Developing the Optimal Osteotome Hand-Sharpening Method.

Background: Rhinoplasty osteotomes can be sharpened in various ways: professional sharpening or hand sharpening using whetstones or rotary powered devices. Objective: To compare the effectiveness of sharpening osteotomes using various sharpening methods with that of professional sharpening as measured by a custom edge tester. Materials and Methods: We performed repeated serial osteotome impacts on bovine femoral cortical bone. These dull osteotomes were sharpened using preidentified sharpening techniques. Edge morphology was evaluated. Sharpness was tested using a custom mechanical testing platform. Optimized sharpness was achieved with a whetstone sharpening method wherein the osteotome is flipped after every stroke. Results: Seven distinct sharpening methods were tested for sharpness five times each to determine the optimal sharpening method versus professional sharpening (control). The two sharpening methods, 5 (5.51 ± 0.32) and 6 (5.55 ± 0.32), that used this flipping technique were significantly sharper than other methods. Methods 5 (p = 1.0) and 6 (p = 1.0) were the only methods that were not significantly different from control. Conclusion: Single stroke with successively alternating surfaces created the sharpest blades that achieved results similar to professional sharpening.

Management of the Nasal Valve.

The nasal valve is an important consideration in patients presenting with nasal obstruction. Controversy exists regarding the anatomy, terminology, evaluation, and management of the nasal valve. Innumerable techniques with variable effects have been described in the literature. The evidence qualifying these techniques has been plentiful, though often lacking in quality. This article reviews the controversial aspects of nasal valve management applying the best available evidence to help clarify potential areas of confusion. Future research using standardized definitions, consistent methodologies, and validated outcome measures are necessary to improve the quality of evidence and impact surgical decision-making.

Complications associated with alloplastic implants in rhinoplasty.

OBJECTIVE: To evaluate the incidence of infection and extrusion of porous high-density polyethylene (pHDPE) and expanded polytetrafluoroethylene (ePTFE) implants used in rhinoplasty at a high-volume, academic facial plastic surgery practice. METHODS: A total of 662 rhinoplasty procedures performed by 3 faculty surgeons from 1999 to 2008 were retrospectively reviewed. Patient demographics, medical comorbidities, operative details, and postoperative course findings were collected from patient records. RESULTS: The incidence of postoperative infection was 2.8% (19 of 662 patients). In each case of infection, alloplastic material had been used. Infections occurred in 1 in 5 rhinoplasty procedures in which pHDPE implants were used. In patients in whom ePTFE was used alone, the infection rate was 5.3%. Exposure developed in 12% of patients in whom an alloplast was used during surgery. Factors notably not associated with infection on bivariate analysis included sex, surgeon, purpose of procedure (functional vs cosmetic), current tobacco use, or history of cocaine use (P > .05 for all). CONCLUSIONS: To our knowledge, this study represents the largest evaluation of the use of pHDPE implants in rhinoplasty to date. Our findings are in contrast to those of previous studies regarding the use of pHDPE in rhinoplasty and parallel to those regarding the use of ePTFE. Caution is strongly recommended when considering the use of pHDPE in rhinoplasty.

Correction of internal nasal valve stenosis: a single surgeon comparison of butterfly versus traditional spreader grafts.

Nasal obstruction due to internal nasal valve (INV) collapse is relatively common. This article evaluates 2 different methods repairing the INV.Our subject population is a single-surgeon group of 82 patients who underwent a septorhinoplasty for nasal airway obstruction. Patients received either a spreader graft or butterfly graft. There are 30 patients who received spreader grafts and 52 patients who received a butterfly graft. All patients had a minimum of 3 months follow-up. All patients were evaluated with standardized questionnaire. Participants were asked to evaluate improvement in their nasal airway on an analog scale of 1 to 5. Participants were also asked to comment on changes in pre and postoperative snoring and sleep habits. Lastly, participants were queried regarding the ear cartilage harvest and if this bothered them.Patients undergoing both procedures demonstrated an overall improvement in their nasal breathing. Significant differences in improvement were observed for patients in the categories of postoperative snoring, sleep, and continuous positive airway pressure use. Patients were not bothered by the ear cartilage harvest.In select patients, the butterfly graft is a useful solution for INV collapse correction.

