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Dorchester Center, MA 02124

Revision Rhinoplasty

Key Points Revision rhinoplasty is the process of correcting secondary deformities from primary surgery. Skin thickness must be analyzed and factored into decision making in revision rhinoplasty. Thin skin–soft tissue envelope (SSTE) contracts with time and can reveal minor irregularities. Thick SSTE must have adequate structure projected into the SSTE to prevent long-term complications with supratip fullness. Costal cartilage quality varies with calcification and age. Sequential…

Non-Caucasian Rhinoplasty

Key Points Non-Caucasian patients have differences that extend beyond anatomy. Cultural norms, communication, expectations, and aesthetic definitions all must be considered in this patient group. Anatomic variants preclude certain common surgical maneuvers performed with Occidental patients. Aesthetic goals in non-Caucasian patients are not necessarily to be westernized. Dorsal profile management and tip refinement remain the workhorse maneuvers in non-Caucasian rhinoplasty. Alloplastic implantation should be done under…

Special Rhinoplasty Techniques

Key Points The external approach for rhinoplasty is found almost exclusively in the severely twisted or previously operated nose. Nasofrontal angle modifications can help shorten or lengthen the nasal dorsum. Batten grafts can help correct both internal and external nasal valve collapse. Spreader grafts are helpful both structurally and cosmetically and can increase the internal nasal valve area. Upper lateral cartilage (ULC) turn-in flaps and auto-spreader…

Rhinoplasty

Key Points The best results in rhinoplasty are achieved by the most conservative possible techniques that respect the structural quality and relationships of nasal elements and maintain natural and normal-appearing outcomes. Most successful outcomes are achieved primarily through tissue reorientation, reshaping, and augmentation rather than with aggressive resection or reduction techniques. Assessing the quality and thickness of the skin is an essential part of preoperative planning.…

Nasal Fractures

Key Points Nasal fractures tend to occur along the thinner bone below the intercanthal line. Septal fractures are commonly found in injuries where the nasal pyramid is deviated by at least half the nasal width. Nasal fractures from lateral trauma are typically less severe in nature and have a better prognosis than those that result from frontal-force injuries. Plain film radiographs have a high false-positive rate…

The Nasal Septum

Key Points Examination of the patient should be performed before and after decongestion to fully evaluate the factors that contribute to nasal obstruction. The nasal cycle is an alternating one; the total resistance in the nose remains constant. In patients with a fixed septal deviation and intermittent nasal obstruction, the interplay of the nasal cycle becomes evident; the sensation of obstruction frequently mirrors the congestion phase.…

Otoplasty

Key Points Protruding ears is one of the most common congenital deformities of the head and neck and occurs in 5% of whites. It is inherited in an autosomal-dominant fashion with variable penetrance. Normal anatomy: 15- to 30-degree posterior angulation, auriculocephalic angle of 20 to 35 degrees; normal pinna position is 15 to 20 mm from the helical rim to the scalp. The most common underlying abnormalities…

Mentoplasty

Key Points The chin plays an important role in the facial profile and in overall facial appearance. The chin should be evaluated as it relates to other adjacent structures, such as the lips, nose, and teeth. It is crucial to evaluate the chin in three dimensions: horizontal (anteroposterior), vertical, and transverse. Horizontal chin deficiency may be camouflaged by an alloplast implant. Bony osteotomy of the mentum…

Blepharoplasty

Key Points Eyes play a central role in human communication because they allow for expression of emotions through nonverbal cues. Periorbital muscle activity allows for expression of emotions through the eyes. A thorough understanding of facial and eye anatomy is of utmost importance for both evaluation and treatment of the aging periorbital area. Evaluation of a patient before blepharoplasty should include careful assessment of the eyelid…

The Aesthetic Brow and Forehead

Key Points The modern female brow peak is closer to the lateral canthus than to the lateral limbus In many patients the medial brow does not descend and may actually elevate with age The shape of the upper lid crease in comparison to the superior orbital rim and the distance between these curves are important components of a person's apparent age Avoid excess cautery, scalp excision,…

