Sam P. Most

Trends in Functional Rhinoplasty

The evolution of the rhinoplastic surgery has spanned several centuries, with the last few decades focused on the development and refinement of techniques that address the nasal airway specifically. This increased focus on functional rhinoplasty has led to significant improvements in our ability to preserve and augment the nasal airway. Techniques are generally categorized by their effects on the external and/or internal nasal valves. Limitations exist, however, in our ability to critically interpret and apply these techniques due to a dearth of validated and reliable outcomes measures as well as confusion regarding the nomenclature of the nasal valves. This chapter will present a brief introduction to the history of functional rhinoplasty, means of evaluating the nose, outcomes, and surgical treatment of the nasal airway during functional rhinoplasty.

Nasal Airway Preservation Using the Autospreader Technique Analysis of Outcomes Using a Disease-Specific Quality-of-Life Instrument

OBJECTIVE To measure the efficacy of a specific midvault reconstruction technique (the autospreader flap) in dorsal reductive rhinoplasty with a validated quality-of-life instrument. DESIGN A prospective observational outcomes study of patients desiring reduction of the nasal dorsum who either (1) had no breathing obstruction, who underwent purely aesthetic rhinoplasty, or (2) had concomitant severe nasal obstruction due to septal deviation, internal valve narrowing, and/or turbinate hypertrophy, who subsequently underwent combined functional and aesthetic rhinoplasty. Preoperative and postoperative evaluation was performed using the Nasal Obstruction Symptoms Evaluation (NOSE) scale. RESULTS Thirty-eight patients completed preoperative and postoperative evaluation. No complications occurred. Patients in the purely aesthetic group were noted to have low preoperative NOSE scores, with no change postoperatively. There was a significant improvement in mean NOSE score postoperatively for the combined functional and aesthetic group (P < .001). CONCLUSIONS Midvault reconstruction using the autospreader graft may help prevent postoperative nasal obstruction due to midvault collapse. Combining this procedure with dorsal reduction in functional rhinoplasty patients with traditional airway reconstruction techniques is effective in improving nasal airway function as measured by a patient-based, disease-specific quality-of-life instrument.

Measurements of Orbital Volume Change Using Computed Tomography in Isolated Orbital Blowout Fractures

OBJECTIVES To measure the orbital volume of unilateral pure blowout fractures with computed tomography before and after surgery and to compare 3-dimensional (3-D) imaging systems. METHODS Twenty-four patients were evaluated with facial computed tomographic scans before and after surgery. Both the orbital volume and the displaced soft tissue volume were measured by 2 operators using 2 different 3-D software programs (Vitrea; Vital Images Inc, Minnetonka, Minnesota; and Dextroscope; Bracco AMT Inc, Princeton, NJ). RESULTS The mean (SD) normal orbital volumes calculated by Vitrea and Dextroscope were 25.5 (2.4) mL and 24.8 (3.0) mL, respectively. The average preoperative orbital volumes were 28.3 (2.3) mL and 27.6 (3.1) mL, while the postoperative volumes were 25.8 (2.5) mL and 24.9 (3.0) mL. Vitrea showed that the average volume of displaced orbital soft tissue was 2.8 (1.9) mL before surgery and that it was reduced to 0.3 (1.3) mL after surgery, while Dextroscope showed that the average displaced orbital soft tissue was 2.9 (1.4) mL before surgery and that it was reduced to 0.1 (1.2) mL after surgery. There was no statistical difference between the 3-D analysis programs. CONCLUSIONS Consistent volume measurements can be obtained using different 3-D image analysis programs. Measuring preoperative and postoperative volume changes and postoperative reduction can ensure a good surgical result and thereby decrease the incidence of enophthalmos.

Preserving Structural Integrity of the Alar Cartilage in Aesthetic Rhinoplasty Using a Cephalic Turn-in Flap

Resection of the alar cartilage has long been a mainstay of aesthetic rhinoplasty. One drawback of this technique is the destabilization of the ala/lateral nasal wall complex. Herein we describe the cephalic turn-in flap, a technique for reinforcement of the alar cartilage after removal of its cephalic portion.

Comparative computation of orbital volume from axial and coronal CT using three-dimensional image analysis.

Purpose: Volume measurements calculated from axial and coronal CT scans were compared to determine which method more accurately determines orbital volume. Methods: Thirty facial CT scans were used to measure 30 normal orbits using an image analysis program (Dextroscope, Singapore). The 3-dimensional volumes determined from axial scans and coronal scans were analyzed. The coronal scan volume measurements were further subdivided based on anterior limit criteria (termed C1 and C2). Three novel cephalometric angular measurements of the anterior orbital aperture were calculated and used to analyze the volumetric methodologies described above. Results: The calculated orbital volume was greatest on axial scan, 25.6 ± 2.4 ml, followed by volume based on coronal calculations with C1 delimitation (23.8 ± 2.9 ml) and C2 delimitation (16.6 ± 2.2 ml). We measured 3 novel orbital aperture angles on sagittal 3-dimensional reconstruction images, anterovertical, posterovertical, and horizontal orbital aperture angles that are related to the volume measurement underestimation. Conclusion: The orbital volume from coronal scans is underestimated compared with that from the axial scans, and the criterion for anterior limit of measurement can affect volume determination. Three novel cephalometric angle measurements may account for inaccuracies in orbital volume measurements.

