Doxycycline Sclerodesis-"Rhinodesis"-for Enhanced Soft Tissue Adhesion in Rhinoplasty: A Preliminary Study.

The use of doxycycline as a sclerosing agent is well-established. Given the clinical efficacy of doxycycline sclerosant therapy, we embarked upon a study to evaluate the efficacy of small-volume liquified doxycycline particularly in thick skinned rhinoplasty patients to promote re-adhesion of the nasal skin-soft tissue envelope (SSTE) thereby minimizing surgical dead space and enhancing surface contour, to improve the eventual outcome of surgery.We present two clinical case series using rhinodesis. All patients were treated with the same rhinodesis protocol that included conventional splinting and taping. The first series consisted of 102 consecutive primary rhinoplasties with medium to thick nasal skin treated via open rhinoplasty. Doxycycline solution at a concentration of 20 mg/mL was applied beneath the skin flap using a 14-gauge angiocath inserted through small gaps in the marginal suture line following closure, retained for 2 to 3 minutes, and then expressed from the dead space. Firm manual compression of the SSTE was maintained for at least 1 additional minute, and the splint was then applied. The second series consisted of 25 thick-skinned primary rhinoplasties that were also treated with open rhinoplasty using the same rhinodesis protocol. However, the second group was evaluated with serial postoperative ultrasonography to characterize the soft-tissue response to rhinodesis, particularly within the tip and supra-tip regions.Results revealed enhanced skin adherence in nearly all patients when compared to traditional taping and splinting alone. Ultrasonic examination demonstrated enhanced adherence of the subcutaneous tissue to the nasal framework and suggests that rhinodesis is effective at minimizing dead space in majority of thick-skinned rhinoplasty patients. No complications were observed. Doxycycline can be used easily and safely to seal the surgical dead space post-rhinoplasty and minimize degradation of nasal contour with excellent outcome.

Advanced Preservation Rhinoplasty in the Era of Osteoplasty and Chondroplasty: How Have We Moved Beyond the Cottle Technique?

BACKGROUND: Over the last 10 years, many new papers on innovative strategies from different surgeons worldwide have elevated the philosophy of preservation rhinoplasty (PR) to a different level: advanced preservation rhinoplasty. OBJECTIVES: The goal of this article was to illustrate how 4 experienced surgeons approach important anatomical and functional issues related to PR. METHODS: M.G.F., A.M.K., B.S., and D.M.T. were asked about how they approach classical problems and relative contraindications for dorsal PR with different modern advanced preservation rhinoplasty techniques. RESULTS: The answers of each surgeon make clear a new reality in dorsal PR that did not exist in the recent past. These advances in dorsal PR techniques are due to many surgeons' contributions, leading this practice to a different level: advanced preservation rhinoplasty. CONCLUSIONS: Dorsal preservation is making a dramatic resurgence and is fueled by the many very talented surgeons who are demonstrating outstanding outcomes with preservation techniques. The authors believe that this trend will continue, and a mutual collaboration between structuralists and preservationists going forward will continue to advance rhinoplasty as a specialty.

Preservation Rhinoplasty: Open or Closed?

BACKGROUND: Preservation rhinoplasty (PR) is an evolving philosophy. OBJECTIVES: The open approach was initially utilized, but the author felt a closed approach might be of benefit in certain patients. METHODS: A total 162 primary rhinoplasty cases were studied retrospectively between May and November 2020. One hundred cases had at least 1 year of follow-up. Patients had follow-up at 1 week, 1 month, 3 months, and 1 year after surgery. Technical details were recorded, including dissection planes, preservation of the dorsum (DP) vs component reductions, surface vs foundational DP techniques, and open vs closed approach. RESULTS: One hundred patients had at least 1 year of follow-up. Fifty-six patients underwent an open approach and 44 a closed approach. Eighty-three patients had preservation of the dorsal soft tissue envelope. All patients who underwent a closed approach had preservation of the dorsal soft tissue envelope. Sixty-seven patients underwent DP, with 38 receiving surface techniques and 29 undergoing impaction techniques. Thirty-three patients underwent structural rhinoplasty with piezoelectric osteotomies and mid-vault reconstruction. All structural cases were performed employing an open approach. Four revision surgeries were necessary. CONCLUSIONS: Open and closed approaches have indications depending on the tip and dorsal deformities. A closed PR is favored with thin skin, minimal dorsal modification, osseocartilaginous preservation (foundation techniques), less complex tip deformities, and overprojected noses. An open PR is favored for extensive dorsal modification, S-shaped nasal bones, complex tip deformities, and tip augmentation. Structural dorsal rhinoplasty is always conducted open and preferred for complex dorsal deformities and severe septal deviations.

