Tertiary Rhinoplasty Research Articles

Limited Incision Rhinoplasty: An Approach for All Primary and Revision Cases.

Rhinoplasty was one of the most frequently performed aesthetic surgeries in the USA in 2022. Traditionally, the open approach has been preferred by the majority of surgeons often due to familiarity and ease of visualization. However, patient interest in closed and preservation rhinoplasty is driving a resurgence in the popularity of endonasal techniques. We present a series of 100 consecutive endonasal primary and revision rhinoplasty cases using bilateral isolated modified rim incisions. One-hundred consecutive patients underwent closed rhinoplasty via isolated modified rim incisions at a single-surgeon private practice. The senior author performs 100% endonasal rhinoplasty. A retrospective chart review was performed from 06/25/20 to 09/21/22. Information on demographics, complications, and need for revision was collected. Eighty-four patients underwent primary rhinoplasty, 11 underwent secondary rhinoplasty, 4 underwent tertiary rhinoplasty, and 1 underwent quaternary rhinoplasty. Isolated modified rim incisions were used in all cases except in cases of septoplasty when a unilateral Killian incision was added, or in cases of lateral osteotomy when vestibular stab incisions were added. Post-operatively, six (6.0%) patients required revision, all of which were performed under local anesthesia. Limited incision rhinoplasty is a reliable surgical approach that produces predictable results with a low revision rate. This technique is highly effective in minimizing soft tissue disruption to ensure safe, reliable, and effective outcomes in primary and revision rhinoplasty. It is an easier technique to learn compared to traditional endonasal and even arguably open rhinoplasty, thus lending itself to widespread adoption especially among novice rhinoplasty surgeons. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Open Rhinoplasty for Nasal Tip Correction by the Transverse Columellar Incision for Egyptian & Mediterranean Noses

Rhinoplasty may be the most common, most challenging, most unforgiving in plastic surgery. It is an ultimate combination of an evolving art and science. Rhinoplasty is a precise surgery in which the margin of error is measured in millimeters. Excellent results can only be obtained by a thorough knowledge of nasal anatomy and the surgical relevance of the alteration of the anatomic structures. To a lot of the Junior Staff, Rhinoplasty is a blind procedure requiring much imagination. This procedure has always been a challenge to the plastic surgeons. Objectives: Since the early eighties I had all the worry a young plastic surgeon has: standardizing his results for Aesthetic Rhinoplasty. Results were not always what one expected, and definitely tip correction was a great challenge. It was then I embarked adopting the open Columellar Incision. I am sharing with you my journey over 40 years and the results of believing and mastering a technique, preaching it in different arenas, and the final results achieved d not only nationally or regionally but also internationally when this technique is now universally accepted as a precise tool for better refinement. The indications limitations and the ghost of the scar are shown and proved to be over stated. In the millennium different strategies (suturing and grafting) have been adopted to obtain better aesthetic outcome and less functional disturbances, all these seem to go hand in had with the open rhinoplasty incision. Different indications are briefly gone through in this review and the long-lasting results are shown. Conclusions: Excellent symmetry, Lack of supratip deformity, particularly in Secondary and Tertiary Rhinoplasty The scar was inconspicuous in the healing phase, then in a few months it tended to migrate lower down and becomes almost invisible. The use of either grafts or various tip sutures can help in the control of the tip dynamics. The aesthetic outcome following a combination of suturing and grafting was more satisfactory than the outcome that can be achieved following either one of them. All these techniques could not be achieved through a closed endonasal rhinoplasty

Clinical assessment of solid cartilage versus diced cartilage in fascia in augmentation rhinoplasty

