Rinoplastia estética primaria cerrada. Revisiones durante tres años / Closed primary cosmetic rhinoplasty. Three years revisions

INTRODUCCIÓN Y OBJETIVO: Para conocer con más certeza, cuáles eran los problemas de nuestras rinoplastias primarias y el porcentaje de revisiones, buscamos y estudiamos los casos operados en un periodo de 3 años en nuestro Centro de Cirugía Estética. Creemos que este es un tema complejo que tiene pocos reportes en la literatura mundial dentro de la especialidad de Cirugía Plástica. MATERIAL Y MÉTODO: Analizamos retrospectivamente en un periodo de 3 años (2015-2017), cuál fue la proporción de rinoplastias primarias cerradas y las revisiones realizadas en ese mismo período, así como qué áreas de la nariz fueron las afectadas. Estudiamos las 4 zonas más frecuentemente sometidas a revisión, denominadas subunidades estéticas: dorso cartilaginoso, dorso óseo, punta y alas nasales y las látero-desviaciones nasales. Todas las revisiones se realizaron con una disección limitada, solo del área a tratar, con rinoplastia cerrada y con anestesia local. RESULTADOS: En el periodo estudiado realizamos 183 rinoplastias primarias de las cuales efectuamos 15 revisiones, lo que significa un porcentaje del 8.19%. Las revisiones más frecuentes fueron de la punta nasal y ala nasal. CONCLUSIONES: En nuestra experiencia, el porcentaje de revisiones obtenido fue comparable con el presentado en otras publicaciones sobre rinoplastia cerrada y abierta, considerando la creciente popularidad de las técnicas abiertas

BACKGROUND AND OBJECTIVE: In order to know our problems after primary rhinoplasty and our percentage of revisions, we studied the cases operated during 3 years in our outpatient Aesthetic Surgery Center. In our opinion, revision rhinoplasty is a complex issue with few reports in the international literature. METHODS: A retrospective study was conducted in a 3 year period (2015-2017) studying the proportion of primary closed rhinoplasty, the revisions made, and also the nasal areas affected. The 4 most frequent aesthetic subunits of review were identified: cartilaginous dorsum, bone humps, nasal tip and alar areas and nasal deviations. All revisions were performed using closed rhinoplasty techniques, local anesthesia and a limited dissection to the affected area. RESULTS: In that period, 183 primary rhinoplasties were performed and 15 revisions were carried out, which means a percentage of 8.19%. The most frequent areas were the nasal tip and the lateral alar areas. CONCLUSIONS: In our experience, the percentage of revisions was comparable to other reports about revisions in open and close rhinoplasties, considering the increased popularity of the open rhinoplasty

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Medial Osteoectomy as a Routine Procedure in Rhinoplasty: Six-Year Experience with an Innovative Technique.

BACKGROUND: Medial osteotomy is an integral part of most rhinoplasty procedures, and when improperly performed, it is associated with postoperative complications and nasal contour deformities. In this article, we present a minimally traumatic and easy-to-perform medial osteoectomy technique with a pair of pliers, as a routine procedure, instead of the traditional medial osteotomy with osteotome and hammer. We report our experience with the use of the technique in a series of rhinoplasty procedures and review in brief the existing literature. METHODS: One hundred and thirty-five patients underwent rhinoplasty operations to correct aesthetic nose deformities, with the use of the suggested surgical technique. Two different types of medial osteoectomy, performed with the pliers, were used: Type I for dorsal nasal hump reduction and slight narrowing of the nose and type II for the management of a wide nasal dorsum along with or without hump removal. RESULTS: Postoperative results were favorable, by both clinical examination and comparison of preoperative and postoperative photographs, in 98.5% of patients. Only two patients with wide nasal dorsums had inadequate narrowing of their broad nose and underwent successful revision surgery. CONCLUSIONS: The suggested technique is easy to perform, has a short learning curve, provides high accuracy over the location and amount of the nasal bone to be removed, but inflicts minimal trauma. As a result of the aforementioned advantages, the risk of postoperative complications is low, and most importantly, reliable, consistent, and aesthetically pleasing results are easily ensured. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Analyses and classification of complexities in rhinoplasties based on factors increasing the difficulty and their appropriate reconstruction.

