Richard E. Davis

Basal and squamous cancer of the facial skin

Nonmelanoma skin cancer (basal cell carcinoma and squamous cell carcinoma) is the most common malignancy of humankind and the incidence continues to rise dramatically. Most nonmelanoma skin cancer occurs on cutaneous sites of the head and neck, and treatment remains largely extirpative, although mor

The Anchor Graft: A Novel Technique in Rhinoplasty

We review our use of a modified tip graft that we termed the anchor graft for the correction of nasal tip deformities. This modified infratip shield graft was used to improve alar rim positioning, while simultaneously improving tip projection and/or augmenting infratip fullness. Standardized preoperative and postoperative photographs were taken of each patient. Aesthetic appearance was subjectively judged by the physician and a patient survey. Complications were tabulated. Sixteen patients met the requirements for inclusion in our study. Eleven patients received follow-up for more than 1 year. All patients demonstrated good aesthetic improvement, with only minor complications. No extrusion of the graft was noted. All patients reported a natural-appearing and normal-feeling nose after a minimum follow-up of 6 months. Revision surgery was elected in 4 patients, 2 of whom initially presented as revision cases. The anchor graft is a new technique to aid in cosmetic modification of the nasal tip as well as to improve the functional and aesthetic appearance of the nasal ala and external nasal valve.

SMAS Debulking for Management of the Thick-Skinned Nose

Introduction Oneof the greatest challenges in cosmetic rhinoplasty is the overly thicknasal skin envelope. In addition toexacerbatingunwantednasalwidth, thicknasal skin is amajor impediment to aesthetic refinement of the nose. Owing to its bulk, noncompliance, and tendency to scar, overly thick skin frequently obscures topographic definition of the nasal framework, thereby limiting or negating cosmetic improvements. Maskingof the skeletal contour is usuallymostevident followingaggressive reduction rhinoplasty where overly thick and noncompliantnasal skin fails toshrinkandconformtothesmallerskeletal framework. The result is excessive subcutaneous dead space leading to further fibrotic thickening of the already bulky nasal covering. Despite the decrease in nasal size, the resulting nasal contour is typically amorphous, ill-defined and devoid of beauty and elegance. Tooptimizecosmetic results in thick-skinnednoses, contourenhancement is best achieved by elongating and projecting the skeletal framework whenever possible (Figure 1). Skeletal augmentation not only reduces dead space tominimize fibrotic thickening, it also stretches and thins the outer soft-tissue covering for improved surface definition. However, in noses in which the nasal framework is already too large, skeletal augmentation is not a viable option, and the overly thick skin envelope must be surgically thinned to achieve better skin contractility and improved cosmetic outcomes. Histologicexaminationofoverly thicknasal tip skin reveals comparatively little dermal thickening or increased adipose content but ratherasubstantial increaseinthicknessofthesubcutaneousfibromuscular tissues.1Dubbed the “nasal SMAS” layer,2 the fibromuscular tissue layer lies just beneath the subdermal fat andmay account for an additional2 to3mmofskin flapthickness.OwingtoadiscretedissectionplaneseparatingthenasalSMAS layer fromtheoverlyingsubdermal fat, surgical excisionof thehypertrophicnasal SMAS layer canbe performedsafely inhealthycandidatesusingtheexternal rhinoplasty approach.3However,theoverlyingsubdermalplexus(containedwithin the subdermal fat)must be carefully protected.3-5 Similarly, inadvertentdisruptionof thepaired lateralnasal arteries—major feedingvessels to the subdermal plexus—must alsobeavoided, and special care should be exercisedwhenworking near the alar crease.3-5 SMASdebulking is also contraindicated in skin less than 3-mm thick because overlyaggressivesurgicaldebulkingmayleadtounsightlyprominence oftheskeletal topography.However, intheappropriatepatient,SMAS debulkingcanreduceskinenvelopethicknessbyasmuchas3.0mm, with greater reductions common in revision rhinoplasty caseswhen vascularity permits.6

Psychological considerations in the revision rhinoplasty patient.

