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Archive for the ‘rhinoplasty’ Category

OR Snapshots – Rhinoplasty with Septal Cartilage Graft

Thursday, October 27th, 2016

 

One of the fundamentals principles in rhinoplasty is the use of cartilage grafts. Since much of the nose is composed cartilage, its reconstruction or aesthetic augmentation is often done using cartilage grafts. There are three harvest sources of cartilage in rhinoplasty including the nose itself (septum), the ear and the ribs.

The septum is the most frequently harvested cartilage site because of its proximity and that it offers perfectly straight grafts. Septal cartilage grafts are not only straight but have significant structural rigidity. This makes them easier to shape and carve and apply to a wide variety of nasal implantation sites.

rhinoplasty-with-septal-cartilage-graft-dr-barry-eppley-indianapolisAugmentation of the dorsum of the nose is commonly done for aesthetic augmentation or correction of saddle nose deformities due to either trauma or prior rhinoplasty surgery. Septal cartilage grafts are perfect for dorsal augmentation because they are straight and can be precisely shaped. As long as one has not had a prior septoplasty it is the preferred cartilage donor site. It can offer more than an adequate amount of graft material to perform most dorsal augmentations.

This is an example of a male patient who had an over resected dorsum from a rhinoplasty that included a large hump reduction. A male that has a concave dorsal line dos usually find that to be an aesthetically pleasing nose. His original surgeon performed a nasal bone augmentation using ear cartilage. The middle vault down to the tip was left ungrafted and created a significant indentation. His septum has never been used as a cartilage donor site and served as a perfect donor site to use all the advantages of the septal cartilage for dorsal augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections for Nasal Contractures

Sunday, October 2nd, 2016

 

Rhinoplasty using an implant for augmentation is most commonly done around the world on Asian patients. With such large numbers of noses being implanted, it is inevitable that a certain percentage of complications will arise from their use. This is usually manifest as infection requiring implant removal. The sequelae of this process is a nose that has developed thick scar tissue that ultimately must be released/excised in a subsequent revision rhinoplasty. In more significantly affected cases the nose becomes severely contracted due to involvement of both the skin and the underlying cartilage framework.
In the September 2016 issue of Plastic and Reconstructive Surgery, an article was published entitled ‘Correction of Severely Contracted Nose’. In this paper the authors report on 59 patients with severe nasal contractures that were treated by adipose-derived stromals cell to soften the nasal skin prior to revision rhinoplasty. The total injection volume was 0.5ml with cell counts of 10,000,000/ml. The lower alar cartilages were released from the scar for advancement with rib grafts used mainly for the cartilage graft reconstruction.
Over an average 10 month followup period, 86% (51 out of 59) of the patients were satisfied with their result. Two patients (3%) subsequently developed infections and cosmetic issues arose with the cartilage grafts in eight patients. (14%) Nine of the patients (15%) need secondary injections into the tip of the nose.
When an implant needs to be removed from the nose due to infection, the question is when should revisional surgery be performed. There is no consensus as to when that should be when the infection appears to be cleared.
fat-injections-to-the-nose-dr-barry-eppley-indianapolisRather than waiting until the nose becomes scarred and contracted down a good argument can be made for early soft tissue intervention. In this paper stromal cell concentrates were used. Other surgeons, as have I, use concentrated fat grafts. Whether one injectate is better than the other is not currently known. For the purposes of cost concentrated fat injections would be preferred. In either case the goal is to soften scar tissue and improve the overall health and vascularity of the nasal skin envelope in preparation for secondary cartilage grafting.
Dr. Barry Eppley
Indianapolis, Indiana

Technical Strategies – Nasal Base Fixation

Monday, September 26th, 2016

Smiling is the single most important facial expression. It takes a lot of facial muscles to smile and their pull causes surrounding facial structures to move beyond that of just the lips. The superiorly positioned nose can move when one smiles as the upper lip elevates. The flexible tip of the nose is what can change at either the tip or the nostrils.

nasal-base-retraction-with-smilingWhile nasal movement with smiling is usually regarded as incidental and not aesthetically bothersome, there are certain nasal movements that can be. The most common is the downturning of the nasal tip caused by a hyperactive depressor septi muscle. The more rare adverse aesthetic movement is an undesired elevation of the base of the nostrils. This is an upward and inward movement of the nostrils where they attach to the face. This is caused mainly by the quadratus labii superioris muscle.

