Narrowing the Nasal Roof with Paramedial Osteotomy in Preservation Rhinoplasty.

INTRODUCTION: Rhinoplasty is frequently performed in aesthetic and plastic surgery, with hump deformity being common in Western populations. Osteotomies play a crucial role in managing this, especially for dorsal hump reduction in closed rhinoplasty. OBJECTIVES: Despite advancements, treatments for simultaneous nasal hump deformity and wide nasal roof are inadequate in preservation rhinoplasty. This study introduces a technique merging push-down and let-down methods with paramedial osteotomy for these cases. METHODS: A retrospective review was conducted on patients undergoing push-down or let-down rhinoplasty, identifying 68 individuals (51 females and 17 males) with both nasal hump deformity and wide nasal roof. They were evaluated using the Rhinoplasty Outcome Evaluation questionnaire before surgery and 1-year post-operation. RESULTS: Follow-up ranged from 12 to 24 months, with significant improvement in patient satisfaction. The median Rhinoplasty Outcome Evaluation score rose from 48.5 pre-surgery to 91.5 post-surgery (p < 0.001), indicating remarkable patient satisfaction in 97.3% of cases. CONCLUSION: This research is to demonstrate narrowing the nasal roof in patients who had nasal hump deformity and wide nasal roof with a combination of dorsal preservation techniques and osteotomy. Surgeons experienced in push-down or let-down techniques can apply this combination technique to obtain better aesthetic outcomes in patients with a wide nasal roof. 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 .

Differences in muscle activity of extrinsic and intrinsic foot muscles in toe grip and push-down movements of the great toe.

Toe flexor strength is generated primarily by the flexor hallucis longus (FHL) of the extrinsic foot muscles (EFMs) and the plantar intrinsic foot muscles (PIFMs) of the great toe. Toe flexion methods can be broadly classified into toe grip (TG) and toe push-down (TP). Additionally, TP's interphalangeal joint (IPJ) position may influence the FHL and PIFMs activity ratios. This study aimed to elucidate the differences in the muscle activity and muscle activity ratios of the FHL and AbdH during TG, TP with IPJ flexion (TPIF), and TP with IPJ extension (TPIE). Surface electromyography and a custom-made instrument were used to measure the FHL and AbdH muscle activity during TG, TPIF, and TPIE of the great toe in 28 healthy men. The muscle activity and AbdH/FHL muscle activity ratio in the three conditions were statistically compared. The FHL activity was significantly higher during TG and TPIF than during TPIE. The AbdH muscle activity was significantly higher during TPIF and TPIE than that during TG. The AbdH/FHL muscle activity ratio was significantly higher for TPIE, TPIF, and TG in that order. This study showed that the FHL and AbdH muscle activity differed depending on the TG and TP of the great toe, and that the AbdH/FHL muscle activity ratio was different in the IPJ position. These results suggest that selecting a toe flexion method according to the target muscle when measuring and training the great toe flexor strength is important.

Unilateral Fixation of the Bony Pyramid in Deviated Nose Correction.

Deviated nose correction is one of the most challenging procedures in rhinoplasty. Recent studies proposed effectiveness of preservation techniques even for patients with crooked nose deformity, although the long-term results are still controversial. Obviously, only addressing the blocking points is not enough to achieve stable midline position in crooked nose. To ensure consistent long-term results, we proposed a unilateral suturing of the bony pyramid along with unilateral resection of the excessive bone along the lateral osteotomy line. The first results of described surgical technique have proven its simplicity, reliability, and high efficiency both in primary and in revision surgeries. LEVEL OF EVIDENCE V: 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 .

"Managing the Severe Septal Deviation Using Dorsal Preservation".

Severe septal deviations are a constant challenge for rhinosurgeons. As the septum is the most important pillar of the nasal framework, septal deformities require correction to insure a straight nose. The septum should be on the midline without any tension to ensure a correct healing of the external nasal pyramid. In certain cases, the association of a correct septoplasty and dorsal preservation allows the treatment of the crooked nose and at the same time gives natural results with rapid postoperative recovery. The aim of this article was to underline the versatility of the dorsal preservation technique for the correction of severe septal deviation.

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.

Ultrasonic Rhinoplasty and Septoplasty for Dorsum Preservation and for Dorsum Structural Reconstruction.

