Asian Septorhinoplasty: Conundrums and Solutions

Preface
Contents
1: The Longevity of Alloplastic Implants
	1.1	 Bony Resorption Under Alloplastic Implants
	1.2	 Silicone Implant over Osteotomized Nasal Bone
	1.3	 Implant Deviation
		Longer Implant than the Pocket
		Bony Axis Vs. Septal Axis
		Implant-Dependent Dorsum
		Secondary Operation Using Silicone Implant (Re-insertion)
	1.4	 Clinical Features of Complications
		Silicone Implants
			Capsule: Contracture
			Calcification
			Demarcation, Transparency
		Gore-tex
			Shrinkage and Demarcation
		IHCC (Irradiated Homologous Cartilage)
			Resorption: Fracture
		Alloderm
			Central Avascular Scar: Contracture Inside the Preexisting Capsule
	1.5	 Surgical Site Infection Vs. Late-Onset Inflammation
	References
2: Surgical Site Infection (SSI) Vs. Late-Onset Inflammation (LOI)
	2.1	 The Differences by Definition
		Surgical Site Infection (SSI)
			SSI After a Septal Surgery
			SSI Without Septal Surgery
		Late-Onset Inflammation (LOI)
	2.2	 The Differences Between Clinical Features and Managements
		Surgical Site Infection (SSI)
		Management of SSI
		Late-Onset Inflammation (LOI)
			Stage 1: Fluctuation: Wax and  Wane
			Stage 2: Skin Lesion: Out-Growth of the Granulation Tissue
			Stage 3: Puncture with or Without Pus-Drainage
			Level 4: Cellulitis with Pus-Drainage
		Pathophysiology of LOI
		Biofilm
			Mucocele-Like Pathology
			Histological Manifestations in Silicone Capsule
				Healthy Capsule (HC)
				Nonhealthy Capsule (NHC)
		The Differences in the Histological Study [13]
			Hematoxylin and Eosin Staining and Masson’s Trichrome Staining
			Colloidal Iron Histochemical Staining
			Immunohistochemical CD31 Staining
	References
3: Nasal Swab Culture: The Preparation for the Safe Surgery
	3.1	 What Did I Learn from these Patients?
	3.2	 The Impact of SSI in Asian Septorhinoplasty
		Framework Destruction
	3.3	 The Potentially Infectious Normal Flora (PINF)
		PINF in Asian Septorhinoplasty
		Clean-Contaminated Wound
		Complicated Septorhinoplasty for Asians
		Bacteremia During Operation
		Nasal Packing: Intraoperative and Postoperative Management
	3.4	 Nasal Swab Study for PINF [6]
		Nasal Swab Negative
		Nasal Swab Positive
		Second Nasal Swab Positive
		Changes in Microbiology
			Positive to Negative Change
			Negative to Positive Change
			Positive to Positive
	3.5	 My Protocol for a SAFE Asian Septorhinoplasty
		Nasal Swab Culture: Two Times
		Applying Antibiotic Ointment
		The Choice of IV Antibiotics
	References
4: Medpor: The Hurdle of Secondary Rhinoplasty
	4.1	 Physical Properties
	4.2	 Complication Reports
	4.3	 Why Is Medpor Such a Big Hurdle for Secondary Operation?
		Dissectiblity
	4.4	 What Do you Have to Prepare for the Reconstruction?
		CT Scan: The Only Aid for Preoperative Diagnosis
		Autograft for the Septal Reinforcement
	4.5	 Patterns of Medpor Application
		Septal Application
			Anterior Application
			Caudal Application
			Anterocaudal Application
		Columella Application
		Nasal Pain
	4.6	 Operative Technique of Reconstruct the Collapsed Septum
		Septum Reconstruction
			Septal L-strut Reconstruction Using Two Conchal Cartilages [10]
