Rhinoplasty: lessons from "errors" : From anatomy and experience to the concept of sequential primary rhinoplasty.

BACKGROUND: Reshaping the nose can be achieved following 3 main concepts: preservation and reshaping of normal anatomy, resection of nasal deformities, reconstruction of nasal framework. Time, experience and nasal anatomic knowledge are keys to understand nasal biomechanics. OBJECTIVES: To describe how experience and morphodynamic anatomy lead to a new concept of sequential primary rhinoplasty, resulting in reducing revision rhinoplasties. METHODS: Through 36 years' experience in different rhinoplasty procedures, 25 years in personal anatomic studies of the nose and reviewing the last 15 years including 600 patients who underwent new concepts in primary rhinoplasty out of 1200 patients operated during this period, the author analyzes how nasal anatomic layers, surgical approaches, and morphological effect of the time interact to modify the aesthetic results according to current rhinoplasty concepts. RESULTS: Nasal bony cartilaginous vaults biomechanics understanding leads to consider the K­area as a flexible joint which can be reshaped without resection of the nasal vaults. The role of the subdorsal septum is highlighted as the main anatomic structure which can be safely resected in rhinoplasty, and which allows to respect the natural anatomy, the nasal valves and the dorsal aesthetic lines. Description of nasal compartments divided by the "T" ligament leads to rethink the incisions and approaches of the nose: the interseptal-columellar and extended infracartilaginous incisions allow to protect nasal ligaments and to perform a deep plane undermining. Protection of the anatomic layers allows quick recovery, nasal function improvement and long-lasting results. CONCLUSION: The goal to reduce the rate of revision rhinoplasty and to improve the natural results can be achieved, considering the concept of sequential primary rhinoplasty. Nasal soft tissues are protected as far as possible. The current rhinoplasty concepts are not antagonist but appear as an intraoperative succession of alternative techniques from anatomy and function preservation to reconstruction of the nasal framework.

The domes crossover: a new method of nasal tip modification.

OBJECTIVES: To discuss overprojected nasal tips, to overview treatment options, and to introduce a new method of nasal tip modification. PATIENTS AND METHODS: A retrospective study was conduced on 29 patients who underwent rhinoplasty where the domes crossover technique was employed. Patients were stratified into 3 groups: 18 patients presented with homogeneous overdevelopment of the LLC (nasal tip over projection type 1), 5 patients with predominant over development of the lobular portion of the LLC (nasal tip overprojection type 2), 6 patients with a true Pinocchio-type nose and a predominant overdevelopment of the columellar portion of the LLC (nasal tip overprojection type 3). Before and after photographs were compared to evaluate nasal tip characteristics. Analysis of results was performed by the use of 3 measurements: Goode's ratio, nasofacial angle and lobule-to-columella ratio. RESULTS: Final nasal tip projection, rotation, volume and shape were satisfactory in all cases. No complication was observed during the follow-up period. CONCLUSION: This new method of nasal tip modification presents the advantage of preserving natural domes, being quick and allowing the achievement of desirable nasal tip projection, rotation, volume and shape. Moreover according to the alar ring concept, the crossover technique preserves the continuity of the inferior cartilaginous arch and gives an excellent support to nasal tip.

[Contribution to the anatomical and surgical study of the infra orbital area. Clinical applications to the tear trough area]. / Contribution à l'étude anatomo-chirurgicale de la region infra orbitaire appliquée à la vallée des larmes.

OBJECTIVES: To define the anatomy of the infra orbital area and assess the possible connections with the facial morphotypes identifying the tears trough. To deduce therapeutic proposition concerning the management of this area in aesthetic medicine or surgery. METHODS: Anatomic dissections of 10 fresh specimens not frozen and not formalin. Dissection layer by layer from skin to bones paying special attention to the infra orbital superficial muscles and the distribution of subcutaneous fat. RESULTS: In this study, it was precised the existence of zygomaticus superficialis and levator genae muscles whose variations in the connections with the orbicularis oculi muscle is probably the origin of the diversity of human facial expression. On the other hand, the tear trough seems to depend on different distributions of the anatomical complex formed by these muscles with the subcutaneous fat and skin that covers it. An anatomical classification into three muscle types has been proposed. CONCLUSION: The main variations between individual facial expression are related to a different muscular anatomy from one subject to another. The myological classical anatomic description, too stereotyped, can not explain those differences. The classification proposed by the authors can differentiate the facial morphotypes in the infra orbital area and offer therapeutic solutions.