The total nasal defect and reconstruction.

The structures of the nose are arguably the most complex within the face to reconstitute when absent. Total nasal reconstruction has evolved to encompass advanced surgical techniques in an effort to achieve increasingly satisfactory cosmetic results while restoring nasal function that mimics the function of a patient's natural nose. In this article, the history of total nasal defects and their reconstruction, relevant nasal anatomy, etiologies of the defect, and the surgical approaches to reconstructing each of the three-layered structure of the nose (ie, nasal skin, cartilage/bone, and lining mucosa) are explored.

Conchal cartilage butterfly graft in primary functional rhinoplasty.

OBJECTIVE: To validate the use of the conchal cartilage butterfly graft in primary functional rhinoplasty and to review our experience using this technique. STUDY DESIGN: A retrospective analysis of patients who underwent conchal cartilage butterfly graft reconstruction of the nasal valve in primary rhinoplasty. METHOD: A retrospective analysis using patient questionnaires was performed. Data were collected to determine patient satisfaction about nasal breathing and cosmesis after the procedure. RESULTS: Among the patients, 90% (n = 90) had improved breathing, 88% (n = 88) were satisfied with their postoperative cosmesis, and 89% said they would recommend the procedure to a friend who had similar preoperative symptoms. CONCLUSION: Conchal cartilage butterfly graft has now been shown to be successful in primary functional rhinoplasty, just as it has previously been proven effective in secondary rhinoplasty. Although we have had success with many techniques for the correction of internal nasal valve collapse, we have found the conchal cartilage butterfly graft to be another outstanding technique for the appropriately selected patient.

Facial resurfacing with coblation technology.

OBJECTIVE: To describe our experience with coblation technology for facial resurfacing METHODS: Retrospective chart review of all patients treated with coblation at our institution RESULTS: Twenty-four patients (22 female) underwent a total of 29 coblation procedures for aging face (n = 21) or acne scarring (n = 3). The perioral region was the most frequently treated aesthetic subunit (n = 14), followed by the lower eyelid (n = 7). Five patients underwent full-face coblation. Three patients underwent a second coblation procedure for aging face while a single patient with severe acne scarring underwent 3 procedures. Repeat coblation was delayed at least 5 months (mean, 9 months). Seventeen coblation procedures (59%) were performed concurrently with procedures including, but not limited to, injection treatment, rhinoplasty, blepharoplasty, or combined face/necklift; no adverse events occurred. Seven procedures, including a full-face coblation, were performed in the office under local anesthesia and oral sedation without any adverse events. Mean follow-up was 6 months (range, 1 week to 24 months). No complications were observed. All patients were satisfied with the results after their final coblation treatment. CONCLUSIONS: Facial coblation is a safe and effective treatment modality for facial resurfacing.

Direct submentoplasty for neck rejuvenation.

Facial plastic surgeons commonly see patients with submental laxity and an excess of skin and fat in the upper neck. This has colloquially been called the "turkey gobbler" deformity. In some cases, this deformity is the patient's only aesthetic concern, and full face-lift surgery is not desired. In this study, we reviewed the English-language peer-reviewed literature for descriptions of direct excisional submentoplasty techniques. Various designs for skin excision and wound closure have been used by surgeons over the past several decades. This article summarizes the surgical technique as well as the advantages and disadvantages of each method. Furthermore, we propose an approach that incorporates many of the other designs but to our knowledge has not been described previously in the peer-reviewed literature. An understanding of these numerous approaches will better enable facial plastic surgeons to appropriately address and correct patient aesthetic concerns.

The utility of concurrent rhinoplasty and sinus surgery: a 2-team approach.