Structural Preservation Rhinoplasty: A Hybrid Approach.

SUMMARY: Structural preservation rhinoplasty merges two popular philosophies of rhinoplasty-structure rhinoplasty and preservation rhinoplasty-in an effort to maximize patient outcomes, aesthetics, and function. This allows the surgeon to both preserve the favorable attributes of the nose, and also to structure the nasal tip and dorsum with grafts to maximize contour and support. The concept of dorsal preservation is to preserve favorable dorsal aesthetic lines without the creation of an "open roof." However, the addition of some structure concepts can expand the utility of dorsal preservation in primary rhinoplasty patients. The authors discuss these structure concepts and their applicability to dorsal preservation.

Optimization of the Soft Tissue Envelope of the Nose in Rhinoplasty Utilizing Fat Transfer Combined with Platelet-Rich Fibrin.

A thin or damaged skin soft tissue envelope may cause concerns in primary and secondary rhinoplasty. During postoperative healing, unpredictable scarring and contraction may occur and lead to significant aesthetic and trophic sequelae. Besides a meticulous surgical technique, there are no reliable techniques to prevent long-term skin damage and shrinkage. Fat transfer with addition of platelet-rich fibrin (PRF) harbors the possibility of local soft tissue regeneration and skin rejuvenation through growth factors and mesenchymal stem cells. It may also facilitate the creation of a thin fat layer on the dorsum to prevent shrink-wrap forces and conceal small irregularities. The goal is to provide evidence for the feasibility, durability, and beneficial effect of diced macrofat transfer bonded with PRF on the nasal dorsum. We present the technique of fat transfer conjugated with PRF as a nasal dorsal graft. Clinical endpoints were the prevention of trophic disturbances and atrophy at a 1-year postoperative follow-up. We present the skin mobility test as a clinical indicator of a healthy soft tissue envelope. The presented case series consists of 107 rhinoplasties. Fat was harvested in the umbilical or costal region. PRF was created by centrifugation of autologous whole blood samples. Macrofat was diced, cleaned, and bonded with PRF. The compound transplants were transferred to the nasal dorsum. There were no perioperative complications or wound-healing issues. Mean follow-up was 14 months. Clinical inspection showed good skin quality and no signs of shrinkage, marked scarring, or color changes with positive skin mobility test in all patients. Survival of fat was confirmed by ultrasonography and magnetic resonance imaging. Diced macrofat transfer in conjunction with PRF to the nasal dorsum is a feasible and safe method. A beneficial effect on the soft tissue envelope is demonstrated as well as the prevention of shrink-wrap forces.

Incorporating Dorsal Preservation Rhinoplasty into Your Practice.

For rhinoplasty surgeons, surgery of the dorsum has never been so dynamic or as easily learned. Reproducible techniques offer excellent results that can be difficult to achieve in certain patients using component reduction. An expanding repertoire of dorsal preservation (DP) techniques is evolving. Each DP operation builds on the others. To understand DP requires a new appreciation of the cartilaginous septum, the perpendicular plate of ethmoid, nasal osteotomies, and anatomy of the nose where surgeons do not operate with traditional component reduction. The result is more beautiful noses where the normal anatomy is preserved.

Expanding Indications for Dorsal Preservation Rhinoplasty With Cartilage Conversion Techniques.

BACKGROUND: Preservation rhinoplasty (PR) is a new and evolving philosophy in rhinoplasty surgery. As a surgeon becomes more experienced with preservation concepts, he/she begins to look for new ways to apply PR to an increasing percentage of primary cases. OBJECTIVES: This article presents a series of 100 primary rhinoplasties that underwent dorsal preservation with an emphasis on the cartilage-only dorsal preservation. METHODS: A total of 226 primary rhinoplasty cases were studied retrospectively between July 2017 and August 2018. One hundred cases of dorsal preservation were included in the study. Data was collected in all cases regarding age, gender, ethnicity, and technical details of the operation. These 100 cases fall into the following 3 categories: (1) dorsal preservation employing a subdorsal strip; (2) dorsal preservation utilizing a cartilage-only pushdown with separate bony pyramid modification; and (3) dorsal preservation employing a cartilage reduction method with separate bony pyramid modification. RESULTS: Fifty-seven patients underwent subdorsal strip technique, 39 underwent cartilage-only pushdown technique, and 4 underwent cartilage modification. The average lowering was 4.5 mm (range, 2-10 mm), 2.5 mm (range, 1-3.5 mm), and 2 mm (range, 1-2.5 mm) for the subdorsal strip, cartilage-only pushdown techniques, and cartilage modification technique, respectively. No patients required revision surgery of their dorsum. CONCLUSIONS: PR is a paradigm shift in rhinoplasty. With time, surgeons will find themselves asking in every situation whether they can preserve structures. Dorsal preservation is a reliable technique if patients are chosen properly. With bony cap modification, more dorsums can be preserved and dorsal aesthetics can be improved.

