BACKGROUND:The most critical exam components in patients seeking rhinoplasty have not been established. OBJECTIVE:To identify concordance among experienced rhinoplasty surgeons regarding the most important exam features for various deformities. METHODS:An online questionnaire was distributed to board-certified facial plastic and plastic surgeons experienced in rhinoplasty, with seven nasal deformity categories: dorsal hump, crooked nose, boxy tip, pinched tip, droopy tip, saddle nose, and nonallergic nasal obstruction. For each, respondents were asked to rank the three most important anatomic regions to examine from the following: nasal bones, midvault cartilage, skin, radix, facial profile, lip, tip, septum, internal nasal valve, nostrils, inferior and middle turbinates. For each ranked region, up to three important features were chosen. Normalized Attention Scores (NAS) were calculated to determine agreement amongst surgeons. RESULTS:A total of 13 facial plastic and 8 plastic surgeons were invited to participate and completed the questionnaire. All cases had high agreement demonstrated by NAS, with the dorsal hump case exhibiting the greatest variability in responses. CONCLUSIONS:In this survey of 21 rhinoplasty surgeons, there was general agreement regarding the most relevant anatomical structures and features, which may provide a conceptual foundation for identifying key exam features for seven common complaints in patients seeking rhinoplasty.

BACKGROUND:Hypoglossal nerve stimulation (HGNS) is used to treat obstructive sleep apnea (OSA); however, evidence is limited for patients who cannot tolerate positive airway pressure therapy. Proximal HGNS (pHGNS) provides multicontact stimulation of proximal nerve portions, with easier electrode implantation than distal nerve stimulation. OBJECTIVE:To evaluate the efficacy and safety of pHGNS in patients with moderate-to-severe OSA. DESIGN:7-month randomized controlled trial followed by a 6-month open-label extension. (ClinicalTrials.gov: NCT04950894). SETTING:23 U.S. health centers. PATIENTS:Adults aged 22 years or older with moderate-to-severe OSA. INTERVENTION:All patients underwent implantation with pHGNS at baseline and were randomly assigned in a 2:1 ratio to treatment or control. Therapy began at month 1 (treatment) or month 7 (control). MEASUREMENTS:Assessments included the proportion of patients achieving greater than 50% improvement from baseline in the apnea-hypopnea index (AHI) and AHI below 20 events/h at month 7 (primary end point), improvements in oxygen desaturation index (ODI) and patient-reported outcomes (for example, Epworth Sleepiness Scale [ESS]), and safety. RESULTS:The 104 randomly assigned patients had a mean age of 55.6 years (SD, 9.0), body mass index of 30.6 kg/m2 (SD, 3.0), a preimplantation AHI of 35.7 events/h (SD, 12.8), and a preimplantation ODI of 36.7 events/h (SD, 13.4). At month 7, 58.2% (95% CI, 45.5% to 70.2%) of patients assigned to treatment (n = 67) versus 13.5% (CI, 4.5% to 28.8%) assigned to control (n = 37) achieved the primary end point, and ODI was reduced by at least 25% in 68.7% (CI, 56.2% to 79.4%) versus 37.8% (CI, 22.5% to 55.2%) of patients, respectively. Median ESS score improved from baseline to month 7 in the treatment group (10.0 [IQR, 7.0 to 14.0] to 6.0 [IQR, 5.0 to 9.0]) but not in the control group (9.0 [IQR, 7.0 to 11.0] to 9.0 [IQR, 6.0 to 11.0]). No serious procedure-related adverse events were reported. LIMITATIONS:Lack of blinding, small sample size, and short follow-up. CONCLUSION:pHGNS for OSA yielded clinically significant responses versus control at month 7, supporting pHGNS as a therapeutic option for OSA. PRIMARY FUNDING SOURCE:LivaNova PLC.

A 63 year old female patient presented to our office with two chief complaints, (1) severe OSA with CPAP intolerance and (2) cosmetic face and neck concerns regarding facial rhytids, jowls, and neck laxity. She was evaluated for Inspire candidacy and found to be an appropriate candidate. She underwent a combined Inspire hypoglossal nerve stimulator implant and deep plane facelift and necklift surgery to address her sleep apnea and her cosmetic concerns. Through the combined approach, we were able to provide appropriate exposure for the hypoglossal nerve implant and achieve excellent cosmetic results. Techniques utilized that contributed to her superior cosmetic results include gonion augmentation, partial submandibular gland resection, anterior belly of the digastric resection, and extended platysmal myotomy and plication. We demonstrate through this case that deep plane facelift/necklift and Inspire hypoglossal nerve stimulator implant can be performed together safely and with successful sleep and cosmetic outcomes. Laryngoscope, 2025