The nose contributes greatly to the facial aesthetic. Derangements in nasal cosmesis, whether from surgery, trauma, or natural causes, have a plethora of implications for the emotional well-being of the individual. Rhinoplasty and revision rhinoplasty are both facial cosmetic operations that have potentially profound cosmetic, and therefore psychological, implications for the patient. Although many revision rhinoplasty patients have hopeful yet realistic surgical expectations, there is a subset of revision rhinoplasty patients having underlying psychological disturbances that may negatively affect the surgical outcome, no matter how favorable the surgical improvement. In this article, the various psychological disorders impacting revision rhinoplasty patients will be discussed. In addition, this article will familiarize the revision rhinoplasty surgeon with many of the hallmark characteristics of psychopathology, as well as the typical emotional presentation of the well-adjusted revision rhinoplasty patient, to facilitate differentiation between these seemingly similar, but distinctly different patient groups.

Nasal tip complications.

As cosmetic nasal surgery becomes increasingly more popular worldwide, postoperative nasal tip deformities have also become far more prevalent. Owing to the cosmetic prominence of the nose and to the functional importance of the nasal airway, postsurgical nasal tip deformities often result in debilitating emotional and physiological consequences. However, contemporary principles of cosmetic and functional nasal surgery, when applied expertly, will typically prevent such complications and will simultaneously permit a natural, attractive, and well-functioning nose. This article explores the mechanisms leading to common iatrogenic deformities of the nasal tip and provides alternative techniques for the safe and effective modification of nasal tip contour.

Common technical causes of the failed rhinoplasty.

The adverse rhinoplasty outcome may result from a wide variety of dissimilar causes. Although these causes include psychiatric patient disturbances and severely aberrant wound-healing responses, by far the most common etiology of the failed rhinoplasty is technical failure on behalf of the surgeon. Moreover, a disproportionate number of technical shortcomings stem from errors in basic rhinoplasty technique. Hence, mastery of rhinoplasty fundamentals will prevent a large number of novice errors that often taint the cosmetic outcome. Because many of the remaining technical errors stem from overaggressive tissue removal, tissue-sparing rhinoplasty techniques will also prevent many common causes of technical failure. This article identifies some of the more common technical errors associated with the unsuccessful cosmetic rhinoplasty and also provides insights as to their avoidance.

Revision of the overresected nasal tip complex.

Tip deformities resulting from previous nasal surgery range from mild to profound. For the mild deformity, morbidity is low and successful correction is usually achieved with a modest and targeted surgical adjustment. However, for the profound deformity, overt cosmetic deformities and corresponding functional impairment are the byproducts of severe derangements in skeletal architecture. Hence, for the severely damaged nasal tip, a complex surgical revision in which the decimated nasal tip framework is reconstructed with autologous cartilage grafts is essential. However, rebuilding the decimated nasal tip is a challenging and risky procedure that is best left to the seasoned rhinoplasty specialist. Careful assessment of the previously operated tissues, combined with an accurate cosmetic analysis, must be juxtaposed with the patients cosmetic desires to derive an individualized and effective treatment plan. Atraumatic soft tissue technique, combined with a strategic yet balanced and judicious application of graft material, often culminate in satisfactory surgical outcomes. Proper assessment, technical skill, and sound clinical judgment are all critical ingredients in successful restoration of the surgically compromise nasal tip.

