Secondary Rhinoplasty Research Articles

The Use of Bony Septum as an Extended Spreader Graft in Primary and Secondary Rhinoplasty

Objective: To describe a surgical technique using bony septum, specifically vomer or perpendicular plate of the ethmoid (PPE), as an extended spreader graft (ESG) for securing septal extension graft (SEG) and for correcting internal nasal valve dysfunction.
 Methods:
 Design: Descriptive Case Series
 Setting: Tertiary Private Hospital
 Participants: Thirty-two (32) patients who underwent aesthetic rhinoplasty from May 2016 to October 2017 were evaluated, and ten (10) patients presenting with symptomatic obstruction were considered for inclusion. The surgical technique was applied in patients with weak SEG for control of nasal length and tip projection who had inadequate septal cartilage for SEG and ESG intraoperatively. Results were evaluated grossly under direct vision intra-operatively and post-operatively to check the patency of the internal valve.
 Results: Bony septum was used as an ESG in five (5) patients (1 male, 4 females, ages 35 to 50-years-old) with inadequate septal cartilage. Intraoperative evaluation under direct vision showed anterior caudal septal deviation in all 5 patients in whom correction was confirmed after placement of SEG and ESG. Immediate post-operative evaluation confirmed bilaterally patent nasal valve in all 5, who reported subjectively improved breathing at 2 and 4 weeks post-operatively. Post-operative photographs showed improvement of nasal length and tip.
 Conclusion: The use of the bony septum (vomer and PPE) as an ESG for primary or secondary rhinoplasty is a potentially effective means of supporting and securing the SEG for control of nasal length, preventing tip deviation or rotation and for improving internal valve function. Further trials are needed to establish its reliability and long-term effectivity.
 Keywords: rhinoplasty; vomer; perpendicular plate of the ethmoid (PPE)

Role of Fresh Frozen Cartilage in Revision Rhinoplasty.

Correction of secondary nasal deformities frequently requires cartilage to build the framework of the nose. Traditionally, autologous costal cartilage has been used because of the paucity of the septal cartilage. Because of associated donor-site complications and increased operating time, irradiated allografts have been used. These grafts have a higher rate of resorption and infection. Thus, the authors have used fresh frozen, nonirradiated, cadaveric rib cartilage as donor cartilage to avoid these shortcomings, and they present their early experience. The operative data of 50 patients who underwent secondary rhinoplasty performed by the senior author between 2014 and 2017 were analyzed. The outcomes of the rhinoplasty were evaluated by preoperative and postoperative photographs by four blinded plastic surgeons, and the results were tabulated using the Independent Rhinoplasty Outcome Score. Fifty patients were followed up over an average period of 3.35 months (range, 1 to 18 months). There was only one complication (infection, 2 percent), which did not need revision surgery. There was no warping or extrusion in this cohort. The authors believe that fresh frozen, nonirradiated cartilage allografts are an evolving source of donor cartilage grafts for revision rhinoplasty because they are associated with lower complication rates. However, further long-term studies with an increased sample size are necessary to prove that fresh frozen cartilage grafts are better than other sources. Therapeutic, IV.

Clinical Analysis of Nasal Bone Fracture in Patients Who Have Previously Undergone Dorsal Augmentation Using Silicone Implants: A Pilot Study.

There are no studies about the treatment of nasal bone fractures in patients with dorsal augmentations using silicone implants. We aimed to describe the characteristics of nasal bone fracture in patients who underwent rhinoplasty and compare the difference between closed reduction and conservative treatment of nasal bone fractures in patients with a history of rhinoplasty. Between January 2013 and June 2018, a total of 463 patients were admitted to our center for nasal bone fracture; 17 patients with nasal bone fractures who underwent rhinoplasty were included, of which, five underwent closed reduction in the nasal bone and 12 underwent conservative treatment. Three of 12 patients who were initially treated conservatively underwent a secondary rhinoplasty for esthetic improvements. All patients were classified according to fracture site and the presence of a nasal septal fracture-in accordance with the modified Murray classification-and were analyzed for the correlation between fracture type and disease course. The nasal bone fracture types per computed tomography findings were unilateral (n = 13), bilateral (n = 4), septal (n = 1), and M-type (n = 1). No significant differences in fracture site (P > 0.05) and the presence of a nasal septal fracture (P > 0.05) were found between the groups. Fracture type did not significantly differ among patients who underwent closed reduction, conservative treatment without secondary rhinoplasty, and secondary rhinoplasty (P > 0.05). Despite risking traumatic capsular rupture, implant removal is seldom required and closed reduction is recommended if visible deviations are present; otherwise, only conservative treatment is recommended. 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.