Rhytidectomy and Facial Liposuction

Key Points Rhytidectomy has been performed in the United States for at least a century. During this time, the technique for performing the operation has undergone marked evolution. To date, no consensus exists among experts regarding what technique achieves the appropriate balance between aesthetic result and the risk of complications. Rhytidectomy involves rejuvenating the aging face by reversing the gravitational effects of aging. The loose skin…

Management of Aging Skin

Key Points Combined resurfacing modalities tailored to skin type and location are more effective than a single modality alone. The ideal patient for skin resurfacing is the thin-skinned woman with a fair complexion and fine rhytids. Impairment of liver and/or kidney function could slow the excretion of phenol and increase the likelihood of cardiac complications. All patients should receive appropriate antiviral therapy to prevent and treat…

Hair Restoration: Medical and Surgical Techniques

Key Points Androgenetic alopecia is the most common cause of hair loss in adults. The hair cycle has four stages—anagen, catagen, telogen, and exogen—and 90% of hair is in the growing, anagen phase. Dihydrotestosterone is associated with inhibiting the growth of genetically predisposed hair follicles. Finasteride blocks the conversion of testosterone to dihydrotestosterone via the inhibition of 5α-reductase activity. Currently, topically applied minoxidil and oral finasteride…

Reconstruction of Facial Defects

Key Points Local flaps may be classified by the method of movement and are referred to as pivotal, advancement, or hinged. Most flaps are moved by a combination of pivoting and advancement. Pivotal flaps move toward the defect they are designed to repair by rotating the base of the flap around a pivot point. Pivotal flaps may be categorized as rotation, transposition, or interpolated. Advancement flaps…

Maxillofacial Trauma

Key Points Repair of craniomaxillofacial fractures requires accurate diagnosis and a plan for repair, which requires physical examination and computed tomography (CT) scanning. Associated injuries must be recognized and addressed. The mandible is often evaluated using panoramic tomography, but CT scans pick up missed fractures and better demonstrate condylar head malpositions. Fractures classified as frontal, skull base, nasoorbital-ethmoid (NOE), orbital wall, zygomatic, maxillary, or mandible. Familiarity…

Facial Trauma: Soft Tissue Lacerations and Burns

Key Points Examination and repair of facial soft tissue trauma must be systematic and thorough. Treatment of traumatic injuries is often a process of restoring facial appearance and function rather than a single procedure. A high index of suspicion and careful examination are required to rule out potential occult injuries to the facial nerve, parotid duct, canalicular system, and underlying maxillofacial skeleton. Identification and repair of…

Scar Revision, Keloids, and Camouflage

Key Points The ideal scar is narrow, flat with surrounding skin, parallel to the relaxed skin tension lines (RSTLs), or camouflaged within natural anatomic lines. Available scar revision techniques include excision, irregularization (including Z-plasty, W-plasty, and geometric broken line closure [GBLC]), and dermabrasion. Hypertrophic scars do not extend beyond the boundaries of the original wound and often regress with time, while keloids invade the surrounding tissue…

Recognition and Treatment of Skin Lesions

Key Points Cutaneous conditions of the head and neck are both common and diverse. Identification of these conditions is often required of an otolaryngologist; although many cutaneous lesions can be identified based upon clinical appearance, biopsy is necessary for definitive diagnosis. Benign lesions are often a cause for cosmetic concern; a variety of treatment options exists, including surgical methods and laser destruction. Nevi should be evaluated…

Aesthetic Facial Analysis

Key Points A detailed understanding of aesthetic facial analysis is imperative to any cosmetic or reconstructive surgeon. The names of both soft tissue and bony anatomic landmarks must be clear and are the basic language in which surgeons communicate. Both nasal and nasofacial angles are the cornerstone of rhinoplasty analysis and planning. Aesthetic subunits and relaxed skin tension lines are critical in designing surgical incisions and…

Sleep Apnea and Sleep Disorders

Key Points Snoring affects at least 40% of men and 20% of women and often accompanies sleep-disordered breathing. However, only 6% of women and 13% of men older than 50 years of age have symptomatic obstructive sleep apnea (OSA). OSA is defined by five or more respiratory events per hour of sleep—apneas, hypopneas, or respiratory effort–related arousals—in association with excessive daytime somnolence; waking with gasping, choking,…