Rhinosurgery during and after the COVID-19 Pandemic: International Consensus Conference Statement on Preliminary Perioperative Safety Measures.

BACKGROUND: The coronavirus disease of 2019 (COVID-19) pandemic has widely affected rhinosurgery, given the high risk of contagion and the elective nature of the aesthetic procedure, generating many questions on how to ensure safety. The Science and Research Committee of the Rhinoplasty Society of Europe aimed at preparing consensus recommendations on safe rhinosurgery in general during the COVID-19 pandemic by appointing an international panel of experts also including delegates of The Rhinoplasty Society. METHODS: A Zoom meeting was performed with a panel of 14 international leading experts in rhinosurgery. During 3.5 hours, four categories of questions on preoperative safety measures in private practice and outpatient clinics, patient assessment before and during surgery, and legal issues were presented by four chairs and discussed by the expert group. Afterward, the panelists were requested to express an online, electronic vote on each category and question. The panel's recommendations were based on current evidence and expert opinions. The resulting report was circulated in an iterative open e-mail process until consensus was obtained. RESULTS: Consensus was obtained in several important points on how to safely restart performing rhinosurgery in general. Preliminary recommendations with different levels of agreement were prepared and condensed in a bundle of safety measures. CONCLUSION: The implementation of the panel's recommendations may improve safety of rhinoplasty by avoiding operating on nondetected COVID-19 patients and minimizing severe acute respiratory syndrome coronavirus 2 virus spread in outpatient clinics and operating rooms.

Airflow Considerations and the Effect of Webster's Triangle in Reduction Rhinoplasty.

BACKGROUND: Reduction rhinoplasties, regardless of the methods used (structural or preservation), can cause a reduction in the internal nasal volume, which may lead to breathing problems. In 1977, Webster proposed preserving a little triangle in the beginning of the lower lateral osteotomy line to prevent breathing problem. However, its importance is still controversial. OBJECTIVES: and methods: This prospective randomized controlled study (level of evidence 1) included 46 patients without nasal breathing problem. High-to-low (Webster's triangle preservation) osteotomy (control group, n = 23) and low-to-low osteotomy (study group, n = 23) were performed. All operations were performed according to the proposed volumetric rhinoplasty steps (examination/measurement, prevention and treatment). Nasal obstruction symptom evaluation (NOSE) test, visual analog scale, acoustic rhinometry, rhinomanometry, peak nasal inspiratory flow (PNIF), and three-dimensional measurements were performed in all patients. Breathing tests were repeated before and 6 months after surgery with and without xylometazoline administration. RESULTS: No statistically significant difference in NOSE and visual analog scale scores was found between the two groups. Acoustic rhinometry, PNIF, and rhinomanometry findings showed no statistically significant breathing difference between the two groups. CONCLUSIONS: In reduction rhinoplasties, a decrease in the internal volume may be expected as directly proportional with the reduction amount. The decrease in the internal volume may create nasal breathing problems. To prevent it, nasal airflow should be adjusted according to new anatomy. In this study, we discussed "volumetric rhinoplasty" steps to prevent breathing problems in reduction rhinoplasty. Following these steps, not preserving Webster's triangle (low-to-low osteotomy) has no effect on the nasal airway. LEVEL OF EVIDENCE II: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Effects of Maxillary Movements on Nasal Aesthetics Following Orthognathic Surgery.

Improvement of the harmony between facial subunits is the ultimate goal of orthognathic surgery and surgeons must accurately make soft tissue projections for planned bony movements. Yet, few studies have examined the effects' of orthognathic surgery on aesthetic parameters of nasolabial area on a thorough basis.This retrospective study included 61 patients that underwent orthognathic surgery. Demographic data, evaluation period, and surgical details were analyzed. Superficial topographical analysis of intercanthal distance, alar width, nasal height, nasal length, nasal tip protrusion, upper lip height, nasal bone angle, supratip break angle, nasal dorsum angle, nasal tip angle, columellar-lobular angle, columellar-labial angle, upper lip angle, and tip-to-midline angle was recorded before and after surgery. Postoperative changes in these parameters and their correlation to maxillary movements were analyzed.Alar width, upper lip height, columellar-labial angle, supratip break angle, nasal dorsum angle, and upper lip angle increased postsurgery, whereas tip-to-midline angle decreased. Upper lip height and columellar-labial angle were significantly correlated with clockwise/counter-clockwise rotation and anterior re-positioning. Columellar-labial angle increased 2° for each 1 mm of anterior movement and decreased 4° for each 1 mm of counter-clockwise rotation. Novel parameters, such as columellar-lobular angle and tip-to-midline angle, were not associated with any maxillary movement postsurgery.Orthognathic surgery primarily affected the lower third of the nose and changed alar width, upper lip height, supratip break angle, nasal dorsum angle, columellar-labial angle, upper lip angle, and tip-to-midline angle in this region; however, only columellar-labial angle and upper lip height were found to be correlated solely with maxillary movements.