[Salivary stones and stenosis. A comprehensive classification]. / Lithiases et sténoses salivaires. Une classification pratique des pathologies non tumorales.

INTRODUCTION: Sialendoscopy and sialo-MRI enable diagnosis of salivary gland obstructive pathologies, such as lithiasis, stenosis and dilatations. Therefore, a classification of these pathologies is needed, allowing large series comparisons, for better diagnosis and treatment of salivary pathologies. MATERIAL AND METHODS: With help from people from the European Sialendoscopy Training Center (ESTC), the results of sialographies, sialoMRI and sialendoscopies, a comprehensive classification of obstructive salivary pathologies is described, based on the absence or presence of lithiasis (L), stenosis (S) and dilatation (D) ("LSD" classification). DISCUSSION: It appears that a classification of salivary gland obstructive pathologies should be described. We hope it will be widely used and of course criticized to be improved and to compare the results of salivary gland diagnostic methods, such as sialography and sialendoscopy and also the results and indications for salivary gland therapeutic methods, such as lithotripsy, sialendoscopy and/or open surgery.

Salivary stones and stenosis. A comprehensive classification.

INTRODUCTION: Sialendoscopy and sialoMRI enables diagnosis of salivary gland obstructive pathologies, such as lithiasis, stenosis, and dilatations. Therefore, a classification of these pathologies is needed, allowing large series comparisons, for better diagnosis and treatment of salivary pathologies. MATERIAL AND METHODS: With help from people from the European Sialendoscopy Training Center (ESTC), the results of sialographies, sialoMRI and sialendoscopies, a comprehensive classification of obstructive salivary pathologies is described, based on the absence or presence of lithiasis (L), stenosis (S), and dilatation (D) ("LSD" classification). DISCUSSION: It appears that a classification of salivary gland obstructive pathologies should be described. We hope it will be widely used and of course criticized to be improved and to compare the results of salivary gland diagnostic methods, such as sialography and sialendoscopy, and also the results and indications for salivary gland therapeutic methods, such as lithotripsy, sialendoscopy, and/or open surgery.

[Artistic anatomy of the nose: proposals for a simplified project of rhinoplasty]. / Anatomie artistique du nez: propositions pour un projet simplifié de rhinoplastie.

OBJECTIVE: The authors developed an original and simple method of evaluation of the aesthetic lines of the nose adapted to the harmony of the face. METHOD: Initially based on their experience, the authors propose an evaluation of the nose in 2 stages and 5 sequencies based on the construction of single circuit lines according to various incidences. They checked thereafter the validity of this method on the operative project and on the appreciation of the results of the rhinoplasties. RESULTS: Controlled on several types of faces, the method suggested by the authors proved to be reliable, simple, reproducible. CONCLUSION: The authors proposed a method of evaluation of the aesthetic lines of the nose integrated to the harmony of the face. This method relies on the construction, in 5 stages, of single circuit lines not requiring any particular material. The artistic method of evaluation of the nose proposed by the authors is very simple. Rapid and immediately usable, it makes it possible to schedule a rhinoplasty in a few minutes. The evaluation of the aesthetic results of the rhinoplasties is also very simple and reproducible. It has moreover the merit to propose a model of teaching making it possible to the rhinoplastician to criticize his results and thus to progress in its technical training and its operational indications.

[Surgical anatomy of the nose]. / Anatomie chirurgicale de la pyramide nasale.

A good anatomical knowledge is a pre-requisite to all surgeries. In rhinoplasty, where many steps are performed without visual control and are only guided by palpation, anatomy must be mastered. Based on classical static anatomy and dynamic surgical modifications of the nose, this study analyses anatomical and surgical correlation and reports their technical implications. Correction of the shape of the nose is to be able to conceptualize the underlying skeleton and to program adapted surgical procedure for each case.

[Rhinoplasty: morphodynamic anatomy of rhinoplasty. Interest of conservative rhinoplasty]. / La rhinoplastie : anatomie morpho-dynamique de la rhinoplastie. Intérêt de la rhinoplastie "conservatrice".

