Pollybeak deformity in rhinoplasty: prevention and treatment.

OBJECTIVE: Patients with pollybeak deformity who underwent rhinoplasty were analyzed retrospectively and across centers to identify their primary risk factors, preventative measures, and treatment modalities. PATIENTS AND METHODS: The retrospective data of 100 pollybeak deformity cases (61 males and 39 females) were enrolled in our study. The causes leading to pollybeak deformity were evaluated and classified as (1) Over-resected bony dorsum, (2) Excessive supra tip scarring, and (3) Inefficient tip support causing an under-projected tip. The treatments applied to patients with pollybeak deformity were retrospectively evaluated and classified as (1) Triamcinolone acetonide injections (one or two injections), (2) Filler injection over the bony dorsum to balance, (3) Using a graft to achieve the desired nose shape, (4) Trimming down the excessive supra tip soft tissue and/or tip cartilage, and (5) Enforcing the tip support. RESULTS: Our results showed that the major cause of pollybeak deformity was excessive supra-tip scarring (48%). The other reasons are inefficient tip support, causing an under-projected tip (28%), and over-resected bony dorsum (24%). The modalities for the treatment of pollybeak deformity were (1) Trimming down the excessive supra tip soft tissue and/or tip cartilage (30%), (2) Triamcinolone acetonide injections (one or two injections) (28%), or (3) Enforcing the tip support (28%), (4) Using a graft to achieve the desired nose shape (14%) and (5) Filler injection over the bony dorsum to balance (6%). In some patients, more than one treatment modality was applied. Triamcinolone acetonide or filler injections were the non-surgical therapies for pollybeak deformities. CONCLUSIONS: We concluded that excessive supra-tip scarring is not directly related to a surgical error but rather depends on the patient and tissue healing. Care should be taken to avoid over-resecting the bony dorsum. Tip support should be provided to prevent inefficient tip support from causing an under-projected tip. However, efforts should be made to minimize supra-tip dead space and possibly proceeding pollybeak formation through proper bandaging.

The Two-Stage Folded Paramedian Forehead Flap Without Cartilage Grafts for Full Thickness Distal Nasal Defects: A Review of 35 Patients.

BACKGROUND: Full thickness defects of the ala, soft triangle, and nasal tip involving the nasal lining have traditionally been repaired with the three-stage folded paramedian forehead flap (FPFF), with a cartilage graft for support. For similar defects, the authors utilize the two-stage FPFF without cartilaginous support which provides reproducible functional and aesthetic results.  Objective: To describe the authors’ experience with the two-stage FPFF, including outcomes, complications, and design modifications to enhance functional and aesthetic success.  Methods: An IRB-approved retrospective database review of FPFF was performed at two sites. Using postoperative photographs, outcomes were assessed by blinded non-investigator dermatologist raters using a modified observer scar assessment scale. RESULTS: Thirty-five patients were reconstructed using the two-stage FPFF without cartilage grafts. Subjective assessment of scar vascularity, pigment, relief, and thickness by 3 independent reviewers yielded an overall cosmesis score of 8.4±1.9 (out of 40). CONCLUSION: The two-stage FPFF without cartilage grafts is a reliable, cosmetically elegant repair that can provide optimal functional and aesthetic results for complex unilateral distal nose defects.J Drugs Dermatol. 2024;23(4): doi:10.36849/JDD.7358.

Implications of Malignancy, Radiation, and Timing of Major Nasal Reconstruction.

Owing to the complex, multilayered anatomy of the nose in the central face, major nasal reconstruction can pose a significant challenge for reconstructive surgeons. It is the responsibility of reconstructive surgeons to have an understanding of the most common cutaneous malignancies and excisional techniques that may lead to complex nasal defects. The purpose of this article is to discuss these malignancies, excisional techniques, and impacts of radiation on tissue that has implications for reconstructive surgeons.

Nasal Lining Reconstruction with Prelaminated Forehead Flap.