Objective The aim was to compare clinical outcome and fate of solid cartilage versus diced cartilage in fascia in augmentation rhinoplasty. Back ground Augmentation rhinoplasty can be achieved through many different techniques and materials. There are many different implantable materials available, both autologous and nonautologous. The major limitation of nonautologous material is the limited biocompatibility, which contributes to allergic reaction, excursion, displacement, and infection. Patients and methods This study was conducted in combination of Plastic Surgery and Burn Department of Mansoura University and Plastic Surgery Department of Menoufia University during the period from December 2012 to November 2015. It included 14 patients who underwent augmentation rhinoplasty, aged from 18 to 35 years, with mean ± SD age of 25.7 ± 6 years. In total, five (35.7%) patients were female and nine (64.3%) patients were male. Patients were divided into two groups. Group I underwent augmentation rhinoplasty by solid cartilage graft (septal, conchal, or rib). It included seven patients, with five (71.5%) male and two (28.5%) female patients, with mean ± SD age of 24.5 ± 6 years. Group II underwent augmentation rhinoplasty by diced cartilage graft enveloped in fascia (deep temporal fascia). It included seven patients, with four (57%) male and three (43%) female patients, with mean ± SD age of 27 ± 5 years. Results A total of five (35.7%) patients were female and nine (64.3%) of them were male. Overall, six (42.8%) patients underwent primary rhinoplasty, six (42.8%) patients secondary rhinoplasty, and two (14.2%) tertiary rhinoplasty. In group I, 43% of the patients had satisfactory (excellent) results, 14.25% of patients had intermediate results, and 42.75% of patients had unsatisfactory results. In group II, 71.5% of patients had satisfactory (excellent) results, 14.25% had intermediate results, and 14.25% had unsatisfactory results. Conclusion Diced cartilage graft is becoming a common place in rhinoplasty. The diced cartilage warped in autogenous fascia has good results, with minimal drawbacks, in comparison with solid cartilage.

Monobloc Reconstruction of Dome, Medial Crura, and Columella with Gamma-Shaped Costal Cartilage Graft.

In severe nasal deformities, the original cartilages are removed, or they become unusable because of previous operations. Costal cartilage (CC) is one of the most important tools for the replacement of deficient nasal osteocartilaginous framework. In 4 secondary and 1 tertiary rhinoplasty cases with severe deformities of medial and lateral crura of the lower lateral cartilages, we have prepared a long strut graft from a CC and then split the graft tip 5-6 mm vertically into 2 equal halves to create a gamma (ϒ)-shaped strut graft. We have sutured the base of this graft to the nasal spine and/or the bases of the medial crural remnants. Then, we have prepared lateral crural grafts and secured the grafts over lateral crural remnants. Then we curved the split tip winglets of the ϒ-shaped strut graft to both sides and sutured them to lateral crural grafts in order to create a new dome. Splitting of the CC strut graft reduces the need for extensive suturing at the tip, obtains smoother contours and ensures graft economy, and provides an original and stable dome shape. The bending capacity of the CC is limited in middle-aged patients. Costal allografts from a young cadaver can be a good alternative. ϒ-shaped costal crural graft is useful for medial crural and domal monobloc reconstruction in secondary and tertiary cases.

Association of Mental Health Status With Perception of Nasal Function.