A New Technique for Robust Stabilization in the Keystone Area during Extracorporeal Septorhinoplasty.

Although extracorporeal septorhinoplasty is the most powerful technique for correcting deviated and leaning noses, many investigators have abandoned it because of keystone problems. The authors defined a new neoseptum fixation technique and used it in 10 patients in 2016. Preoperative and postoperative Nasal Obstruction Symptom Evaluation scale and peak nasal inspiratory flow measurement, and septal indexes of the patients were compared. There was statistically significant improvement in the respiratory condition of all patients. No recurrence or dorsal irregularity has been observed. This new, easily applicable, and robust fixation method of extracorporeal septorhinoplasty may be a definitive solution to prevent keystone irregularities. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

The Composite Spreader Flap.

Background: The effect of a spreader flap on the keystone area and the upper bony vault depends on the structural strength and cephalic extent of upper lateral cartilages, both of which can be significantly variable among individuals. Objectives: The authors present a novel cephalically extended osseocartilaginous composite spreader flap technique that was designed to overcome the limitations of a conventional spreader flap on the keystone area upper bony vault, in patients with cephalically short and structurally weak upper lateral cartilages and thin nasal bones. Methods: This study was a retrospective review of the recorded perioperative information to investigate the frequency of the use of the composite spreader flap technique and perioperative parameters that relate to postoperative dorsal deformities. One-hundred-seventy-six consecutive primary open approach rhinoplasty cases performed by the first author (O.B.) between November 2015 and February 2017 were included in the study. Patient data were obtained from rhinoplasty data sheets, standardized photographs, and postoperative physical examinations. Results: Of the 176 cases who underwent primary open approach rhinoplasty whose data were reviewed for the purpose of this study, 38 (32 females, 6 males) had dorsal reconstruction with the use of a composite spreader flap. Seventeen patients had a deviated nose with an asymmetric bony pyramid. In 8 patients, the composite spreader flap was used unilaterally. No patients in the composite spreader flap group had a postoperative dorsal deformity or required surgical revision. Conclusions: Composite flap preparation extends the reliability and the reach of the spreader flap technique beyond its previous borders.

Assessment of survival rates compared according to the Tamai and Yamano classifications in fingertip replantations.

BACKGROUND: The fingertip is the most frequently injured and amputated segment of the hand. There are controversies about defining clear indications for microsurgical replantation. Many classification systems have been proposed to solve this problem. No previous study has simultaneously correlated different classification systems with replant survival rate. The aim of the study is to compare the outcomes of fingertip replantations according to Tamai and Yamano classifications. MATERIALS AND METHODS: 34 consecutive patients who underwent fingertip replantation between 2007 and 2014 were retrospectively reviewed with respect to the Tamai and Yamano classifications. The medical charts from record room were reviewed. The mean age of the patients was 36.2 years. There were 30 men and 4 women. All the injuries were complete amputations. Of the 34 fingertip amputations, 19 were in Tamai zone 2 and 15 were in Tamai zone 1. When all the amputations were grouped in reference to the Yamano classification, 6 were type 1 guillotine, 8 were type 2 crush and 20 were type 3 crush avulsions. RESULTS: Of the 34 fingertips, 26 (76.4%) survived. Ten (66.6%) of 15 digits replanted in Tamai zone 1 and 16 (84.2%) of 19 digits replanted in Tamai zone 2 survived. There were no replantation failures in Yamano type 1 injuries (100%) and only two failed in Yamano type 2 (75%). Replantation was successful in 14 of 20 Yamano type 3 injuries, but six failed (70%). The percentage of success rates was the least in the hybridized groups of Tamai zone 1-Yamano type 2 and Tamai zone 1-Yamano type 3. Although clinically distinct, the survival rates between the groups were not statistically significantly different. CONCLUSIONS: The level and mechanism of injury play a decisive role in the success of fingertip replantation. Success rate increases in proximal fingertip amputations without crush injury.

