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BACKGROUND The nose is at the center of the face and has essential functional and aesthetic properties. Over recent years, rhinoplasty has gained increasing popularity through the influence of "selfies" and social media. As a result, a growing demand for secondary correction has also emerged. Revision rhinoplasty is more complex than primary cases and often requires the use of extranasal grafting material. The authors sought to analyze the indications, techniques, and outcomes after primary and revision rhinoplasty. METHODS A total of 245 patients (153 primary cases and 92 revisions) undergoing surgery at the authors' specialized clinic for facial plastic surgery were included. All patients were treated by an experienced facial plastic surgeon according to the authors' established clinic standards. A retrospective data analysis was performed to evaluate the differences between the groups regarding the indications, intraoperative techniques, and postoperative outcomes. RESULTS Although more patients sought revision surgery for aesthetic reasons alone than isolated functional issues, almost two-thirds of the revision patients had functional and aesthetic problems in combination. Complex reconstructive techniques, extracorporeal septoplasties, and extranasal grafts were more commonly used in revision cases. The occurrence of another revision during the follow-up period was significantly higher after revision surgery compared to primary rhinoplasty cases (primary rhinoplasty, 10.5 percent; revision surgery, 23.9 percent; p = 0.006). CONCLUSIONS There are differences between primary and revision rhinoplasty that must be appreciated by the treating surgeon. The patient should be informed about the increased complexity of the secondary procedure, the possible need for extranasal grafts, and the increased risk of a further revision. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Here we describe a new technique to deal with alar retraction, a highly undesirable imperfection of the nose. The procedure involves placing a caudal extension graft below the vestibular portion of the lower lateral cartilage (LLC) after its detachment from the vestibular skin. The graft is fixed to the cartilage and, subsequently, to the vestibular tissue. The present retrospective study included 20 patients, 11 females and 9 males, with a mean age of 28.90 years. Follow-up ranged from 1 to 18 months. Surgery improved alar notching to a smoother dome shape and nostril exposure was reduced in every patient. The caudal extension graft of the LLC contributed to rise in overall patient satisfaction, as revealed by the postoperative increase of the Rhinoplasty Outcomes Evaluation (ROE) mean score from 40.0 to 79.17 (p

Shape, tip projection, and position can be controlled by the use of septal extension grafts (SEG). A retrospective cohort study of patients undergoing primary and secondary rhinoplasty was reviewed. The purpose of this study was to analyze maintenance of nasal length, dorsal length, and nasolabial angle postoperatively comparing different types of SEG using standardized photography and digital measurement. Two-hundred twenty-one patients undergoing rhinoplasty were included. There was a statistically significant change regarding the nasolabial angle during the time of follow-up decreasing from 97.53 to 95.30 degrees. No changes could be found in dorsal and nasal length. There was no significant difference among the techniques used to fixate the SEG. The nasolabial angle appeared to decrease from the position 2 weeks postoperatively without changes in the dorsal and nasal length. This means that the decrease in the nasolabial angle depends on the swelling effect and not on drooping of the tip confirming the reliability of SEG over time.

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.

The importance of a straight and stable central framework is beyond dispute. Many authors allude to technical aspects how to achieve the above-mentioned requirements. Far less is said about the contact zones of the framework and how to achieve a long-lasting and solid fixation. In the authors' patient group, they found the need to work on the septum/the central framework in approximately 84% of the cases. In 61% of the patients, the authors had to operate on the fixation point. Of course, there is a great variety of anatomical findings. So the required techniques differ immensely. The surgeon must be prepared for all kinds of different situations. Especially the dorsal fixation and the anchoring on the maxilla without having a standard anterior nasal spine can be a great challenge. In their daily routine, suture techniques (e.g., the transcutaneous transosseous cerclage suture) have become the authors' working horse for these complex fixation situations.

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.