A successful nasal reconstruction relies heavily on a stable internal lining. Larger defects pose unique challenges for internal lining reconstruction as obtaining tissue of adequate size while maintaining airway patency is difficult. The prelamination technique uses a staged skin graft to the paramedian forehead flap prior to transfer. As such, a composite flap can be later transferred to reconstruct internal and external nasal defects concomitantly. This article reviews the current background, techniques, and clinical considerations in the use of the prelaminated forehead flap for nasal lining reconstruction in partial to total nasal defects.

Total Nasal Reconstruction: Advances in Free Tissue Transfer for Internal Lining and Structural Support.

Total nasal reconstruction is a complex challenge due to the need to establish new internal lining, internal structural support, and external skin covering that is both functional and esthetic. The medial femoral condyle corticoperiosteal free flap represents an innovative option for restoration internal structure and internal nasal lining. When used in conjunction with a paramedian forehead flap, acceptable results in both function and esthetics can be achieved.

Nuances in Forehead Flap Reconstruction for Large Nasal Defects.

The forehead flap is a time-tested and robust resurfacing flap used for nasal reconstruction. Owing to its excellent color and texture match, acceptable donor site morbidity, and robust and independent blood supply that can support both structural and internal lining grafts, this flap remains the workhorse flap for resurfacing large nasal defects. Various nuances of this technique relating to defect and template preparation, flap design, flap elevation, flap inset, donor site closure, and pedicle division are discussed in this article. These nuances are the guiding principles for improved outcomes using a forehead flap for the reconstruction of large nasal defects.

Reconstruction of Large Composite Defects Extending Beyond the Nose.

Nasal reconstruction remains one of the most challenging surgeries for facial plastic and reconstructive surgeons. The addition of defects extending beyond the nose adds a layer of complexity to an already technically demanding surgery. This article will focus on the management of composite defects extending beyond the boundaries of the nose. Surgeons need to have a variety of techniques at their disposal. These complex defects often require multiple local flaps, multiple stages, and, in select cases, free tissue transfer.

Changes in patient-reported satisfaction and quality-of-life 6 months after rhinoplasty.

BACKGROUND: Rhinoplasty is a challenging and demanding procedure in plastic surgery. Surgical success, patient satisfaction, and improved quality-of-life are important outcomes. OBJECTIVES: This study aimed to evaluate patient-reported satisfaction with appearance, treatment, and decision outcomes as well as quality-of-life after rhinoplasty using validated questionnaires. The role of patient demographics on outcomes was also studied. METHODS: Patients who underwent a primary rhinoplasty were selected for this cohort study. Patient-reported satisfaction with appearance, treatment, and decision as well as quality-of-life were evaluated with the Utrecht Questionnaire and FACE-Q at intake and 6 months postoperatively. RESULTS: Overall, 380 patients were included. Patients reported a more positive subjective perception of nasal appearance (VAS score) at 6 months post-surgery compared with preoperative scores (7.9 ± 1.6 vs 3.2 ± 1.4, p < 0.05). Furthermore, higher quality-of-life and body image scores were observed at 6 months postoperatively compared with preoperative scores (7.7 ± 3.5 vs 15.2 ± 4.4, p < 0.05). Patients reported high satisfaction with treatment outcome (70.3 ± 23.4) as well as with their decision to undergo surgery (75.9 ± 23.4) on a scale of 0-100 at 6 months postoperatively. Patients reached similar postoperative scores regardless of their intake scores. Patients ≥30 years and patients with a history of cosmetic surgery were less satisfied postoperatively. CONCLUSION: Despite differences in appearance satisfaction at intake, most patients showed greater satisfaction with appearance, treatment, and decision outcomes as well as quality-of-life 6 months postoperatively. However, older age and a history of cosmetic surgery influenced these outcomes negatively. These factors should be considered during preoperative management of outcome expectations.

