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Archive for the ‘rhinoplasty’ Category

5-FU Injections in Rhinoplasty

Sunday, February 18th, 2018

 

Rhinoplasty surgery produces an expected amount of swelling and bruising based on the extent of the surgery. Like all facial surgeries the swelling and bruising is temporary and takes time go resolve. The swelling from rhinoplasty, however, is well known to be prolonged and is most manifest in the tip area. The tip swelling can be quite prolonged and it is well known that it can take a year or even longer to see the final remnants of the swelling to have dissipated and the remodeled tip shape to appear.

Fortunately for most rhinoplasty patients the final shape of the nose does not usually take a full year and an acceptable result occurs much sooner. But in the thick-skinned nose patient the swelling that will occur and the time is takes to go down is very prolonged and often requires some postoperative management to help the process. In such thick-skinned noses it is even possible that the surgery can make the nose tip more enlarged and amorphous if some postoperative management strategy is not done. Known as a polly beak deformity excessive scar tissue formation is prone to form in the tip and supratip areas in thicker-skinned patients that have a large amount of sebaceous tissue.

Steroid injections is the historic method used to treat nasal tip swelling and has been done for decades. While it can be effective steroids are a double-edged therapy with the potential for adverse long-term soft tissue effects if the dose is too high or the injections are done too frequently.

In the February 2018 issue of the journal Facial Plastic Surgery an article was published entitled ‘Use of 5-Fluorouracil for Management of the Thick-Skinned Nose’. In this paper the authors describe their technique for using 5-FU injections after rhinoplasty. Targeted injections of 5-FU (1mg to 25mg) mixed with a low concentration of Kenalog (triamcinolone) are given in 0.1ml aliquots into the desired nasal areas. They provide these injections anywhere from 1 to 5 injection sessions spaced 1 to 4 weeks apart. Such injections can be given as early as one week after surgery or even years later but their greatest effectiveness is in the first three months after surgery. In a one year series of 31 patients who had 55 5-FU injections the only side effects was pain on injection. No adverse soft tissue effects were seen.

5-FU is a well known chemotherapeutic agent used in the treatment of various cancers of the breasts and gastrointestinal tract. Its main mechanism of action is on fibroblasts.  It has an antimetabolite effect by being incorporated into the cell with impairment on collagen formation. As a result of this effect, 5-FU has been used for years in treating hypertrophic and keloid scars and is believed to work by the inhibition of TGF-beta. It is therefore logical that 5-FU would be applied to scar tissue formation after rhinoplasty as well.

Since it is an off-label use, there is no approved or well studied dosing regimen for post rhinoplasty injections. It is commonly practiced as a combination therapy by diluting the 5-FU with steroids in various combinations per surgeon preference. The role of steroids as a diluent is to decrease the pain of injection and to precent recurrent scarring. Since most noses need more than one single injection I also like to mix in some lidocaine as well and wait a bit after the first injection before doing more.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty in the Older Patient

Saturday, January 27th, 2018

 

Rhinoplasty is usually perceived as being a young person’s facial surgery… and for the most part it is. The majority of elective nasal reshaping surgery is done on male and female patients between the ages of 18 to 35 years old. But on the further end of the spectrum is the ‘senior rhinoplasty’ patient. Probably representing 5% or less of aesthetic rhinoplasty surgeries, they offer some unique considerations both anatomically and psychologically.

In the First Online edition of the December 2017 issue of the European Journal of Plastic Surgery, an article was published entitled ‘Rhinoplasty in elderly patients: analysis of outcomes and patient’s satisfaction following 20 years experiences’. In this paper the authors looked at the necessity of rhinoplasty in elderly patients, to determine the perception of patients before and after surgery and compare the older patients with younger patients. In a retrospective manner the total number of patients studied was 125 of which 25 of them had their results compared to a control group of younger patients.

Through a pool of over 1700 rhinoplasty patients over a twenty year period, 125 were found to be oder than 65 years. (7.3%) The average age was 68 years old with a near even distribution between men and women. Most of these were done through an open approach. (71%) Most rhinoplasties were augmentation (86%) rather than reductive, When comparing older vs. younger patients the greatest difference as that older patients were almost exclusively focused on the tip of the nose.