OBJECTIVE: To evaluate the safety and efficiency of and patient satisfaction with a 2-team approach for combined rhinoplasty and sinus surgery. METHODS: We conducted a retrospective medical chart analysis of consecutive patients with sinus disease and functional nasal obstruction. Forty-four patients (29 women and 15 men; age range, 22-75 years) had severe nasal obstruction with chronic sinusitis and were found to have indications for this procedure. All patients were followed up for a minimum of 6 months after surgery. Patients completed a standardized questionnaire at the time of medical chart review, and 36 patients completed a telephone interview. RESULTS: All 44 patients underwent rhinoplasty with an endoscopic sinus procedure. Twenty-seven procedures (61%) were endonasal, whereas 17 (39%) were open rhinoplasty. Patients with internal nasal valve collapse underwent 28 butterfly grafts, 6 spreader grafts, and 8 batten grafts. The endoscopic sinus procedures consisted of maxillary antrostomy (30/44 [68%]) and ethmoidectomy (28/44 [63%]). Overall, 20 (65%) of 31 patients reported a postsurgical nasal airway that was significantly improved. Most sinus symptoms were resolved postoperatively, with 25 (71%) of 35 patients describing their improvement as significant. Thirty-two (92%) of 36 patients stated that they would recommend the concurrent procedure. CONCLUSION: Patients presenting with nasal obstruction and chronic sinusitis tolerated combined rhinoplasty and sinus procedures without added morbidity.

The effect on snoring of structural nasal valve dilatation with a butterfly graft.

OBJECTIVE: To evaluate the effect on snoring of structural nasal valve dilatation with butterfly spreader grafts in patients with nasal valve insufficiency. DESIGN: Retrospective medical chart review and telephone follow-up; mean +/- SD follow-up time, 20.7 +/- 11.34 months (range, 3-48 months). SETTINGS: Tertiary care referral center. SUBJECTS: A total of 37 snoring patients with nasal valve insufficiency who underwent nasal valve dilatation with a butterfly spreader graft. INTERVENTIONS: The conchal cartilage butterfly graft technique was performed during rhinoplasty through either an external or endonasal approach. MAIN OUTCOME MEASURE: To establish through a retrospective review that butterfly graft conchal cartilage nasal reconstruction is effective in reducing snoring. RESULTS: After surgery, 30 patients (81%) had significant improvement in breathing, 5 (14%) had slight improvement, and 2 (5%) had no benefit in breathing. Snoring stopped completely in 11 (30%) of the patients after surgery. The improvement in snoring was significant in 13 patients (35%) and slight in 3 (8%). Twenty-six patients (70%) reported tiredness and grogginess on awakening before the surgery. Surgery significantly improved patients' tiredness and grogginess on awakening in 15 cases (58%), slightly improved them in 5 (19%), and did not change the patients' tiredness and grogginess in 6 cases (23%). CONCLUSION: The conchal cartilage butterfly graft yields successful results not only in breathing but also in snoring symptoms in patients with nasal valve insufficiency.

Irradiated homograft rib cartilage in facial reconstruction.

OBJECTIVE: To evaluate long-term structural, functional, and cosmetic results as well as resorption with the use of irradiated homologous rib cartilage grafts (IHRGs). DESIGN: Cases in which IHRGs were used were reviewed for a long-term follow-up study for nasal and auricular reconstruction, dating back 18 years. A retrospective medical chart review was conducted in the cases in which the patients had returned for clinical examination with photographic documentation. RESULTS: A total of 118 patients who had undergone nasal reconstruction with a mean follow-up of 36 months were identified from our database. There were 12 patients who had undergone auricular reconstruction, with a mean follow-up of 82 months. Resorption with compromise in cosmesis was noted in 11% (11/102) of the grafts used in nasal reconstruction but in 71% (5/7) of those used in auricular reconstruction. Minor resorption without change in form or function was found in 29% (30/102) of the cases. Loss of support, which was related more to graft displacement rather than resorption, was identified in 19% (21/109) of the cases, and loss of support affecting cosmesis was observed in 8% (9/109) of the cases. Maintenance of form and function appeared to be unrelated to the amount of resorption noted for the nasal grafts but was significant for the auricular grafts (P < .01). CONCLUSIONS: The longevity of IHRGs has been favorable for functional, structural, and cosmetic nasal reconstruction, with low levels of resorption identified clinically. The use of IHRGs was associated with an unacceptable rate of graft failure in auricular reconstruction; therefore, they are no longer selected for use in such cases.

