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.

[Smarter medicine in Otorhinolaryngology - Top 5 List]. / Smarter Medicine in der ORL.

Smarter medicine in Otorhinolaryngology - Top 5 List Abstract. Many diseases or symptoms with a high prevalence in the population, such as vertigo / dizziness, tinnitus, or sinusitis, but also nasal bone fractures and otitis externa, lead to a high number of visits to the physicians due to their frequency alone. Often, conventional X-rays (sinusitis, nasal bone fractures) or - in cases of vertigo and tinnitus - magnetic resonance imaging are ordered for further diagnostic clarification even though the benefit of theses is not generally given according to the current state of knowledge. The indication for imaging can be set much more restrictive after critical review of these clinical conditions without reducing the quality of treatment. The same applies to the usage of systemic antibiotics in uncomplicated otitis externa, which can be reduced without any problems. The extensive discussion of these issues within the Society of Otorhinolarnygology (SGORL) formed the basis for the creation of the Top 5 -list with its recommendations which are presented in detail below.

Narrowing and Operated Appearance of the Middle Nasal Third after Hump Resection without Middle Vault Reconstruction.

BACKGROUND: Little is known about the incidence of narrowing and an operated appearance of the dorsum after hump resections if the dorsum is not reconstructed with spreader grafts or spreader flaps. METHODS: Patients who had undergone a composite hump resection (n = 22) or a component hump resection (n = 25) were interviewed and photographed with a minimum follow-up of 12 months. Four expert rhinoplasty surgeons and four laypersons rated the appearance of the middle third of the dorsum on the preoperative and postoperative en face photographs. The quartile of the most surgical appearing outcomes was analyzed regarding potentially preventive surgical maneuvers. RESULTS: No patient was dissatisfied with the frontal view of the nose. Agreement between expert and lay raters (Kendall's coefficient of concordance) was 0.51 (p < 0.01) and 0.34 (p = 0.06) for appearance and 0.55 (p < 0.01) and 0.46 (p < 0.01) for width, respectively. Expert raters found that a surgical appearance of the dorsum had both increased and decreased after surgery, with an average increase of 0.27 ± 1.05 and 0.21 ± 1.18 points on a five-point Likert scale for composite and component resection, respectively. Pearson correlation between the degree of dorsal lowering and surgical appearance on the anterior view was 0.31 (p = 0.026). Reconstruction of the middle third could potentially have improved the outcome in 15 percent of the patients. CONCLUSIONS: Lowering of the dorsum without middle vault reconstruction on average increased an operated appearance to a small degree that was not noted by the patients. This effect was similar for composite and component hump resections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Rhinoplasty Photography: Lighting from Above Improves Visualization of Deviations and Irregularities.

Importance: Standard lighting with two flashlight diffusors for pre- and postoperative photography deviates from typical natural lighting and may mask relevant irregularities and deviations of the nose due a decreased contrast. Objective: This study aimed at testing the hypothesis that lighting from above improves the depiction of irregularities and deviations of the nose. Design, Setting, and Participants: This was a prospective randomized controlled trial at an academic tertiary medical center. Forty consecutive rhinoplasty candidates who requested a correction of irregularities or deviations of the nose were photographed first with standard anterolateral lighting (two studio strobe lights and diffusor boxes) and second with lighting from above. Ten lay judges rated the degree of irregularity or deviation of the nose on cropped images of the anterior view of the nose with both lighting conditions on a 5-point Likert scale. Results: Ratings for deviation or irregularity of the nose were higher for the photograph taken with lighting from above in 30 (75%), equal in 3 (7.5%), and lower in 7 (17.5%) of 40 pairs of photographs. The mean rating of nasal deformity for lighting from above (2.47; confidence interval [CI]95: 2.22-2.72) was significantly higher than mean rating for anterolateral lighting (1.86; CI95: 1.61-2.11). Conclusions and Relevance: Photographic documentation for rhinoplasty may be improved by including lighting from above if the standard lighting fails to adequately depict nasal irregularities or deviations.

Minimally invasive techniques in rhinoplasty.

PURPOSE OF REVIEW: To present criteria of minimally invasive surgery, which include minimal and hidden incision lines, reduced injury to tissue and application of endoscopic techniques, when feasible; to analyze techniques in rhinoplasty for their minimally invasive character - in light of recent publications; and to discuss the techniques that best meet the criteria of minimally invasive surgery. RECENT FINDINGS: The nose consists of about 60 percent soft tissue and 40 percent skeletal elements. Surgery causes injury to both tissue types through various mechanisms, including mechanical traction, separation, incision, heat, desiccation, and others. Multiple aspects including extent of approach and degree of tissue undermining determine the minimally invasive character of techniques and maneuvers in rhinoplasty. SUMMARY: A single incision endonasal approach, the subperichondrial and subperiosteal septal plane, the supraperichondrial plane over the cartilaginous dorsum, the subperiosteal plane over the bony dorsum, limited dorsal undermining with endoscopic visualization when feasible, conventional straight lateral osteotomy or percutaneous curved lateral osteotomy; percutaneous transverse osteotomy; conventional straight paramedian osteotomy; piezo and drill paramedian ostectomy; dorsal uncapping osteotomy; conventional rasp gross dorsal contouring; piezo or drill fine dorsal contouring; (cartilaginous) middle vault 'let down'; and minimal access subperiosteal turbinate bone resection were found to best fulfil the criteria of minimally invasive surgery. A classification system for the degree of minimally invasiveness of rhinoplasty techniques is proposed as a basis for discussion.