Mental health issues are thought to be overrepresented among patients undergoing rhinoplasty and may be associated with patient presentation prior to surgery. To assess the association of poor mental health with perception of nasal function. A cross-sectional study of patients presenting for airway assessment was performed from December 1, 2011, to October 31, 2015, at 2 tertiary rhinoplasty centers in Sydney, Australia. Mental health was independently defined preoperatively by the Mental Component Summary of the 36-item Short Form Health Survey version 2 (a score of <40 indicated poor mental well-being), the Rosenberg Self-Esteem Scale (a score of <15 indicated low self-esteem), and the Dysmorphic Concerns Questionnaire (a score of >11 indicated above-average dysmorphic concerns). Nasal function was assessed with patient-reported outcome measures, including the Nasal Obstruction Symptom Evaluation Scale, the 22-item Sinonasal Outcome Test, a visual analog scale to rate ease of breathing on the left and right sides, and Likert scales to assess overall function and nasal obstruction. Nasal airflow was assessed by nasal peak inspiratory flow, nasal airway resistance, and minimum cross-sectional area. Among 495 patients in the study (302 women and 193 men; mean [SD] age, 36.5 [13.6] years), compared with patients with good mental health, those with poor mental health had poorer scores in all patient-reported outcome measures, including the visual analog scale for the left side (mean [SD], 51 [25] vs 42 [25]; P = .001), visual analog scale for the right side (mean [SD], 54 [24] vs 45 [26]; P < .001), Nasal Obstruction Symptom Evaluation Scale (mean [SD], 2.64 [0.95] vs 1.96 [1.04]; P < .001), 22-item Sinonasal Outcome Test (mean [SD], 2.14 [0.84] vs 1.33 [0.83]; P < .001), nasal obstruction (58 of 145 [40.2%] vs 83 of 350 [23.7%] with severe or worse obstruction; P < .001), and nasal function (72 of 145 [49.7%] vs 111 of 350 [31.8%] with poor or worse function; P < .001). Subclinical differences in nasal peak inspiratory flow could be demonstrated, but all other nasal airflow measures were similar. Low self-esteem produced a similar pattern, but dysmorphia did not. Poor mental health status is associated with a poorer self-perception of nasal function compared with those who are mentally healthy with clinically similar nasal airflow. Clinicians should be aware that patients with poor mental health reporting obstructed airflow may in part be representing an extension of their negative emotions rather than true obstruction and may require further assessment prior to surgery. NA.

Osseous-Cartilaginous Spreader Graft and Nasal Framework Reconstruction.

Revision rhinoplasties and saddle nose deformities usually require grafting for reconstruction. Between January 1, 2000, and January 1, 2017, autologous rib grafts were used in 127 secondary and tertiary rhinoplasty patients [(57/127 females) and (70/127 males)]. Osseous-cartilaginous rib grafts (OCRGs) were divided into three parts (i.e., 1/3 upper peripheral, 1/3 central, and 1/3 lower peripheral). The harvested OCRGs were also shaped as vertical strips using a number 11 scalpel blade. These OCRGs were shaped to form the L-strut cartilaginous graft (LSCGs), osseous-cartilaginous spreader grafts (OCSGs), osseous-cartilaginous onlay grafts, nasal valve grafts (NVGs), and lower lateral cartilaginous grafts (LLCGs). The upper peripheral portion of the rib was usually used as an onlay graft for dorsal reshaping. The shape of this part was minimally convex after being cut from the main graft, and the convex shape was very appropriate for use as an onlay graft. The middle portion of the graft that consisted of the osseous and cartilaginous structure was used for the OCSGs. The middle portion of the graft that contained only cartilage was used for the LSCGs, NVGs, and LLCGs. OCRGs were used for the dorsal, alar, septal, upper lateral, and columellar struts for all patients. OCSGs were used for all of the septal grafts to provide further stability. In the nasal valve failure patients, the rib cartilage was fixed onto the lower lateral and upper lateral cartilage and was sutured using polyglactin to improve nasal valve function. One edge of the graft was sutured over the septum, and the other edge was positioned against the maxillary crest to allow for air flow at the nasal valve. After an OCSG was sutured to the septum, a flat and smooth dorsum was shaped before the dorsal onlay graft was placed and fixed. The bone fragments of the grafts that consisted of spreader and onlay grafts were tied to the radix nasi bone without any space. After 6months of follow-up, a minimally warping defect was apparent in 8 patients but none of these patients requested another surgery. The analysis of the questionnaire responses revealed that >90% of the patients were satisfied with the outcome of the procedure. Level of evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Auricular Cartilage in 197 Secondary and Tertiary Rhinoplasties.