BACKGROUND:Modern techniques in structure rhinoplasty require cartilage for grafting. The optimal source of this cartilage is debated. Fresh frozen homologous costal cartilage (FFHCC) grafts are a promising source of cartilage; further investigation is needed into efficacy and safety. The purpose of this article is to review an extensive rhinoplasty experience using FFHCC in cosmetic and functional applications. METHODS:Retrospective review of one surgeon's experience performing 123 rhinoplasties using FFHCC grafts was performed. Outcomes were postoperative complications and patient-reported outcome measures (PROMs). RESULTS:The average follow-up time was 11.0 months (range, 1 to 44 months). Infection was noted in 3 patients (2.4%). Resorption was noted in 1 patient (0.8%). Analysis of PROMs was at last follow-up. Nasal Obstruction Symptom Evaluation scores showed mean improvement of -7.9 ± 8.1 ( P < 0.001). Twenty-Two Item Sinonasal Outcomes Test scores showed mean improvement of -18.9 ± 17.5 ( P < 0.001). Epworth Sleepiness Scale scores showed mean improvement of -4.8 ± 5.8 ( P < 0.001). The Standardized Cosmesis and Health Nasal Outcomes Survey revealed total, functional, and cosmetic scores with a mean improvement of -13.5 ± 11.1 ( P < 0.001), -5.1 ± 5.9 ( P < 0.001), -8.2 ± 7.3 ( P < 0.001). CONCLUSIONS:FFHCC grafts provide a convenient and economical off-the-shelf solution for rhinoplasty. The findings of this study support the safety of FFHCC use and demonstrate positive improvement in PROMs across multiple domains.

RATIONALE: Treatment of obstructive sleep apnea(OSA) with distal hypoglossal nerve stimulation(HGNS) is becoming more prevalent despite having only uncontrolled single-arm clinical trial evidence. In contrast, proximal, targeted HGNS(pHGNS) is supported by the THN3 randomized, controlled trial(RCT) where an earlier generation system yielded superior responses in active Treatment compared to inactive Controls. The OSPREY RCT of next-generation pHGNS was undertaken to confirm efficacy and safety based on primary outcomes reported herein. METHODS: Subjects with moderate-to-severe OSA (apnea-hypopnea index, AHI,15-65/hr, body mass index, BMI≤35kg/m2, no sleep endoscopy required) were implanted with the pHGNS system and randomized 2:1 to receive 6 months of active Treatment or not (Control) beginning 1-month post-implantation. The difference in the proportion of Treatment and Control subjects at Month 7 achieving AHI <20/hr with ≥50% reduction versus Baseline (responder rates, RRs) served as the primary endpoint. A Bayesian “Goldilocks” design with pre-specified interim analyses at 20-subject intervals from 50 to 150 randomizations was used to predict early success or futility. Safety was assessed by adjudication of all adverse events by an independent Clinical Events Committee.RESULTS: On interim analysis of 90 subjects, predictive probability of success exceeded 97.5%. Recruitment was halted shortly thereafter, resulting in 104 subjects in the intention-to-treat cohort. Enrollees were middle-aged (55.6±9.0 years, Mean±SD), overweight to obese (BMI=30.6±3.0kg/m2), and population-representative in sex (28/104,26.9%, female) and ethnicity (18/104,17.3%, Hispanic/Latino). Baseline parameters were notable for an AHI=35.2±12.9/hr (63/104,60.6%, severe), 4% oxygen desaturation index of 36.2±13.6/hr, and percentage of sleep time with SpO2<90% of 11.9±14.7%. Median implant operative time was 72 minutes with all discharged home the same day. At Month 7, RR was 56.7% (38/67) in Treatment versus 13.5% (5/37) in Control, for a difference of 43.2% (95% Confidence Interval, 95%CI:[27.0%,59.4%], p<0.001). Likewise, Median AHI decreased in Treatment (34.3/hr→ 11.6/hr,ΔMedian=-17.7/hr,95%CI:[-23.7/hr,-10.1/hr]) but not in Control (33.7/hr→ 34.5/hr,ΔMedian=+2.2/hr,95%CI:[-10.6/hr,+8.9/hr]). No serious adverse events were adjudicated as related to the device or procedure.CONCLUSIONS: pHGNS in OSPREY was safe and effective at improving moderate-to-severe OSA. Responses compared favorably with other HGNS trials but in a more diverse subject population having greater OSA severity. OSPREY demonstrated high-quality evidence of definitive responses in treatment vs. controls, and rapid, simpler implantation of only 2 components, requiring minimal dissection. OSPREY confirmed AHI responses in the THN3 trial, further increasing confidence in therapeutic efficacy of pHGNS in clinical practice. Absolute AHI responses in the OSPREY RCT were comparable to those in non-randomized Phase III HGNS trials, providing compelling Level-1 evidence for the pHGNS therapeutic approach.