OBJECTIVES: This study aims to classify the factors that make rhinoplasty difficult and appropriate reconstruction of it. PATIENTS AND METHODS: We retrospectively evaluated the records of 103 patients who underwent rhinoplasty at our private clinic between April 2002 and December 2014. The most important reagent affecting the degree of difficulty in our study was the adhesion of the bone and cartilaginous structures to the skin and mucosa, as an outcome of on previous operations. Structural deficiencies in various parts of bone and cartilaginous structures, presence of septum deviation at a very advanced level, asymmetries in the lower and upper lateral cartilages, fracture deformities or trauma-related bone compressions, skin quality and thickness and the age of the patient were other criteria that affected the degree of difficulty of rhinoplasty. Taking these compelling factors into consideration, a difficulty coefficient table was set up with a new classification that determines complexity and suggests appropriate reconstructions. RESULTS: The total of difficulty coefficients of rhinoplasties between 1-3 were considered to be less complex, those between 4-6 as intermediate complex and those being >7 as very complex rhinoplasty. CONCLUSION: Calculation of the difficulty coefficient provides objective determination of the degree of difficulty of the operation. Reconstruction plans, probable duration of surgery, preoperative preparations, all grafts and materials considered for use may be predicted according to the difficulty coefficient. The surgeon can test whether his or her experience is sufficient or not according to the difficulty coefficient. Surgical risks can be assessed in the light of the difficulty coefficient and shared with the patient.

A Staging System for Revision Rhinoplasty: A Review.

IMPORTANCE: Rhinoplasty is known to be one of the more technically challenging cosmetic procedures, with a revision rate of 5% to 15%. Reasons for revisions may range from minor deformities that can be treated in the office to major cosmetic and functional defects that require multiple surgical procedures to correct. The literature lacks a uniform scale that systematically evaluates the patient presenting for revision rhinoplasty. The TNM staging system for classifying malignant tumors was developed to aid the physician in planning treatment, providing some information about prognosis, assisting in evaluating the results of treatment, and facilitating the exchange of information. Although the patient presenting for a revision rhinoplasty does not have a potentially lethal disease, a classification system for such patients resembling that used for malignant tumors may provide similar benefits. OBSERVATIONS: As in TNM staging, we describe 3 major components that determine the overall difficulty of surgery for revision rhinoplasty. In our PGS system, "P" represents "problem," consisting of the specific anatomic anomaly with which the patient presents. The second component in our system is "G" for "graft," based on the number of grafts required. The third component of this system is "S," for "number of previous surgical procedures." In addition, we have included a category "E," for "patient expectations," which is added after the stage of the patient's condition has been determined through the PGS classification. CONCLUSIONS AND RELEVANCE: Rather than being measured in terms of survival, as with the TNM system for malignant tumors, the prognosis in revision rhinoplasty is measured in terms of what can be achieved with surgery as opposed to what cannot. This preoperative staging system may help the patient understand the complexity of the repair required and help manage expectations. The PGS system will facilitate exchange of information between surgeons who perform revision rhinoplasty. A standardized evaluation system will allow meaningful comparisons of surgical techniques and evaluations of outcomes of rhinoplasty procedures.

[The results of a comparative randomized study on the effectiveness of various methods for the correction of the nasal valve: the subjective evaluation].

The objective of the present study was to compare the effectiveness of several extensively used techniques for the correction of the nasal valve in terms of the main clinical manifestations with the application of various scales for subjective evaluation of the outcomes of the treatment. It was demonstrated in the course of this prospective study that the patients described the elimination of nasal valve dysfunction with the help of expanding transplants as the most effective method in terms of the improvement of nasal breathing and the achievement of the acceptable aesthetic results. The plastic correction with the use of local tissues was reported to be less efficacious even if ensuring the stable result. This method did not worsen the shape of the nose but failed to remove its existing cosmetic defect. As far as the aesthetic outcome of the treatment is concerned, the suture correction technique was recognized to be the least efficacious approach because it resulted in the deterioration of the nose shape in more than half of the cases.

Classification of rhinoplasties performed in an otorhinolaryngology referral center in Brazil.

INTRODUCTION: Facial plastic and reconstructive surgery involves the use of surgical procedures to achieve esthetic and functional improvement. It can be used for traumatic, congenital, or developmental injuries. Medicine, with an emphasis on facial plastic surgery, has made progress in several areas, including rhinoplasty, providing good long-term results and higher patient satisfaction. OBJECTIVE: To evaluate cases of rhinoplasty and its subtypes in a referral center, and to understand the relevance of teaching rhinoplasty techniques in a service of otolaryngology residency. METHODS: A retrospective study that assessed 325 rhinoplasties performed by third-year medical residents under the supervision of chief residents in charge of the Service of Facial Plastic Surgery in this hospital was conducted from January of 2003 to August of 2012. The Service Protocol included the following subtypes: functional, esthetic, post-traumatic, revision, and reconstructive rhinoseptoplasty. RESULTS: Of the rhinoplasties performed 184 (56.21%) were functional, 59 (18.15%) were post-traumatic, 27 were (8.30%) esthetic, 15 were (4.61%) reconstructive, and 40 (12.30%) were revision procedures. CONCLUSION: Functional rhinoseptoplasties were the most prevalent type, which highlights the relevance of teaching surgical techniques, not only for septoplasty, but also the inclusion of rhinoplasty techniques in teaching centers.