Assessment of Patients Who Underwent Nasal Reconstruction After Non-Melanoma Skin Cancer Excision.

BACKGROUND: Basal and squamous cell carcinomas are the most common malignant cutaneous lesions affecting the nose. With the rising incidence of skin cancers, plastic surgeons increasingly face nasal reconstruction challenges. Although multiple options exist, optimal results are obtained when "like is used to repair like". We aimed to introduce a simple algorithm for the reconstruction of nasal defects with local flaps, realizing that there is always more than one option for reconstruction. PATIENTS AND METHODS: We retrospectively reviewed 163 patients who underwent nasal reconstruction after excision of non-melanoma skin cancer between March 2011 and April 2014. We analyzed the location of the defects and correlated them with the techniques used to reconstruct them. RESULTS: There were 66 males and 97 females (age, 21-98 years). Basal cell carcinoma was diagnosed in 121 patients and squamous cell carcinoma in 42. After tumor excision, all the defects were immediately closed by either primary closure or local flap options such as Limberg, Miter, glabellar, bilobed, nasolabial, V-Y advancement, and forehead flaps. CONCLUSIONS: Obtaining tumor-free borders and a pleasing aesthetic result are major concerns in nasal reconstruction. Defect reconstruction and cosmesis are as important as rapid recovery and quick return to normal daily activities, and these should be considered before performing any procedure, particularly in elderly patients.

Long-term changes in nipple-areolar complex position and inferior pole length in superomedial pedicle inverted 't' scar reduction mammaplasty.

BACKGROUND: Proper nipple-areolar complex position in reduction mammoplasty patients is a challenging problem regardless of the preferred technique. Postoperatively, the nipple-areolar complex is often not located at the most projected area of the breast. This retrospective observational study aimed to find the long-term measurements of the nipple-areolar complex position and inferior pole length after inverted T scar-superomedial pedicle reduction mammoplasty. METHODS: Forty-eight female patients (96 breasts) were included in this study. The inclusion criteria were that no previous operation should have been done on any of the breasts and both NAC complexes should be at least 30 cm from the midclavicular point. Preoperatively, the distance from the midclavicular point to the new nipple was recorded. All patients were operated on with the inverted T pattern and superomedial pedicle technique. The resection weights, the distance from the midclavicular point to the nipple distance, and the distance from the NAC lower border to the inframammary fold were evaluated postoperatively with an average of 15-month follow-up. RESULTS: The mean preoperative distance from the midclavicular point to the nipple was 34.21 cm for the right breast and 34.26 cm for the left breast. The mean resection weight per breast was 1035 g for the right breast and 1081 g for the left breast. The descent of the NAC was 1.61 cm for the right breast and 1.79 cm for left breast (mean: 1.7 cm) at the end of the follow-up. Additionally, the inframammary length increased 3.31 cm for the right breast and 3.59 cm for the left breast (mean: 3.45 cm). CONCLUSION: In this study, we found that the new nipple-areolar complex does not go upward but goes downward. However, it was not located at the most projected area of the breast as it was set intra-operatively. This was because the lower pole of the breast sagged more than the nipple: clinically, we observed a nipple superior displacement of 1.75 cm (3.45 - 1.7 = 1.75). According to this calculation, we believe that the new nipple position should be marked at 1.5-1.75 cm below the most projected area of the breast after final shaping so that in the long term, the nipple-areolar complex would be at the proper position. 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 .

Revisiting the role of columellar strut graft in primary open approach rhinoplasty.