Ultrasonic rhinoplasty and ultrasonic septoplasty reshape the nasal bones using piezoelectric instruments specifically developed for these operations. They allow the realization of precise osteotomies under direct visual control after having performed first an open or closed extended approach, but also ostectomies and rhinosculpture. Piezoelectric instruments preserve bone stability by not damaging bone support structures and avoiding unwanted fractures. They allow precise control of nasal bone movements, their orientation, and their final position. The different inserts of ultrasonic rhinoplasty and ultrasonic septoplasty are detailed, with their scope of action. The applications to dorsum preservation and structural remodeling of dorsum are presented.

My First Twenty Rhinoplasties Using Dorsal Preservation Techniques.

Dorsal preservation involves eliminating the dorsal hump by performing reduction while preserving the patient's natural dorsal anatomy. This can involve surface manipulation or foundational techniques or a combination of both. When surgeons begin performing dorsal preservation, there are important factors to consider to avoid complications. In an effort to inform surgeons on how to avoid unfavorable outcomes, I will discuss my first 20 cases where I performed dorsal preservation. I review less than ideal outcomes and how these issues can be prevented.

Matched Cohort Comparison of Dorsal Preservation and Conventional Hump Resection Rhinoplasty.

BACKGROUND: Structural preservation techniques (SPR) minimize disruption of the dorsal aesthetic lines, with potential aesthetic and functional benefits over conventional hump resection techniques (CHR). The goal of this study is to compare patient reported outcomes between these techniques. METHODS: This study was a retrospective matched cohort analysis of patients undergoing rhinoplasty with dorsal hump reduction using patient-reported outcomes measures: Standardized Cosmesis and Health Nasal Outcomes Survey (obstructive: SCHNOS-O, cosmetic: SCHNOS-C) and visual analog scale (functional: VAS-F, cosmetic: VAS-C). A cohort of patients undergoing SPR were matched to a cohort undergoing CHR based on age, gender, and preoperative SCHNOS scores. Intraoperative techniques and patient-reported outcomes were compared between groups. RESULTS: There were no significant differences in the dorsal height between groups. While radix grafting was more common in SPR, dorsal onlay grafting and midvault reconstructive techniques (e.g. autospreader flaps) were more common in CHR. Within both groups, post-operative SCHNOS and VAS improved significantly at short- and long-term follow-up. There were no differences between SCHNOS or VAS scores preoperatively. Post-operative SCHNOS-O and SCHNOS-C scores were similar between groups at both short-term and long-term follow-up. Post-operative VAS-F scores were not different; however, VAS-C scores at short-term follow-up were statistically greater in the SPR group compared to the CHR group (8.92 vs 8.20, p = 0.03). At long-term follow-up, the difference was not significant. CONCLUSION: While there are theoretical functional and aesthetic benefits of SPR techniques, the patient reported benefits may be minimal when compared to CHR techniques with appropriate midvault reconstruction. 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 .

Modification of Push-Down Rhinoplasty with Maxilla-Pyramid Sutures.

A key point, that determines the late outcome of push-down procedures, is a stable fixation of the bony pyramid in its new position. Therefore, rhinoplasty surgeons are consistently trying to find the effective technique for fixation of the osseocartilaginous vault that has been investigated. Nonetheless, all described techniques are less or non-effective in cases when simultaneous septoplasty is required. Thus, we have found more relevant a lateral fixation of the bony pyramid. Using a needle piezotome, two holes above and below lateral osteotomy lines should be performed bilaterally. The downward inserted pyramid is fixed with maxilla-pyramid sutures through these holes.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 .

An assessment of techniques and practices used to elevate intra-abdominal pressure when assessing pelvic floor dysfunction.

