Search

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.

The framework reconstruction of the nose is a significant and complex component of its partial or total reconstruction. On the one hand, the design of the individual framework parts is based on the anatomic nature of available rib or ear cartilage, which must on the other hand be adapted to the anatomic characteristics of the defect. The framework parts must be anchored not only to each other but also stably to the facial skeleton. The symmetry of the framework reconstruction is an essential component of the aesthetics of the reconstructed nose. If these points are already considered in planning, the reconstruction of the nasal framework can be standardized insofar as the same principles for the basic design of the individual parts as well as stable solutions for the anchoring points can be chosen. With reproducible techniques, functionally and aesthetically good to very good results can be achieved, including in the long term. The surgeon must possess special skills in the field of nasal reconstruction to correctly choose, apply, and combine the various techniques of nasal framework reconstruction.

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 .

Objective outcome analysis of nasal surgery remains difficult. Recently, evaluation of nasal shape following rhinosurgery shifted from two-dimensional evaluation to more sophisticated three-dimensional (3D) analysis techniques, including stereophotogrammetry, computed tomography, and 3D laser scanning. This article explores the feasibility of using 3D laser surface scanners as a tool for preoperative planning and quality control in rhinosurgery.

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.

This article focuses on the surgical treatment of nonmelanoma skin cancers of the head and neck. The risk factors of nonmelanoma skin cancers for recurrence and metastases that are important for choosing the best treatment option are summarized. Surgical treatment options including surgical excision with standard margins, frozen section, staged surgery, and Mohs micrographic surgery are described. Indications, techniques, outcomes, and advantages and disadvantages of each approach are reviewed. Finally, management of incomplete excisions is discussed.

Excessive concavities of the lower lateral crura can lead to heavy aesthetic disfigurement of the nasal tip and to insufficiencies of the external nasal valve. This study reviewed experience with the lower lateral crural reverse plasty technique that uses the existing cartilage to create the desired lower lateral cartilage contour and provides sufficient alar rim support. A retrospective review was conducted with a follow-up period ranging from 9 to 33 months. The technique was applied in primary (n = 13) and secondary (n = 3) open rhinoplasties to correct severe concavities of the lower lateral cartilages. Two case examples and intraoperative photographs are presented to illustrate the technique and its results. The lower lateral crural reverse plasty proved its applicability for the functional and aesthetical correction of severe lower lateral crura concavities. By dissecting the distorted lateral crus, turning it around, and suturing it back in place, surgeons can “reconstruct” a new lateral crus with existing cartilage. No additional cartilage is needed, and no harvesting at a different location needs to be performed. After rhinoplasty, no alar rim instabilities were observed. In three cases, even preexisting instabilities were corrected. Aesthetically enduring results were observed, and no overcorrection or alar retraction was seen. With the lower lateral crural reverse plasty, severe concavities of the lower lateral crura can be corrected. This technique is a useful and reproducible procedure, performed without additional tissue to achieve functionally and aesthetically satisfying and enduring results.

Interleukin-1 receptor antagonist (IL-1Ra) is a good indicator of disease activity in patients with systemic lupus erythematosus (SLE). Glucocorticosteroids are the most frequently used drugs in SLE. Our goal was to compare IL-1Ra activity in SLE patients with and without renal involvement and to determine the effect of different dosage of glucocorticosteroids used in 17 patients with active SLE without nephritis, 7 patients with inactive lupus nephritis (LN), and 8 patients with active LN, along with 10 healthy controls. IL-1Ra levels were measured in the serum of SLE patients by Human Luminex [100] analyzer. Both in patients with active SLE without nephritis and in patients with LN, serum levels of IL-1Ra (p