This muscle has two portions, the medial and lateral heads. The medial head is known as the levator labii superioris alaeque nasi muscle. This slip of the muscle originates from the frontal process of the maxilla and comes downward to insert into the alar cartilage and the skin of the nostril attachment to the face. (another slip of the muscle goes on to insert into the upper lip. Since muscles pull towards their origins it is this action that pulls the base of the nose upward.

Counteracting the action of the legator labii superiors alaeque nasi muscle can be done by disinsertion of the muscle from the nose. But to be absolutely certain that the action of the muscle is countered an addition technical maneuver can be helpful. Securing the base of the nose in a downward direction to the bone provides a point of fixation that can resist any residual muscle action.

nasal-base-fixation-technique-dr-barry-eppley-indianapolisintraoral-nasal-base-fixation-technique-dr-barry-eppley-indianapolisThis is done by a bone anchoring technique to the pyriform aperture. Using a permanent 4-0 Tevdek suture attached to a 1.5mm x 5mm titanium microscrew, the anchor is initially placed into the bone through a small intraoral incision. The needle of the suture then takes a bite of tissue just under the nostril attachment. The suture is tied down loosely, making it tight but not cinching it down enough that it pulls the nostril inward.

This intraoral bone anchoring technique provides firm fixation to prevent the nasal base from pulling upward when smiling. It is a useful adjunct to muscle release and provides a two-way approach to the nasal animation problem.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Thick Skinned Revision Rhinoplasty

Monday, September 19th, 2016

 

Background: Rhinoplasty involves changing the nasal shape through changes in the underlying bone and cartilage support. The only location for skin removal in a rhinoplasty is when the nostril width is reduced through various patterns of tissue excision.Thus in the large nose any reductive efforts and their results are heavily impacted by how well the overlying soft tissue shrinks down and around the reduced structural framework. This is also why in any rhinoplasty it may take up to a year to see the final result as the skin adaptation process can take this long to fully occur.

In the thick skinned nose, regardless of ethnicity, it can be a real challenge to achieve the rhinoplasty results many such patients want. This is particularly true when the overall goal is to make the nose smaller and have a more refined shape. This challenge is magnified when the patient has already had prior rhinoplasty surgery. The best chance for the nasal skin’s ability to shrink down is the first time before scarring forever limits what can occur with subsequent manipulations.

Case Study: This 35 year-old female presented with a history of two prior rhinoplasties by another surgeon. It was not clear what changes were done inside the nose but she felt that her nose was actually bigger after these two efforts than before any surgery was done. Her initial and revision rhinoplasties were done 15 and 9 months previously.

thick-nose-revision-rhinoplasty-result-front-view-dr-barry-eppley-indianapolisUnder general anesthesia an open rhinoplasty was performed. The nasal skin in the tip area was defatted and scar tissue removed. The lower alar cartilages were completely sewn together up to the middle vault without any evidence of resection. The lower alar cartilages were separated and releases, cephalic resections done and reshaped by dome suturing after the placement of a septal columellar strut cartilage graft. Nasal osteotomies were also performed.

thick-nose-revision-rhinoplasty-result-oblique-view-dr-barry-eppley-indianapolisthick-nose-revision-rhinoplasty-result-side-view-dr-barry-eppley-indianapolisHer results at just six weeks after revision rhinoplasty already show improvement in nasal shape even at this early postoperative time period. Further healing over the next year should continue to favorably improve the shape of the nasal tip.

The thick skinned revision rhinoplasty is a challenge and there are limits as to how much further improvement can be obtained. Thinning out the soft tissues of the nasal tip and proper supportive nasal tip cartilage reshaping can offer some improvement over prior rhinoplasty efforts.

Highlights:

1) The thickness of the nasal skin in any form of rhinoplasty poses limitations as to the quality of results seen.

2) Revision rhinoplasty in the thick skinned nose poses significant challenges in getting a smaller and more refined nasal shape result.

3) Defatting of the nasal tip and avoiding over resection or over plication of the lower alar cartilages can provide some narrowing of the thick skinned nose.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Rhinoplasty for the Pinocchio Nose

Thursday, September 1st, 2016

 

Background: The long protruding nose is well known in rhinoplasty and has been referred to as the ‘Pinocchio Nasal Deformity’. Such a description has been cited in plastic surgery articles all the way back to 1974. More anatomically described as an over projecting nose, it is the result of an elongated cartilaginous framework from the septum and lower alar cartilages. These three cartilage structures merge at the nasal tip making the lower third of the nose look way out of proportion to the nose and face behind it.