Self-induced nasal ulceration.

BACKGROUND: Nasal ulcerations have many causes. Ulcerations that are self-induced are difficult to diagnose and treat. Two rare conditions with self-induced nasal ulceration are trigeminal trophic syndrome (TTS) and factitious disorder (FD). Trigeminal trophic syndrome is characterized by trigeminal anesthesia, nasal alar ulceration, and facial paresthesia. Appearance of the nasal ulcer after trigeminal ablation for neuralgia is diagnostic. Self-induced nasal lesions that occur in FD are primarily distinguished from those in TTS by the presence of normal trigeminal nerve function and frequent patient denial of lesion manipulation. OBJECTIVES: To increase physician awareness of the disorders leading to self-induced nasal ulceration and to discuss management issues in our patient series. DESIGN: A retrospective review of 7 cases in which the patients presented for reconstructive consultation between March 1985 and October 1997 and were found to have self-induced nasal ulcerations. SETTING: Tertiary university medical center. RESULTS: Five patients were identified with TTS and underwent nasal reconstruction an average of 43 months (range, 4-72 months) after nasal ulcer presentation. Four of the 5 patients developed ulcer recurrence between 1 and 58 months after reconstruction; secondary reconstruction resulted in recurrence in 2 of these patients. Two patients were identified with FD and self-induced nasal ulceration. One of these 2 patients underwent total nasal reconstruction 15 months after ulcer occurrence and developed recurrence 2 weeks after surgery. CONCLUSIONS: Self-induced nasal ulceration remains a difficult condition to diagnose and treat. Readily treatable conditions should be excluded, and diagnostic workup should include tissue biopsy and laboratory studies. Patients with TTS may have associated ocular findings, and those who do should be referred for ophthalmologic consultation. Surgical reconstruction can be considered in the highly motivated patient with TTS; however, delayed ulcer recurrence is common. Patients with FD should be treated primarily with local wound care and referred for psychiatric intervention. We strongly recommend nasal prosthetic devices as the primary means of aesthetic correction and discourage surgical repair in the patient with FD.

Total nasal reconstruction: utility of the free radial forearm fascial flap.

BACKGROUND: Total nasal defects present daunting challenges to the reconstructive surgeon. The nasal skeleton can be successfully fabricated with bone and cartilage. Reconstruction of the nasal skin with a forehead flap produces an excellent color match for nasal skin. Resurfacing of the internal lining is the most difficult of the 3 layers. Local tissue is often unsatisfactory in amount and/or vascular supply. METHODS: A patient requiring total nasal reconstruction was prospectively examined. Intraoperative technique was recorded, and postoperative function was determined. RESULTS: A paramedian forehead flap was used to resurface the external defect. Split calvarium and conchal cartilage were used to reconstruct the nasal skeleton. A fascial flap harvested from the forearm was used to replace the intranasal lining. Turbinate grafts were placed to line the flap. Postoperative breathing was excellent. CONCLUSIONS: The intranasal portion of a total nasal defect can be successfully reconstructed with a fascial forearm flap. Placement of a turbinate or mucosal graft allows for a thin mucosalized lining with an excellent functional outcome.

Evaluation of pericranial skull adherence during healing in the rabbit model.

BACKGROUND: The endoscopic brow-lift is a popular technique for rejuvenation of the aging brow and forehead. Long-lasting results depend on readherence of the pericranium to the underlying skull in the newly elevated position. Determination of the time required for pericranial readherence to occur is important when considering optimal brow fixation time postoperatively; however, few studies of pericranial healing exist in the literature. OBJECTIVE: To quantify the time required for pericranial adherence after pericranial elevation in a rabbit model. DESIGN: Anesthetized New Zealand white rabbits underwent elevation of a pericranial flap on day 0. The flap was then repositioned and the skin sutured. One unoperated-on group served as a control. A tensiometer was used to measure the force required to separate the pericranial flap from the skull of the control animals and of test animals killed on postoperative days 3, 5, 8, 10, 13, 17, 20, 25, and 28. Statistical analysis was performed to determine the effect of healing time on the strength of pericranial readherence. RESULTS: There was a statistically significant decrease in the force required for pericranial separation at 3 and 5 days after surgery compared with the control group. By 8 days postoperatively and throughout the subsequent times examined, no statistically significant differences from the control group were observed. CONCLUSION: In this rabbit model, pericranial adherence (as measured by tensile strength) is decreased postoperatively and does not return to baseline levels until postoperative day 8.

