Aesthetic rhinoplasty requires a detailed understanding of nasal anatomy, structural support, and airway preservation to achieve balanced functional and aesthetic outcomes. Contemporary techniques emphasize individualized preoperative analysis, conservative modification of the osseocartilaginous framework, and preservation of nasal support mechanisms. Here we describe a systematic approach to primary open rhinoplasty, including preoperative assessment, operative planning, septoplasty, dorsal modification, osteotomies, tip refinement, grafting strategies, and postoperative management. Key concepts include maintenance of the septal L-strut, preservation of the internal nasal valve, controlled osteotomies, and structural tip support through grafting and suture techniques. Commonly utilized grafts, including spreader grafts, columellar strut grafts, subdomal grafts, onlay domal grafts, and alar rim grafts, are discussed in the context of functional support and aesthetic contouring. Postoperative splinting, edema management, and longitudinal follow-up are also reviewed. A structured and anatomy-based approach to rhinoplasty allows for predictable aesthetic refinement while maintaining long-term nasal function and structural stability.

Rhinoplasty is a delicate surgical procedure that requires a thorough understanding of the dynamic interplay between the various structures of the nose. Any changes made to one part of the nose can have downstream effects on the overall harmony and appearance of the nose. For this reason, it is crucial for surgeons to be aware of these potential impacts in order to achieve predictable and aesthetically pleasing results. In this article, we aim to provide a summary of the current evidence-based conclusions on the dynamic influence of the radix, dorsum, tip, and ala during rhinoplasty. By understanding the complex relationships between these structures, surgeons can make informed decisions and achieve the best possible outcomes for their patients.

BACKGROUND: Maintenance of nasal tip projection and rotation are important factors to consider when evaluating the utility of specific rhinoplasty techniques with respect to desired long-term outcomes. Whereas septal extension grafts have been shown to be associated with preserved tip projection and rotation over time, the long-term efficacy of the columellar strut graft remains debatable. This study aims to evaluate the impact of the columellar strut graft on nasal tip projection and rotation. METHODS: This is a retrospective study of patients who underwent primary rhinoplasty at a single private practice between 2003-2022 and had at least two follow-ups with standardized photography. Preoperative and postoperative standardized right profile images were compared. Nasal tip projection was evaluated using both the nasofacial angle and the Goode ratio. Nasal tip rotation was evaluated using the nasolabial angle. Statistically significant variation between postoperative measurements was assessed using paired t-tests. Bivariate analysis was used to determine the significance of time on long-term maintenance of tip rotation and projection. RESULTS: A total of 51 patients underwent primary rhinoplasty with a columellar strut graft and had at least two follow-ups with standardized photography. The mean age was 29.98±14.61 years. From the operation date, the mean time to the first follow-up was 444.83±338.13 days, and the mean time to the second follow-up was 1047.88±497.60 days. The mean nasolabial was 99.09±11.74 preoperatively, 103.52±12.16 at the first postoperative follow-up, and 100.17±10.93 at the second postoperative follow-up. The second postoperative nasolabial angle differed significantly from the first postoperative nasolabial angle (p=0.0007). The mean Goode ratio was 0.65±0.051 preoperatively, compared to 0.62±0.047 and 0.57±0.048 at the first and second postoperative follow-ups, respectively. The second postoperative Goode ratio was significantly lower than the first postoperative Goode ratio (p<0.0001). The mean nasofacial angle was 142.30±7.27 preoperatively, 142.09±7.50 at the first postoperative follow-up, and 142.90±6.35 at the second postoperative follow-up. Postoperative nasofacial angles were not found to be significantly different from one another (p=0.16). The time between the first and second postoperative follow-ups was not significantly associated with increased or decreased changes in nasolabial angle (p=0.93), Goode ratio (p=0.38), or nasofacial angle (p=0.24). CONCLUSIONS: The columellar strut graft remains an effective technique for the long-term optimization of nasal tip projection, as the final postoperative Goode ratio was found to be closer to the ideal ratio of 0.55-0.60 compared to the preoperative Goode ratio. The nasofacial angle was maintained over time, indicating that the columellar strut graft may be effective for long-term maintenance of tip projection. Although both the nasolabial angle and Goode ratio were susceptible to change over time, the contributory role of postoperative swelling on these results remains unclear. Given that time between follow-ups was not associated with an increased magnitude of change for any metric, indicating that tip projection and rotation stabilize over time, surgeons may leverage estimated longitudinal changes in tip projection and rotation to achieve optimal long-term outcomes.