It should probably be no surprise that as one ages the tip of the nose changes. While often referred to the nose growing as we age, it does not really grow. Rather the cartilage weakens and sags and the tip of the nose drops a bit. When measured from a straight line from the top of the nose to the tip, it has indeed lengthened. It is this droopy tip that most older patients want improved or lifted. To do requires adding cartilage support to the tip to derotate it and have it stay up.

Dr. Barry Eppley

Indianapolis, Indiana

Septal Extension Graft Techniques in Rhinoplasty

Saturday, January 13th, 2018

 

The projection of the tip of the nose is an important element in rhinoplasty. This becomes of almost primary importance in noses that have inadequate tip projection due to congenital development such as in Asian and African-American noses. Numerous techniques have been used to increase tip projection based on the nasal tripod concept with the central septal support as its foundation. This has led to numerous concepts to create increased tip projections from which the most effective approach is to use it as a support platform to push out the tip from behind it. It is believed that due to the inherent strength of the caudal septum, maintaining as much of its structure as possible is important.

In the January 2018 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Septum-Based Nasal Tip Plasty: A Comparative Study between Septal Extension Graft and Double-Layered Conchal Cartilage Extension Graft’  In this paper the authors compared two methods of increasing tip projection through extension grafting, a septal extension graft (10mm long grafts) or double-layered ear cartilage interposition grafts, in the amounts of tip projection obtained and its ability to control its rotation. Twenty-seven (27) patients (14 with septal extensions grafts and 13 with ear cartilage grafts) over a two year period were studied. Nasal tip projection and nasolabial angles were measured before, 2 weeks after surgery as well as 7 months after surgery.

Nasal tip projection increased 60% in septal extension grafts and 75% by ear cartilage extension grafting. Longer term followup showed that relapse rates were nearly 40% and 25% respectively. The nasolabial angles increased after surgery by about 3 degrees for both groups which was maintained over time. Over 10% of the total patients required revision surgery for aesthetic reasons. Almost 15% of the total patients developed an infection.

This paper documents that septal extension grafts are effective at increasing and maintaining tip projection. Whether it is harvested from the septum or the ear, both types of extension grafts offered similar structural enhancement, stability and complication rates.

If one wants to maintain complete septal integrity and place a septal extension graft, options also include a rib graft as well as ear cartilage grafts. Ear cartilage grafts in my experience always seem weak and not very stiff. Thus a sliver of rib cartilage is much better. Adding an ear cartilage graft to a PDS plate us another option that could be effective in this rhinoplasty technique.

Dr. Barry Eppley

Indianapolis, Indiana

Open Structural Technique in the Asian Cleft Rhinoplasty

Saturday, January 13th, 2018

 

Rhinoplasty can be a difficult operation in many noses. But its difficulty rises when rhinoplasty is needed in the cleft patient due to the structural deficiencies and asymmetry of the nasal cartilages and the often scarred and thick tissues from prior nasal surgeries. It becomes even more challenging in the Asian cleft patient who has a genetic tendency of a  flat, short and under projected nose. This then become a challenge of not only making the cleft side of the nose look better but to enhance the non cleft side of the nose as well.

In the December 2017 issue of the Aesthetic Surgery Journal an article was published entitled ‘Asian Cleft Rhinoplasty: The Open Structural Approach.’  In this paper the authors present their experience using an open structural technique for Asian cleft rhinoplasty using rib cartilage and temporalis fascia. The basic tenets of their approach include a central septocolumellar graft combined with extender spreader grafts (from rib) to lengthen the tip of the nose. The dislocated lower alar cartilage on the cleft side was then completely detached and mobilized off the vestibular lining. The deficient medial crura was lengthened with the lateral crural steal procedure. The resultant shortened lateral crura was reconstructed with the lateral crural strut graft. Tip suturing and cartilage grafting was done. Dorsal augmentation was accomplished using diced cartilage wrapped in temporal fascia. At closure, a reverse-U excision of the vestibular lining was performed to correct the alar hooding on the cleft side. Alar base reductions were done as needed and the depressed alar base augmented with a small rib graft.

Over a five year period, thirty-fee (35) Asian parents underwent open cleft rhinoplasty.  (18 females, 17 males and 23 unilateral clefts and six bilateral clefts) There were 18 female patients and 17 male patients. Twenty-nine patients were unilateral clefts and 6 were bilateral clefts. All patients were highly satisfied with the functional and aesthetic improvements of their nose. The complications ( infection) and revision rates (2 patients) were low.