The 'butterfly' graft in functional secondary rhinoplasty.

OBJECTIVE: To describe a surgical technique (the conchal cartilage "butterfly" graft) which, when used in properly selected patients, has been found to be a dependable method for alleviation of postrhinoplasty internal nasal valve dysfunction. STUDY DESIGN: Retrospective chart review. METHODS: Analysis of consecutive patients with weakness and/or collapse of the upper lateral cartilages following rhinoplasty. Seventy-two patients (37 women and 35 men, age range 17-76 y) had severe nasal obstruction and were found to have indications for this procedure. All patients had undergone at least one rhinoplastic procedure. All patients were followed for a minimum of 2 years after surgery. RESULTS: All 72 patients experienced significant subjective improvement in relative nasal obstruction. Two patients (3%) reported less than total resolution of their difficulty breathing through their nose; the remaining 70 patients (97%) reported complete resolution of their nasal airway problems. No patients reported their postoperative nasal obstruction as the same or worse than their preoperative baseline. Sixty-two patients (86%) reported improvement in the appearance of their nose, 8 patients (11%) felt that their appearance was unchanged, and 2 patients (3%) felt that the appearance of their nose was made worse by the procedure. CONCLUSIONS: Patients presenting with nasal obstruction after rhinoplasty are frequently found to have collapse and/or weakening of their upper lateral cartilages with resulting nasal valve dysfunction. The conchal cartilage "butterfly" graft is a technique which, when properly performed during revision rhinoplasty, yields predictable functional and cosmetic results with minimal morbidity.

Immediate reconstruction of extruded alloplastic nasal implants with irradiated homograft costal cartilage.

OBJECTIVE: To describe a novel surgical protocol for the management of patients presenting with extruded nasal implants. STUDY DESIGN: Retrospective chart review. METHODS: Analysis of consecutive patients presenting with extruded nasal implants from 1986 to 2000. Patients were selected from a large database of revision rhinoplasty cases. Inclusion criteria were: 1) at least one previous rhinoplasty procedure, 2) an extruded nasal implant that was documented preoperatively, 3) immediate reconstruction that was carried out with irradiated homograft costal cartilage (IHCC), and 4) at least 1 year of follow-up recorded, including standard postoperative rhinoplasty photographs. A total of 18 patients met the inclusion criteria and form the basis of this study. Data gathered from the charts included date of surgery, last date of follow-up, location of implant extrusion, alloplastic material, specific use of IHCC for reconstruction, percent of clinical IHCC resorption at last follow-up, and presence of warping of the IHCC. RESULTS: All 18 patients were satisfied with the cosmetic outcomes of their nasal reconstructions. The most common extruded alloplast was Silastic, followed by Gore-Tex (W.L. Gore & Associates, Inc., Flagstaff, AZ). There were no cases of extrusion or infection of the IHCC implant subsequent to immediate reconstruction of the extruded alloplast. Clinical resorption of the IHCC was minimal, with a mean follow-up of 26 months. Only one patient had a complication, warpage, resulting in removal of the IHCC. In that patient, the IHCC still had carving markings on the implant after 2 years in vivo. CONCLUSIONS: In this series of patients, a novel surgical protocol was used. The extruded implant was removed and immediate reconstruction with irradiated rib cartilage was done. All patients were evaluated for postoperative infection, graft extrusion, and satisfaction with cosmetic result. There was one major complication in this series of 18 patients, warping of the IHCC, which necessitated removal and replacement. This approach appears to be a reasonable method for reconstruction of extruded nasal alloplasts.