The rhinoplasty surgeon will undoubtedly encounter a cosmetic patient who is persistently dissatisfied with their results, no matter the objective outcome achieved. This article seeks to describe risk factors for postoperative dissatisfaction and highlight effective management strategies for the “difficult patient.” A literature search was performed using PubMed and Embase databases during September and October of 2023 to identify articles that analyzed factors related to dissatisfaction in rhinoplasty. Forty unique references were identified. The majority of structural aesthetic complaints related to dissatisfaction after rhinoplasty were residual dorsal hump (20%) or persistent tip dissatisfaction (19%-37%). Demographic factors including younger age, male sex, self-referral, history of body dysmorphic disorder or abuse/neglect were risk factors for postoperative dissatisfaction. Ineffective patient-provider communication, litigation due to inadequate informed consent, and surgeon inattentiveness were contributing factors to postoperative dissatisfaction. Revision rhinoplasty rates ranged from 5%-15%, where most patients sought revision surgery due to the development of a new deformity or failure to correct the original deformity, with the greatest complaints at the nasal bridge and nasal tip. Validated patient-reported outcome measures including Rhinoplasty Outcome Evaluation (ROE) and FACE-Q can be effective questionnaires to assess satisfaction. Appropriate patient selection, adequate preoperative counseling and consent, effective communication, and reaching a consensus about surgical goals are all effective strategies in the management of a dissatisfied patient.

Irregularities of the nasal dorsum or tip are a potential risk after rhinoplasty. Patients with thin skin are considered to be at a higher risk of these irregularities. Different materials and grafts to address areas that may result in a contour irregularity postoperatively include diced or crushed cartilage, temporalis fascia, fascia lata, and AlloDerm. We describe a new graft, the supracrural ligament graft, which can be used to camouflage or add bulk during primary rhinoplasty. The graft is harvested easily during the initial exposure and does not require additional surgical sites or extra dissection. In this research, we described the use of the supracrural ligament graft in 49 patients. We found the average graft size to be 0.6 x 0.4 cm. The graft was used in the following locations: nasal tip (49%), radix (40%), and nasal dorsum (10%). No complications were seen using the graft in any of the 49 patients. In conclusion, the supracrural ligament graft is a safe, simple, and effective camouflage graft for commonly encountered irregularities in rhinoplasty. Common areas of use include the nasal dorsum and nasal tip. Routine harvest of this graft may obviate the need to use either additional grafting material or an additional surgical site to help camouflage areas of concern in thin skin patients.

Three-dimensional (3D) imaging technology has become a popular clinical technology for surgical planning and simulation in rhinoplasty. This technology offers the opportunity to translate a simulated 3D image into a surgical plan in the operating room in a quantitative manner. Herein, we describe a technique for creating patient-specific 3D-printed rhinoplasty marking templates from preoperative 3D imaging. Five adult patients presenting for primary rhinoplasty were recruited as subjects. 3D photographs were captured of each patient, and goals of surgery were digitally simulated based on patient preference. Simulated and baseline digital renderings were exported to a third-party 3D printing company. 3D-printed plastic molds were created to precisely fit the patient’s preoperative nose when overlaid on the dorsum. Molds included windows through the lateral walls corresponding to the preoperative simulation whereby the patient’s desired dorsal height and contour was marked on the skin immediately prior to surgery. 3D image capture, digital rendering, and goals of surgery simulations were created using standard office-based 3D imaging equipment and added an additional 10 minutes the standard preoperative rhinoplasty consultation. Turnaround time was 5 days and cost was $100 per patient. The senior author found the patient-specific marking templates to effectively transfer the patient’s desired dorsal height and contour onto the patient in the form of skin markings. The technique described herein aids quantitative translation of patient goals in dorsal reduction rhinoplasty into the operating room and onto the patient in the form of preoperative marking. The workflow is fast, cost-effective, uses standard office-based technology, and requires little technological expertise.