The correction of the Pinocchio nose was originally described by a radical tripartite cartilage excision of the nasal tip and the subsequent reduction of the nose above it to fit the new tip position. In essence this means that the the tripod cartilage unit at the end of the nose is resected and set back. This may or may not involve some degree of tip rotation. Once the nasal tip is set back it often becomes evident that there is a nasal hump above the new lowered dorsal line that also needs to be addressed.

While cartilage and bone can be reduced and reshaped, the same can not be said for the skin. What happens to the now excessive skin depends on its natural ability to shrink back down to a smaller underlying supportive cartilage framework. Fortunately in many case of the over projecting nose the skin is thinner and does this fairly well. But thicker nasal skin patients may not have the same soft tissue response.

Case Study: This 43 year-old female presented for rhinoplasty surgery. She had a very long and thin nose that also had significant tip asymmetry due to buckling of the tip cartilages.

Pinocchio Nose Rhinoplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia and using an open rhinoplasty approach, the caudal end of the septum was resected and the lower alar cartilages shortened by a dome division/resection technique. The septum was straightened and cartilage grafts harvested. The now apparent nasal hump was reduced and middle vault spreader grafts placed.

Pinocchio Nose Rhinoplasty result oblique view Dr Barry Eppley IndianapolisPinicchio Nose Rhinoplasty result front view Dr Barry Eppley IndianapolisAt one year after surgery the dramatic improvement in the appearance of her nose could be appreciated. It is not an ideal result as there remains some residual fullness and asymmetry on the left side of the nasal tip.

The over projecting nose illustrates what happens when the cartilage structure of the nose becomes overgrown. Driven by the midline septum, the growth center of the nose, its elongated development drives the upper and lower alar cartilages with it. This creates the Pinocchio nose deformity.

Highlights:

1) The pinocchio nose deformity is the result of an elongated septum and long lower alar cartilages.

2) Shortening the long nose requires cartilage reduction and tip reshaping manuevers to pull the nose back toward the face.

3) How much shortening the nasal tip that can be obtained partially depends on how well the overlying skin shrinks down to the shortened cartilage framework.

Dr. Barry Eppley

Indianapolis, Indiana

The Upper Nasal Lift

Saturday, August 27th, 2016

 

Reshaping of the nasal tip is an important element of many rhinoplasty surgeries. Elevation of the nasal tip, known as increasing tip rotation, opens up the nasolabial angle and is commonly done in many female rhinoplasties. Having a nasolabial angle greater than 90 degrees (usually 95 to 105 degrees) is desired for the female nose. There are many technical maneuvers done to create this nasal tip change (cephalic trim, caudal septal resection, tip-septal suturing to name the most common) and they all can be very effective.

In rare cases direct ‘tip lifting’ techniques may not work well. This can occur in the nose that has had numerous surgeries and has developed thick scar tissue and lacks good skin retraction capabilities. Thicker scarred skin is harder to lift unless it is driven upward by a cartilage framework that is expanded to provide the underlying push. But building out the  tip cartilages can make the nose too long and is not appropriate for all cases.

The older nose is also known to develop tip ptosis or sagging due to loss of ligamentous support from the tip cartilages. Thus it is true that the nose does elongate with age. Many older patients may not want to undergo a formal tip rhinoplasty for a tip rejuvenation benefit.

Nasal Lift intraop Dr Barry Eppley IndianapolisNasal Lift intraop side view Dr Barry Eppley IndianapolisOne method for refractory or older nasal tip sagging is an upper nasal lift. This is where a segment of skin is removed across the bridge of the nose where the frontonasal frown line is located. A horizontal elliptical skin excision of 5mms or more can be done. Like any distant skin pull on the face, it does not translate into a 5mm upward pull on the nasal tip however. The distant effect is less, usually only about 25% to 50%, down 3 to 4 cms from the excision site. When combined with other traditional direct tip lifting techniques its effect can be enhanced.

Because it is a skin excision, it will result in a fine line scar across the upper bridge of the nose. While this type of nasal incision can heal very well, it is best reserved for older patients who have developed some skin laxity. In older patients I have observed that the scar becomes imperceptible with time and scar maturation.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Wide Nose Rhinoplasty

Saturday, August 20th, 2016

nasal anatomy

Background: The tip of the nose is the most individual feature of one’s face. The size, shape and arrangement of the lower alar cartilages over the end of the septum create a wide array of end of the nose appearances. While each nasal tip can be said to be almost as unique as a fingerprint, multiple classifications of tip shapes have been described and categorized.