Replacement of the Nasal Dorsum with a Diced Cartilage Glue Graft.

The reconstruction of the nasal dorsum after a hump resection is challenging if narrowing of the nose is to be avoided, the nasal skin is very thin, and the nasal bones are short. This report describes the replacement of the bony and cartilaginous nasal dorsum after resection with an anatomically shaped dorsal replacement graft of diced cartilage in fibrin glue. The technique is illustrated with a clinical case and sonographic morphometry of the nasal dorsum and tip. A modification of the diced cartilage glue graft for thin-skinned patients is presented.

The Nasal Width and Boxiness Index: Introduction and Pilot Study on Reliability and Validity of Sonographic Morphometry.

Both intended and unintended surgical modifications of nasal width and shape of the nasal tip continue to be of interest to the rhinoplasty surgeon. As validated instruments for quantifying width and boxiness are lacking, the objective of this study was to introduce a width index and a boxiness index for the nasal dorsum and the nasal tip. A width index and a boxiness index were defined within the methodological limits of noncontact sonography. The reliability of both indices was studied by comparing the measurements of two examiners on the noses of five volunteers. The validity of the indices was studied by correlating the sonographic width and boxiness with the 5-point Likert scale ratings of photographs of 5 noses by 21 lay persons. Nasal width was defined as the diameter at a distance of 5 mm from the skin surface on a sonographic cross-section perpendicular to the skin surface. Boxiness was defined as the quotient of width at a depth of 1 and 5 mm. Bland-Altmann analysis revealed negligible bias between both examiners and 95% of limits of agreement of 13, 7, and 13% for width at 1 mm, width at 5 mm, and boxiness, respectively. Corresponding Pearson's correlation coefficients were r = 0.93, r = 0.93, and r = 0.71. The correlation between the cumulative lay persons' scores and sonographic width and boxiness were r = 0.97, r = 0.66, and r = 0.81 for nasal tip width, dorsal width, and boxiness, respectively. Both the width at a depth of 5 mm as measured with sonography and the boxiness index that is defined as width at a depth of 1 mm divided by the width at a depth of 5 mm may prove to be acceptable surrogate parameters for width and boxiness of the nose in comparative morphometric studies.

Management of the Prominent Ear.

This article incorporates the opinions and preferred surgical options in managing patients of 3 prominent facial plastic surgeons who have large otoplasty practices. Six different questions covering the management of prominent ears are answered by the 3 practitioners. Nonsurgical options for the treatment of prominent ears are discussed. The role of cartilage-cutting and cartilage-sparing techniques as well as individual preferred otoplasty techniques are thoroughly covered. Postoperative management of these patients is presented by the individual surgeons.

Reducing Periorbital Edema and Ecchymosis after Rhinoplasty: Literature Review and Personal Approach.

Postoperative periorbital edema and ecchymosis are most bothersome to rhinoplasty patients. The degree of swelling and bruising is influenced by several factors, and numerous prophylactic and therapeutic measures have been described in the literature. This article reviews the current literature and concludes with the author's suggestions on how to best minimize postoperative periorbital edema and ecchymosis.

Dorsal Augmentation-Diced Cartilage Techniques: The Diced Cartilage Glue Graft.

The quest for the ideal method for augmenting the nasal dorsum continues to be a matter of debate, with both most surgeons and patients preferring autologous tissue. This article reviews the current use of diced cartilage for nasal augmentation, emphasizing the diced cartilage in fibrin glue (DCG) graft. It offers the first collation of unfavorable outcomes and complications of the DCG graft seen in a series of 108 patients treated at the author's institution. The DCG graft continues to be a versatile graft that is stable over time and combines unique features. It has proved to be particularly well suited for segmental augmentations of the dorsum. Resorption of the graft has been rare and infrequent unfavorable outcomes have all been amenable to successful minor surgical revisions.

Cleft Lip Nose.

All patients with a cleft lip deformity have an associated nasal deformity that varies in degree of severity. A three-dimensional understanding of the anatomy of the cleft nose aids surgeons in selecting the proper technique for repair. Analysis and performance of orthognathic surgery should be done before nasal surgery to optimize the overall result. Goals of the secondary rhinoplasty include relief of nasal obstruction, creation of symmetry and definition of the nasal base and tip, and management of nasal scarring and webbing. Septal reconstruction in the cleft nose is a key maneuver in cleft rhinoplasty.