A Nasal Columellar Base Stabilizing Suture Technique.

SUMMARY: To achieve a more aesthetic and narrower columella, most of the required changes concern the middle and base of the columella. Narrowing and reshaping the columellar base require a sequential approach with good anatomical knowledge and aesthetics analysis. The columellar base is a three-dimensional structure that must be analyzed following three axes: transverse (thickness or width), frontal (height), and sagittal (nasolabial angle). Sutures that aim to close the distance between the medial crura footplates frequently result in modifying the nasolabial angle because of caudal protrusion of the columellar soft tissue. Methods to keep an adequate nasolabial angle are needed. A transverse columellar base stabilizing suture acting on these three axes, which enables maintenance of results after columellar base management, is described in this article.

A Systematic Analysis of the Nasal Septum in Crooked Noses and Suggested Treatment Algorithm According to Preservation Rhinoplasty (PR) Principles.

BACKGROUND: A deviated nose is a common problem among patients for both cosmetic and functional reasons. The correction remains a major challenge for the rhinoplasty surgeon. Unrecognized nasal septal deviations stand as the primary reason for failed rhinoplasty outcomes. There is a paucity of data in the literature about septoplasty classifications and technical details in preservation rhinoplasty (PR) for various crooked noses. MATERIALS AND METHODS: The aim of this article is to provide a comprehensive overview of the various septum deviations according to the nasal axis. Moreover, a treatment algorithm is suggested with technical details based on PR principles. RESULTS: The directions and curvature of the cartilaginous deviation of crooked nose such as C-shaped, reverse C-shaped, straight axis deviations (I-shaped), and S-shaped are described. According to the deviation, a septoplasty classification (Type 1-Type 4) is suggested. CONCLUSIONS: On the basis of septal deviation, different PR techniques are proposed to achieve the desired straight nasal dorsum with an optimal functional outcome. Compared to the classical L-strut concept, the quadrangular cartilage remains preserved in the swinging door technique. The cartilage might be further used in the future for grafting in the hybrid structural/preservation technique if needed, ultimately saving rib cartilage and/or conchal cartilage. Finally, surgery time is reduced, and patient's morbidity remains minimal. LEVEL OF EVIDENCE III: 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 .

Long-Term Follow-Up with Dorsal Preservation Rhinoplasty.

The rapid resurgence of interest in performance of dorsal preservation (DP) rhinoplasty techniques in recent years has come with scarcity of data for long-term outcomes. In this article, the authors aim to contribute to preservation rhinoplasty (PR) literature by providing long-term follow-up with dorsal preservation, specifically presenting data related to superior strip DP functional and esthetic complications, followed by a detailed analysis of the same.

Dorsal Preservation Surgery: A Novel Modification for Dorsal Shaping and Hump Reduction.

BACKGROUND: A new technique for dorsal preservation rhinoplasty that minimizes recurrent hump deformity is introduced. OBJECTIVES: The authors sought to present a novel dorsal roof flap (DRF) technique for modifying the nasal hump and dorsum while reducing morbidity. METHODS: Twenty-two primary and 3 secondary rhinoplasty patients had 1 of 2 types of nasal DRF depending on hump composition. A triangular roof flap was created utilizing 2 incisions from W-point to lateral Keystone junction in cartilaginous humps (cartilaginous DRF) and to the nasion in osseocartilaginous humps (osseocartilaginous DRF). Then, septal strip excisions were conducted to lower the profile followed by nasal base narrowing. The DRF was then lowered to the desired profile line, any excess lateral wall height trimmed, and the DRF sutured to the upper lateral cartilages. Preoperative and postoperative nasolabial and nasoglabellar angles were measured on the photos. RESULTS: Mean follow-up was 10.3 (standard deviation, 4.41) months (range, 6-20 months). A total 22 humps were V-shape and 3 were S-shape. The composition of the hump was cartilaginous in 5 cases, bone in 7 cases, and combined in 13 cases. A cartilaginous DRF was utilized for the 5 cases with a cartilaginous hump and osseocartilaginous DRF was employed in the other 20 cases. There were no complications observed in the follow-up period and thus no revisions. CONCLUSIONS: The DRF technique allows preservation of the nasal dorsum and elimination of the dorsal hump while minimizing hump recurrence.