Current Trends in Preservation Rhinoplasty.

Recently there has been a dramatic acceptance of the preservation principle in rhinoplasty surgery. Surgeons worldwide now preform preservation rhinoplasty, which has led to an expanding list of indications and techniques. Most rhinoplasty surgeons have accepted the fundamental principle that preservation is better than resection and that a natural result is superior to a fabricated or reconstructed structure, especially with regards to the nasal dorsum. Currently, the main emphasis is on defining the indications/contraindications, technical refinements, and minimizing complications. This paper provides an overview of the current trends in preservation rhinoplasty. In the 2 years following publication of the Editorial, "The Preservation Rhinoplasty: A New Rhinoplasty Revolution," 1 there has been a dramatic acceptance of the preservation principle. Numerous surgeons throughout the world are preforming preservation rhinoplasty, which has led to an expanding list of indications and techniques. The majority of rhinoplasty surgeons have accepted the fundamental principle that preservation is better than resection, and that a natural result is superior to a fabricated or reconstructed structure, especially as regards the nasal dorsum. Currently, the main emphasis is on defining the indications/contraindications, technical refinements, and minimizing complications. The present paper is an overview of the current trends in preservation rhinoplasty.

Decision Making in Preservation Rhinoplasty: A 100 Case Series With One-Year Follow-Up.

BACKGROUND: Preservation rhinoplasty (PR) is a new chapter in rhinoplasty history. The term was coined by Daniel in 2018 and represents a fundamental change in philosophy. OBJECTIVES: The aim of this study is to discuss a single-surgeon case series utilizing PR techniques. METHODS: One hundred fifty-three primary rhinoplasty cases were studied retrospectively between December 2016 and August 2017. One hundred cases had at least 1 year of follow-up. Technical details were recorded, including dissection plane, ligament preservation, tip support, lateral crural maneuvers, alar contour grafts, and preservation of the dorsum vs traditional reduction. These 100 cases can be categorized as either complete preservation rhinoplasty (PR-C) or partial preservation rhinoplasty (PR-P). RESULTS: All patients had open rhinoplasty and the average follow-up time was 13 months. All patients had preservation of the dorsal soft tissue envelope, and in 36 the entire soft tissue envelope and ligaments were preserved. Fifty-four had preservation of the alar cartilages. Thirty-one had dorsal preservation. The combinations include: PR-C (skin, dorsum, and alars): 24; PR-P (skin and dorsum): 2; PR-P (alars and dorsum): 2; and PR-P (skin and alars): 7. CONCLUSIONS: In most patients, the dorsal soft tissue envelope and nasal ligaments can be preserved. When possible, the lateral crura should be preserved and tensioning chosen over excision. Dorsal preservation is a versatile technique when proper patient selection is undertaken, and long-term issues with the middle vault and keystone area can be avoided. Some patients will benefit from total preservation where nothing is removed/disrupted and underlying structures are reshaped.Level of Evidence: 4.

Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery.

BACKGROUND: The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal skin and underlying soft tissue. OBJECTIVES: This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures. METHODS: Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi "skin pinch test" was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue. RESULTS: Patients determined to have thin, normal, and thick skin by the "skin pinch test" were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer. CONCLUSIONS: The "skin pinch test" is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively to treat patients with difficult soft tissue envelopes. LEVEL OF EVIDENCE 4.

Rhinoplasty: The Asymmetric Crooked Nose-An Overview.

There are three reasons why the asymmetric crooked nose is one of the greatest challenges in rhinoplasty surgery. First, the complexity of the problem is not appreciated by the patient nor understood by the surgeon. Patients often see the obvious deviation of the nose, but not the distinct differences between the right and left sides. Surgeons fail to understand and to emphasize to the patient that each component of the nose is asymmetric. Second, these deformities can be improved, but rarely made flawless. For this reason, patients are told that the result will be all "-er words," better, straighter, cuter, but no "t-words," there is no perfect nor straight. Most surgeons fail to realize that these cases represent asymmetric noses on asymmetric faces with the variable of ipsilateral and contralateral deviations. Third, these cases demand a wide range of sophisticated surgical techniques, some of which have a minimal margin of error. This article offers an in-depth look at analysis, preoperative planning, and surgical techniques available for dealing with the asymmetric crooked nose.