Septoplasty is one of the most common surgery of ENT but even today the difficult septum still presents a great surgical problem. A severe septum deformity is usually due to an accident quite often in childhood. It is also seen in patients with malformation such as cleft lip and cleft palate deformity. It affects not only the nasal function, but also the aesthetic part of the nose. Severe septal deformities can not be corrected properly by the standard septoplasty techniques. Therefore in such cases an extracorporeal septoplasty is recommended. In this technique the whole septum is taken out, the bony and cartilaginous septum in one piece if possible, a new septal plate is reconstructed by different surgical techniques, followed by replantation and reconstruction of the cartilagenous dorsum. The first author kept on improving the safe septal fixation, rebuilding of cartilagenous dorsum and overall the extracorporeal septoplasty technique over the period of time and this technique with all its refinement can be recommended to all the surgeons dealing with this challenging noses.

To describe a technique of extracorporeal septal reconstruction to correct the markedly deviated nasal septum.Retrospective medical chart review of 2119 patients undergoing extracorporeal septoplasty from January 1, 1981, through July 31, 2004, by the author in a tertiary care facial plastic surgery center. The main outcomes measured included surgical complications, revision rate, and the surgeon's subjective determination of functional and aesthetic outcomes.Of the 2119 patients, 2 cohorts were available for review. From January 1, 1981, to July 31, 1987, the author performed the operation on 459 patients. Fifty-seven complications (12%) occurred, with irregular contour of the dorsum or saddling noted in 38 (8%). Twenty patients (4%) elected to have revision septoplasty. From January 1, 1996, to December 31, 1996, the author supervised residents performing extracorporeal septoplasty in 108 patients. Fourteen postoperative complications (13%) occurred, with dorsal irregularity noted in 12 (11%). Eight patients (7%) elected to have revision septoplasty.Extracorporeal septal reconstruction is an important surgical option for the correction of the markedly deviated nasal septum. Fixation of the straightened and replanted septum at the nasal spine and dorsal septum border with the upper lateral cartilages is essential. Spreader grafts for stabilization of the internal nasal valve and dorsal onlay grafts to prevent dorsal irregularity are strongly encouraged.

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.

Background In nasal reconstruction, the paramedian forehead flap is traditionally performed in 2 stages. To minimize the risk of flap necrosis, Millard described a 3-stage technique in a series of 5 cases in 1974. In this technique, an intermediate step of flap thinning is performed after flap transfer and before pedicle division. In this article, we compare the 2- and 3-stage techniques of paramedian forehead flaps for nasal reconstruction to determine the type and prevalence of complications related to each procedure. Methods Here, we present a retrospective review of a prospectively maintained database of paramedian forehead flaps for nasal reconstruction performed during a period of 6 years. We included all patients with 2- (n=87) and 3-stage (n=100) paramedian forehead flaps who had consistent and complete electronic patient records and followed them up for at least 6 months after pedicle division. We performed a regression analysis to adjust for the unequal distribution of complex cases. Results Demographic factors and the causes for the nasal defects were similar in both groups. Although the nasal reconstructions were significantly more complex in the 3-stage group, the rate of partial forehead flap necrosis was similar in both groups (2-stage, 3.4%; 3-stage, 5%; P=0.601). A regression analysis showed that the relative risk of partial flap necrosis in complex cases did not differ significantly between groups (relative risk, 0.80; P=0.705). Conclusions To our knowledge, our study is the largest series published to date and the first one to compare the prevalence of forehead flap necrosis in the 2- versus the 3-stage technique for paramedian forehead flaps. We found no evidence that the use of a 3-stage forehead flap lowers the prevalence of necrosis. Until larger multicenter studies or meta-analyses can be conducted, smaller yet well-conducted studies such as the present one provide critical data and represent an important contribution to the field. Future research should investigate whether the 3-stage technique produces better aesthetic results than the 2-stage technique.