Rinoplastia secundaria: infección nasal en el postoperatorio / Secondary rhinoplasty: postoperative nasal infection

La rinoplastia es una de las intervenciones más comunes en cirugía plástica. Se opera aquí una rinoplastia secundaria por vía abierta injertando los alares y la punta con cartílagos auriculares, mientras el tabique cartilaginoso fue usado para los spreader grafts. Se describe aquí una infección posoperatoria de su punta nasal. Al 9no día de su posoperatorio comienza con la punta nasal congestiva y levemente inflamada. Se medica con una crema con antibióticos, pero el día 14 aparece con la punta nasal muy inflamada y con colección. Cuando en el consultorio el cirujano la ve, como cualquier absceso, decide realizarle drenaje con un trocar 18G, 3 miniincisiones en la piel debajo de la punta nasal, de la que drena un líquido amarronado. Luego con el mismo trocar se realiza un lavado dentro de la cavidad con rifampicina solución. Se medica con trimetoprima-sulfametoxazol (Bactrimforte®) 2 comp/día. Al otro día se observa una notable mejoría. Se continuó con lavado diario durante 4 días con el mismo antibiótico evolucionando rápidamente bien. El Bactrim se lo continúa por 20 días. Al mes la punta nasal está muy bien, deshinchada con cicatrices apenas visibles. A los cuatro meses, la punta está muy blanda, las alas nasales y las narinas normales, la punta con buena proyección igual que el dorso con los spreader graft.

Rhinoplasty is one of the most common interventions in plastic surgery. A secondary open rhinoplasty was carried out grafting the allae and the tip of the nose with conchae cartilage, while the septum was used for spreader grafts. We are here describing this post operatory with a tip of the nose infection.In the control, at the 9th postoperative day, the nasal tip began to be congested and at the 14th post op day the patient showed a clear inflammatory collection. In the office, the surgeon decided to evacuate it with three punctureslike little incisions at the inferior part of the skin tip with a trocar 18G. Through them, drained brownish purulent secretion. With the same trocar, rifampicin solution was injected through these little incisions, like washing the subdermal area. It was medicated with trimethoprim-sulfamethoxazole (Bactrim forte®) 2 tablets/day. The following day, there was a clear improvement in the congestion and erythema of the nose. This procedure of washing was repeated for four days. There was a quick evolution of the inflammatory process and 20 more days, there was no sign of the infection. Four months later, the tip of the nose was soft and the result was considered optimal by the patient and doctors.

Improvement in nasal airway obstruction after secondary rhinoplasty for cleft lip: A systematic review.

BACKGROUND: The purpose of the study was to comprehensively review the improvement in nasal airway obstruction after secondary rhinoplasty for cleft lip. METHODS: The search was conducted on PubMed, Embase, and Scopus databases for relevant studies published within the past twenty years. Inclusion criteria encompassed patients undergoing secondary rhinoplasty with cleft lip nasal deformity and some evaluation of the nasal outcome. RESULTS: A thorough analysis of available studies identified 29 articles that met the inclusion criteria for final assessment. Seven (24.1%) studies were classified as Therapeutic Ⅱ (T II) according to the American Society of Plastic Surgeons level of evidence scale, while the majority were categorized as T III (17.2%), T IV (51.7%), and T V (6.9%). Subjective methods were employed in 21 articles to measure nasal ventilation outcomes, whereas 8 studies utilized objective methods. Overall findings from all included studies consistently indicated an improvement in nasal ventilation post-surgery. CONCLUSIONS: Although there is no consensus regarding the impact of secondary rhinoplasty on nasal airway obstruction in cleft lip patients, this review suggests that it can effectively alleviate such obstructions. We conducted an anatomical analysis to investigate the impact of various surgical techniques on nasal ventilation to provide recommendations for postoperative ventilation assessment.

Nonsurgical Rhinoplasty with Hyaluronic Acid.

The history of nonsurgical rhinoplasty with hyaluronic acid fillers dates back to the early 2000s when medical advancements in cosmetic dermatology began exploring less-invasive alternatives to traditional surgical procedures. Hyaluronic acid, a naturally occurring substance in the body known for its hydrating and volumizing properties, was being used successfully in other facial augmentation treatments. Around the mid-2000s, the use of hyaluronic acid fillers for nonsurgical rhinoplasty gained momentum. By injecting hyaluronic acid fillers into precise areas of the nose, cosmetic practitioners could effectively smooth out irregularities, correct minor asymmetry, augment the nasal bridge and even enhances nasal tip projection and definition.