This paper documents the use of the open rhinoplasty approach using all autologous materials. (rib and temporal fascia) It avoids the use of any synthetic materials which are commonly used in many aesthetic Asian rhinoplasties. The key to the technique is the septocolumella graft in the midline which saves as the central tentpole of support onto which tip projection and nasal length can then be set.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Rhinoplasty for the Long Thin Nose

Monday, January 8th, 2018

 

Background: Rhinoplasty changes the shape of a wide variety of noses. This is why a large number of nasal reshaping techniques exist and the ‘cookie cutter’ approach to rhinoplasty surgery will leave some patients wanting. Besides identifying what anatomic structures create the nasal shape seen, it is also important to recognize what effects modifying the structural support of a nose will do. Failure to do ends up with indentations  and asymmetries long term as scar tissue contraction distorts a weakened cartilage structure.

One such nose that poses a challenge is the long skinny nose. It has excessive cartilage length but at the same time the lower alar cartilages are thinner and structurally weak. The nasal skin is almost always very thin revealing any irregularities underneath it. Shortening the tip of such a nose is fraught with the potential for lower alar collapse and notching.

Case Study: This petite young female presented for rhinoplasty with the following aesthetic deformities; a small nasal hump, an overprotected nasal tip, an irregular dorsal line, nasal asymmetry, left middle vault collapse, alar rim retraction and widely flaring nostrils. She had no breathing difficulties.

Under general anesthesia an open rhinoplasty approach was used to perform the following maneuvers. A eptoplasty to straighten it as well as harvest grafts, angled resection of caudal septum, hump reduction by cartilage shave and bony rasping (no osteotomies), bilateral spreader grafts, tip shortening by medial footplate resection, medial cephalic trim of lower alar cartilages,  tip suturing, columellar strut grafts, alar rim grafts and alar flaring reduction.

In many rhinoplasties the concept of what is added is just as important as what is removed. While not true for all aesthetic nasal surgery, many patients need a redistribution of cartilage structure rather than a removal of cartilage alone.

Highlights:

1) The long thin nose is a challenge in rhinoplasty that requires both reduction as well as adding structural support.

2) Deprojecting the kong thin tip must be done carefully to avoid over rotation and weakening of the low alar crura.

3) Spreader grafts can help widen the middle vault in a thin nose as well as improve asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Alar Flare Reduction in Rhinoplasty

Thursday, January 4th, 2018

 

In rhinoplasty there are numerous features of the nose that can be reshaped. Some of these are of major size while others are comparatively small. Small size in rhinoplasty surgery, however, does not make it aesthetically insignifcant. One such small nasal feature is tknown as alar flare. This should not be confused with nasal base width which is located more inferiorly at the alar-facial groove. Reducing the amount of alar flare is a not uncommon procedure that is usually performed as the final step in rhinoplasty after the nasal incisions are closed due to the potential effects of tip manipulation on the appearance of alar flare..

Because alar flare reduction is an excision technique, it is irreversible. There are numerous technique to perform it.  Choosing the correct alar excision technique and balancing that with the scar burden that results from its use is another one of the many finesse procedures in rhinoplasty.

In the November 2017 journal issue of Plastic and Reconstructive Surgery an article was published entitled ‘Managing Alar Flare in Rhinoplasty.’ In this paper the authors highlight the following important concepts of surgical alar flare reduction.

Alar flare and nasal base width should not be confused as they are not interchangeable terms. Alar flare is the most lateral projection of the alar rim. This may or may not be equal to the alar base. Limited alar flare of a few millimeters is common.

Alar flare is classified into three types based on how the lateral part of the alar rim (LAR) is vertically located relative to the nasal sill-base junction (NSBJ) in the submental view. Type 1 = LAR < NSBJ, Type 2 = LAR = NSBJ and Type 3 LAR > NSBJ.

Reduction of alar flare can be done by excision of alar lobular skin with an important goal of minimizing  scar visibility and matching the excision technique to the alar flare type.

Type 1 alar flare is managed by a limited obliquely-oriented skin excision just above the alar-facial groove.

Type 2 alar flare reduction is done with a more horizontally-oriented skin excision that is carried further up along the alar-facial groove.

Type 3 altar flare reduction uses a superiorly-oriented skin excision that extends upward to the most lateral point along the alar-facial groove.

The skin excision should be placed 1mm anterior to the alar groove.