One broad category of nasal shapes is the wide nose. The wide nose always implies that the tip of the nose is broad and lacks a distinct tip shape. This is the result of the lower alar cartilages having an increased interdomal distance as well as an exaggerated intradomal distance. The nose tip usually lacks much recoil on pushing on it and will feel soft and spongy. The tip will have varying degrees of inadequate projection and may have  shorter columella and wider nostrils as well.

Reshaping of the nasal tip lower alar cartilages is one of the most described  techniques in all of rhinoplasty. Various forms of cephalic resections, suture reshaping methods and cartilage grafting of the columella and tip can be used. Determining and putting these nasal tip reshaping maneuvers together in any single patient to create the desired effect is an art form in and out itself.

Case Study: This 19 year-old female requested a rhinoplasty to change the shape of her nose. She was most bothered by her wide nasal tip that lacked refinement and made her face look flatter than what it really was.

Under general anesthesia she underwent an open rhinoplasty that included a small hump reduction, nasal bone osteotomies, cephalic trim of lower alar cartilages with double dome suture plication with a columellar strut made from septal cartilage harvest. Lateral crural sutures were also placed to create a supratip depression while also creating some tip rotation.

Wide Tip Rhinoplasty result frnt view Dr Barry Eppley IndianapolisWide Nose Rhinoplasty result oblique view Dr Barry Eppley IndianapolisAt 6 weeks after surgery, her nose showed significant improvement in its shape. The tip was noticeably more narrow and add some increased projection. The dorsum was smoother and the upper nose less wide. She was given a single Kenalog injection to the nasal tip at this point and was placed on evening compressive therapy using a soft nasal clamp.

Wide Nose Rhinoplasty result side viewThe methods used in a wide nose rhinoplasty can be very effective. But the thickness of the skin and any scar tissue that can develop can ultimately adversely affect the final result. Postoperative management to ensure that the exterior tip of the nose ultimately reflects how the cartilages underneath it are shaped is necessary in the wide nose that almost always has thicker nasal skin.

Highlights:

1) The width of the tip of the nose is controlled by the both the shape of the lower alar cartilages as well as their structural rigidity.

2) The wide nasal tip has large lower alar cartilages that has a flatter dome shape with increased interdomal distance.

3) Reshaping of the lower alar cartilages through an open rhinoplasty requires a combination of shape-changing sutures and a reinforced columella region onto which they can be secured and supported.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Female Slimming Rhinoplasty

Wednesday, August 10th, 2016

 

Background: The appearance of the female nose is quite different from that of men. While it is usually smaller when patient size is relatively comparable, it is more than just a size difference. The female nose is known to have shape changes as well with a lower dorsum, a more narrow tip and an increased nasolabial angle. Often perceived as a more refined nasal appearance it fits better with most feminine faces.

Many females that present for rhinoplasty do not have ‘major’ problems with their nose. They seek a few small changes to have a more refined or slimmer appearance to their nose. While smaller nose changes may appear easier or simpler, that is not necessarily so.  The technical aspects of the surgery may be less than in more major septorhinoplasties, but expectations of the result are also more demanding. The patient will be more scrutinizing of every detail and one can not always completely control how the skin will redrape over reshaped tip cartilages or the rotation of the tip.

Case Study: This 23 year-old female requested a rhinoplasty to have a more slim nose. She wanted to get rid of her nasal hump and have a thinner and more upturned nasal tip. She was looking for a more feminine nose.

Under general anesthesia an open rhinoplasty was performed. The nasal hump was reduced, the nasal bones narrowed and the tip cartilages reshaped by suture and the caudal septum trimmed to allow for tip rotation.

Small Dorsal Hump Rhinoplasty result side view Dr Barry Eppley IndianapolisSmall Dorsal Humpo Rhinoplasty result oblique view Dr Barry Eppley IndianapolisSlimming Nose Rhinoplasty result front view Dr Barry Eppley IndianapolisAt 6 weeks after surgery, her nose shows all of the improvements she was seeking. It will take a full year for the most subtle of nose changes to appear. Although at 6 weeks she probably has about 90% of the results she can expect. the upward rotation of the tip goes a long way in making the dorsal profile lower. While it is not classic rhinoplasty teaching to aim for a concave or more ‘swooped’ dorsal profile, this is nevertheless what some women want for their nose shape.