The purpose of this study was to describe and evaluate the efficacy of the use of auricular cartilage to treat aesthetic and functional deformities of patients who underwent secondary rhinoplasty o tertiary. From July 2005 to July 2014, 197 patients (144 women and 53 men) underwent rhinoplasty with the use of cartilage grafts. A total of 137 patients (70%) underwent secondary rhinoplasty, 60 patients (30%) underwent tertiary rhinoplasty. Patients in whom the Cottle maneuver was positive (108 patients, 55%) underwent a rhinomanometry test and responded to a simple questionnaire that reported on their nasal patency. Patients were evaluated at 6, 12, 24 months after surgery. The results of this study revealed an effective correction of aesthetic deformities of patients and a significant improvement in airway patency in 108 patients with respiratory obstruction. No major complication was observed. The use of auricular cartilage graft is efficacy to solve aesthetic and functional remnants after an incorrect procedure, or primary or secondary.

A New Technique to Correct Saddle Nose Deformity in Failure of Diced Cartilage Grafts: Diced Cartilage Flap.

To correct saddle nose deformity, diced cartilage grafts have been commonly used over the past decade. However, following the correction of saddle nose deformity with diced cartilage graft, some problems like graft absorption or displacement may occur, which require revision surgery. Here, a new technique is presented for correcting saddle nose deformity when diced cartilage graft fails. Twelve cases were admitted to my clinic with complaints of nasal dorsal irregularity and depressions, asking for tertiary rhinoplasty. Seven (four women and three men) of these patients, who had a gap smaller than 1 cm in the lower 1/3rd of nasal dorsum, were selected for the described technique. After the nasal dorsum is undermined through the supra-perichondrial and subperiosteal plane, the diced cartilage island attached to the nasal dorsal skin is released distally until the island can be transposed to the tip area. This island attached to the nasal dorsal skin proximally, is formed as a flap and moved caudally as an advancement flap and sutured to the posterior of the dome area. The patients were followed for minimum 1 year (12-20 months) with intervals of 3 months. All the patients and also the surgeon were satisfied with the results. No complications such as resorption of the grafts were observed in any of the cases. This is an alternative, new, practical technique for correcting saddle nose deformity in the lower 1/3 of the nasal dorsum, in which the diced cartilage graft technique has failed to correct. In addition, tip projection and upward rotation can be achieved with this technique. 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 46 Authors www.springer.com/00266 .

Reconstructive rhinoplasty: operative revision of patients with previous autologous costal cartilage grafts.

Costal cartilage grafts are used more frequently in secondary rhinoplasty. However, these procedures result in patients that require further revision operations that are not trivial. The purpose of this study was to assess the outcomes of reconstructive rhinoplasty performed on patients with a history of prior secondary or tertiary rhinoplasty using autogenous costal cartilage grafts. A retrospective review was conducted of tertiary rhinoplasty procedures. Outcomes of interest included the indications for the revision operation; revision rate following the tertiary costal cartilage revision; whether or not the use of costal cartilage grafts for the reconstructive rhinoplasty was a planned event; and perioperative incidents such as infection, structural collapse, and scarring requiring further surgery. Forty-six patients met inclusionary criteria. The revision rate following tertiary rhinoplasty performed by the primary author was found to be 24 percent (11 of 46). The reasons for these revision operations were nasal airway obstruction (n = 6), aesthetic dissatisfaction (n = 4), and infection (n = 1). Outcomes of the revisions were satisfactory, with no adverse complications requiring further surgery. Reconstructive rhinoplasty may be required in patients who have undergone previous costal cartilage grafting for secondary rhinoplasty. These revision operations can be performed successfully to help patients achieve both improved function and aesthetic results but have a higher than usual revision rate themselves. The revisions of these operations can be managed with standard revision operations that result in satisfactory outcomes. Therapeutic, IV.

