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Being a very common and highly stigmatizing deformity following primary rhinoplasty, a pollybeak deformity should be avoided during any primary rhinoplasty, especially in patients with thick nasal skin. Two surgical techniques used in the authors' department to decrease the probability of its development in at-risk patients are described in this article: the authors' modification of the supratip suture initially described by Guyuron, and a direct excision of excessive skin that the authors term supratip excision, reserved for rare cases with massive skin excess. In addition, a brief overview of the results of the authors' case series of 74 patients treated with the supratip suture technique, and 21 patients treated with the supratip excision technique over a 5-year period, is given. In the authors' experience, very good aesthetic results are achieved using either of the two techniques in selected cases.

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

Background Even today, severe septal deformities are a challenging problem for any rhinoplasty surgeon. Standard techniques are often not able to achieve satisfactory long-term results regarding function or aesthetic form. In such severe cases, a partial or total extracorporeal septal reconstruction may be used, as these techniques provide reliable and lasting results. Methods The aim of this work is to present the authors' experience with the technique of total extracorporeal septal reconstruction and its development to today's standard and to prove its effectiveness in the long-term follow-up. Results This article presents 40 years of clinical experience in this field and describes the technical changes that have evolved. Low complication rates, safe techniques, and favorable long-term outcomes of the total extracorporeal septal reconstruction show the benefits of this technique. Conclusion The indication for a total extracorporeal septal reconstruction has been limited by the development of less complex surgical procedures, but it still represents the best technique to achieve long-term functional and aesthetic results in patients with very complex septal deformities. Clinical question/level of evidence Therapeutic, V.

Irregularities or deformities of the nasal dorsum after hump reduction account for a significant number of revision rhinoplasties. The authors therefore developed a technique of meticulously dicing and exactly placing free diced cartilage grafts, harvested from septum, rib, or ear cartilage. The cartilage paste is used for smoothening, augmentation, or camouflaging of the nasal dorsum in primary or revision rhinoplasties.A retrospective analysis of multisurgeon consecutive open approach rhinoplasties from January to December of 2014 was conducted at a single center. The authors compared the outcome of three different techniques to augment or cover the nasal dorsum after an observation period of 7 months. In group I, 325 patients with free diced cartilage grafts as the only onlay were included. In group II, consisting of 73 patients, the dorsal onlay was either fascia alone or in combination with free diced cartilage grafts. Forty-eight patients in group III received a dorsal augmentation with the classic diced cartilage in fascia technique.Four hundred forty-six patients undergoing primary and secondary rhinoplasties in which one of the above-mentioned diced cartilage techniques was used were included in the study. The authors found revision rates for dorsal irregularities within the 7-month postoperative observation period of 5.2, 8.2, and 25 percent for groups I, II, and III, respectively.The authors' findings strongly support their clinical experience that the free diced cartilage graft technique presents an effective and easily reproducible method for camouflage and augmentation in aesthetic and reconstructive rhinoplasty.

BACKGROUND: Severe septal deformations require adequate treatment to restore shape and function using extracorporeal septoplasty. Because it has been criticized for being technically demanding to execute and has increased risk for aesthetic complications, the authors have developed two new suture techniques for refixation of the neoseptum. METHODS: A retrospective analysis of multisurgeon consecutive extracorporeal septoplasties performed from January of 2014 to December of 2014 was conducted at a single institution using the criss-cross or transcutaneous transosseous cerclage suture (group 1) compared with fixation at the upper lateral cartilages only (group 2). RESULTS: One hundred ten extracorporeal septoplasties were performed in 110 patients over 12 months. Group 1 consisted of 58 patients (53 percent), whether receiving the criss-cross [12 patients (21 percent)] or the transcutaneous transosseous cerclage suture [46 patients (79 percent)], and group 2 consisted of 52 patients (47 percent). The median follow-up was 11 months (range, 6 to 16 months). Operative revision because of complications at the dorsum or the keystone area had to be performed in no case in group 1 and in five cases (9.6 percent) in group 2, resulting in a statistically significant difference between the two groups (p = 0.0212). There were no complications such as bleeding or infection observed in any of the 110 cases. CONCLUSIONS: To facilitate and to reduce the complication rate after extracorporeal septoplasty, the authors have developed the criss-cross and transcutaneous transosseous cerclage suture to overcome the important and technically demanding reimplantation of the neoseptum. Thus, the authors believe that these new operative techniques are safe and reproducible procedures that may take a permanent place among extracorporeal septoplasty procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Diced cartilage in fascia has become the graft material of choice for dorsal grafts in rhinoplasty. Allogenic fascia lata has not yet been investigated as an isolated fascial graft or as a combined graft with ear and rib cartilage, especially in comparison with autologous fascia and over a long implantation period.Ten different grafts were built from either autologous or allogenic fascia lata alone or as diced cartilage in fascia grafts with diced costal or ear cartilage and implanted into the dorsal skin of 15 rabbits. After 3 or 9 months, the grafts were explanted and analyzed histologically. Chondrocytes and cartilage matrix characteristics, including calcification, ossification, formation of bone marrow, fibrosis ingrowth and fibrotic transformation, the presence of immune reactions, vascular ingrowth, regenerative capacity, and capsule formation, were examined in a semiquantitative manner.All grafts were vital and without inflammatory response. The cartilage showed regular nuclei, a normal matrix, and regenerative capacity. A higher grade of calcification and ossification was observed in the fascia/cartilage grafts than in isolated cartilage grafts, and was more pronounced for costal cartilage. Both types of fascia were shown to be equally stable and without degradation. There were no significant differences in the diced cartilage in fascia grafts built with autologous compared to allogenic fascia.This study shows the equivalency of diced cartilage in fascia grafts and isolated fascial grafts using allogenic fascia lata compared to autologous fascia. The type of cartilage used accounts for different long-term characteristics of diced cartilage in fascia grafts.

Orthotopic cartilage transplants are performed in the course of numerous rhinosurgical operations. Precondition of a permanent success of the operation is preservation of vitality of the transplanted cartilage. Although numerous study results of heterotopic cartilage transplants exist, corresponding examinations in orthotopic transplants have not been done so far. Therefore, in 33 rabbits we did a partial submucous septumresection and put the cartilage back between the mucosal wall. After 1, 2, 3, 6, and 12 weeks, the animals were killed and the cartilage histologically proved. These results were compared to analogous human biopsies. Cartilage reintegration showed a characteristic picture. In the rabbit, the replanted cartilage was healed and stable after 3 months in each case. During reintegration, appositional growth started from the inner perichondrium. With microangiographical examinations, we were able to demonstrate that the speed of reintegration increased with decreasing distance of the cartilage cell from the blood vessels. We managed to confirm the experimental results in human cartilage biopsies.

The severely deformed septum remains a problem. We recommend removing the whole septum and reconstructing a new, straight, septum plane that will be replanted (i.e., extracorporeal correction). Until April 1993 we had used this technique in 1012 patients with functionally as well as aesthetically encouraging results. All septal replants healed primarily. A problem may occur with this technique in reconstructing the dorsum and in stabilizing the replant. The exact technique is explained in detail, and the results are compared with those reported in the literature. Even with this radical procedure, the rate of complication was only 2.2 percent. Biopsies provided the histologic proof of cartilage survival.