AbstractAn ideal nasal osteotomy should deliver precise, predictable, and reproducible cosmetic and functional results while minimizing soft-tissue trauma and postoperative complications. In addition to closing an open roof deformity after hump reduction, other common indications for osteotomies include the crooked nose and a wide bony vault. The literature has reported numerous and diverse osteotomy techniques as well as differences in timing of osteotomies. Each has its own merits and indications, and its proponents. In this article, we review the anatomy and nomenclature relating to osteotomies. We review the locations and paths of the osteotomies—lateral, intermediate, medial, and superior/transverse. We consider the percutaneous and endonasal approaches, as well as timing of osteotomies and other considerations. We also discuss technical considerations in the selection of instrumentation for osteotomies.

Purpose of review To examine the recent literature on extracorporeal septoplasty. Recent findings The literature suggests that extracorporeal septoplasty is an effective approach for both functional and cosmetic treatment of moderate to severe deformities of the caudal and dorsal septum. The procedure can be performed via an endonasal or external approach based on the nature of the deformity and the experience of the surgeon, although recent literature highlights various advantages of an external approach. The use of polydioxanone foil as a scaffold for septal reconstruction is widely accepted, and can enhance the technical performance of this technique. Although reported complication rates are low, tip deprojection and rotation have been observed in cases where extracorporeal septoplasty is performed without simultaneous rhinoplasty. Summary Extracorporeal septoplasty is a useful technique in the armamentarium of surgeons addressing deviations of the dorsal and caudal septum.

Objective To survey patients following sinonasal surgery regarding postoperative pain and opioid use. Study Design Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids. Setting Four academic medical centers and 1 private practice institution. Subjects Consecutive adult patients undergoing sinonasal surgery. Results A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain (R2 = 0.2, P < .01) but was not correlated with the use of acetaminophen (R2 = 0.002, P = .48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers (P < .001) and also required more postoperative opioids (P = .02). Conclusions An evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.

Septal pathology is extremely common in the population, and even minor abnormalities can have serious functional and cosmetic consequences for a patient. Choosing the appropriate technique to address this common problem requires a thorough preoperative examination, so the nature of the deviation is understood before a surgical plan is made. This chapter will explore the preoperative evaluation of septal defects as well as a number of different surgical strategies to address and achieve the best outcomes.

Purpose of review We examine the current literature on pain management after sinus and nasal surgery. The goal after surgery is to provide effective pain management without having too many ‘leftovers’, as leftover medications are an important source of opioids that are fueling the current prescription narcotic epidemic in the United States. There are more than 250 000 sinus operations and 260 000 septoplasties performed annually, and surgeons commonly prescribe a narcotic pain medication for postoperative pain management. Recent findings The literature suggests that an evidence-based approach may lead surgeons to prescribe significantly less narcotic pain medication for these procedures without affecting pain management. Summary An evidence-based approach to pain management can result in unchanged pain control and a significant positive impact on the narcotic abuse epidemic.

Most surgeons recognize the broad utility of both endonasal and external rhinoplasty approaches. Most understand that there are situations when a given approach offers advantages and may be considered preferable. In this article, the anatomy, incisions, and approaches that are available to the surgeon are reviewed. General indications are discussed for the external and endonasal approaches. The pros and cons of each approach are discussed, and further thoughts on the decision-making process are provided.

What is the single most difficult challenge in revision rhinoplasty and how do you address it? During revision rhinoplasty, when dorsal augmentation is necessary and septal and ear cartilage is not available, what is the best substance for correcting the problem? If rib cartilage is used for dorsal augmentation during revision rhinoplasty, what is the technique to prevent warping of the graft? Alloplast in the nose when, where, and for what purpose? Does the release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid-one-third nasal pinching in reductive rhinoplasty?' Analysis: Over the past 5 years, how has your technique evolved or what have you observed and learned in performing revision rhinoplasty?

Purpose of reviewUnderstanding nasal form and function is critical in performing successful cosmetic rhinoplasty. Careful evaluation of the patient's nasal airway with identification of areas of existing or potential obstruction is important in avoiding potential pitfalls that may compromise nasal function following rhinoplasty. This article will review surgical techniques that can be utilized to preserve and improve nasal function during cosmetic rhinoplasty.Recent findingsRecent literature on nasal functionality focuses on the management of the internal and external nasal valve as well as the nasal septum during rhinoplasty.SummarySuccessful cosmetic rhinoplasty requires a thorough preoperative analysis of both aesthetic and functional characteristics of the nose. Close attention should be paid to the internal and external nasal valves and nasal septum before and during surgery to preserve and improve nasal function following cosmetic rhinoplasty.