BACKGROUND: The effect of a columellar strut graft on final nasal tip position has been a subject of ongoing debate. The purpose of this study was to retrospectively analyze a series of 100 consecutive primary rhinoplasty cases performed without the use of columellar strut grafts, with a specific focus directed toward comparing preoperative, morphed, and actual postoperative changes in nasal tip position. METHODS: Data were collected from patient charts and digital images of 100 consecutive primary open rhinoplasty patients. Preoperative, morphed, and actual postoperative digital images were quantitatively analyzed using image-processing software to compare various anatomical features, including nasal tip projection, nasolabial angle, and Goode ratio. Patient satisfaction regarding long-term postoperative results was also surveyed. RESULTS: Primary rhinoplasty did not demonstrate a universal trend toward either an increase or a decrease in nasal tip projection. The planned changes in nasal tip projection, nasal tip rotation, and nasal profile proportions were obtained with statistically significant accuracy without the use of columellar strut grafts. The overall incidence of columellar contour irregularities was 3 percent. CONCLUSION: In primary open approach rhinoplasty, if native anatomical support structures of the nasal tip are preserved or reconstructed, preoperative goals regarding nasal tip projection, nasal profile proportions, and columellar integrity can be consistently achieved without using columellar strut grafts.

A case of myoepithelioma mimicking a parotid cyst.

Myoepithelioma is an uncommon tumor of the myoepithelial cells that is considered to represent a distinct category of tumor by the World Health Organization. It accounts for less than 1% of all tumors that develop in the salivary glands. We describe the case of a 35-year-old woman who presented to us with a painless swelling on the right side of her face. She was diagnosed with a parotid gland cyst by ultrasonography and computed tomography. Following excision of the mass, however, the pathology report identified the tumor as a solid myoepithelioma. To the best of our knowledge, this is the first reported case of a myoepithelioma that exhibited cystic features on radiologic examination even though it had a solid architecture. We also discuss the preoperative diagnostic aspects of the myoepitheliomas.

Osteoid osteoma of the lunatum mimicking Kienböck's disease.

Hands, especially lunatum, are involved very rarely with osteoid osteoma. This report presents an osteoid osteoma of the lunatum, which was previously misdiagnosed as Kienböck's disease and had undergone surgery. Magnetic resonance imaging may lead the clinician to misdiagnose because of the excessive bone edema around the carpus. The operation should be planned according to radiography and computed tomography findings.

Closed rhinoplasty with open approach advantages: extended intranasal incisions and tip rearrangement sutures.

BACKGROUND: Two main well-known approaches are used in rhinoplasty: open and closed techniques. This study aimed to define two new tip suture modifications that enhance and stabilize tip shape, projection, and position through an extended infracartilaginous incision with an open rhinoplasty exposure. METHODS: This study investigated 56 consecutive primary rhinoplasty patients 18-51 years of age (mean age 27.8 years) who underwent surgery between June 2011 and June 2012 and had at least a 1-year postoperative follow-up period. Rhinoplasty was performed through an extended infracartilaginous incision with an open exposure. Transdomal suture modification for columella-lobular angle augmentation and a footplate repositioning suture for tip projection (and position) enhancement also were defined. A postoperative satisfaction survey was applied to all the patients at their 1-year follow-up visit. RESULTS: The postoperative satisfaction rate was 96 %. The nasal tip positions and projections of the patients were fine and stable in all the patients after a 1-year postoperative period. At this writing, no over- or underprojection, supratip deformity, saddle-nose deformity, or dorsal-surface irregularities have been encountered. Representative cases are displayed. CONCLUSION: This study defined two new tip suture techniques and combined them with an extended infracartilaginous incision. Also, control of the entire nose and nasal valve area was possible through this incision. 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 .

Nasal tip suspending transfixion suture.

BACKGROUND: Anterior septal height is an important determinant of nasal tip projection. Accordingly, the anterior septal extension technique has proven itself to be a powerful tool for achieving long-lasting nasal tip projection in rhinoplasty. However, anterior septal extension does not protect against postoperative loss of nasal tip rotation unless an additional suspension strategy is used. A tip-suspending transfixion suture is the authors' strategy for supporting nasal tip rotation whenever an anterior septal extension technique is performed. METHODS: Of 156 rhinoplasties performed by the authors between 2010 and 2012, a cohort of 22 droopy-tip rhinoplasties was extracted in which the described technique was used. The patients in this cohort were included in a retrospective nasal tip projection and rotation analysis. The nasolabial angle (NLA) and Goode ratio measurements were compared between preoperative, 3-week postoperative, and 1-year postoperative profile-view photographs. RESULTS: The NLA and the Goode ratio measurements were significantly higher in the 3-week postoperative group than in the preoperative group, indicating an effective gain in both tip projection and rotation. The NLA and the Goode ratio measurements did not differ statistically between the postoperative 3-week and postoperative 1-year groups, indicating long-term maintenance of nasal tip position. CONCLUSION: A tip-suspending transfixion suture is an easy method for securing nasal tip rotation when used in conjunction with an anterior septal extension. 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 .