Aesthetic surgery of the face, especially when the focus is to alter facial skeleton, requires a thorough facial analysis before devising an operative plan. Surgical intervention alongside orthodontic treatment helps achieve an optimal and predictable result. The patient’s perspective and desire must be understood and discussed in detail because it might be different from that of the surgeon’s. Dental evaluation is crucially important in the evaluation of facial aesthetics; psychologic consideration is paramount to final patient satisfaction; standardized and life-size photographic and radiographic documentation helps with thorough analysis and planning; and systematic entire facial analysis is essential to precise and comprehensive surgical planning.

The nose is a complex three-dimensional structure with critical structural and functional roles; its relationship to surrounding structures is, in part, responsible for a harmonious, pleasing visage as a whole. There are many variables and dimensions that can be adjusted to alter the esthetic appearance, structural components, and functional role of the nose and many tools and maneuvers available to the rhinoplasty surgeon to adjust these numerous variables. Although every rhinoplasty operation should be individualized, a systematic order and algorithm may be helpful in operative planning as well as establishing a logical progression of steps and maintaining stability. While each adjustment may have a primary anticipated effect, it will invariably have a secondary impact.

Planning rhinoplasty is unlike planning of any other procedure in plastic surgery. Unquestionably, the nose is the most unforgiving structure of the face, whereby a quarter of a millimeter makes a major difference in the outcome of the surgery. Another complicating factor in designing a successful rhinoplasty is the dynamics of maneuvers, which plays a cardinal role in making rhinoplasty enormously challenging. The third factor is the plethora of flaws that can mar the nose; it requires experience and needs keen insight to detect these imperfections. In the order of complexity, dynamics of rhinoplasty is the most tasking one. However, planning starts with a vigilant analysis. If the flaws are not detected, they cannot be corrected. In this chapter, we will discuss these elements and details.

OBJECTIVE:The goal of this manuscript was to provide a comprehensive review of the surgical treatment for migraine headaches with a focus on trigger points and their clinical presentations, and to emphasize the importance of appropriate patient selection.BACKGROUND:Migraine is a prevalent neurological disease with headache being a disabling component of it. Surgical treatment for migraine headache became available two decades ago, which is based on proper identification and the deactivation of the specific trigger sites in the head and neck area.DESIGN:This manuscript reviews the discovery and evolution of migraine surgery with changes in patients' selection throughout the years.CONCLUSION:Patients with migraine headaches who do not respond or cannot tolerate the medical treatment might benefit from trigger site deactivation surgery. The success of the surgery is closely related to proper identification of trigger point (s) and close collaboration with a neurologist or a headache specialist. This collaboration would enhance patients' positive outcomes and help to rule out other causes of the headache.

Background The widespread popularity of browlifts and blepharoplasties speaks directly to the importance that patients place on the periorbital region of the face. In literature, most esthetic outcomes are based on instinctive analysis of the esthetic surgeon, rather than on patient assessments, public opinions, or other objective means. We employed an artificial intelligence system to objectively measure the impact of brow lifts and associated rejuvenation procedures on the appearance of emotion while the patient is in repose. Methods We retrospectively identified all patients who underwent bilateral brow lift for visual field obstruction between 2006 and 2019. Images were analyzed using a commercially available facial expression recognition software package (FaceReader™, Noldus Information Technology BV, Wageningen, Netherlands). The data generated reflected the proportion of each emotion expressed for any given facial movement and the action units associated. Results A total of 52 cases were identified after exclusion. Pre-operatively, the angry, happy, sad, scared, and surprised emotion were detected on average of 13.06%, 1.68%, 13.06%, 3.53%, and 0.97% among all the patients, respectively. Post-operatively, the angry emotion average decreased to 5.42% ( p =0.009). The happy emotion increased to 9.35% ( p =0.0013), while the sad emotion decreased to 5.42%. The scared emotion remained relatively the same at 3.4%, and the surprised emotion increased to 2.01%; however, these were not statistically significant. Conclusion This study proposes a paradigm shift in the clinical evaluation of brow lift and other facial esthetic surgery, implementing an existing facial emotion recognition system to quantify changes in expression associated with facial surgery. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Trigeminal Autonomic Cephalalgias (TAC) are excruciating headaches with limited treatment options. The chronic forms of TACs, including chronic cluster, chronic paroxysmal hemicrania, and hemicrania continua, are disabling conditions. In addition to drug therapy, there are some studies regarding nerve blocking and nerve stimulation with acceptable results. Here we report four cases of decompression nerve surgery with promising results on pain control in these difficult to treat headaches.