Purpose of reviewUnderstanding nasal form and function is critical in performing successful cosmetic rhinoplasty. Careful evaluation of the patient's nasal airway with identification of areas of existing or potential obstruction is important in avoiding potential pitfalls that may compromise nasal function following rhinoplasty. This article will review surgical techniques that can be utilized to preserve and improve nasal function during cosmetic rhinoplasty. Recent findingsRecent literature on nasal functionality focuses on the management of the internal and external nasal valve as well as the nasal septum during rhinoplasty. SummarySuccessful cosmetic rhinoplasty requires a thorough preoperative analysis of both aesthetic and functional characteristics of the nose. Close attention should be paid to the internal and external nasal valves and nasal septum before and during surgery to preserve and improve nasal function following cosmetic rhinoplasty.

Objective. (1) To develop a method for quantification of osteotome sharpness in a rhinoplasty model, using artificial bone; (2) to demonstrate changes in osteotome sharpness over multiple uses; and (3) to compare osteotomes from different manufacturers in terms of sharpness and cost.Study Design. Prospective surgical model.Setting. Academic hospital and engineering research facility.Methods. Osteotomes were used to make 4-cm cuts through 4-mm wedges of artificial bone. Sharpness was assessed at baseline and following 1, 4, 7, and 10 uses by measuring the load required to cut a #2 Prolene suture. Changes in sharpness from baseline were measured over time, and comparison of manufacturers was performed using analysis of variance (ANOVA). Cost per use was computed for each osteotome.Results. Five osteotomes were tested (Biomet, Black & Black, Miltex, NexEdge, Storz). At baseline, the Storz osteotome was sharpest (1.74 lb, P < .001), followed by Miltex and Biomet (2.50 lb, 2.68 lb) and NexEdge and Black & Black (3.48 lb, 3.40 lb). All osteotomes except NexEdge (P = .098) demonstrated significant decreases in sharpness over time (P = .02 to P < .001), although relative changes and absolute sharpness varied greatly. ANOVA demonstrated Storz to be significantly sharper at all time points (P < .001). Storz and Miltex were superior in cost-per-use analysis.Conclusion. Sharp osteotomes are important in cosmetic and functional rhinoplasty. Instruments may appear the same but can be quite dissimilar in efficacy and cost. Indeed, relative efficacy has not been previously tested. Quantitative analysis performance and cost-effectiveness analyses are reported here and can assist the surgeon in selection and maintenance of instruments.

OBJECTIVE:To assess the relative sharpness of osteotomes after multiple uses, routine maintenance, and sharpening.METHODS:This prospective clinical study and mechanical model quantified the relative sharpness of identical osteotomes at baseline; after 3, 6, and 9 uses; and after sharpening techniques compared with osteotomes from hospital central supply. The Instron universal tester developed a force-displacement curve as the osteotome blade cut a standardized suture. Force required to cut the suture is inversely proportional to osteotome sharpness.RESULTS:For osteotomes 1, 2, and 3, dullness occurred after 9 uses (4.836 lb; P < .001), 6 uses (4.431 lb; P < .005), and 3 uses (4.093 lb; P < .02), respectively. Osteotome 1 was professionally sharpened after 9 uses and retested (3.156 lb); results were similar to those for an osteotome used 6 times (3.160 lb). Additional sharpening showed significantly poorer performance (7.737 lb; P < .001 at baseline and after 9 uses). Osteotome 3 was hand sharpened after 6 uses and retested (7.750 lb; baseline P < .001). Two osteotomes from central supply required almost twice the cutting force relative to the senior author's osteotomes.CONCLUSIONS:Although osteotome performance decreased significantly over time, professional sharpening only achieved results similar to an osteotome used 3 to 6 times. Further resharpening seems detrimental to performance. Surgeons may want to consider osteotomes disposable instruments.