Asymmetry is very easy to occur in alar flare reduction, like nasal width reduction, is precision of markings and detailed execution is critical to avoid it.

Some alar flare is preferable to over resection of it to avoid nostril distortion.

Very significant nose width reduction may need to combine nasal base width reduction (e.g., sill excision) with alar flare reduction.

Alar flare reduction creates a more subtle change than the more powerful techniques of nasal base width reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Compressed Diced Cartilage Grafting in Rhinoplasty

Thursday, December 14th, 2017

 

Cartilage grafting in rhinoplasty is an essential part of aesthetic nasal augmentation. It is traditionally used as an onlay method, using single layer or stacked grafts. While effective for some cases, it requires straight grafts that can be shaped with smooth edging.  This does not always fit, however, every defect and straight grafts can be hard to find. This has led to the contemporary use of diced cartilage grafting which allows an injectable graft though syringes that can be molded intraoperatively.

The use of diced cubes of cartilage in rhinoplasty is associated with using a containment method. This has been either temporal fascia, the product Surgicel or thin allogeneic dermis. There is great debate about which wrap for diced cartilage is best. But the debate is now switching to whether any containment method is really needed at all.

In the November 2017 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Injection of Compressed Diced Cartilage in the Correction of Secondary and Primary Rhinoplasty: A New Technique with 12 Years’ Experience’. In this paper the authors reviewed their decade plus experience in over 3,000 patients of which over 2,300 were primary procedures and almost 800 were secondary rhinoplasties. Diced cartilage was injected using a special syringe design which compresses the cartilage into a malleable cylindrical-shaped mass. They report a 98% graft take, creating a smooth external surface contour. Less than 1% (21 patients) had partial resorption of the injected grafts. They were treated by secondary injection. Over 1% (36 patients) had over correction which was treated one years later by rasping when the graft was completely consolidated.

This paper offers an extensive clinical experience with using compressed diced cartilage grafting. By compressing the graft it becomes easier to place as well as is composed of pure cartilage. This accounts for its high take that would be comparable to solid cartilage grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study- Hump Reduction Rhinoplasty

Tuesday, December 12th, 2017

 

Background: The surgical reduction of a nasal hump is one of the oldest techniques in rhinoplasty. It has been done since the nasal reshaping procedure was introduced and, historically, defines what a rhinoplasty was. It has long been recognized that a raised or convex profile to the dorsum of the nose is not an aesthetically desirous nasal feature for most people. In addition it can he perceived as an ethnic nasal feature and in trying o achieve better nasal shape its removal can also make the nose more ethnically neutral.

The upper third of the nose is commonly known as the bridge. While often perceived as being bony in composition, it is really a combination of bone (nasal bones) and cartilage. (septum and upper lateral cartilages) This becomes apparent when a hump is present and its removal is requested. Taking down a dorsal hump on the nose always requires removal of both bone and cartilage of which cartilage usually makes up the greatest percentage of the hump.

The standard goal in most hump reduction is to change the profile of the nose to a straight line. This linear dorsal profile is most commonly accepted and is one that optimally maintains nasal airway function. But it is not the only dorsal profile that is requested. Some females may want a more concave dorsal profile while some men may want to maintain a bit of convexity to it or the semblance of a small dorsal hump.

Case Study: This young female had several features of her nose that she wanted changed for a slimmer more feminine nose. One was the long dorsal hump that covered the entire distance of her nasal profile.

Under general anesthesia an open rhinoplasty was done to completely remove the nasal hump to a straight nasal profile as well as thin out the tip and give it a slight upturn.

Because most hump reductions are usually not done in isolation, an open rhinoplasty approach is most commonly used. This is the most assured approach for a smooth dorsal line that is optimally reduced.

Highlights:

1) The presence of a hump on the nose is the most common reason patients seek rhinoplasty surgery.

2) A straight dorsal line is the most desirous shape that those with a hump reduction seek.

3) Hump reduction consists of both bone and cartilage removal for which ‘rasping’ alone is not an adequate treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Dorsal Line Modifications in Rhinoplasty

Tuesday, November 28th, 2017

 

The shape of the nose is as varied amongst people as the weather is on any one day around the world. While not quite as distinct as a fingerprint, one’s nose shape is fairly unique in each individual. But despite this tremendous diversity in appearance, there are certain nasal shapes that many patients strive to achieve regardless of what their natural nose looks like. This creates a real challenge for any rhinoplasty surgeon in trying to achieve patient expectations.