AIMS: To determine terminology and methods for raising intra-abdominal pressure (IAP) currently used by clinicians to assess pelvic floor dysfunction (PFD) and to measure the effect of these maneuvers on IAP. METHODS: Three-hundred questionnaires were distributed at two scientific meetings in the United Kingdom to determine methods clinicians used to raise IAP and their perceptions of these methods. Twenty healthy volunteers were also recruited to measure the effect of two methods of raising IAP: Valsalva maneuver (VM) and bear down maneuver (BDM). IAP pressure was measured with rectal catheters connected to pressure sensors. The IAP was measured during each maneuver in both standing and supine positions. RESULTS: Maneuvers used in practice were cough (79%), BDM (60%), and VM (38%). 44% of clinicians felt patients found it difficult to raise their IAP. There was uncertainty among clinicians as to which method was the most effective in raising IAP and whether the different methods produced the same rise in IAP. On testing IAP in 20 healthy volunteers, median (interquartile range) IAP generated during BDM; 101 (59.1) cmH2 O was significantly higher than that generated during VM; 80.3 (43.6) cmH2 O (p < .0001). CONCLUSION: Clinicians varied widely in the maneuvers they used to raise patients' IAP to test for PFD and there was uncertainty about the maneuvers' effect on IAP. In healthy volunteers, BDM produced significantly higher IAP than VM. We recommend standardization of terminology and techniques used to raise IAP when assessing PFD, to ensure consistency of diagnosis and assessment of treatment outcomes.

Prevention of Nasal Deviation Related to Preservation Rhinoplasty in Non-deviated Noses using Suturing Approaches.

INTRODUCTION: Rhinoplasty is one of the most common aesthetic surgeries, and dorsal hump reduction surgery is the most commonly applied type of surgery in Western countries. Every patient should be considered challenging based on the negative outcomes of this surgical procedure. Thus, aesthetic and plastic surgeons attempt to provide the safest and best resulting rhinoplasty techniques. OBJECTIVES: While performing dorsal preservation techniques in patients who had hump deformity but did not have septal deviation, deviation occurs due to surgery. In the present research, the author defines new suturing techniques for overcoming deviation associated with dorsal preservation surgeries. METHODS: Data from patients who underwent dorsal preservation rhinoplasty for the nasal hump were evaluated. Patients who had nasal hump deformities without nasal deviation deformities were included. Following these inclusion and exclusion criteria, the records of 43 patients were assessed. All patients included in the study completed the Rhinoplasty Outcome Evaluation questionnaire before surgery and at their one-year follow-up appointment. New suturing approaches such as "8" shaped and loop sutures were assessed. RESULTS: The median Rhinoplasty Outcome Evaluation score before surgery was 60.6. The median score after one year of surgery was 90.8. The Rhinoplasty Outcome Evaluation score significantly increased after surgery (p<0.001). Patient satisfaction was excellent in 90.47% of the included patients. CONCLUSIONS: These "8" suturing approaches present surgeons overcoming the possibility of deviation, which is associated with dorsal preservation techniques, such as push-down and let-down procedures in non-deviated noses. Further studies are needed to confirm the preliminary results of the present research. 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 .

[Dorsal preservation septorhinoplasty]. / Die nasenrückenerhaltende "Dorsal-Preservation"-Septorhinoplastik.

BACKGROUND: Nasal dorsum deprojection is a very important tool in functional and aesthetic rhinoplasty. In classic techniques, resection of dorsal bone and cartilage renders dorsal reconstruction necessary. The concept of dorsal preservation rhinoplasty has been known for more than a century but has experienced a renaissance in recent years, with many critical technical modifications. MATERIALS AND METHODS: We present the latest technique of piezo-assisted dorsal preservation rhinoplasty with subdorsal triangular resection and subdorsal Cottle modification based on clinical experience of 205 cases. Furthermore, the advantages and disadvantages of this technique are discussed and several other current variations are presented. RESULTS AND DISCUSSION: Piezo-assisted osteotomy enables a very precise fracture line and sparing of periosteum, with bone sculpting possible even after mobilization. Subdorsal septal height reduction always precedes completion of the osteotomy and nasal bone mobilization, to ensure patient safety with regard to skull base injury. Using the presented technical modifications, the risk of step deformities in the radix is minimized. In selected patients, dorsal preservation septorhinoplasty enables the surgeon to perform very conservative and precise deprojection of the nose with excellent outcomes, although the spectrum of possible complications is shifted in comparison to classic techniques. CONCLUSION: The preliminary experience of 205 cases with a revision rate of less than 10% is promising. A final evaluation of the technique will only be possible after further studies and evaluation of long-term results.

Push down technique with ostectomy.