Quality of Life (QoL) and Outcome After Preservation Rhinoplasty (PR) Using the Rhinoplasty Outcome Evaluation (ROE) Questionnaire-A Prospective Observational Single-Centre Study.

BACKGROUND: Rhinoplasty is a challenging procedure, and the ultimate goal is not only to restore the function and youthful appearance, but also to improve the quality of life (QoL). Little is known about the QoL after preservation rhinoplasty (PR). The aim of this study was to assess patient satisfaction after PR by using a validated questionnaire. PATIENTS AND METHODS: Patients undergoing primary PR were included in this prospective cohort single-centre (private) study. Overall, 58 patients (41 female and 17 male patients, mean age 32 ± 9.7 years) were operated on between 2017 and 2021. Patient assessment regarding their outcome was evaluated before surgery and at final follow-up using a validated questionnaire (Rhinoplasty Outcomes Evaluation Questionnaire = ROE). Subgroup analyses were performed between the ROE questions and radiological analysis by using the cone-beam computed tomography (CT) before surgery and at final follow-up. RESULTS: After a mean follow-up of 19.7 ± 7.9 months (range = 1-50 months), a high overall patient satisfaction was observed (37.9 ± 9.2 vs. 81.25 ± 14.17, p < 0.0001). Subgroup analysis showed the highest improvement in nose appearance, breathing, and self-confidence after surgery. The improvement of subjective breathing (1.471 ± 0.90 vs. 3.1 ± 0.88; p<0.0001) goes in line with an overall improved internal nasal valve (INV) angle (19.88° ± 3.3° vs. 22.04° ± 4.1°, p = 0.0231). CONCLUSIONS: Our study showed a high patient satisfaction after PR as evaluated by the ROE, which goes in line with aesthetics and function. 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 .

A multivariate analysis after preservation rhinoplasty (PR) - a prospective study.

BACKGROUND: Preservation rhinoplasty (PR) is considered to be an innovative approach with high patient satisfaction. However, little is known about its functional outcomes and radiological analyses. PATIENTS AND METHODS: In this prospective clinical study, 30 patients (20 female and 10 male patients, mean age 30.7 ±9.8 years) were operated on between 2017 and 2021. Radiological assessment was evaluated by cone beam computed tomography before surgery and at final follow-up. Patient assessment regarding their outcome was assessed at final follow-up using a validated questionnaire (rhinoplasty outcomes evaluation questionnaire = ROE). RESULTS: After a mean follow-up of 8.4 ± 5 months (range = 1 - 18 months), radiological analyses denoted an overall improved internal nasal valve (INV) angle after surgery (preoperative = 20.77° ± 3.2° vs. postoperative = 21.82° ± 5.7°, p = 0.18). Those results are in accordance with an overall high patient satisfaction for both function and aesthetics (ROE score 18.4 ± 4.3). CONCLUSION: Our study showed a preserved and widened INV angle after PR, along with high patient satisfaction. LEVEL OF EVIDENCE: III.

Botulinum toxin-induced blepharoptosis: Anatomy, etiology, prevention, and therapeutic options.