Classification of rhinoplasties performed in an otorhinolaryngology referral center in Brazil / Classificação das rinoplastias realizadas em um centro de referência em otorrinolaringologia no Brasil

Introduction: Facial plastic and reconstructive surgery involves the use of surgical procedures to achieve esthetic and functional improvement. It can be used for traumatic, congenital, or developmental injuries. Medicine, with an emphasis on facial plastic surgery, has made progress in several areas, including rhinoplasty, providing good long-term results and higher patient satisfaction. Objective: To evaluate cases of rhinoplasty and its subtypes in a referral center, and to understand the relevance of teaching rhinoplasty techniques in a service of otolaryngology residency. Methods: A retrospective study that assessed 325 rhinoplasties performed by third-year medical residents under the supervision of chief residents in charge of the Service of Facial Plastic Surgery in this hospital was conducted from January of 2003 to August of 2012. The Service Protocol included the following subtypes: functional, esthetic, post-traumatic, revision, and reconstructive rhinoseptoplasty. Results: Of the rhinoplasties performed 184 (56.21%) were functional, 59 (18.15%) were post-traumatic, 27 were (8.30%) esthetic, 15 were (4.61%) reconstructive, and 40 (12.30%) were revision procedures. Conclusion: Functional rhinoseptoplasties were the most prevalent type, which highlights the relevance of teaching surgical techniques, not only for septoplasty, but also the inclusion of rhinoplasty techniques in teaching centers. .

Introdução: A cirurgia estética e reconstrutora têm por objetivo a utilizacão de procedimentos cirúrgicos para alcancar melhora estética e funcional. Pode ser utilizada para lesões traumáticas, congénitas ou de desenvolvimento. A Medicina, com ênfase na plástica facial, obteve avancos nas mais diversas áreas, inclusive na rinoplastia, permitindo bons resultados a longo prazo e maior satisfacão dos pacientes. Objetivo: Avaliar a casuística do setor de rinoplastia e suas subdivisões em um centro de referência. Compreender a relevância do ensino das técnicas de rinoplastia em um servico de residência médica de otorrinolaringologia. Método: Estudo retrospectivo onde foram analisados 325 rinoplastias, realizadas por médicos residentes do terceiro ano com supervisão dos preceptores responsáveis pelo servico de Cirurgia Plástica da Face desse hospital, no período de janeiro de 2003 a agosto de 2012. O protocolo do serviço foi preenchido com enfoque nas seguintes subdivisões: rinosseptoplastia funcional, estética, pós-traumática, revisional e reconstrutora. Resultados: Das rinoplastias realizadas, 184 (56,21%) foram funcionais, 59 (18,15%) póstraumáticas, 27 (8,30%) estéticas, 15 (4,61%) reconstrutoras e 40 (12,30%) revisionais. Conclusão: As rinosseptoplastias funcionais foram as mais prevalentes, o que mostra a importância do ensino, não somente das técnicas de septoplastias, mas também, da inclusão do aprendizado de técnicas de rinoplastias em centros de ensino. .

A new classification of spreader flap techniques.

The objective of this study was to introduce various spreader flap technique modifications to adjust the width of the middle nasal vault in patients who underwent rhinoplasties with humpectomy. Decisive modifications of current spreader flap techniques were performed to allow a more natural restoration of the middle nasal vault and the internal nasal valve after humpectomy. Additional steps provide tools to adjust the width and shape of the middle nasal vault according to patients' requirements. The techniques were categorized into "basic spreader flaps," "flaring spreader flaps," "support spreader flaps," and "interrupted spreader flaps." The various spreader flap techniques were used during 576 primary septorhinoplasties in patients with hump noses, hump/crooked noses, or hump/tension noses. The average follow-up was 19 months. Patients who received basic spreader flaps or a flaring spreader flaps tended to show a slightly too wide middle nasal vault, revision surgery was necessary in four of these cases. All other patients showed an appropriate width in the middle nasal vault and an aesthetically pleasing course of the dorsal aesthetic lines. No signs of inverted v deformities or collapse of the internal nasal valve were observed in any of the patients. Patients who had reported impaired nasal breathing preoperatively described clearly improved subjective symptoms. The described techniques appear to be appropriate and highly promising as a supplement to existing procedures for reconstructing the middle nasal vault and internal nasal valves. No additional cartilage grafts are needed.