OBJECTIVES: To highlight the morphodynamic anatomical mechanisms that influence the results of rhinoplasty. To present the technical modalities of nasal dorsum preservation rhinoplasties. To determine the optimized respective surgical indications of the two main techniques of rhinoplasty: interruption rhinoplasty versus conservative rhinoplasty. MATERIALS AND METHODS: Based on anatomical dissections and initial morphodynamic studies carried out on 100 anatomical specimens, a prospective study of a continuous series of 400 patients operated of primary reduction rhinoplasty or septo-rhinoplasty by one of authors (YS) has been undertaken over a period of ten years (1995-2005) in order to optimize the surgical management of the nasal hump. The studied parameters were: (1) surgical safety, (2) quality of early and late aesthetic result, (3) quality of the functional result, (4) ease of the technical realization of a possible secondary rhinoplasty. The other selected criteria were function of the different nasal hump morphotypes and the expressed wishes of the patients. RESULTS: The anatomical and morphodynamic studies made it possible to better understand the role of the "M" double-arch shape of the nose and the role of the cartilaginous buttresses not only as a function but also the anatomy and the aesthetics of the nose. It is necessary to preserve or repair the arche structures of the septo-triangular and alo-columellar sub-units. The conservative technique, whose results appear much more natural aesthetically, functionally satisfactory and durable over the long term, must be favoured in particular in man and in cases presenting a risk of collapse of the nasal valve. CONCLUSION: The rhinoplastician must be able to propose, according to the patient's wishes and in view of the results of the morphological analysis, the most adapted procedure according to his own surgical training but by supporting conservation of the osteo-cartilaginous vault whenever possible.

[Surgical anatomy of the face lifting]. / Anatomie chirurgicale du lifting de la face.

OBJECTIVES: Contrast between an immutable anatomy and procedures which constantly evolve requires a dynamic vision and knowledge of the surgical anatomy. The surgeon, confronted with the reality of the anatomical risk must regularly re-examine his "basics" in anatomy and adapt them to techniques sometimes very invasive whose aesthetic benefit must be seriously counterbalanced by the operational risk. The authors endeavoured to present the surgical anatomy of the facelifts while insisting on the practical aspects and the concept of the evaluated surgical risk. METHOD: Based on more than 15 years experience related on the one hand to more than 400 anatomical dissections of the face and the neck and on the other hand on more than 600 lifts of the face and the neck, the authors analyze the various successive plans from the skin toward the deep osseous plan as they are anatomically and as the surgeon meets them. Each one of these plans is presented according to the various anatomical areas while insisting on its anatomical characteristics and its specific surgical risks.

Efficacy and tolerability of budesonide aqueous nasal spray treatment in patients with nasal polyps.

OBJECTIVE: To assess the efficacy and tolerability of once-daily treatment with budesonide aqueous nasal spray in patients with nasal polyps. DESIGN: Randomized, double-blind, placebo-controlled, parallel-group study. SETTING: Sixteen hospital clinics. PATIENTS: One hundred eighty-three patients with moderate-sized nasal polyps causing clinically significant symptoms during a 1-week run-in period. INTERVENTIONS: Patients were randomized to receive 1 of the following 4 budesonide aqueous nasal spray treatments: 128 microg once daily in the morning and placebo in the evening, 128 microg twice daily, 256 microg once daily in the morning and placebo in the evening, or placebo for 8 weeks. Nasal polyp size was scored and peak nasal inspiratory flow was measured at clinic visits at the beginning and end of the run-in period and after 4 and 8 weeks' treatment. Patients recorded daily peak nasal inspiratory flow, symptom scores (ie, blocked nose, runny nose, and sneezing) and sense of smell on diary cards. MAIN OUTCOME MEASURES: Mean change in nasal polyp size at the end of treatment; mean changes in combined and individual symptom scores. RESULTS: All doses of budesonide aqueous nasal spray significantly (P<.01) reduced polyp size; no significant differences were noted between the 4 treatment groups. The mean improvement in clinic peak nasal inspiratory flow at 8 weeks was 65.9 L/min with budesonide aqueous nasal spray, 128 microg twice daily; 71.6 L/min with budesonide aqueous nasal spray, 256 microg once daily; and 54.6 L/min with budesonide aqueous nasal spray, 128 microg once daily (all P<.001 vs placebo). Combined and individual symptom scores and sense of smell improved significantly in all budesonide-treated groups; the effect on symptoms became apparent within 1 to 2 days of the first dose. Budesonide aqueous nasal spray was well tolerated. CONCLUSIONS: Doses of budesonide aqueous nasal spray, 128 microg once daily, were found to be effective in the treatment of nasal polyps, and doses of budesonide aqueous nasal spray, 256 microg once daily, did not show any significant additional efficacy.