Restoring nasal lining is one of the essential parts during reconstruction of full-thickness defects of the nose. Without a sufficient nasal lining the whole reconstruction will fail. Nasal lining has to sufficiently cover the shaping subsurface framework. But in addition, lining must not compromise or even block nasal ventilation. This article demonstrates different possibilities of lining reconstruction. The use of composite grafts for small rim defects is described. The limits and technical components for application of skin grafts are discussed. Then the advantages and limitations of endonasal, perinasal, and hingeover flaps are demonstrated. Strategies to restore lining with one or two forehead flaps are presented. Finally, the possibilities and technical aspects to reconstruct nasal lining with a forearm flap are demonstrated. Technical details are explained by intraoperative pictures. Clinical cases are shown to illustrate the different approaches and should help to understand the process of decision making. It is concluded that although the lining cannot be seen after reconstruction of the cover it remains one of the key components for nasal reconstruction. When dealing with full-thickness nasal defects, there is no way to avoid learning how to restore nasal lining.

The nose represents the center of the face. The nasal shape changes with the progression from infancy to adulthood. In newborns, the main supporting structure of the nose is the dorsal septal cartilage; it is the facial growth center. The loss of septal cartilage at different ages leads to various facial syndromes involving the nose, maxilla, and orbita. Therefore, every surgical treatment can compromise not only the nasal growth but also the growth of the whole face. Childhood trauma or a malformation of the nose can also cause enormous functional impairments similar to those caused by surgical treatments. Our contribution represents different aspects of nasal deformities and their treatment. An individual concept is indispensable to reach the best compromise in all cases. The postulate of an early treatment gives priority to physical and mental damage control. The late therapy concept uses the inimitable potential of the growth of different tissues needed for a septoplasty and should be protected from iatrogenic impairment. We recommend a first-line pediatric nasal reconstruction, an attentive follow-up, and finally, a secondary nasal reconstruction in the adult patient if required for achieving normalcy.

Because of better public education and earlier diagnosis of skin tumors, the number of soft tissue defects of the nose with limited size and depth after tumor resection is increasing. A variety of surgical methods such as skin grafts, regional flaps such as forehead flap, and local flaps have been described. The method of choice is dependent on the defect size, localization, skin structure and the wishes and expectations, and general condition of the patient. Nasal reconstruction for soft tissue defects in the supratip area, dorsum, and sidewalls using local rotation and/or advancement flaps is our primary option. But achieving supreme results with these non-subunit-based techniques is still a challenge. Showing schematic figures and case studies, this article is aimed at assisting surgeons in the planning and decision making of which flap is appropriate for the reconstruction of soft tissue defects of the nose.

The aim of this paper is to delineate the importance of the correction of the nasal septum when attempting to improve the nasal shape and function in patients with cleft lip and palate (CLP) deformity. The particular problems of the nasal shape in CLP patients are assessed. Various approaches for adequate correction are reviewed and discussed. The method of extracorporeal septoplasty is presented in detail. This method was used between 1982 and 1997 in 141 out of 332 CLP patients who required septoplasties and appears particularly suited for this purpose since it offers the possibility of reconstructing an almost normal septum. This is necessary in order to achieve both a functionally and an aesthetically good result. Our experience over the past 16 years confirms the advantages of this approach.

Based on a review of the literature and our own experience, we propose criteria for the site of implantation that, in our eyes, is suitable for a silicon implant or a cartilage transplant. Special interest is focused on rhinoplasty and chin augmentation, as both determine the facial profile of the patient. During the last 17 years we have treated 443 patients with augmentation rhinoplasty, of whom 360 received autologous ear cartilage grafts and 83 received autologous rib cartilage grafts. At the same time we saw 30 patients requiring removal of artificial implant materials that were used by other surgeons for rhinoplasty augmentation purposes. Since 1986 we have performed 60 chin augmentations with anatomically shaped silicone implants (McGhan), of which 40 patients had a combined rhinomentoplasty done.