			Septal L-strut Reconstruction Using Sliced Costal Cartilages
		Cantilever Graft
	References
5: Nasal Obstruction in Asian Rhinoplasty
	5.1	 Diagnosis
		History and Inspection
			Nasal Cycle
			Rhinitis and Sinusitis
		CT Scan
			Inferior Turbinate
			Concha Bullosa
		Acoustic Rhinometry
		Causes of Nasal Obstruction after Surgery
			Intranasal Adhesion
			Neglected Preoperative Septal Deviation
				Aggravated Caudal Septal Deviation
				Implant Instability over Weak Nasal Framework
				Internal Valve Problem
	5.2	 “The Tip Extension Anchoring (Suture)” Pushes down the INV
	5.3	 Aggravated Tip-Middle Vault Airway Discrepancy
	5.4	 Too Narrow INV Angle
		Thickened Caudal Septum
		Other Combined Symptoms with Nasal Obstruction
			Nasal Pain
			Foul Odor
	References
6: The Various Preparations of Autologous Materials
	6.1	 Auricular Cartilage
		Dissection
	6.2	 Must Do and Must Not Do
	6.3	 Folded Concha: Is it Large and Stable Enough?
		Folded Cymba and Cavum Concha Technique: Straightening and Stability
		Average Length and Width of Folded Cymba
		For Caudal Septal Extension Graft (CSEG)
			Floating Type Columella Strut Graft
			Tongue-in-Groove Technique for CSEG
		The Stability: Columellar Strut Vs. CSEG
		Cavum Concha
		Tragal Cartilage
		The Superficial Mastoid Fascia (SMF)
			Dissection
			For Dorsal Augmentation
		The Sacral Dermis-Fat (SDF)
			Harvest
		Septal Cartilage
		Rib Cartilage
	References
7: The Resorption: The Hurdle for Autogenous-Based Asian Rhinoplasty
	7.1	 Diced Cartilage
		Diced Cartilage Vs. Crushed Cartilage
		Diced Cartilage Wrapped with Fascia
	7.2	 Septal Cartilage
	7.3	 Ear Cartilage
	7.4	 The Resorption Rate of Soft Tissues
		Resorption Rate
			Usefulness of Standardized Two-Dimensional Photo Analysis
			How to Correct Yawing and Rolling in 2D Photographs
			The Resorption Rate
	References
8: Controlling Asian Tip: Tip Defining Point and Supratip Break
	8.1	 Steps for Nasal Tip Plasty
	8.2	 The Tip Defining Point
		Septum-Dependent Tip Projection
		Septum-Independent Tip Projection
	8.3	 The Supratip Break: STB
		Definition
	8.4	 My Strategy for Ideal STB in Primary Case
	8.5	 My Strategy for Restoring STB in Secondary Case
	References
9: Controlling Asian Tip: Facet and Supra-Alar Groove
	9.1	 The “Facet”
		Definition
		Anatomic Considerations
		How to Preserve the Facet?
		How to Create a Beautiful Soft Triangle?
	9.2	 Alar Rim Graft [5]
	9.3	 Subdomal Graft
	9.4	 Shield Graft + Cap Graft
	9.5	 Middle Crural Extension Graft
	9.6	 Septal Extension Graft
		Lateral Crural Strut Graft
	9.7	 Pitfalls Related to Skin Envelop
	9.8	 How to Recruit the Skin Envelope?: The “Sleeve-Down” Technique
	9.9	 How to Reduce the Soft Triangle
	9.10	 The Supra-Alar Groove
		How to Reduce the Bulbosity and Create the Supra-Alar Groove?
	References
10: Controlling Asian Tip: Infratip Lobule and ACR
	10.1	 The Infratip Lobule
		Definition
		Anatomic Considerations
		How to Create a Beautiful Infratip Lobule?
	10.2	 Spacer Graft
	10.3	 Lobule Graft
	10.4	 Alar-Columellar Relationship: ACR
		Definition
			Cause of Alar-Columellar Discrepancy (ACD)
			Central Component Vs. Lateral Component Discrepancy
			Strategy for Lateral Component Extension
	10.5	 Lowering LLC by Lateral Crural Spanning Suture (LCSS)
	10.6	 Alar Batten Graft: Alar Extension Graft
	10.7	 Camouflage of Retracted Alar Ridge
	10.8	 Lateral Crural Strut Graft (LCSG)
		How to Recruit the Skin Envelope?: The “Sleeve-Down” Technique
		Strategy for Lifting the Alar Base: Alar Lift
		Strategy for Achieving the Ideal Resting Angle of LLC
		Correction of Alar-Columellar Discrepancy (ACD) in Primary Rhinoplasty
			Small Nose: Short Septum + Alar Retraction
			Columella Retraction + Hanging Alar
			Hanging Columella + Alar Retraction
	References
11: Correction of the Short Secondary Nose: Dissection and the Framework Reconstruction
	11.1	 The Secondary Rhinoplasty in Asians
		Alloplastic Implant with SRP: Is it Safe?