New classification for correction of alar retraction using the alar spreader graft.

BACKGROUND: Identifying the cause of alar retraction is essential for proper correction of this deformity. In secondary surgery, aimed primarily at cephalic orientation and medialization of the lateral crus, corrections involving spreading and lateralization of the lateral crus can achieve a more horizontal orientation. In their clinic, the authors have practiced the use of an alar spreader graft to support the spread of the lateral crus. For the lateral crus to move freely without any resistance, it is critical to release the nasal hinge and pyriform ligament. A frontal view of the alar notching and the direction of the lateral crus are highly important factors needed to determine the cause of alar retraction. This report describes a new classification system for alar retractions viewed from the front to aid in determining the cause of the retraction and the surgical management. METHODS: From March 2008 to July 2010, 31 alar retractions were corrected using alar spreader grafts for patients showing clear alar retractions in frontal views. RESULTS: Satisfactory results without severe complications were obtained in 30 cases, with undercorrection in only 1 case. The alar cartilage was completely released to facilitate lateralization and caudal mobilization. An alar spreader graft then was used to support the lateral crus until a biologic scar cast was formed. CONCLUSION: The use of alar spreader grafts to correct alar retractions provided consistently good results. The attempt also was made to enhance the treatment strategy based on this classification system derived from frontal views of alar retraction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266 .

An analysis of 101 primary cosmetic rhinoplasties.

PURPOSE: Primary cosmetic rhinoplasty is one of the most complex of cosmetic surgical procedures in the maxillofacial area that requires precise consideration to both form and function. The complex and variable anatomy, highly visible position of the nose, and distinct patient desires contribute to the complexity of this procedure. This study reports the combined results of 101 consecutive primary cosmetic rhinoplasties at 2 centers. PATIENTS AND METHODS: A retrospective chart review was completed on all patients who had primary cosmetic rhinoplasty with or without septoplasty and who were operated on by the senior authors (S.C.B. and H.M.) from June 2006 through December 2008. A standard physical examination, including photo documentation, was completed on each patient preoperatively. All patients were followed periodically after surgery for at least 12 months. Outcome was measured by both subjective and objective measures of cosmetic and functional (breathing) outcome. The following data were collected and analyzed: age of patient, gender, chief cosmetic and functional complaint, details of surgical procedure (including septoplasty, grafts, and donor sites), complications, and report of subjective outcome at final evaluation. RESULTS: One hundred one patients (n = 101, average age 24.4 ± 6.8 years old) were enrolled in the study. Most patients presented for consultation regarding cosmetic rhinoplasty (80%) versus septorhinoplasty (20%). Although most of the patients (63%) were treated with septorhinoplasty, the open rhinoplasty (transcollumellar) incision was used in 61% of patients versus the closed rhinoplasty (39%) technique. The most commonly performed combination of techniques used was the combination of nasal tip modification, with dorsal reduction and nasal osetotomies (54%), followed by tip modification with dorsal reduction (19%), and dorsal reduction with osteotomies (18%) and no tip modification. In the 50 patients who required a graft, in 80% the donor site was the nasal septum. Spreader grafts were used in 14% of patients, and a combination of shield/tip graft was used in 52%. The following complications were observed: unhappy patient 16%, dehiscence at incision 5%, asymmetry requiring revision 6%, and infection 1%. In the 63 patients that had septoplasty, 6 (9.5%) reported that their breathing was not improved. In this series 11 patients (11%) received a revision rhinoplasty. CONCLUSIONS: Primary cosmetic rhinoplasty is 1 of the more complex facial cosmetic procedures. The vast majority of complications can be avoided with careful and extensive treatment planning. In this series we found a complication and revision rate similar to that reported in the literature.

The importance of the nasal septum in the deviated nose.

The nasal septum plays an important role in both the appearance and function of the nose. Deviation of the nose is common and correction requires a focused, anatomically based treatment. Reconstruction and support of the septum is a necessary component to a straight nose. The "four R's" of nasal septal repair--resection, reposition, reconstruction, and replacement--can be used to straighten the septum and maximize nasal appearance and function.

Nasal base reduction: a treatment algorithm including alar release with medialization.