How to perform subperichondrial and subperiosteal rhinoplasty

Rhinoplasty, via either an open or a closed approach, is classically performed in the supraperichondrial plane, i.e. underneath the SMAS. Total subperichondrial and subperiosteal approaches, providing large exposure of all of the osteocartilaginous framework of the nose, have been described in recent years. This deeper dissection requires adaptation of surgical instruments to perform both subperichondrial and subperiosteal dissection, but also to perform osteotomies. New tools, such as the Rhinosculpture or piezoelectric motor are particularly useful in this context. Acquisition of this dissection technique, although it requires a long learning curve, is largely rewarded by the advantages of this technique in primary and secondary rhinoplasty. The objective of this technical note is to provide a detailed description of the operative technique and the instrumentation required.

Secondary Rhinoplasty: Aesthetic and Functional Concerns.

Aesthetic and functional concerns, especially after multiple revision rhinoplasties, continue to provide a challenge even for the experienced surgeon. This study aimed to report the results in terms of "secondary rhinoplasty," performed by the senior author after previous rhinoplasty. This descriptive prospective study was carried on 150 patients with surgical indication of secondary rhinoplasty and they were asked to fill out the questionnaire divided into 3 parts: overall epidemiological questions, questions of patients' aesthetic and functional complaints, and objective evaluation by the surgeon. The nasal problems in the upper and middle regions were divided into high or low, broad or narrow, crooked, irregularity of nasal bridge, or other alterations. The patients included in the study had surgical programming of secondary rhinoplasty, with mandatory aesthetic and optional functional purposes, having previous rhinoplasty with the same or different surgeon. There were 136 females and 14 males with the mean age of 31.52 (6.36) years. The most common complaints were related to the nose tip with 123 cases included deviated tip and pinched (bilateral) with 25.3%, 30.7%, and 25.3%, middle nose with 78 cases included mid vault deviation, inverted V, and polly beak with 31.3%, 18%, and 9.3%, and upper nasal region with 69 cases included dorsum irregularity and wide dorsum with the rates of 22.7% and 16.7%, respectively; respiratory problem was reported in 13 cases. Unilateral or bilateral twisting at the nasal tip had the highest percentages, and the lowest incidence was in relation to the complaints of the upper nasal part.

Feasibility of a polydioxanone plate as an adjuvant material in rhinoplasty in Asians.

BackgroundNasal framework-supporting procedures such as septal extension grafts, derotation grafts, and columellar strut grafts are usually required in rhinoplasty in Asian patients because the skin envelope is tight, but the nasal framework is small and weak. Autologous materials are preferred, but they have some limitations related to the amount that can be harvested and the frequency of use. Therefore, synthetic materials have been used to overcome these limitations.MethodsA total of 114 patients who received a polydioxanone (PDS) plate as an adjuvant material in rhinoplasty from September 2016 to August 2017 were retrospectively investigated. The PDS plate was used as to support the weak framework and to correct the contour of the alar cartilages. The PDS plate was used for reinforcement of columellar struts and septal L-struts, alar cartilage push-down grafts, fixation of septal extension grafts, and correction of alar contour deformitiesResultsPrimary and secondary rhinoplasty was performed in 103 and 11 patients, respectively. Clinically, no significant inflammation occurred, but decreased projection of the tip was observed in seven patients and relapse of a short nose was noted in five patients.ConclusionsPDS plates have been used in the United States and Europe for more than 10 years to provide a scaffold for the nasal framework. These plates can provide reinforcement to columellar struts, L-struts, and septal extension grafts. In addition, they can assist in deformity correction. Therefore, PDS plates can be considered a good adjuvant material for Asian patients with weak and small nasal cartilage.

Current Practical Concepts for Using Rib in Secondary Rhinoplasty.