Highlights:

1) The degree of changes that a rhinoplasty offers to a patient depends on their anatomy and how much change they want to see.

2) For many noses small changes on numerous areas produces an improved and slimmer nose appearance.

3) Rhinoplasty can make the nose appear thinner with a slightly more upturned tip for a more feminine appearing nose shape.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Costal Cartilage Allografts in Rhinoplasty

Monday, August 8th, 2016

 

Augmentative rhinoplasty requires either a graft or implant to perform. In most cases the use of the patient’s own septum or ear donor site is adequate. In more substantative dorso-columellar augmentations consideration must be given to either rib grafts or synthetic implants to achieve the desired effect. In some cases even an amalgamated approach can be used combining an implant (dorsal) with a cartilage graft. (tip)

Rib Grafts in Rhinoplasty Dr Barry Eppley IndianapolisThere are well known advantages and disadvantages to both rib grafts and implants. Neither one is perfect. Rib grafts require a donor site and can be prone to warping. (if not diced) Implants have a higher risk of infection and can become displaced over time.

A third alternative does exist, however, that marries the benefits of both rib grafts and implants….that of cadaveric costal cartilage grafts. Harvested from cadavers through the Musculoskeletal Transplant Foundation (MTF), this allograft costal cartilage has several advantages. It eliminates the need for a donor harvest site which decreases operative time and lessens patient’s postoperative pain and scarring. They are minimally processed which helps preserve their biologic and mechanical integrity. (unlike irradiated or freeze-dried rib grafts from the past)

What is really surgically convenient and for the patient’s benefit is how the form in which the grafts are prepared. They come in either segments or sheets in a variety of lengths, widths and thicknesses. The costal cartilage sheets are greater than 3cms in length, 1 to 2 cms in width and around 2mms in thickness.  The costal cartilage segments are greater than 3 cms, have widths up to 3 cms and thicknesses up to 20mms. It has a comparative cost to that of many nasal implants.

The costal cartilage allograft is another augmentative rhinoplasty option between rib grafts and synthetic nasal implants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Nostril Narrowing Surgery

Monday, August 1st, 2016

 

Background: There are many elements that make up a desirable shape of the nose. While nostril width is not the most important, it is relevant for some patients and in some rhinoplasty surgeries to help achieve a better nose shape. It is one of the dozen shape considerations when analyzing and planning for a rhinoplasty surgery.

The width of the nose has been studied and numerous measurements have been determined as to what is the ideal nostril width. Keeping the sides of the nostrils between vertical lines drawn down from the pupil, a close to two-thirds width compared to mouth width and what makes for an equilateral or isoceles triangle when the nose is viewed from below. But in the end all that matters is whether the patient sees that their nostrils are too wide. In some patients this has to be shown by computer imaging when the nasal tip shape is changed.

There are numerous methods for reducing nostril width, most of which involve the excision of skin somewhere long the nostril base. One of these methods is nasal sill excision where skin is removed from the floor of the nostril. It is particularly useful when there is a wide nasal floor present in addition to flared or wide nostrils. A diamond shaped skin incision pattern is usually used. The scar ends up at the junction of the nasal sill and the ala. (side wall of the nostril) Many people already have an existing crease there so the scar can be fairly well hidden.

Case Study: This 25 year-old female had wide nostrils that she did not like and wanted them reduced. She was otherwise happy with the rest of her nose shape including the tip.

She underwent multiple other facial procedures under anesthesia so the nostril narrowing was done at the same time. A 4mm nasal sill excision was done in a diamond shape pattern. Resorbable sutures were used for closure.

Nostril Narrowing result submental view Dr Barry Eppley IndianapolisNostril Narrowing result front view Dr Barry Eppley IndianapolisHer six week results showed a visible reduction in her nostril width with a scar that was barely noticeable even at this early time after surgery.

Nostril narrowing is most often done as part of a rhinoplasty. But infrequently it can be the only part of the nose a patient dislikes. Nostril narrowing surgery by itself can be done under local anesthesia in an office setting.

Highlights:

1) Th width of the nostrils can be narrows by numerous techniques based on the amount of flare and the width of the nasal floor.

2) The nasal sill excision technique for nostril narrowing is effective for moderate nostril flare and with a wide nasal floor.

3) Meticulous placement of the excision and closure can result in very acceptable nasal scars.

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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