BACKGROUND: Botulinum toxin A (BoNT-A) has grown tremendously in aesthetic dermatology since 2002 when the United States Food and Drug Administration (FDA) first approved its use for treating moderate-to-severe glabellar lines. Blepharoptosis, due to local spread of toxin, is a reported side effect of BoNT-A which, although rare, more frequently occurs among inexperienced practitioners. OBJECTIVES: The purpose of this review is to highlight the causes and management of eyelid ptosis secondary to BoNT-A administration including new anatomic pathways for BoNT-A spread from the brow area to the levator palpebrae superioris muscle. METHODS: A literature search was conducted using electronic databases (PubMed, Science Direct, MEDLINE, Embase, CINAHL, EBSCO) regarding eyelid anatomy and the underlying pathogenesis, presentation, prevention, and treatment of eyelid ptosis secondary to BoNT-A. Anatomic dissection has been performed to assess the role of neurovascular pedicles and supraorbital foramen anatomic variations. RESULTS: Blepharoptosis occurs due to weakness of the levator palpebrae superioris muscle. Mean onset is 3-14 days after injection and eventually self-resolves after the paralytic effect of BoNT-A wanes. Administration of medications, such as oxymetazoline hydrochloride or apraclonidine hydrochloride eye drops, anticholinesterase agents, or transdermal BoNT-A injections to the pre-tarsal orbicularis, can at least partially reverse eyelid ptosis. Anatomic study shows that a supraorbital foramen may be present in some patients and constitutes a shortcut from the brow area directly into the orbital roof, following the supraorbital neurovascular pedicle. CONCLUSION: Providers should understand the anatomy and be aware of the causes and treatment for blepharoptosis when injecting BoNT-A for the reduction of facial wrinkles. Thorough anatomic knowledge of the supraorbital area and orbital roof is paramount to preventing incorrect injection into "danger zones," which increase the risk of eyelid ptosis.

Guidelines for Dorsum Preservation in Primary Rhinoplasty.

The multiplication of scientific articles related to the fast-growing interest in preservation rhinoplasty (PR) may lead to confusion in the decision-making process, thus requiring a need for guidelines through a focus on benefit-risk ratio and revisions. This study analyzes a 352 consecutive primary rhinoplasties series during a 3 year (2016 to 2019) period with 1-year follow-up. The evaluation of the most appropriate procedure to the patient's nasal anatomy and expectations requires to correlate (1) a convenient classification of nasal profile lines; (2) a review of the dorsum preservation techniques (DP) classified as: full DP, DP + resurfacing, bony cartilaginous disarticulation, and finally traditional rhinoplasty; (3) the role of septoplasties, subdividing this series in two main groups; (4) analyzing the revisions in the different subgroups and to the literature. Thirty-five revisions (9.94%) were done. Correlations between profile lines, surgical procedures, and revisions show (1) 129 straight noses underwent full DP in 88 cases with 5.68% revisions; however, DP+ hump resurfacing in 32 patients with no revision. (2) Among 71 tension noses, 33 underwent full DP with 6 revisions (18.18%), while 32 patients had bony cap resurfacing, 1 revision (3.13%). (3) Among 109 kyphotic noses, 64 patients underwent DP + resurfacing with 10 revisions (15.63%); 27 patients had cartilage-only DP with two revisions (7.41%). (4) In the 43 difficult noses group, revisions were done equally in DP + resurfacing and cartilage-only subgroups. Septum stability modifies the correlations, introducing Cottle's septorhinoplasty in the paradigm. The revision rate is jumping ×2.50% when a septoplasty is associated with the rhinoplasty. Correlated to the benefit-risk ratio and the revisions, the following guidelines may be suggested in primary rhinoplasty: (1) Straight noses: full DP, (2) tension noses: DP + dorsum resurfacing and/or Cottle's variations, (3) kyphotic noses: cartilage-only DP, and (4) difficult noses: traditional rhinoplasties.

Biomechanical Nasal Anatomy Applied to Open Preservation Rhinoplasty.

Preservation rhinoplasty is a new way to reshape the nose by preserving the dorsum, nasal ligaments, soft tissue envelope, and muscles. This new concept provides the opportunity to achieve a more natural aesthetic and functional result. To achieve a good aesthetic and functional outcome while maintaining surgical safety, knowledge of the relevant anatomy is key. This is especially true for the preservation rhinoplasty technique, where a firm grasp of the anatomy of the nasal soft tissue and bony-cartilaginous framework is critical. The preservation technique is made more accessible by the open approach, which provides an opportunity for the deformity to be clearly visualized from the tip of the nose and the dorsum. Furthermore, tip plasty is easier to perform under direct vision, which is an advantage of the open approach. The goal of this article is therefore to make clear all the important anatomical structures and their relevance to the surgical steps taken when performing the open preservation rhinoplasty technique.