Rhinoplasty is universally considered as the most demanding procedure in facial plastic surgery. Secondary rhinoplasty is its crown jewel, even more complex, and likewise highly fascinating. The evolution of thought and practice in rhinoplasty in the last decades has been quick and steady, progressively acknowledging the importance of maintaining structure in primary rhinoplasty and rebuilding structure in secondary procedures. No longer is the paradigm to achieve a small, thin, and pointy nose, but rather a well-proportioned nose which looks natural, albeit elegant and breathing well. Rib is an essential tool in many secondary procedures, and thus some important concepts have to be well understood and some finesse points mastered. This will provide an elegant reconstruction, identical if possible, or at least not far apart, to what could be achieved by a well-executed primary rhinoplasty, while avoiding the feared luck of a bulky nose stuffed with grafts. These guiding concepts and specific nuances regarding harvesting rib and working with it are the scope and contents of this article.

Extended L-Framework: An Innovative Technique for Reconstruction of Low Nasal Dorsum by Autogenous Costal Cartilage Graft.

Background:Congenital, iatrogenic, and traumatic etiologies can produce a deficient nasal dorsum requiring dorsal augmentation. Traditional techniques for dorsal augmentation as onlay dorsal graft, cantilever graft, or conventional L-framework usually have less stability and produce a rigid lobule if the single unit framework extends to the tip. Because of abundant volume and relative ease of harvest and carving, the autogenous rib cartilage has been considered the graft of choice for dorsal nasal augmentation when structural support is necessary and sufficient septal cartilage is not available.Methods:Eighteen patients with congenital, iatrogenic, and posttraumatic low nasal dorsum were reconstructed with the extended L-cartilage framework over the past 3 years with an average postoperative follow-up of 15 months. The framework was reconstructed from 3 carved cartilaginous pieces. If needed, columellar strut, spreader, and tip grafts were also provided.Results:All the 18 patients were generally satisfied with the cosmetic and functional outcomes at around 1-year follow-up. The nasal projection and dorsal aesthetic lines were pleasing and maintained over a prolonged postoperative follow-up period. There was free natural movement of the lobular part of the nose. No major complications were encountered.Conclusions:Consistent, reproducible results were achieved with using the extended L-framework in primary and secondary rhinoplasty and in posttraumatic dorsal nasal deformities as well. This technique has different advantages over the conventional techniques as the extended framework is more anatomical, preserves pliability of the lobule, maintains stability without any means of fixation, and offers good control of aesthetic needs.

Evaluation of aesthetic and functional outcome of different techniques of secondary cleft lip rhinoplasty

Objectives The objective of this article is to evaluate the esthetic and functional outcome of secondary rhinoplasty in patients who have unilateral cleft lip nasal deformity with the help of using costal cartilage as a source of different graft materials. Background Although there have been improvements in primary rhinoplasty techniques in patients with unilateral cleft lip nasal deformity, this does not exclude the possibility of later revision surgery. In secondary rhinoplasty for cleft lip patients, the underlying skeletal support of the nose should be addressed to improve projection of the nose. In addition, correction of the hypoplastic lower lateral cartilage requires insertion of cartilage or bone grafts to add better support and symmetry. Costal cartilage is considered a better source of graft material to be used in secondary rhinoplasty. Patients and methods This clinical trial included 20 patients who were managed in Plastic Surgery Department, Menoufia University Hospital, from January 2016 to January 2018. All patients had unilateral cleft lip in infancy with residual nasal deformity in adulthood. Costal cartilage rib graft was harvested, carved, and used for maxillary augmentation, columellar strut graft, and lateral crural strut graft. Results Three anthropometric measurements (nostril height, width, and gap area) were used for evaluation of esthetic results, and subjective evaluation of nasal obstructive symptoms was used for functional improvement. A significant improvement of both esthetic and functional results was reported in the study and satisfactory outcome for both surgeons and the patients. Conclusion Maxillary augmentation beneath the base of the nose is important in cleft lip secondary rhinoplasty for better support of the columella and lower lateral cartilage. Costal cartilage is a good source of nasal grafting materials owing to its strength, availability in large amount, and ability of being carved for different options.

Clinical Application of Three-Dimensionally Printed Biomaterial Polycaprolactone (PCL) in Augmentation Rhinoplasty.