Prevalence of Occult Nostril Asymmetry in the Oversized Nasal Tip: A Quantitative Photographic Analysis

OBJECTIVE To objectively determine the prevalence of occult nasal base asymmetry in adults with wide nasal tips using a standard photographic editing program. METHODS We performed a retrospective observational study in a private practice, ambulatory care setting. The photographs of 100 randomly selected patients undergoing rhinoplasty who presented with excessive nasal tip width and no apparent nasal base asymmetry were evaluated for occult nostril asymmetry. Patients varied by ethnicity and sex and ranged in age from 16 to 40 years. We excluded patients with discrete nasal base asymmetry, crooked or twisted noses, caudal septal deviation, columellar tilt, a history of craniofacial trauma, or a history of nasal surgery. Measurements were obtained using a standard photographic analysis program. RESULTS On the basal view, the median percentage of asymmetry (95% confidence interval) was 4.91% (4.17%-5.66%); on the frontal view, 4.66% (3.68%-5.62%). On the basal view, 73% of noses were at least 2.5% asymmetric; on the frontal view, 67% (McNemar P = .53). On the basal view, 48% of noses were at least 5% asymmetric; on the frontal view, 50% (McNemar P = .74). On the basal view, 11% of noses were at least 10% asymmetric; on the frontal view, 20% (McNemar P = .11). CONCLUSIONS A large percentage of individuals presenting with excessive nasal tip width and no obvious alar size discrepancies have nasal base asymmetry. Moreover, nostril asymmetry is demonstrated from the frontal and basal views with reasonable consistency. In a small subset of study patients, occult nostril asymmetry exceeded 10% of the total nasal base width. We postulate that clinically significant nostril size discrepancies are hidden by excessive tip width, and we speculate that these nostril size discrepancies become more apparent after surgical refinement of the oversized nasal tip, thereby potentially leading to unexpected postoperative cosmetic imperfections and patient dissatisfaction. The apparent frequency of (occult) nostril asymmetry in patients with excessive nasal tip width underscores the importance of nostril size assessment in the preoperative aesthetic analysis. We offer a reliable and convenient method for objective analysis of nasal base symmetry.

Complex Nasal Fractures in the Adult-A Changing Management Philosophy.

Acute management of complex nasal fractures in the adult nose is still frequently conducted using closed reduction techniques as first-line therapy. Treatment outcomes from closed reduction are often disappointing and secondary surgical corrections are required in a sizeable subset of patients. In response to the shortcomings of closed fracture manipulation, classic rhinoplasty techniques have been introduced to improve anatomic fracture reduction. Although these techniques improve the accuracy of skeletal reduction, they also weaken the nose, leaving it susceptible to the deformational forces of healing. To provide optimal anatomic fracture reduction and concomitant stabilization of the skeletal framework, we have been using contemporary strategies derived from open structure rhinoplasty and extracorporeal septal reconstruction for initial fracture treatment. Using wide-field exposure with open rhinoplasty, these strategies provide optimal fracture reduction and rigid stabilization of the septal L-strut using suture-based fixation and structural grafting techniques. The result is unsurpassed contour restoration and lasting architectural stability of the nose. When combined with power-driven instruments to cut, shape, mobilize, and create osseous suture holes, open structure stabilization of the disrupted skeletal framework establishes a new benchmark in acute fracture management.

Surgical Management of the Thick-Skinned Nose

Abstract When executed properly, open structure rhinoplasty can dramatically improve the consistency, durability, and quality of the cosmetic surgical outcome. Moreover, in expert hands, dramatic transformations in skeletal architecture can be accomplished with minimal risk and unparalleled control, all while preserving nasal airway function. While skeletal enhancements have become increasingly more controlled and precise, the outer skin‐soft tissue envelope (SSTE) often presents a formidable obstacle to a satisfactory cosmetic result. In noses with unusually thick skin, excessive skin volume and characteristically hostile healing responses frequently combine to obscure or sometimes even negate cosmetic skeletal modifications and taint the surgical outcome. For this challenging patient subgroup, care must be taken to optimize the SSTE using a graduated treatment strategy directed at minimizing skin thickness and controlling unfavorable healing responses. When appropriate efforts are implemented to manage thick nasal skin, cosmetic outcomes are often substantially improved, sometimes even negating the ill‐effects of thick skin altogether.