Refining the nasal dorsum has become a major challenge in modern rhinoplasty as irregularities of the nasal dorsum account for a significant number of revision surgeries. In our department, free diced cartilage is now routinely applied for smoothening of the nasal dorsum. In this retrospective study, the outcomes with regard to irregularities or contour deficits of the nasal dorsum of 431 rhinoplasty cases operated by a single surgeon between July 2013 and June 2015, using free diced cartilage, are compared with 327 cases operated by the same surgeon between January 2007 and December 2008, before the introduction of the free diced cartilage technique. A decrease in early revision surgeries (i.e., revision within the 2-year period evaluated) due to dorsal irregularities or contour deficits is seen. Being a quick, easy, and highly cost-effective procedure, we feel that free diced cartilage is currently the ideal technique for refinements of the nasal dorsum.

BACKGROUND The 3-stage forehead flap technique has been described as an aesthetic improvement after nasal reconstruction compared with the 2-stage technique. A standardized evaluation of aesthetic and functional outcomes of the 2-stage versus 3-stage paramedian forehead flap after nasal reconstruction was performed. METHODS Between July 2003 and December 2012, 102 patients underwent either 2-stage or 3-stage paramedian forehead flap techniques. A standardized patient satisfaction questionnaire was used to assess resulting nasal appearance and function. Additionally, 2 plastic surgeons performed blinded assessments of the aesthetic outcome using a standardized photographic evaluation form. Together, these evaluations demonstrated functional and aesthetic outcomes (flap thickness, shape, color, flap hair growth, donor-site scars, and nasal symmetry). RESULTS Functional and aesthetic outcomes according to the self-assessment questionnaire were similar between groups. On inclusion of the surgeon's evaluation, with a greater satisfaction was apparent from the reconstructed alar of the 2-stage group (Mann-Whitney U test, p = .03, Fisher exact test, p = .024, respectively). CONCLUSION No clear evidence supported enhanced aesthetic results when the 3-stage forehead flap technique was used, especially in relation to flap thickness compared with the 2-stage technique. The 2-stage technique remains the state-of-the-art choice for nasal reconstruction, even in cases involving complex defects. LEVEL OF EVIDENCE Therapy, Level III, and retrospective comparative study with prospectively collected data.

The principles of secondary dorsal augmentation are largely the same as those used in primary rhinoplasty. However, owing to the previous surgical disruption of nasal soft tissues, scar contracture and/or fibrosis may complicate or limit secondary dorsal augmentation. Frequently, wide undermining of the soft-tissue envelope is necessary to enable adequate dorsal augmentation. In severe cases preoperative conditioning of the fibrotic skin envelope with stretching exercises and/or repeated massage is necessary to gradually loosen the tethered and noncompliant soft-tissue envelope. Unfortunately, the nose is poorly suited to the use of conventional tissue expanders, and while self- or autoinflating expanders may offer effective alternatives, we have no experience with these devices.

The septum is the central part of the framework of the nasal skeleton. It is partially cartilaginous, partially bone. It is also perhaps the most underestimated and neglected structure of the nose. In a review of 469 of our own rhinoplasties performed in 2009, 198 procedures were found to be revision cases. One hundred and fifty-three of these revision cases (77.2 %) required surgical correction of a residual septal deformity that created a negative functional and aesthetic outcome. And whereas the functional importance of the nasal septum is often appreciated, its importance to the aesthetic outcome of surgery is often greatly underappreciated. As a consequence, failed cosmetic and functional surgeries are increasingly common.

The most common cosmetic profile deformity in secondary rhinoplasty is irregularity of the nasal dorsum. Dorsal irregularities can be minor or major and can arise from overresection, underresection, or insufficient skeletal camouflage. In the overresected dorsum, restoration requires replacement grafting similar to treatment of a saddle-nose deformity. Conversely, the underresected dorsum merely needs removal of the overprojected segment, and in minor cases this may be accomplished with a sharp rasp or power drill (Fig. 6.1).