Background: The effects of subjective gender bias during the plastic surgery residency application process remains understudied. We hypothesized that an objective merit-based gender-neutral algorithm results in a gender distribution of interviewees proportional to the applicant pool. This study evaluated the efficacy of the Case Western Resident Application Assessment (CWRAA) as a tool to screen applicants while avoiding gender bias. Methods: A retrospective study was conducted using the CWRAA, a tool utilizing a tripartite weighted system evaluating USMLE Step 1 scores, publications/posters/presentations, and academic achievements including AOA and school ranking. Each category assigns points, adding to 15. Five years of applicant data was assessed for gender, interview invites, ranking, rank position, and matching with our institution. Welch two sample t-tests were used to assess average scores, and the chi-squared test was used to assess gender proportions. Effect size was assessed using means and pooled standard deviations. Results: Over 5 years, 829 applicants, 61.9% male, 38.1% female applied to the residency program. Average CWRAA score for all applicants was 6.68, median 7. There was no significant difference in mean scores between genders (p=0.62). The average scores of those offered interviews were not significantly different (p=0.13) and the proportion of genders granted interviews was not different (p=0.69). Of applicants present on interviews, there was no difference in scores or proportions (p=0.77, p=0.87). Ranked applicants had no difference in score or gender proportion (p=0.3, p=0.94). The proportion of female residents who matched out of the female resident pool, compared to males, was found to be significant (p=0.049). Scores were not significantly different (males 6.73, females 6.66, p=0.76). Conclusions: Our study demonstrated that the CWRAA score system is an objective ranking mechanism of applicants based on multiple non gender specific metrics, accounting for differences in opportunity for research, test-taking, and academic awards. Subjective assessment does not ultimately come into play until residents are interviewed at the institution. Using an objective metric to filter applicants does not result in unequal gender proportions, suggesting an objective merit-based algorithm helps avoid gender bias in the application process.

Background There is a significant variation in the assessment, treatment, and outcomes of nasal airway obstruction and management in the published literature. This study aimed to: (1) define key components of the nasal airway, (2) identify frequent causes of nasal obstruction, and (3) review existing treatment methods. Methods A systematic review of the literature was performed, and 135 studies were included via the following criteria: English, human subjects, and a primary endpoint of nasal airway improvement. Exclusion criteria were: abstract only, no airway data, pediatric patients, cleft rhinoplasty, sleep apnea, isolated traumatic nasal reconstruction, and cadaveric-only or animal studies. Results The relevant obstructive sites include the ENV, septum, inferior turbinates, INV, and nasal bones. Addressing the alar rim alone may be insufficient, and inspection of the lateral wall and crura may be indicated. Correction of septal deviation involves attention to the bony base. Mucosal sparing treatment of inferior turbinates improves outcomes. INVs are a major source of nasal obstruction, and treatment includes spreader grafts. The bony nasal vault can contribute to nasal obstruction, including due to surgical osteotomies. Conclusions Anatomic causes of airway obstruction include the alar rims and lateral nasal walls, deviated nasal septum, inferior turbinate hypertrophy, decreased INV angle, and narrowed nasal bones. Treatments include graft placement; septoplasty; mucosal sparing turbinectomy; and lateral wall support. Pitfalls include failing to address the bony septum, over-resection of inferior turbinates, and narrowing of the nasal vault. Appreciation of airway management during rhinoplasty will improve functional outcomes. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Migraine surgery is an increasingly popular treatment option for migraine patients. The lesser occipital nerve is a common trigger point for headache abnormalities, but there is a paucity of research regarding the lesser occipital nerve and its intimate association with the spinal accessory nerve. Methods: Six cadaver necks were dissected. The lesser occipital, great auricular, and spinal accessory nerves were identified and systematically measured and recorded. These landmarks included the longitudinal axis (vertical line drawn in the posterior), the horizontal axis (defined as a line between the most anterosuperior points of the external auditory canals) and the earlobe. Mean distances and standard deviations were calculated to delineate the relationship between the spinal accessory, lesser occipital, and great auricular nerves. Results: The point of emergence of the spinal accessory nerve was determined to be 7.17 ± 1.15 cm lateral to the y axis and 7.77 ± 1.10 caudal to the x axis. The lesser occipital nerve emerges 7.5 ± 1.31 cm lateral to the y axis and 8.47 ± 1.11 cm caudal to the x axis. The great auricular nerve emerges 8.33 ± 1.31 cm lateral to the y axis and 9.4 ±1.07 cm caudal to the x axis. The decussation of the spinal accessory and the lesser occipital nerves was found to be 7.70 ± 1.16 cm caudal to the x axis and 7.17 ± 1.15 lateral to the y axis. Conclusion: Understanding the close relationship between the lesser occipital nerve and spinal accessory nerve in the posterior, lateral neck area is crucial for a safer approach to occipital migraine headaches, occipital neuralgia, and new daily persistent headaches and other reconstructive or cosmetic operations.