Validation of a grading system for lateral nasal wall insufficiency

This study was designed to validate a grading scheme for lateral nasal wall insufficiency with interrater and intrarater reliability measures. Representative endoscopic videos depicting varied degrees of lateral nasal wall insufficiency were collated into a 30-clip video (15 clips in duplicate). This was rated by five reviewers for a total of 150 observations. Interrater and intrarater reliability were determined using Fleiss kappa and intraclass correlation coefficient (ICC) statistics, respectively. Good agreement was established between reviewers (interrater reliability), with a Fleiss kappa of 0.7733 (p < 0.01). Analysis of intrarater variability with the ICC revealed a very strong agreement (ICC = 0.88; p < 0.01). The proposed grading system is shown to have good interrater and intrarater reliability. It provides a reliable instrument for assessing lateral wall insufficiency.

Pre- and Postoperative Portrait Photography: Standardized Photos for Various Procedures

Photodocumentation in facial plastic surgery is essential in the perioperative setting, and with meticulous uniformity and standardization it serves as the primary tool for surgical planning and critical analysis of results. Accurate photodocumentation is dependent on strict and consistent use of equipment, lighting, and patient positioning. The purpose of this article is to review the principles of standardization in perioperative patient photography for common facial plastic procedures and to provide the facial plastic surgeon with the tools necessary to develop consistent and accurate patient photographs.

An introduction to stem cell biology.

The field of stem cell biology has undergone tremendous expansion over the past two decades. Scientific investigation has continued to expand our understanding of these complex cells at a rapidly increasing rate. This understanding has produced a vast array of potential clinical applications. This article will serve as an overview of the current state of stem cell research as it applies to scientific and medical applications. Included in the discussion is a review of the many different types of stem cells, including but not limited to adult, embryonic, and perinatal stem cells. Also, this article describes somatic cell nuclear transfer, an exciting technology that allows the production of totipotent stem cells from fully differentiated cells, thereby eliminating the use of embryonic sources. This discussion should serve as a review of the field of stem cell biology and provide a foundation for the reader to better understand the interface of stem cell technology and facial plastic and reconstructive surgery.

Anterior Septal Reconstruction for Treatment of Severe Caudal Septal Deviation: Clinical Severity and Outcomes

Objective To report the long-term efficacy of a modified extracorporeal septoplasty technique in the treatment of anterocaudal septal deviations. Study Design Case series with chart review. Setting Academic tertiary care medical center. Subjects and Methods Data were obtained by a retrospective review of patients treated by a single surgeon (S.P.M.) from December 2010 to April 2014. A total of 77 patients (52 male, 25 female) met inclusion criteria. The Nasal Obstruction Septoplasty Effectiveness (NOSE) scale and a visual analog scale (VAS) were administered to all patients preoperatively and at each postoperative visit. Statistical analysis was performed using a matched-pair t test comparing preoperative and postoperative NOSE and VAS scores. A recently described severity scale for nasal obstruction was applied to NOSE scores to demonstrate postoperative results. Results Average follow-up was 4.7 months. Average preoperative NOSE and VAS scores were 68.2 ± 17.4 and 7.2 ± 1.8, respectively, placing these patients in the “severe” symptoms classification. Average NOSE and VAS scores in the early postoperative period (1-3 months after surgery) were 21.1 ± 19.8 (P < .0001) and 2.1 ± 2.6 (P < .0001), respectively. Average NOSE and VAS scores in the late postoperative period (>3 months after surgery) were 15.8 ± 19.0 (P < .0001) and 1.4 ± 1.8 (P < .0001), respectively. Both early and late postoperative NOSE scores represented “mild” symptomatology. Conclusions Anterior septal reconstruction represents a powerful method for correction of nasal valve stenosis resulting from severe anterocaudal septal deviations.

Evidence-Based Medicine: Rhinoplasty.

Evidence-based medicine has become increasingly prominent in the climate of modern day healthcare. The practice of evidence-based medicine involves the integration of the best available evidence with clinical experience and expertise to help guide clinical decision-making. The essential tenets of evidence-based medicine can be applied to both functional and aesthetic rhinoplasty. Current outcome measures in functional and aesthetic rhinoplasty, including objective, subjective, and clinician-reported measures, is summarized and the current data is reviewed.