But one aspect of nasal shape that is the least controversial and can be argued to be the most straightforward to change is the of the dorsal line. Viewed primarily in the side view the dorsal line of the nose is the profile shape from the top of the nose down to the tip along the skin. It can only have have three different profiles, straight, convex or concave. While the dorsal line does have aesthetic considerations in the front view, these do not have quite the significance as how it appears in the profile and oblique facial views.

The dorsal line is affected by the height of the nasal bones and the septum and can appear convex with a hump or concave with a saddle nose. In general a straight dorsal line is the safest aesthetic shape and would be considered one primary goal in many rhinoplasty surgeries. It is also considered the functionally safest nasal shape as it prevents collapse of the middle vault and potential nasal airway insufficiency.

The dorsal line is also considered gender neutral, being that a straight-line shape is desired by both men and women. But this is not always the case. In some women who seek a ‘cuter’ or definitely a strong feminine nose, a more concave dorsal line profile is preferred. It is the antithesis for treating a larger dorsal hump or a hook nose. Changing the dorsal line to this profile is particularly useful in transgender male to female rhinoplasty where ‘overdoing’ the dorsal line reduction helps create a more feminine appearance. As it turns out I have yet to have a male who wants anything other than a straight dorsal line and some may even prefer the maintenance of a residual dorsal hump or convexity.

In the older female nose where some tip dropping may have occurred, rotating the tip upward and lowering the dorsal line, can have a rejuvenating facial effect.

Determine before surgery what type of dorsal line profile a patients wants is one of the most straightforward imaging changes to make. Its impact affects the entire rhinoplasty result and is usually one of the top three types of changes a patient wants to surgically make to their nose.

Dr. Barry Eppley

Indianapolis, Indiana

Case Report – The Combined Rhinoplasty Lip Lift Procedure

Sunday, November 5th, 2017

 

Background: Reshaping of the central part of the face is done by changes to the nose and lips. Whether through a rhinoplasty or various lip augmentations or lifts, the shape of these two midline facial structures have a major influence on one’s appearance whether it is seen from the front or side views.

Rhinoplasty and lp enhancement procedures are not surprisingly requested and done during the same surgery. Normally combining changes to the nose and lips does not pose any adverse risks. The one exception is when an open rhinoplasty and a subnasal lip lift are desired. The proximity of the incisions needed for these operations raises concerns about whether the columellar skin between them would survive if done together. This is a well known debate and surgeons have opinions on both concomitant and staging the procedures.

Case Study: This young female wanted to change the shape of her nose to get rid of her small hump and narrow the tip. In addition she wanted a fuller upper lip and to decrease the vertical skin distance between the nose and the upper lip.

Under general anesthesia an open rhinoplasty was done to reduce the hump, narrow the tip and perform nasal osteotomies. No septal work done including shortening of the caudal septum or separation of the medial footplates. Once the nose was closed a subnasal lip lift was performed removing 4mms of skin at the central lip position.

After surgery she suffered no vascular compromise of the intervening skin segment between the incisions of the open rhinoplasty and the subnasal lip lift.  Her aesthetic outcomes were acceptable with a more shapely nose, a shorter nose-lip distance and a fuller central upper lip.

If these two procedures are going to be performed together, maximal preservation of the vascular inflow to the lower columellar skin must be preserved. This requires non-disruption of the tissues that are on the backside of the columella, the septal mucosa and the anterior nasal spine area. This will be adequate for skin survival even with high and low skin incisions on its front surface. If a more extensive septorhinoplasty is to be performed then a subnasal lip lift should not be performed at the same time.

The alternative approach to a combined rhinoplasty lip lift procedure is to use just one incision at the base of the columella. This creates a longer superiorly-based skin flap but as long as excess tension is not placed on the tip skin due to increased projection this should not be a problem. This does, however, potentially create a downward tension the nasal tip which is avoided when a skin segment is maintained between them.

Highlights:

  1. 1) An open rhinoplasty uses a mid-columellar incision.
  2. 2) A subnasal lip lift uses an incision that crosses the base of the columella
  3. 3) Combining open rhinoplasty and a subnasal lip lift requires an appreciation for the integrity of the blood supply to the intervening columellar skin segment.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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