The correction of a nasal deformity is a decisive step in the secondary treatment of patients with cleft lip and palate. The complex nasal deformity in these patients is caused partly by the anormaly itself and is partly a result of previous corrective surgery. Correcting the nasal deformity involves solving four complex problems: the septal deformity; the malposition of the exterior nose; the deformity of the nasal tip; and the deviation of the ala on the cleft side. The stigma of the patients with a cleft is sustained mainly by the asymmetry of the nasal entrances. Many operations, some of which cause extensive additional scarring, have been suggested for removing this typical feature in patients with clefts. We developed a triple swinging flap technique which has proved successful when used with an open as well as a closed approach. This also enables us to achieve symmetry of the nostrils.

We present three cases of mucous cyst as a rare postrhinoplasty complication that were seen in our clinic during the last 16 years. They were located in three different positions of the nose: bony and cartilaginous part of the dorsum of the nose as well as over the alar cartilage part of the nose. We were able to treat all three patients successfully by excision of the cyst through intranasal or open approaches. In reviewing the literature and from our own experience we come to the conclusion that postoperative clearing of all tissue remnants, especially mucous parts, and a careful, atraumatic operation by forming an intact mucoperichondrial tube for intransal osteotomy as well as for hump removal are the best prevention of postrhinoplasty complications such as mucous cysts.

One of the most important preconditions for a straight nose is a straight and stable cartilaginous L-shaped frame with sufficient support for the nasal tip and the cartilaginous dorsum. Where the structure of the septal cartilage is destroyed, a sufficient L-strut must be reconstructed. This article presents a technique for reconstruction of an autogenous L-strut using double-layered conchal cartilages.A retrospective review was conducted with a subsequent follow-up evaluation 10.5-22 months later. The conchal L-strut was used for 26 patients to reconstruct a new septal frame. The full details of the planning process, L-frame construction, and technical data are described together with two typical cases.In all 26 cases, the authors were able to reconstruct a sufficient neoseptum. In 25 cases, the neoseptum remained straight. Only in one case did the anterior border deviate immediately after the operation. No slippage from the nasal spine was found. The anchoring to the nasal bones and the upper lateral cartilages was stable. However, one asymmetric columella base was found, caused by an asymmetric support to the footplates by the transplant. The osteocartilagenous vault was successfully reconstructed in all the patients. Of the 26 patients, 25 described a marked improvement in their nasal breathing.The reported technique enables the surgeon to reconstruct the complete cartilagenous L-frame with both conchal cartilages. For certain cases, this technique of autogenous reconstruction of the nasal septum could be a valuable alternative to reconstruction with rib cartilage.

The correction of nasal deformities in cleft patients presents a challenge in the secondary treatment of this malformation. The complexity of the nasal deformity in cleft patients partly depends on the congenital anomaly itself and partly on the surgical procedures which were previously carried out. The nasal deformities in unilateral CLP patients are typical. The nasal floor and the nostril sill are mainly constructed during primary lip repair. While the ala on the cleft side is repositioned, the septum deformity and the anterior spine dislocation are not touched. If large circular incisions are used at the time of primary operation to achieve symmetry, the situation usually deteriorates. One of the main characteristics of a classic cleft lip nose is the deviation of the external nose to the non-cleft side due to the typical septal deformity, where the anterior part of the septum and the caudal edge of the septum are subluxated to the non-cleft side (Fig. 1). Furthermore, there is a typical asymmetry of the nasal tip and the ala (Figs. 5 to 7). The columella is slanted and shortened on the cleft side. The ala cartilage on the cleft side is distorted and displaced. There are two important points in the concept of surgical rehabilitation: First, straightening the deviated nose, which often needs extracorporeal septum correction. This seems to be the prerequisite for correction of the external deviation. Second, rehabilitation includes the correction of the asymmetry of the tip and the nostril. A number of techniques have been suggested for this problem, which indicates that there is no ideal procedure. In our hands the triple-flap repair produced good and reliable results. There was no difference in the results, whether an open approach or an endonasal one was used.

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.