The relay graft, a tailored supplement between the nasal hump and established tip in East Asian rhinoplasty.

BACKGROUND: In East Asian individuals, the nasal bone already has sufficient height for an ideal dorsal profile, but the tip requires enhancement for a desired projection. Consequently, the gap between the intrinsic bony structure and the established nasal tip requires appropriate management. The options are either to reduce the keystone region to create a smooth bed for a conventional dorsal onlay graft or to preserve the original osseocartilaginous structures and then customize a supplementary graft. The aim of this study was to detail and validate the utilization of a relay graft, a transition graft that fills the structural gap between the upper dorsum and established tip graft. The proper application of this graft could prevent osteotomy and preserve the intrinsic dorsum. METHODS: Relay grafts were applied during rib-based rhinoplasty in East Asian patients. Three-dimensional stereophotogrammetric evaluations of the patients were performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection improvement, radix elevation, and the angulation of kyphion and pronasale. RESULTS: Fifteen female patients, ranging in age from 21 to 40 years (average 24.5 years), were included. In all cases, the relay graft was applied as one essential element for filling the structural gap. No crooked dorsal profile or visible graft was noted in all cases. Fifteen patients completed the pre- and postoperative stereophotogrammetric study. Postoperative analysis showed great improvement of tip position as well as a slight elevation of the radix, evidenced by the consistent change of kyphion/pronasale angulation and sellion elevation. CONCLUSIONS: The relay graft effectively mitigates the necessity of a disruptive dorsal reduction. It is entirely possible for East Asians to achieve a smooth dorsal profile when only the lower half of the dorsum is transitioned to the proposed tip position. LEVEL OF EVIDENCE: Level IV, case series.

Facial Feminization: Middle Third of the Face.

Facial feminization surgery (FFS) as applied to the midfacial region targets modifications to the nasal and malar esthetic complexes. Although a global assessment is paramount in achieving desired functional results, most patients benefit from malar feminization in the form of bony and soft tissue augmentation, and nasal feminization in the form of reductive rhinoplasty. For patients with signs of aging, additional interventions in the form of rhytidectomy are powerful adjuncts to feminization. As with FFS techniques directed toward the upper and lower thirds, the overarching goal is to obtain complementary outcomes that enhance facial harmony and beauty.

Evaluating the therapeutic and reconstructive efficacy of flap transplantation techniques in managing nasal tissue deficiency resulting from post-rhinoplasty surgical infections.

Rhinoplasty is a frequently performed aesthetic surgery with a high procedural volume. Despite the operational ease and safety profile of biocompatible materials such as silicone and inflatable prosthetics, postoperative complications like surgical site infections can lead to significant clinical challenges. These complications necessitate effective therapeutic and reconstructive interventions. This study aims to evaluate the efficacy of different flap transplantation techniques for early treatment of post-rhinoplasty nasal tissue deficiencies. A retrospective study was conducted from May 2018 to May 2023, involving 38 patients divided into a control group receiving standard anti-infective treatment and an observation group undergoing early flap grafting procedures. Efficacy was evaluated using objective metrics-namely, nasal appearance, function and flap condition-each assessed through a 10-point scoring system, and subjective metrics such as patient satisfaction gauged through self-administered questionnaires. Statistical analyses were performed using SPSS version 27.0. Both groups were statistically comparable in terms of demographics such as age, marital status and educational background. The observation group displayed significantly improved outcomes in terms of nasal aesthetics (mean score 7.92 ± 1.00), nasal function (mean score 8.47 ± 0.51) and flap condition (mean score 7.89 ± 1.12) compared to the control group. Flap transplantation techniques demonstrated superior therapeutic and reconstructive efficacy in the management of nasal tissue deficiencies arising from post-rhinoplasty surgical infections. These findings contribute to evidence-based recommendations for optimal clinical practice.

Primary rhinoplasty in patients with bilateral cleft lip: Longitudinal results and comparison between closed and semi-open approaches.