Most patients seeking rhinoplasty desire enhancements of their nasal profiles. In fact, more than 80 % of all rhinoplasty patients are seeking a reduction rhinoplasty because they feel their nasal profiles are too prominent. However, it is first necessary to determine why the patient feels this way, since there are many different causes of the overly prominent nose. Proper characterization is critical, since failure to correctly analyze the cosmetic deformity may lead to inappropriate treatment and patient dissatisfaction. Is the problem a simple overprojected dorsal hump? Or is the entire nasal profile, including the nasal tip, overprojected (i.e., rhinomegaly)? Alternatively, does the excessive prominence result from a tension-nose deformity in which an overprojected dorsal septum gives rise to pinching of the middle vault and excessive elongation of the nostrils (Fig. 5.1)?

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.

Level of Evidence V 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 .

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.

Reconstruction of the nose requires attention to form and function considering the size and localization of the defect with regard to the existing aesthetic subunits.1 Despite the availability of fundamental principles for nasal reconstruction, every nasal reconstruction requires a very individual, challenging, and time-consuming preoperative planning.2,3 For full-thickness defects, restoration of cover, framework, and lining has to be considered in the surgical plan. Besides the reconstruction of the 3-dimensional nasal structure, one has to maintain its aesthetic form and function. The paramedian forehead flap still represents the golden standard for cover; however, several surgical steps of thinning and refinements have to be included to achieve pleasant results.4,5 As foreign materials are associated with an increased risk of infection, the framework should be reconstructed with autogenous grafts from rib or ear cartilage,6 which have to be fixed firmly to guarantee stable projection and correct axial positioning of the nose. For lining composite skin grafts, skin and mucosa grafts, hingeover flaps, perinasal local flaps, folded or second forehead flaps, and free flaps7 are available.

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.

The principles of nasal pyramid correction in secondary rhinoplasties are identical to the ones in primary rhinoplasties.

Although saddle-nose deformities are present in approximately 20 % of all rhinoplasties, the extent of saddle collapse varies widely. Hence, a wide variety of techniques are necessary to correct saddle noses. Because all saddle-nose defects arise from skeletal deficiency, augmentation is the primary means of surgical treatment. We prefer to use autologous augmentation materials for this purpose, with one exception: Tutogen (allogenic) fascia lata (Tutoplast® Inc., Neunkirchen am Brand, Germany). Tutoplast fascia lata is a gamma radiation processed human allograft which we have used successfully in over 3000 patients during the past 8 years (Fig. 7.1). Soaking the graft in antibiotic solution is necessary to rehydrate the graft and reduce infection risk. In addition to the avoidance of a donor site scar, fascia lata offers an ideal structure and stiffness for use in augmentation rhinoplasty. Conversely, autologous fascia lata lacks adequate stiffness, necessitating the use of percutaneous stay sutures to guide graft positioning and to prevent graft displacement.

Naturally occurring malformations of the lower lateral cartilages (LLCs) are common, and the use of the open rhinoplasty approach makes the recognition and characterization of tip malformations far more reliable and precise. Likewise, many unsuccessful rhinoplasties result from the inability to properly recognize and treat congenital LLC malformations because of poor surgical exposure using the closed approach. Malformations of the nasal tip may occur unilaterally or bilaterally with variations in both type and magnitude. Virtually any segment of the LLC can be affected by congenital anomalies, including the medial crural footpods, the medial crura themselves, or the nasal domes. However, the most common site for naturally occurring tip malformations is the lateral crus, with crural concavity being the most commonly seen anomaly. Although most malformations of the LLC are associated with cosmetic disturbances, concave malformations of the lateral crura are also commonly associated with functional impairment, particularly in noses with weak lateral crura that are prone to inspiratory collapse or in noses with an adjacent septal deformity that exacerbates nasal valve obstruction. In the thin-skinned nose, concavities of the lateral crus are often visible externally, but overlying soft tissues may conceal smaller concavities, underscoring the importance of a careful endonasal examination as part of the preoperative evaluation process. While some LLC deformities are hidden by the overlying soft tissues, we prefer not to rely solely on soft-tissue camouflage for treatment. Instead, correction of all skeletal deformities is preferred in order to optimize both the functional and cosmetic results. Although Daniel feels that a slight crural concavity (coupled with convexity of the intermediate crura) will yield the best tip contour, we believe that flat and sturdy lateral crura yield not only a pleasant tip contour but also provide the structural rigidity necessary for reliable function of the nasal airway.