This clinical study aimed to investigate the safety and surgical outcome of three-dimensionally (3D) fabricated polycaprolactone (PCL) mesh in rhinoplasty. In particular, this study explored how a 3D-printed PCL mesh performs as a bioabsorbable scaffold after a long period following implantation. A retrospective review of 101 patients who received primary or secondary rhinoplasty with a PCL mesh was performed. Patient demographics and surgery-related outcomes were examined. Clinical efficacy and safety were evaluated using the Global Aesthetic Improvement Scale at postoperative 18months. From two revisional cases, a biopsy specimen of implanted PCL was acquired and histopathological analysis was performed. Of all the patients, 98.0% showed no postoperative infection-related foreign body reaction or distinct abnormal reaction, and the implants were observed to maintain long-term efficacy until 18-month follow-up. In patients who received spreader grafts, significant differences between preoperative and postoperative Cottle sign scores were found. Histopathological analysis showed features of adjacent tissue infiltration into pores of the PCL mesh and regeneration of neo-cartilaginous tissue and collagen around the mesh 20months after implantation. This study demonstrates that a novel biodegradable PCL mesh with a 3D structure is a safe and effective material for corrective rhinoplasty because it is easy to use and capable of maintaining its volume in the long term without foreign body response. This biocompatible material will have a wide range of applications as the most suitable alternative to nonabsorbable materials in rhinoplasty and reconstruction surgeries, such as fashioning spreader grafts and septal extension grafts. 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 .

The epidemiology of autologous tissue grafting in primary and revision rhinoplasty.

To determine the percentage of primary versus revision rhinoplasty cases that require an extranasal source of grafting, as well as age and gender-specific trends. Cross-sectional analysis of multistate ambulatory surgery and hospital databases. Ambulatory rhinoplasty procedures were extracted from the State Ambulatory Surgery Databases for New York, Kentucky, North Carolina, Michigan, and Florida for 2014 to 2015. Cases were examined for simultaneous use of extranasal grafts. A total of 8,510 rhinoplasties were extracted (65.3% female, mean age = 35.6 years), and 11.9% were revision cases (95% confidence interval [CI]: 11.2-12.6). An extranasal, autologous source of grafting was required in 12.7% of cases (5.3% auricular, 95% CI: 4%-6.6%; 1.8% costal, 95% CI: 1%-2.6%). Revision cases were more likely to require a secondary source of grafting (24.4%, 95% CI: 21.8%-27.1% vs. 11.1%, 95% CI: 10.3%-11.8%). In revision cases, the most common graft was auricular cartilage (14.4%, 95% CI: 12.2%-16.6%) followed by costal (7.1%, 95% CI: 5.52%-8.69%). Only 1.1% of primary cases required costal cartilage (95% CI: 0.88%-1.36%) compared to 7.1% of revision cases (95% CI: 5.52%-8.69%). Of the primary cases, 4.1% required auricular cartilage grafting (95% CI: 3.67%-4.57%) compared to 14.4% of revision cases (95% CI: 12.2%-16.6%). Patients who required a graft were older. Significantly more males required autologous grafting than females (P = .047). Cartilaginous or bony grafting is a critical surgical technique in both primary and secondary rhinoplasties. This is the first study to examine percentages of site-specific autologous grafting from auricular and costal donor sites for primary and revision cases. Gender and age-specific trends associated with specific grafting sites are also identified. These data are important to help guide preoperative counseling and informed consent for all rhinoplasty surgeries. NA Laryngoscope, 129:1549-1553, 2019.

"Dual-Knot Fixation" Technique for Better Stabilization of the Extended Columellar Strut Graft with the Anterior Nasal Spine.

Extended columellar strut graft (ecsg.) is one of the most crucial cartilage tissues used especially in secondary rhinoplasties. Stabilization of an ecsg. with the anterior nasal spine (ans.) is very important. Regular suture placement is the most common practice. Nevertheless, this kind of suture fixation may result in sliding of the ecsg. through either side of the ans. Suture placement like the figure of eight may prevent sliding of the ecsg. to sides. However, the figure of eight suture forces the graft to turn around during its fixation. I have tried to solve these two problems with a simple still better suture technique. After passing the suture through the hole of the ans., a stabilization knot is tied over the spine tip. Then passing the suture through the lower end of the ecsg. and fixating it with a second knot named as the "fixation knot" results in very good stabilization and prevents both side sliding and rotation of the graft. This stabilization technique can be called "dual-knot fixation" (dkf.). Opening a small notch at the lower tip of the graft may help to hide the "stabilization knot" inside the graft which will help to obscure the tiny space between the cartilage and the bone, and thus the bonding process between the graft and spine would be better. 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 .

