required framework reconstruction. Harvest of autologous costal cartilage can result in increased operative times and possible secondary-site complications such as contour irregularity, poor scarring, and even pneumothorax. METHODS: A retrospective review was conducted of the senior author's (R.J.R.) patients from 2011 to 2020 who underwent primary or revision rhinoplasty. Inclusion criteria consisted of patients with fresh frozen off-the-shelf cartilage used in revision rhinoplasty only with a minimum of 6 months' follow-up. Outcomes for evaluation were warping, resorption, displacement, and infection. RESULTS: The authors identified 226 patients who underwent open rhinoplasty with the use of fresh frozen rib cartilage grafts and met inclusion criteria. The mean follow-up period was 12.18 months (range, 6 months to 8 years). The majority of patients had undergone one prior rhinoplasty procedure (54 percent); however, 4 percent of patients had undergone four or more prior procedures on their nose. The overall infection rate was 2.7 percent ( n = 6), with the majority successfully managed with antibiotics alone (2.3 percent). CONCLUSIONS: The results in revision rhinoplasty are significantly enhanced with the creation of a stable nasal framework using off-the-shelf, easily accessible, specifically tailored fresh frozen cadaveric rib grafts. The long-term outcomes and complication rate in this 9-year retrospective study demonstrates the safety of fresh frozen rib graft in comparison to autologous or irradiated rib graft. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Versatility of the Fixed-Mobile Septal Extension Graft for Nasal Tip Reshaping.

SUMMARY: Key goals of nasal tip reshaping include precise control of tip shape and position, along with restoration of proper structural support. Unfortunately, traditional techniques attempting to address these goals have yielded unpredictable results. In this article, the authors detail their surgical technique and discuss the numerous aesthetic and functional benefits of this graft, along with its applicability to a wide variety of patient populations and nasal deformities. The authors' technique utilizing the fixed-mobile septal extension graft has demonstrated reliability in establishing proper tip positioning through precise adjustments to tip rotation and projection, while simultaneously providing a stable structure for maintaining tip support. While fixed at the anterior septal angle, this graft also proves beneficial in maintaining natural tip mobility because of its anterior extension past the septum. The fixed-mobile septal extension graft is versatile and reliable when used for tip reshaping and support.

Assessing Long-Term Outcomes in Breast Implant Illness: The Missing Link? A Systematic Review.

SUMMARY: The purpose of this special topic article is to explore the current state of outcomes-based literature related to breast implant illness and summarize the key understandings that emerge from the summation of existing studies. While implanted silicone devices are some of the most ubiquitous products in modern medicine, the safety of silicone breast implants has long remained under scientific scrutiny. In the era of social media and with breast implants once again under public scrutiny with the recent connection of texture silicone implants to breast implant-associated anaplastic large-cell lymphoma, the borders between breast implant illness and other implant-related diseases are becoming clouded in the public eye. The surgical management options for breast implant illness range from simple implant explantation alone to complete en bloc capsulectomies, or even secondary exploratory operations for additional capsulectomy in persistently symptomatic patients. In this review of outcomes-based studies related to breast implant illness, the authors found that a subset of patients improves with surgical intervention but limited evidence to inform most current surgical management practices. Further, the nature of this illness renders it difficult to study. A carefully designed, large, prospective, outcomes-based study is still required if an evidence-based and sound treatment approach for this condition is to be established.

Nonsurgical Rhinoplasty.

Nonsurgical rhinoplasty is increasing in popularity, and when used appropriately, can be less costly and have less downtime than surgical rhinoplasty. It can offer patients a means of seeing how they would feel about a surgical rhinoplasty later. Injection can be safe but patients should still be counseled regarding the rare, possible risks of tissue loss and potentially irreversible tissue ischemia and irreversible blindness. Treatment with hyaluronidase can be partially effective when signs and symptoms are caught early; however, avoidance is still the best medicine along with seeking an experienced, qualified rhinoplasty plastic surgeon.

Autologous Reconstruction of a Face Transplant Candidate.

Since 2005, facial transplantation has emerged as a viable reconstructive option for the most severe defects not amenable to conventional reconstructive techniques, with promising aesthetic and functional outcomes to date. Key facial subunits and midface structures such as the eyelids, lips, and nose are now able to be successfully replaced rather than reconstructed, enabling adequate functional outcomes in even the most extensive defects. However, even in cases of severe facial disfigurement, the decision to proceed with transplantation versus autologous reconstruction remains a source of debate, with no current consensus regarding precise indications and inclusion/exclusion criteria. This report details the case of a candidate referred for face transplantation who ultimately underwent autologous facial reconstruction. Through this representative case, our objective is to clarify the criteria that make a patient a suitable face transplant candidate, as well as to demonstrate the outcomes achievable with a conventional autologous reconstruction, using a methodically planned, multistaged approach.