PURPOSE: Rhinoplasty is one of the most commonly performed aesthetic surgeries among patients who are admitted to plastic surgeons. Recent research has focused on dorsal preservation in hump reduction and consequently dorsal preservation techniques have become more popular. The current study aimed to revise the push down technique by adding ostectomy. PATIENTS AND METHODS: In the present retrospective study, data from patients who underwent rhinoplasty to fix a nasal hump were assessed. All patients were administered the push down technique with ostectomy. Following these inclusion and exclusion criteria, the records of 52 patients were assessed (45 females and 7 males). The median age of the patients was 22.2 years. Patients were evaluated using the "Rhinoplasty Outcome Evaluation" (ROE) questionnaire both before surgery and 12 months after surgery. The follow-up period ranged between 13 and 21 months (median of 15.1 months). RESULTS: Patients were evaluated before surgery and after one year of surgery by the ROE scale. The median of the ROE score before surgery was 63.4. The median score after one year of surgery was 91.6. Thus, the ROE score significantly increased 12 months after surgery (P<0.001). CONCLUSIONS: This study was the first to demonstrate the benefits of performing the push down technique with ostectomy in terms of obtaining a wider nasal cavity. In addition, it can be assumed that the disadvantage of using the push down technique can be overcome with ostectomy.

Preservation Dorsal Hump Surgery: A Changing Paradigm.

Preservative dorsal hump surgery is an old approach that has revitalized recently. Preservation rhinoplasty aims to shape the existing structures instead of resection/reconstruction approaches. A thorough understanding of the applied anatomy of the nose is the backbone of preservative hump surgery. In preservative hump surgery keystone works as a joint, and by lowering this joint the hump is eliminated.

History of Dorsal Preservation Surgery: Seeking Our Historical Godfather(s) for the "Push Down" and "Let Down" Operations.

There are 2 approaches for lowering the osseocartilaginous nasal dorsum. The most frequently used method includes resection of the osseocartilaginous nasal dorsum. The second method is based on preservation of the osseocartilaginous nasal dorsum. The concept of dorsal preservation surgery is to preserve, not resect, the nasal bones and upper lateral cartilage. Reduction rhinoplasty with preservation of the nasal dorsum is not only possible, but results in a natural appearing postoperative dorsal esthetic line. Thus, the rhetorical question: Why reconstruct the nasal dorsum when you can simply preserve it?

Combination of the Push-Down and Let-Down Techniques: Mix-Down Approaches.

BACKGROUND: Rhinoplasty is one of the most widely conducted and challenging types of aesthetic surgical operations, and dorsal hump reduction is a commonly performed aesthetic surgery among Caucasian patients. Dorsal hump resection is traditionally conducted by removing the dorsal nasal bone and cartilage. The push-down and let-down techniques are used for dorsal preservation in dorsal hump reduction operations. Different patients require different approaches to achieve the best results in terms of aesthetic appearance and functionality. OBJECTIVES: In the present research, the author describes two novel approaches that combine the push-down and let-down techniques for appropriate patients. METHODS: The records of 45 patients (40 females and 5 males) were assessed, and those who were eligible for the present approaches were included. The author defined two approaches in which the push-down and let-down techniques were used simultaneously (mix-down methods). All patients included in the study completed the Rhinoplasty Outcome Evaluation (ROE) questionnaire before surgery and at their one-year follow-up appointment. RESULTS: The median ROE scores were 60.1 points before surgery and 92.2 points one year after surgery; this difference was statistically significant (p<0.001). CONCLUSIONS: The present study is the first to demonstrate the beneficial effects of combining the push-down and let-down techniques in a selected patient population. These new approaches will improve both cosmetic and functional outcomes and allow surgeons to choose the best option for patients who are eligible for these mix-down approaches. 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 .

Response to Commentary on: Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty.

Rhinoplasty is a sophisticated surgery that needs high technical skills with knowledge. The DR technique is a refined technique to deal with the selected cases which are challenging for rhinology (wide dorsum, base and humpy nose). Still, so many things are unknown and one life span will be never enough to solve it. However, the author thinks that any solution fills the gaps, is the only thing we can improve the medicine. LEVEL OF EVIDENCE V: 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.

Push-Down Technique Without Osteotomy: A New Approach.