BACKGROUND: The broad nasal base is occasionally not correctable by excisional procedures alone because nostril distortion or stenosis may result (if resection enters the vestibule). Moreover, recurrence is a common problem when alar mobilization and suture approximation techniques are used. The authors developed an algorithm for nasal base reduction to prevent these complications. METHODS: A new classification of the broad nasal base was utilized that included patients with general nasal base enlargement and patients with a vertically oriented alar axis (traditionally difficult to correct without distortion). Both groups received an alar release including the following: (1) the soft tissues and pyriform ligament of the anterior maxilla; (2) the periosteum posterior to the pyriform rim (in the bony nasal vault); and (3) when necessary, soft tissues along the horizontal pyriform rim. Interalar sutures maintained the alae in their new medialized position. Twelve patients who only underwent alar release were evaluated. RESULTS: Nasal base reduction was achieved in all cases without distortion. Three patients required release of the horizontal tissues of the pyriform rim (including a condensation of the pyriform ligament). After a follow-up period of 11 months to 3(3/4) years, there were two cases of partial recurrence and one partial airway obstruction. CONCLUSIONS: Not all causes of a broad nasal base are amenable to resection procedures, especially the generally broad nasal base such as that due to thick skin or a vertically oriented alar axis. However, a tension-free alar release with medialization by suture fixation is effective. The incidence of recurrence can be expected to be reduced.

Closed-open rhinoplasty with extended lip dissection: a new concept and classification of rhinoplasty.

BACKGROUND: Open rhinoplasty represents a surgical technique that has increased in popularity during the past several decades. However, to achieve full access to the entire nasal framework, a transcolumellar incision is required. In this study, the authors present the results of a rhinoplasty technique avoiding the transcolumellar incision while offering full access to the entire osteocartilaginous framework. METHODS: Twenty-four patients (17 women and seven men) with a mean age of 28.7 years (range, 21 to 49 years) were the subjects of this study. Four patients underwent secondary rhinoplasty and 20 patients underwent primary rhinoplasty. The surgical procedure comprises an alar base resection incision with thorough undermining of the anatomical area between the nasal base and the upper lip, allowing nondistorted access to the entire osteocartilaginous framework and performance of all standard rhinoplasty techniques. A transcolumellar incision is not performed. The minimum follow-up period was 12 months. RESULTS: All 24 patients expressed a high degree of satisfaction with the surgical result achieved. Postoperative swelling and initial lip dysesthesia resolved in all cases within the first 6 weeks without any morphologic or functional sequelae. Considering different rhinoplasty approaches, a classification of the existing surgical procedures is proposed. CONCLUSIONS: The authors believe the rhinoplasty technique presented in this article is a combination of closed and open approaches. It offers excellent access to the entire osteocartilaginous framework, while preserving the columella. The proposed rhinoplasty classification may simplify and aid the surgeon in deciding among the different rhinoplasty techniques.

[Guidelines for the clinical practice: aesthetic and functional rhinoplasty]. / Recommandations pour la pratique clinique: rhinoplastie esthétique et fonctionnelle.

A multidisciplinary working group of experts met in 2006 in order to establish a list of recommendations concerning the aesthetic and functional rhinoplasties. These experts tried to answer various practical problems while relying, on one hand, on a critical analysis of the literature, and on the other hand, on a consensus within the group. Six topics were approached. The management of the preoperative consultation, the surgical environment, the contra-indications, the materials used, the management of the post operative period, some particular pathological situations. This collective reflexion thus did not relate to the surgical techniques but to the methodology of treatment of patients who are candidates for rhinoplasty. It comes out clearly from this collective work that surgical indication can only be addressed after having clarified all the technical and psychological aspects. The use of computer graphics is recommended. Cartilage autograft are recommended as a priority.

Frequently used grafts in rhinoplasty: nomenclature and analysis.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Accurately name the most frequently used grafts in primary and secondary rhinoplasty. 2. Describe the precise anatomical position of each graft. 3. Discuss the clinical indications of each graft. SUMMARY: In this article, the authors present the grafting techniques most commonly used to sculpt the nasal framework in primary and secondary rhinoplasty. The grafts are described in terms of their nomenclature, anatomical location, and clinical indications, presenting a simple and easy-to-reference guide for both beginners and expert surgeons.

Considerations in ethnic rhinoplasty.

Although it is difficult to define specific ethnic groups as they are multiracial mixtures determined by historical, geographical, and cultural factors, we can define basically five non-Caucasian groups that commonly request rhinoplasty. The specific anatomy, surgical options, implant material, grafts, and possible complications are discussed. The importance of blending the "new" nose with the ethnic features to achieve harmony in the facial aesthetic components is emphasized.