BACKGROUND: Although several studies have shown that primary rhinoplasty in patients with cleft lip provides good outcomes with limited effect on nasal growth, the surgical procedure remains to be standardized. The purpose of this study was to evaluate the long-term outcome of primary semi-open rhinoplasty with Tajima reverse-U incision, compared with that of closed rhinoplasty. METHODS: Consecutive nonsyndromic patients with complete bilateral cleft lip and palate (n = 52) who underwent primary semi-open rhinoplasty between 2001 and 2016 were reviewed. Patients who underwent primary closed rhinoplasty (n = 61) and control group individuals were recruited for comparison. Computer-based standardized measurements of 2D photographs and panel assessments by laypersons were collected and statistically analyzed. RESULTS: In the comparative analysis at preschool age, semi-open rhinoplasty significantly improved the typical nasal deformities, including transversely oriented wide nostrils, short columella, and de-projected nasal tip, more effectively than closed rhinoplasty. Without major drawbacks, these parameters in the semi-open group were well maintained closer to those in the control group till skeletal maturity. After primary rhinoplasty, 54% of patients in the closed group and 4% in the semi-open group underwent intermediate rhinoplasty at preschool age. CONCLUSION: This study showed that the patients who underwent primary semi-open rhinoplasty achieved long-term and persistent outcomes that were closer to the normal nasal morphology compared with the patients treated with closed rhinoplasty, while avoiding intermediate rhinoplasty during the preschool to adolescent periods.

Novel classification system for adult Asian secondary bilateral cleft lip with nasal deformity that guides surgical strategy.

BACKGROUND: Bilateral cleft lip is a congenital defect often accompanied by secondary lip and nose deformity. The current classification system for secondary cleft lip deformity has limitations in guiding surgical planning. In this article, we report a method for secondary bilateral cleft lip classification that can guide surgery on the basis of the pathological anatomy of the columellar and upper lip. METHODS: Photographs of patients were retrospectively classified into four types on the basis of the ratio of columellar height to alar base width (CH/AW) and upper lip protrusion (UP) to lower lip, as follows: type I - with CH/AW ≥ 0.2 and UP ≥ 0; type II - with CH/AW ≥ 0.2 and UP <0; type III - with CH/AW < 0.2 and UP ≥0; type IV - with CH/AW < 0.2 and UP < 0. Surgical treatments and the change of the nasal profile were documented. RESULTS: A total of 105 patients from January 2008 to December 2018 were included in this study. The nasal profile was significantly improved in type III and IV patients with postoperative CH/AW values close to normal. The upper lip was distinctively retruded in type II and IV patients before treatment, and the postoperative view revealed improved upper lip protrusion with UP values close to normal. Ninety-eight patients reported satisfactory outcomes after treatment. CONCLUSIONS: The new classification method described provides key information regarding the deformity of different types of secondary bilateral cleft lip patients and provides clear guidance for surgical planning on the basis of the anatomical defect of each type.

Temporoparietal Fascia Graft and Polydioxanone Plate Repair of Nasal Septal Perforation.

BACKGROUND: Surgical repair of septal perforations has been historically cumbersome. Recently described techniques utilizing interposition grafting with polydioxanone (PDS) plates wrapped in a temporoparietal fascia (TPF) graft have reported successful closure in 90% to 100% of cases. Our objective is to expand the investigation into the use of interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft for nasal septal perforation repair. METHODS: Retrospective review of the medical record was performed for all septal perforation repairs using the TPF-PDS plate interposition graft technique from August 1, 2017 to March 1, 2021 at the University of Iowa. Minimum post-operative follow-up was 1 month. RESULTS: Our series included 31 patients with symptomatic nasal septal perforations. Thirteen patients underwent open while 18 patients underwent endonasal graft placement. The mean perforation size was 1.49 cm2. The mean post-operative follow-up was 11.5 months. CONCLUSIONS: Repair of symptomatic nasal septal perforations using an interposition graft of polydioxanone plate wrapped in temporoparietal fascia demonstrated an overall success rate of 90%.

Non-surgical rhinoplasty through minimal invasive nose thread procedures: Adverse effects and prevention methods.