BACKGROUND: Dorsal hump reduction is one of the most frequently performed rhinoplasty operations among white populations. The best method for preserving a natural nasal dorsum and avoiding revision surgery is to perform the push-down technique. The concept of the push-down technique is not new and has been improved over time. OBJECTIVES: In the present study, the author introduces a new approach for the push-down technique in which there is no need for osteotomy. METHODS: According to the inclusion and exclusion criteria, sixty-two patients were included in the present study. All patients who were included in the study were assessed with the Rhinoplasty Outcome Evaluation (ROE) questionnaire at their 1-year follow-up appointment. In the present technique, the superior dorsal cartilage was pushed down to the reverse side of the septal deviation, and the nasal dorsum was rasped with a micromotor rasping machine instead of undergoing osteotomy. RESULTS: The initial median ROE score was 68.5 points, and the postoperative median score was 90.5 points. A final score greater than 85 was considered excellent and an indication of high patient satisfaction. Among the sixty-two patients, 56 had a score greater than 85 points (90.32%) (p = 0.001). There were no complications, and there was no need for revision surgery. CONCLUSION: This push-down technique can be considered an easy and suitable approach for selected patient populations. Additionally, the recovery time is shortened with the push-down technique without osteotomy. 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.

Production of Supra-regular Spatial Sequences by Macaque Monkeys.

Understanding and producing embedded sequences in language, music, or mathematics, is a central characteristic of our species. These domains are hypothesized to involve a human-specific competence for supra-regular grammars, which can generate embedded sequences that go beyond the regular sequences engendered by finite-state automata. However, is this capacity truly unique to humans? Using a production task, we show that macaque monkeys can be trained to produce time-symmetrical embedded spatial sequences whose formal description requires supra-regular grammars or, equivalently, a push-down stack automaton. Monkeys spontaneously generalized the learned grammar to novel sequences, including longer ones, and could generate hierarchical sequences formed by an embedding of two levels of abstract rules. Compared to monkeys, however, preschool children learned the grammars much faster using a chunking strategy. While supra-regular grammars are accessible to nonhuman primates through extensive training, human uniqueness may lie in the speed and learning strategy with which they are acquired.

Comparing Different Methods of Measuring Accommodative Amplitude with Hofstetter's Normative Values in a Ghanaian Population.

AIM: Amplitude of accommodation (AoA) can be determined clinically using different methods. Some methods are known to be more reliable than others for measuring AoA in different age categories. The purpose of this study was to compare Hofstetter's age-expected norms with five recommended methods of measuring AoA in order to determine age-appropriate techniques for a Ghanaian population. MATERIALS AND METHODS: AoA was measured using four subjective methods (push-up, push-down, minus lens, and modified push-up) and one objective method, the modified dynamic retinoscopy. The amplitudes obtained by each technique were compared to each other and also compared to the age-expected amplitudes as predicted by Hofstetter's equations. RESULTS: 352 non-presbyopes aged 10-39 years were included in this study. All five methods except the push-up (p = 0.089) and modified push-up (p = 0.081) differed significantly from Hofstetter's data, while the modified dynamic retinoscopy recorded the strongest agreement with Hofstetter's average (ICC = 0.78, p Ë‚ 0.001). With reference to Hofstetter's expected AoA, the minus lens, push-down, modified dynamic retinoscopy, and modified push-up methods underestimated AoA by -4.18D, -1.99D, -0.48D, and -0.43D, respectively. As age increased, underestimated AoA values by the minus lens (10-19 years: -5.57D, 20-29 years: -3.50D, 30-39 years: -2.39D), modified push-up (10-19 years: -1.51D, 20-29 years: +0.40D, 30-39 years: +0.56D), and push-down (10-19 years: -2.90D, 20-29 years: -1.07D, 30-39 years: -1.46D) methods decreased but the modified push-up in relation to Hofstetter's expected was most accurate for the older age. The push-up, on the other hand, overestimated accommodation in all age categories by +0.42D (10-19 years: +0.01D, 20-29 years: +0.82D, 30-39 years: 0.67D). Thus, the push-up method became more accurate as age decreased. CONCLUSION: This study suggested that Hofstetter's formulae could be used to predict the amplitudes of Ghanaian non-presbyopes aged 10-39 years using the push-up and modified push-up. With regard to Hofstetter's data, the push-up method was more accurate for the younger age-group 10-19 years while the modified push-up was more accurate for the older age-group 20-39.