Autologous Fascia Lata Graft for Contour Restoration and Camouflage in Tertiary Rhinoplasty

Tertiary rhinoplasty is a surgical procedure to correct nasal deformities that have been developed after prior unsuccessful surgeries. Such surgery requires complicated manipulations and tissue grafting for proper restoration. In the current study, we report the use of fascia lata graft combined with cartilage grafts for contour restoring and camouflage. Twenty-three patients who had severe nasal deformities were included, of whom 14 were men and 9 were women. Their ages ranged between 24 and 34 years (mean, 29 y). All patients were twice previously operated on by surgeons other than the authors. An informed consent was obtained from all patients. After harvesting the costal cartilage, the fascia lata graft (mean size, 2-3 cm) was uniformly harvested from the right lateral thigh. Application of the fascia lata and the cartilage graft was achieved through the open rhinoplasty incision. The fascia lata was applied over the cartilage in the dorsal region in 20 patients (86.9%), applied over the reconstructed alar and dome area in the nasal tip in 8 patients (34.7%), and applied over both areas simultaneously in 4 patients (17.3%). Postoperative follow-up was between 14 and 35 months (mean, 24.5 mo); clinical evaluation, photographic documentation, and a questionnaire form related to donor-site morbidity and patient satisfaction were applied after 12 months of the follow-up period. Results showed that all patients had an improved aesthetic result, and no apparent irregularities were observed in the integument of the aesthetic lines. No complications or no requirement for revision surgery was observed later on. In conclusion, refinements of the nasal dorsum and the nasal tip in tertiary rhinoplasty are indeed important and difficult to be managed. Placing the fascia lata over the applied cartilage grafts provide a good cover that conceals the possible irregularities or distortions that may appear in the late postoperative period.

Indications and Use of Composite Grafts in 100 Consecutive Secondary and Tertiary Rhinoplasty Patients: Introduction of the Axial Orientation

AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK

Indications and use of composite grafts in 100 consecutive secondary and tertiary rhinoplasty patients: introduction of the axial orientation.

The fragile alar rims are complex structures whose specialized and supportive skin ensures the competence of the external valves and the patency of the inlets to the nasal airways. A chart review was performed of 100 consecutive secondary or tertiary rhinoplasty patients in whom the author had placed composite grafts before February 1999. Follow-up continued for at least 12 months. In 94 percent of the patients, composite grafts were harvested from the cymba conchae by removing the cartilage with its adherent anterior skin. In 6 percent of the patients, independently indicated alar wedges supplied the grafts. Six patients required secondary procedures to thin the alar rims, but such revisions have not been necessary since primary contouring of the cartilaginous graft component was instituted. Three auricular donor-site complications (one keloid, two thickened graft contours) were successfully revised through office procedures. Prior cosmetic rhinoplasty in a patient with normal alar cartilage anatomy exceeded all other etiologies as the cause of the deformity for which composite grafts were indicated (50 percent). The second most common etiology was deformity from prior rhinoplasty in a patient with alar cartilage malposition (33 percent of patients). Congenital deformities (7 percent of patients), trauma (6 percent), and prior tumor ablation (4 percent) comprised the remaining etiologies. Composite grafts were used most frequently to correct alar notching or asymmetry in rim height (43 percent of patients) or to provide an increase in apparent or real nasal length (28 percent). External valvular incompetence (14 percent of patients), nostril or vestibular stenosis (11 percent), or combined vestibular stenosis and lateral alar wall collapse (4 percent) were less common indications. Most composite grafts were oriented in the coronal plane (parallel to the alar rims). However, nostril or vestibular stenosis was corrected by sagittally placed composite grafts, and a third orientation (axial plane), to the author's knowledge not described previously, was used in patients with combined nostril stenoses and flattening of the alar walls. In this secondary rhinoplasty series, iatrogenic alar rim deformities or stenoses following cosmetic rhinoplasty dominated other causes requiring composite graft reconstruction (83 percent of patients). Of these 83 patients, 39.7 percent had preexisting alar cartilage malpositions, further supporting the importance of making accurate anatomical diagnosis part of every preoperative rhinoplasty plan.

Case Discussion: Rhinoplasty – Tertiary Rhinoplasty

Case Discussion: Rhinoplasty – Tertiary Rhinoplasty