Wrist Tenosynovitis due to Mycobacterium bovis Infection: Case Series and Review of the Literature.

SUMMARY: Tuberculosis infections are still one of the most important public health problems among developing countries. Musculoskeletal involvement represents 10-15% of all extrapulmonary cases. Tuberculosis tenosynovitis is usually misdiagnosed as nonspecific tenosynovitis. To avoid misdiagnosis and mistreatment, it is important to be alert for mycobacterial infections. This article presents 3 patients with wrist tenosynovitis, which was caused by Mycobacterium bovis infection. The article also includes review of the literature.

Skin bridging secondary to ingrown toenail.

Ingrown toenails are painful conditions that especially affect young people and may become chronic if not treated. We describe a case of chronically inflamed ingrown toenail left untreated for three years. In the physical examination, skin bridging and epithelialization was observed in midline secondary to soft tissue hypertrophy of the lateral nail matrixes. Epithelized fibrous tissue was cut across the lateral nail matrix and left for secondary healing. Partial matrixectomy was applied and the remnants were cauterized in compliance with the Winograd procedure after removal of the nail. Our case is an advanced condition which is the second report in the literature. Skin bridging secondary to excess soft tissue hypertrophy can be observed in untreated bilateral Heinfert or Frost stage 3 ingrown nails. This rare case can be classified as advanced stage 3 disease or stage 4.

Enhancement of venous drainage with vein stripper for reversed pedicled neurocutaneous flaps.

The flaps based on the vascular axis of superficial sensitive cutaneous nerves had gained increased popularity in reconstructive surgery because of such major advantages as preservation of major extremity arteries and avoidance of microsurgical procedures. However, postoperative venous congestion resulting in partial or total necrosis is still a common problem for these flaps. The aim of the current study is to introduce a new method for reducing the postoperative venous congestion of neural island flap with the results of reconstruction of the soft tissue defects of foot and ankle. This method was used to treat 19 patients with various chronic soft tissue defects of the foot and ankle between 2011 and 2012. We observed that the novel method presented in this report enables effective venous drainage, solving the postoperative venous congestion problem of these flaps.

A new flap design: prefabricated neuro-osseous flap.

We hypothesized that an osseous tissue can be prefabricated with a peripheral nerve by vascular induction, and by using a rat model, we tested this hypothesis.Twenty Wistar rats were used in the prefabricated neuro-osseous flap study. Bilateral sciatic nerves were placed linearly within the medullary cavities of the femurs. Left femurs were accepted as the experimental group. The right femurs of all the rats were used as internal control where the sciatic nerves were ligated at the bony entrance of the flap.After 6 weeks, all experimental femur flaps were viable. Radioactivity counts and metabolic activity studies showed viable and functional bone tissue in experimental group compared with control group (P = 0.001). On microangiographic evaluation, significant dilatation of the perineural vasculature was observed in experimental group. Histologic investigations showed viable bone tissue only in the experimental group flaps.Due to its easy applicability, reproducibility, and robust circulation, the prefabricated neuro-osseous flap would be an option in reconstructive surgery.

A new microvascular anastomosis technique using muscle graft.

A novel microvascular anastomosis technique is described. Forty-five male Sprague-Dawley rats were divided equally into three groups before undergoing femoral artery anastomosis. The first group received standard eight-suture anastomotic repair. Group 2 (muscle group) received three sutures plus autogenous muscle graft wrapped around the anastomosis. In group 3 (fascial surface group), a muscle graft was wrapped around the anastomosis with the fascial side of the graft facing the anastomosis. Significantly less time and suture usage were noted using both fascial surface and muscle groups compared with controls (p < 0.05). No significant difference regarding patency rates or aneurysm formation existed among the three groups (p > 0.05). Additionally, grade 2 anastomotic leakage was less frequent in the study groups compared with the control group (p < 0.05). This new microvascular anastomosis technique took less time and achieved better performance than standard anastomotic repair.