[Fiber optic endoscopically-guided intranasal dacryocystorhinostomy in post-traumatic surgery of the lacrimal ducts]. / Dacryocystorhinostomie endonasale sous guidage optique endoscopique dans la chirurgie posttraumatique des voies lacrymales.

Increasingly today, dacryocystorhinostomy seems to be the common obligatory path to functional surgery in case of traumatic lesions of the lacrimal ducts. The endonasal approach provides direct access to the nasolacrimal canal, while permitting to avoid the cutaneous approach through tissues that may be coming apart. The use of optic endoscopes renders the operation easier and provides access to the dome of the lacrimal sac, which is impossible under conventional endonasal microscopy. Monitoring and postoperative care are carried out with the same instrument, thereby improving the quality of the end result. The operation usually takes place under potentiated local anesthesia and lasts one hour, on average. The various surgical steps are described and particular attention is given to endonasal localization of the lacrimal ducts and to the technique of marsupialization.

[Köle's operation]. / L'opération de Köle.

Kole's operation combines segmental alveolar osteotomy of lower incisor-canine region with a reduction mentoplasty. The procedure usually provides a reduction in height of mentum, sometimes with an advancement, and involves ablation of an intermediate bone fragment. Ablation of lower border as described by Kole too frequently results in an esthetically poor chin. Insertions of platysma and digastric muscles are untouched. The inferior segmental osteotomy separates the lower incisor-canine region, which is displaced upwards or upwards and backwards after extraction of premolars, displacement being maintained by interposition of bone detached during mentoplasty. A reduction glossectomy is almost constantly associated. The best indication for Kole's operation is anterior gaps with or without proalveoli. It is often combined with segmental or total surgery to maxilla. Results are generally stable, especially after mentoplasty, but from the dental aspect pulp mortifications are not rare.

[Mandibular laterognathism and its treatment]. / A propos des latérognathies mandibulaires et de leur traitement.

It is proposed to alter the classification of laterognathy due to excessive unilateral development of the mandible into hypercondyly and mandibular hemihypertrophy. Two forms are distinguished: those with occlusal modifications and those with conserved occlusal ratios and compensatory skeletal deformities usually involving the two stages. Treatment of laterognathy with occlusal deformity is usually by condylectomy--a simple operation with rapid results and excellent articular tolerance. Treatment of those forms with marked skeletal deformity is usually by condylectomy combined with a Lefort I of occlusal adaptation, surgery for the basilar border being difficult and aleatory except in the region of the chin.

[2 cases of anaphylaxis from droperidol]. / Deux cas d'anaphylaxie au dropéridol.

Following two cases of anaphylactoid reactions during anaesthesia, immunoallergological investigations showed up the responsibility of droperidol, which probably acted by way of an anaphylactic mechanism. In both cases, there were no cardiovascular signs, the main clinical symptom being bronchospasm. The exceptional nature of allergic accidents due to neuroleptic drugs, as opposed to extrapyramidal phenomena, must be underlined. However, these reactions should cast doubts on the safety and usefulness of neuroleptanalgesia.

[Severe anaphylactoid accidents occurring during general anesthesia]. / Accidents anaphylactoïdes graves survenus au cours d'une anesthésie générale.

Four patients were studied following an anaphylactoid accident occurring during general anaesthesia. Histamine release was assessed on clinical signs, basophil degranulation and, in one case, an early serum histamine peak. Past medical history revealed previous allergies in all cases. An immunological study showed that IgE, CH50, C3 and C4 serum levels were within the normal range. Skin reactivity to histamine was normal in all but one case. In every case, one of the drugs used during the anaesthetic gave a positive skin test and was considered as the causative agent. There were discrepancies between the in vitro and in vivo tests of basophil degranulation, a second drug being positive in one case, and several drugs inducing abnormal degranulation reactions in the other cases. The drugs considered as involved in these accidents are noteworthy: suxamethonium (two cases), fluid gelatin (Plasmion) and droperidol. The results are discussed by the authors.