BACKGROUND: This review addresses the intricacies of non-surgical rhinoplasty, particularly focusing on the utilization of absorbable sutures known as "Volumizing threads" in combination with fillers. The aim is to explore the enhanced precision of nasal contouring offered by these combined procedures compared to sole filler injections. METHODS: Through comprehensive clinical cases, this article scrutinizes the landscape of adverse effects and their prevention strategies associated with minimal invasive nose thread procedures. The discussion emphasizes various complications, including thread protrusion, migration, infections, skin dimpling, and granuloma formation, along with their respective management approaches. RESULTS: This article delineates cases of complications arising from thread placement, ranging from visibility issues to skin infections and granuloma formation. It highlights instances of thread visibility, oral mucosa protrusion, skin infections, dimpling, and granuloma formation. Additionally, it outlines the corresponding management strategies, accentuating the criticality of early intervention to preclude severe complications in non-surgical rhinoplasty involving nose threads. CONCLUSION: Non-surgical rhinoplasty, leveraging nose thread procedures, offers heightened precision compared to conventional filler injections. However, the review underscores the importance of recognizing potential risks and promptly addressing complications like thread extrusion, migration, and infections. Understanding these complexities in non-surgical rhinoplasty aids in informed decision-making and efficient patient care.

The Ram Graft: Using One Complete Piece of Conchal Cartilage for Nasal Tip Reconstruction in East Asians.

SUMMARY: Adequate nasal tip projection remains a challenge in aesthetic rhinoplasty for East Asians. Various surgical techniques have been developed to reshape the nasal tip using auricular cartilage. In this article, we introduce the new ram graft to increase nasal tip projection by using one complete piece of conchal cartilage. Between 2019 and 2021, 19 patients who underwent nasal tip reconstruction using ram grafts were reviewed in a single hospital. The complication rate, satisfaction rate, and changes in nasolabial angle and nasal proportion were recorded. Nineteen patients with a mean age (± SD) of 28.9 ± 6.1 years underwent nasal tip reconstruction. The mean follow-up time was 15.4 ± 6.6 months. Nasolabial angle increased from 87.4 ± 10.0 degrees to 91.2 ± 10.2 degrees ( P > 0.05). Sixteen of 19 patients (84.2%) were satisfied with their results. The nasal length-to-nasal tip projection-to-dorsal height-to-radix height ratio is 2:0.8:0.62:0.19 preoperatively and 2:0.92:0.77:0.35 postoperatively. Complications including alloplast-related infection (two of 19) and septal extension graft-related decrease of nasal tip projection (one of 19) were recorded. By using one complete piece of conchal cartilage, the ram graft is a simple and effective approach to increase nasal tip projection for East Asians. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Dorsal Preservation Rhinoplasty in Asian Hump Noses.

SUMMARY: Dorsal preservation rhinoplasty, which preserves the bony-cartilaginous junction and the keystone area, has been gaining popularity in Western countries for hump nose correction. The authors aimed to report the feasibility, surgical outcome, and technical considerations of dorsal preservation rhinoplasty in Asian hump nose correction. A retrospective case series study was performed on nine patients who had undergone primary dorsal preservation rhinoplasty for hump nose correction. Rhinoplasty was performed by the senior author (H.R.J.) from March of 2019 to December of 2021. Clinical charts, graphic operation records, and standardized photographs of the patients were retrospectively reviewed and analyzed. Operations were performed using an open approach in all patients. Either the push-down technique ( n = 3) or the let-down technique ( n = 6) was used for dorsal preservation. All patients underwent tip modification, with or without radix grafting, together with dorsal preservation rhinoplasty. Bony step-off camouflage at the transverse osteotomy site was required in three patients. After surgery, both the nasofacial and rhinion angles exhibited significant changes ( P = 0.008). In all cases, hump reduction was successful, without recurrence or saddle nose, and no major complications occurred. All patients were satisfied with the aesthetic and functional results. Dorsal preservation rhinoplasty seems to be a viable option for correcting Asian hump noses. Technical considerations include a preference for the open approach; camouflage of bony step-off deformity; and strategic management of the septal cartilage, in consideration of tip modification.