Functional and Radiological Assessment After Preservation Rhinoplasty - A Clinical Study.

BACKGROUND/AIM: We hypothesized that improved functional outcome after preservation rhinoplasty can be validated by radiological analyses. PATIENTS AND METHODS: In this retrospective study, five patients were included. Radiological assessment was evaluated by cone-beam computed tomography. Patient satisfaction regarding nasal function was evaluated by a Likert scale from 0 to 10 (0=poor result; 10=very satisfied). RESULTS: After a mean follow-up of 5±1 months (range=4-6 months), significantly improved function was noted by all patients, with a mean Likert scale of 9.2±0.45 (preoperative score=2.8±0.8, p=0.0079). These results are in line with the radiological results, showing an improved internal nasal valve angle (preoperative=26.2°±1.8° vs. postoperative=32.3°±1.2°, p=0.02). CONCLUSION: Our study showed that besides nasal appearance, nasal function can also be dramatically improved after preservation rhinoplasty.

Dorsal Preservation Rhinoplasty: Core Beam Computed Tomography Analysis of the Nasal Vault, Septum, and Skull Base-Its Role in Surgical Planning.

Dorsal preservation rhinoplasty in cases of a convex or overprojected noses has significant advantages over resection and reconstruction of the dorsum. Analysis of the subdorsal septum in relation to the radix osteotomy to achieve a drop or hinge of the natural dorsum is important in avoiding possible complications involving the skull base, frontal sinus, and subsequent radix position. In the majority of patients, simple cut release of the perpendicular plate rather than resection superiorly may be necessary where the quadrangular cartilage junction with the perpendicular plate is caudal to the radix osteotomy. Computed tomography is helpful in delineating this position as well as providing information on the frontal sinus and position of the cribriform plate prerhinoplasty.

Regenerative potential of the Bichat fat pad determined by the quantification of multilineage differentiating stress enduring cells.

Published studies regarding Bichat fat pad focused, quite exclusively, on the implant of this adipose depot for different facial portions reconstruction. The regenerative components of Bichat fat pad were poorly investigated. The present study aimed to describe by an ultrastructural approach the Bichat fat pad, providing novel data at the ultrastructural and cellular level. This data sets improve the knowledge about the usefulness of the Bichat fat pad in regenerative and reconstructive surgery. Bichat fat pads were harvested form eight patients subjected to maxillofacial, dental and aesthetic surgeries. Biopsies were used for the isolation of mesenchymal cell compartment and for ultrastructural analysis. Respectively, Bichat fat pads were either digested and placed in culture for the characterization of mesenchymal stem cells (MSCs) or, were fixed in glutaraldehyde 2% and processed for transmission or scanning electron microscopy. Collected data showed very interesting features regarding the cellular composition of the Bichat fat pad and, in particular, experiments aimed to characterized the MSCs showed the presence of a sub-population of MSCs characterized by the expression of specific markers that allow to classify them as multilineage differentiating stress enduring cells.  This data set allows to collect novel information about regenerative potential of Bichat fat pad that could explain the success of its employment in reconstructive and regenerative medicine.

Dorsal Preservation: The Push Down Technique Reassessed.

Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author's current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author's operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (Less than 4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors' experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be "Can I keep the nasal dorsum intact?" Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a "not operated" aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty.

Nasal lift-nasal valve lift and nasal tip lift-preliminary results of a new technique using noninvasive self-retaining unidirectional nasal suspension with threads.

In the context of nasal obstruction treatment, an alternative, no invasive technique is described. It consists in the suspension of the nasal valve or in the association of the suspension of the valve and rotation of the tip, through the placement of one or two absorbable threads, already known in aesthetic medicine. This technique allows to open the nasal valve and to correct the moderate closure of the nasolabial angle obtaining an immediate benefit of breathing. Functional improvement has been evaluated at regular intervals, that is, 1, 3, 6, and 12 months and then provided for every 6 months, through the use of a visual scale of 0/10 to 10/10. In our experience, the technique allows to obtain satisfactory results, avoiding more invasive techniques and postoperative recovery days.