		Specific Considerations of Secondary Surgery
		The Dissection
			Dissection Above Nasal Sidewall and Root
			Dissection Between Nasal Bone and ULC
			Dissection Between Skin Flap from Maxillary Process
			Dissection Between Sidewall and Maxilla
			Dissection Between Septum and ULC
			Dissection Between ULC and LLC (Scroll Area)
			Dissection Between LLC and LLC
			Dissection Between LLC and Pyriform Aperture
			Secondary Septal Dissection
		Postoperative Re-scarring
	11.2	 Camouflage or Restoring the Framework?
		Specific Considerations in Septal Surgery in Asians
		Septal L-Strut Extension Graft (SLEG)
	11.3	 Techniques of Septal L-Strut Extension Graft for Asians
	11.4	 Extended Spreader Graft: Modified Tongue-and-Groove Graft
		Cantilever Graft
	References
12: Secondary Septal Surgery
	12.1	 The Previous SMR State: “No Man’s Land”
	12.2	 The Revisional Septoplasty
		Cause
		Anatomic Considerations
	12.3	 Saddle Nose Deformity
		Cause
		Treatment
		The Dorsal Margin of Anterior Extended Spreader Graft (AESG)
	12.4	 Implant-Related Problems
	12.5	 Collapsed Septum
		Clinical Features
		Strategy
			The “Key Factor”: The Keystone Area
			The Reverse Swing Door Concept
	12.6	 The Infected Nose
	References
13: Think Inside the Box: Absorbable Plate, IHCC, and the Stem Cells
	13.1	 Absorbable Materials
		The Fate of Absorbable Plate
		Two Different Concepts in Adopting Absorbable Plates
			Temporary Support
			Scaffold Recruiting Cartilage
		Two Different Techniques
			Combining with Cartilage
			Absorbable Materials Only
				SEG
				Tip Plasty: Soft Ball
				Thread Tip Plasty
	13.2	 Pitfalls of the “Myth”
	13.3	 IHCC (Irradiated Homologous Costal Cartilage)
		Is it a Viable Material?
		Pitfalls of the “Myth”
	13.4	 Human Adipose-Derived Stromal (Stem) Cells: hASCs
	13.5	 Direct-to-Consumer Portrayal of Stem Cell Medicine
		Counterpoints of Injecting “Adipose-Derived Stem Cells(?)” into the Contracted Nose
		Human Adipose-Derived Stem (Stromal) Cells Differ from Stromal Vascular Fraction
	13.6	 Can ASCs Be Administered to Treat Contractures?
		Pitfalls of the “Myth”
	References
14: Pus Draining Status After Complicated Septorhinoplasty: When to Do the Secondary Rhinoplasty?
	14.1	 Background of Choosing this Case
	14.2	 Case Study
		History
		Physical Exam and Diagnostic Findings
			Endoscopic Findings
			CT Scan
			Culture Study and Antibiotics
		Preoperative Surgical Planning
		Intraoperative Findings
	14.3	 Operative Strategies
		Postoperative Results
15: Nasal Tip Necrosis: The Midline Forehead Flap Should Be the Last Choice
	15.1	 Background of Choosing this Case
	15.2	 Case Study
		History
		First Choice by the Author: Composite Graft
			Physical Exam and Diagnostic Findings
			Preoperative Surgical Goals
			Strategy for Composite Graft
			Intraoperative Findings
			Operation Method
			Result
		Secondary Operation: SRP
			Physical Exam and Diagnostic Findings
			Strategy for SRP
			Intraoperative Findings
			Operation Method
			Result
16: When You Encounter Very Small Septal Cartilage
	16.1	 Background
	16.2	 Case Study
		History
		Physical Exam and Diagnostic Findings
			Endoscopic Findings
			Acoustic Rhinometry
		Preoperative Surgical Planning
		Intraoperative Findings
	16.3	 Operative Strategies
		Postoperative Results
17: Hypoplastic Lower Two-Third Nose: Camouflage Vs. Reconstruct the Framework
	17.1	 Background of Selecting this Patient
	17.2	 Case Study
		History
			First Operation
			Revision at the Private Clinic
			Tertiary Operation at a Different Clinic
		Physical Exam and Diagnostic Findings
	17.3	 Nasal Swab Study
		Endoscopic Findings and CT Scan
	17.4	 Acoustic Rhinometry
		Preoperative Surgical Goals
		Strategy for the Operation
		Intraoperative Findings
	17.5	 Operation Method
	17.6	 Result