Background An important element of most rhinoplasty surgeries is the treatment of the nasal bones, which involves various combinations of osteotomies and hump removal. Objectives The aim of this paper was to describe a rhinoplasty technique in which piezoelectric instruments (PEIs) are used to shape nasal bones, with the priority being to preserve the stability of these bones. In most clinical cases, nasal bones can be stabilized if rhinosculpture (RS) is applied broadly, both separately and in combination with different osteotomies, while preserving the nasal bridge. Methods A step-by-step algorithm was applied to achieve the required aesthetic results when working with PEIs on the bony pyramid, depending on the degree of asymmetry. We used the fully open approach in all clinical cases, which provided the greatest visual field when performing all the steps involved in treating the bony pyramid, thus fully exploiting all the possibilities and advantages of PEIs. Results We report our experience with 165 clinical cases performed over 18 months from December 2016 to July 2018. The patients were divided into 5 groups, depending on the algorithm selected to treat the bony pyramid. Conclusions When working with the bony pyramid, our approach limits patient movement, thus ensuring stability of the side walls of the bones in both the short and the long term—a property that greatly improves the aesthetic results. Level of Evidence: 4
Background The skin-soft tissue envelope (STE) is a critical component of rhinoplasty and can have a significant impact on the final result. To prevent potential complications related to the skin detachment and to improve rhinoplasty results, we applied the concept of skin contour sutures (SCS). The aim of this study is to assess the efficiency of SCS for nasal skin approximation. Objectives We describe a technique using a SCS which implies the use of external sutures to stabilize the STE flap and is based on the principle that the pressure of the sutures helps to approximate the STE to the underlying nasal skeleton. The clinical use of SCS for nasal skin approximation has minimized nasal edema, shortened the healing period, and improved aesthetic results. Methods The first study group demonstrates the utilization of SCS in 459 consecutive rhinoplasty cases between December 2016 and April 2022 which were retrospectively reviewed. The second study group consists of 30 patients with thick skin who had insertion of SCS with ultrasonic evaluation both preoperatively and postoperatively. Results The average postoperative follow-up period in the first study group was 41 months (range, 12-64 months). Any suture site that was visible after removal of the suture disappeared completely after 6 weeks in most patients. No complications were reported. In the second group our ultrasound data indicated that STE healing was faster as its thickness returns to its preoperative state earlier in the healing process when SCS were used. Conclusions It is our impression that SCS helps to decrease severe nasal edema, hematomas, loss of tip definition, fibrosis, and pollybeak deformity, which improves the results and predictability of rhinoplasty surgery.
Background Camouflage of nasal dorsum, aesthetic augmentation and highlighting the dorsal aesthetic lines are essential elements in modern rhinoplasty. Numerous techniques have been utilized including deep temporal fascia, rectus abdominis fascia, and diced cartilage in fascia (DC-F). Despite their wide spread adoption, technical challenges remained, especially when utilized for aesthetic purposes. Objectives The paper details the use of fascia (F) and diced cartilage in fascia grafts (DC-F) for aesthetic dorsal refinement in primary and secondary cases. One of the main goals was to achieve ideal dorsal aesthetic dorsal lines rather than just volume augmentation. Methods We used grafts from the deep temporalis fascia (F) and rectus abdominis fascia (RF) in 4 configurations: 1) single layer, 2) double layer, 3) full length diced cartilage in fascia grafts (DC-F), and 4) partially filled – segmental DC-F grafts. Technical refinements included careful determination of dimensions and meticulously suturing to the dorsum at appropriately 10 points to prevent graft displacement. Results We report our experience: 146 clinical cases over 35 months from January 2017 to December 2019. The patients were divided for 4 groups depending on which type of graft was used. Conclusions Use of autogenous deep temporal fascia, rectus abdominis fascia, and diced cartilage in fascia (DC-F) to camouflage dorsal irregularities, to highlight dorsal aesthetic lines, and to aesthetically augment either the entire nasal dorsum or its individual parts. Optimization of cutting, stitching, filling the graft, careful fixation of these grafts on the nasal dorsum, significantly increases the predictability of these techniques and minimizes problems.
Rhinoplasty as an operation is akin to a game of chess, where every maneuver will influence the eventual outcome. Undoubtedly, more than one approach to the nasal soft tissues envelop can produce beautiful and safe results as will be described in the paper namely, the subcutaneous, sub-superficial musculoaponeurotic system, supra- and sub-perichondral planes. For different justifiable reasons surgeons have their preferences, regarding dissection planes on the tip, middle and upper thirds, and regarding the manipulation of the soft tissue layers and nasal ligaments. The concept of the nasal layers and the presence of relevant ligamentous structures and how to restore them in an anatomical fashion, will help to understand the logic behind various approaches.
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