The septum plays an important role in most cases of revision rhinoplasty, since residual deformity is often present. The residual deformity is often caused by an insufficient analysis and subsequent inappropriate or incomplete surgical technique. If this is the case, the long-term outcome is often disappointing, with drooping of the tip, saddling of the dorsum, and/or recurrence of the septal and/or nasal deviation.

Surgical alteration of the bony pyramid is often anxiety-provoking for the prospective rhinoplasty patient. Just talking about “breaking” the bone in the middle of the face creates fear and apprehension. However, contemporary techniques, combined with sophisticated cutting instruments, intraoperative ice-water cooling, and postoperative mechanical cooling devices to minimize swelling and bruising, have greatly improved surgery of the bony vault. Yet despite technical advances, the most important factor is still a well-conceived and individualized treatment plan executed with meticulous precision and extreme care.

Alterations of nasal tip contour are perhaps the most challenging aspect of cosmetic rhinoplasty. And because tip contour must harmonize with the surrounding facial features in a natural but pleasing manner, some degree of surgical tip refinement is a goal of nearly every cosmetic rhinoplasty. However, in addition to constituting a major determinant of facial beauty, the tip is also an integral component of the human nasal airway. Hence, surgical alterations to the nasal tip framework must be circumspect in order to prevent impairment of nasal airway function. Naturally weak tip cartilages are at increased risk of collapse with surgical manipulation, and cartilage size may not always correspond to cartilage strength.

The twisted nose is the most common deformity in noses, in our practice up to 50 %, but it presents a challenge to rhinoplastic surgeons as functional problems as well as aesthetic deformities often occur. The terminology used – deviated, twisted, crooked, asymmetric, scoliotic, and deflected – is confusing.

The nose is the central aesthetic element of the face, and a failed rhinoplasty may lead to significant psychosocial stress and dysfunction. The impact of a failed rhinoplasty should prompt the surgeon to explore the cause of treatment failure and to consider attempting to salvage the outcome with secondary surgery. However, the inexperienced surgeon often exacerbates the initial treatment failure when attempting to correct his or her own work, creating an ever greater challenge for the next surgeon. In such cases, the patient is often apprehensive, skeptical, and mistrusting of further surgery, even at the hands of an accomplished revision rhinoplasty specialist. However, the embarrassment and emotional angst of a failed rhinoplasty eventually prompt further surgery despite the associated fear and anxiety. Yet, in addition to the psychological issues of the revision rhinoplasty patient, the revision surgeon must also contend with the technical challenges of a previously operated nose. Disruption of surgical navigation planes, excessive bleeding, and dense scarring typically make the dissection far more challenging. Moreover, missing, distorted, or damaged skeletal structures typically necessitate complex skeletal grafting, and graft survival is less reliable due to compromised circulation. In the worst-case scenario, vascular insufficiency can lead to graft or skin necrosis. Even when the technical aspects of surgery are successful, postoperative swelling is often increased, and the healing process is usually prolonged. For all of these reasons, a candid and explicit preoperative discussion in which the limitations, risks, and complications of revision rhinoplasty are reviewed in detail must be undertaken. Additional time must also be allotted for a complete discussion of the relevant issues.

A septal deformity with severe deviation of the septal L strut is seen in nearly every crooked or scoliotic nose. Unless the underlying septal deformity is properly diagnosed and treated, the nasal axis cannot be completely straightened. In addition, because standard septoplasty techniques often fail to adequately address severe L-strut deformities, extracorporeal septoplasty is often a prerequisite for straightening the crooked nose. This article presents a detailed explanation of the extracorporeal technique, as well as representative long-term clinical results showing the efficacy and durability of extracorporeal septoplasty. Extracorporeal septoplasty a safe and reliable method for straightening the severely deviated nose.