Importance of Stem Cell Transplantation in Cleft Lip and Palate Surgical Treatment Protocol.

Cleft lip and palate is a congenital malformation that requires a multidisciplinary treatment that evolves pediatrician, obstetrics, fetal medicine, genetics, plastic surgery, orthodontics, speech therapist, nursery, and psychology. Actually, the authors believe that it could be possible to ad protocols to use stem cells.The intrauterine diagnosis leads to preborn parental orientation and better parental collaboration to accept a precocious multidisciplinary treatment. After birth the authors' protocol is: orthodontic devices, phonoaudiology, and surgical procedures.The authors' cleft lip and palate reconstructive surgery protocol demands several steps and begins at 4 to 6-month old with rhinocheiloplasty and soft palate closure at the same moment. The treatment sequence involves the hard palate surgery (8-18 months after the first surgical step), alveoloplasty (after 10 years old), and secondary rhinoplasty (after 14 years old).New ideas to use stem cells and blood from the umbilical cord and also blood from placenta are discussed to improve final surgical results. Maternal stem cells are easy to collect, there are no damage to the patient and mother, it is autologous and it could be very useful in the authors' protocol.Nine patients with clef lip and palate were operated and had stem cells from umbilical cord blood and placenta blood injected into the bone and soft tissue during the primary procedure (rhinocheiloplasty).The stem cells activity into soft tissue and bone were evaluated. Preliminary results have shown no adverse results and improvement at the inflammatory response. A treatment protocol with stem cells was developed. It had a long time follow-up of 10 years.

The Characteristics and Safety of Previous Fillers in Secondary Rhinoplasty

The Characteristics and Safety of Previous Fillers in Secondary Rhinoplasty

Application of costal cartilage in oriental secondary rhinoplasty

Objective To introduce the experience of using costal cartilage in oriental secondary rhinoplasty. Methods From January 2012 to December 2016, we used costal cartilage grafts to obtain a functional and aesthetic reconstruction, in which silicone was used in 34 previous cases and e-PTFE was used in 5 cases. Results The mean duration of follow-up was 1.5 years, 43 (86%) patients showed high satisfaction with the shape of nose. 1 case of infection and 2 cases of costal cartilage warping occurred. 1 case was somewhat dissatisfactied with outcome. There was no case of chest wall deformity and pneumothorax, but scar on the chest wall at the donor site was observed in 2 cases. Conclusions We have obtained good aesthetic results using costal cartilage grafts which could display sufficient and stable support for the scaffold of nose. We can conclude that costal cartilage is a good material in secondary rhinoplasty, and can be used to reconstruct an aesthetic nose. Key words: Autogenous costal cartilage; Secondary rhinoplasty; Satisfaction

Autogenous control augmentation system - A refinement in diced cartilage glue graft for augmentation of dorsum of nose.

Background:In the context of different grafts being used for dorsal augmentation, diced cartilage with glue has gained worldwide acceptance.Aims:To develop a system of tools to objectively evaluate the desired dimensions of the required graft for dorsal augmentation and to prepare a corresponding customized-glued-diced cartilage construct.Materials and Methods:A modification of the diced cartilage glue technique called Autogenous control augmentation system (ACAS) was used in ten patients.Results:Of the ten patients, in which this technique was used, eight underwent primary rhinoplasties and two underwent secondary rhinoplasties between July 2017 and December 2017 with a follow-up ranging from 3 to 8 months. In all the cases, the dorsum is straight, and height is maintained.Conclusion:The technique has all the advantages of the diced cartilage glue. The shape resembles alloplastic implant with height and width varying from radix to tip. There is tapering of the cephalic and caudal ends for more natural results. The brow tip aesthetic lines are better defined. The limitation of this study is short follow up.

Correction of secondary unilateral cleft-lip nasal deformity using autologous costal cartilage grafts

Objective To explore the comprehensive approach and efficacy of secondary unilateral cleft rhinoplasty by using autologous costal cartilage grafts. Methods Secondary rhinoplasty was performed in 28 patients with unilateral cleft-lip nasal deformity. The costal cartilage was harvested through a mini-invasive incision. Septal deviation was corrected, and nasal tip framework was reconstructed with the autologous costal cartilage through direct transcolumellar incision. Diced cartilage fragments were used to augment the depressed alar base. Nasolabial muscles were repositioned to restore the balance of muscular tension system. Results The appearance of the nasal deformity was greatly improved in all the 28 cases postoperatively by follow-up from 3 to 12 months. Increased stability and symmetry of the nasal tip, along with the improvement of nasal breathing function was achieved and sustained effectively. Conclusions Definitive secondary unilateral cleft rhinoplasty using autologous costal cartilage grafts provides good aesthetic and functional results. Key words: Costal cartilage graft; Unilateral cleft lip; Nasal deformity

Rotational Advancement in Cleft Nose Rhinoplasty – Buccal Mucosal Grafts Serve as a Powerful Tool

Our aim was to analyze our technique of a modified rotational advancement in conjunction with buccal mucosal grafts (BMGs) in a subgroup of severe cleft cases. A retrospective clinical and photographic evaluation was conducted. Columella angle (CA) and tip projection (TPR) served as instruments in a photometric analysis. Academic university hospital and specialized craniofacial cleft center. At the time of the secondary rhinoplasty, 61 cleft patients were included, all 17 years or older. Rotational advancement with usage of BMGs was performed in selected cases by a single surgeon. Nasal symmetry and aesthetic appearance. From 2003 to 2011, 29 unilateral severe cleft cases (group I) underwent a modified alar rotational advancement with BMGs. Group II, with 32 cases, represented patients without BMGs. Technique and management of BMGs were described in detail. The complication rate of donor and recipient site presented as very low. The CA was improved significantly in both groups. Also, TPR improved (not significantly) in group I. Using our technique, we considerably enhanced the aesthetic results and symmetry in secondary cleft rhinoplast. Rotating the vestibular skin makes it possible to eliminate the traction of this skin on the repositioned alar cartilage, therefore achieving a more pleasing and stable nasal symmetry in secondary cleft rhinoplasty. Versatile BMGs close this gap, thus making them a powerful tool in the arsenal of the reconstructive cleft surgeon.

Association of Nasal Tip Rotation Outcome Estimation With the New Domes Technique in Primary Rhinoplasty.

The postoperative changes in the rotation of the nasal tip in rhinoplasty must be estimated for the surgical planning. To determine whether the outcome in the rotation angle of the nasal tip can be estimated in patients undergoing primary rhinoplasty with the new domes technique. This retrospective analytic cohort study included 323 patients undergoing primary rhinoplasty with the new domes technique in a private clinic in Bogotá, Colombia, by a single surgeon from January 1, 2011, through January 31, 2016. Patients undergoing secondary rhinoplasty and those with less than 6 months of follow-up were excluded. Primary rhinoplasty using the new domes technique. Measurement of the rotation angle of the nasal tip before and 1 week and 6 months after surgery. The main variable taken into consideration was the measurement, in millimeters, of the lateralized nasal domes. A total of 323 patients (288 women [89.2%] and 35 men [10.8%]; mean age, 27.8 years; age range, 13-70 years) were included in the study. The mean (SD) preoperative nasolabial angle was 92.7° (4.4°; range, 77°-107°); at 1 postoperative week, 105.5° (4.9°; range, 92°-120°); and at 6 postoperative months, 102.1° (4.6°; range, 90°-115°). The mean (SD) increase of the rotation that was achieved per lateralized millimeter was 3.6° (2.0°). The mean (SD) rotation angle at 6 months decreased to 3.4° (2.4°). The new domes technique was reliable and reproducible in most patients. Despite the unpredictable inflammatory changes, the exact lateralization in millimeters with the new domes technique allowed precise estimation of the long-term outcome of the rotation of the nasal tip, enabling the surgeon to determine from the preoperative plan the definitive rotation angle of the nose. 4.

Secondary Rhinoplasty by the Global Masters

Secondary Rhinoplasty by the Global Masters