Objective: To compare subdorsal strip excisions in patients undergoing dorsal preservation (DP) rhinoplasty using patient-related outcome measures (PROMS). Methods: Patients were treated from 2020 to 2022 using the modified subdorsal strip method (MSSM) or Z flap approach. A two-sample t-test determined whether there was a difference in functional and aesthetic scores using the NOSE, Sinonasal Outcome Test (SNOT-22), SCHNOS, and ESS scales. Results: Seventy-one primary rhinoplasty patients met inclusion criteria at 12 months with an average age of 23 years (62 female, 9 male), with 35 (49%) undergoing the MSSM technique, while 36 (51%) receiving the Z flap. PROMS at 1, 3, 6, and 12 months postoperatively were compared. The average preoperative and postoperative NOSE score was 9.36 and -4.4 (standard deviation [SD] 3.1, p < 0.001). The average preoperative SNOT-22 score was 23.9 and -16.4 (SD 10.2, p < 0.001). ESS scores was average was 6.2 and -1.6 (SD 3.2, p = 0.01). The average SCHNOS total, functional, and cosmetic scores were 27.6 (6-47), 8.2 (0-20) and 18.7 (0-37), respectively, and -5.7 (SD 8.2, p < 0.001), -5.73 (SD 6.24, p < 0.001), -18.1 (SD 9.7, p < 0.001). No significant complications were found and no difference in PROMs among groups. Conclusion: There was no difference in septal strip techniques as evaluated by PROMS.

Objective: To measure the change perceived by patients after endonasal rhinoplasty using a, septal extension graft (SEG), as measured by patient-reported outcome measures (PROMs). Methods: A retrospective review of patients with nasal obstruction underwent septoplasty, turbinoplasty, and SEG. PROMs were assessed to compare operative outcomes for breathing (Nose Obstruction Symptom Evaluation [NOSE], Sinonasal Outcome Test [SNOT]-22, Standardized Cosmesis and Health Nasal Outcomes Survey [SCHNOS]), and sleep quality (Epworth Sleepiness Scale [ESS]) Results: Of the 34 patients undergoing rhinoplasty with Endonasal SEG, the median patient age was 38.3 years (range 17-58) and mostly male (n = 18, 52.9%). Additional procedures performed on the patients included septoplasty (n = 34, 100%) and turbinate reduction (n = 34, 100%). Average follow-up was 126.6 days (range 28-573) for a majority of PROMs. There were no complications. The average change in NOSE score was 71.5 and -49.4 (standard deviation [SD] = 19.0, p < 0.001). SNOT-22 change was 35.4 and -24.2 (SD = 14.5, p < 0.001), and ESS scores averaged 6.7 and -3.4 (SD = 4.3, p < 0.001). The average SCHNOS total, functional, and cosmetic scores were 40.6, 67.9, and 22.4, respectively, and -28.0 (SD = 19.8), -44.5 (SD = 22.9), and 17.1 (SD = 24.6) (p < 0.001). Conclusion: In this pilot study, patients reported improvement in nasal breathing after correcting a deviated caudal septum and applying an Endonasal SEG.

Background: The endonasal septal extension graft (ESEG) was first introduced as a rhinoplasty technique to aid in nasal tip support. It has since been modified and adapted for its utility in functional nasal breathing through either an open or endonasal approach. Objective: To demonstrate the feasibility and utility of the ESEG grafting technique for cosmetic and functional nasal breathing. Methods: The video shows a patient undergoing the procedure with a chief complaint of nasal obstruction who subsequently underwent septoplasty, turbinoplasty, and endonasal septal extension grafting. Results: The video submission demonstrates the feasibility and utility of the ESEG technique. Conclusion: The endonasal septal extension grafting technique utilized in functional and cosmetic nasal surgery in patients complaining of nasal obstruction with septal deviation, and nasal valve collapse is a highly successful and reliable treatment option in patients who have failed maximum medical management. The study concept and design were developed by Dr. Barrera. The acquisition, analysis, and interpretation of data were done by Dr. Barrera. Article writing, administrative, technical, and material support were by Dr. Barrera. Video footage and editing was performed by Mr. Max Swiergol. Supervision was by Dr. Barrera. Consultant, Stryker, LLC. No funding was received for this article. Runtime of video: 3 mins 42 secs

Background: Preservation rhinoplasty is a re-emerging technique that lacks data on functional and aesthetic outcomes. Objective: To measure the change in patient-reported nasal aesthetic perception, nasal breathing, and sleep and compare outcomes between two different septal cartilage manipulation techniques among patients undergoing preservation rhinoplasty. Methods: Functional and aesthetic outcomes of a let down dorsal preservation rhinoplasty using either the modified subdorsal strip method (MSSM) or subdorsal Z-flap are assessed pre- and postoperatively using the validated assessment tools Nose Obstruction Symptom Evaluation (NOSE), Sinonasal Outcome Test (SNOT-22), Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), and Epworth Sleepiness Scale (ESS). Results: Fifty-two patients, 40 women and 12 men ages 15-69 years, underwent dorsal preservation rhinoplasty and the majority reported at 1, 3, 6, and 12 months postoperatively significant improvement based on a paired t-test in NOSE, SNOT-22, SCHNOS, and ESS scores except for ESS scores at 6 and 12 months. No significant difference based on a two-sample t-test was observed between the MSSM and Z-flap techniques implemented. Conclusion: Let down dorsal preservation rhinoplasty with either the MSSM or Z-flap cartilage manipulation technique can achieve significant improvement in nasal aesthetics, nasal breathing, and sleep according to patient responses on validated assessment tools.

The integration of virtual surgical planning (VSP) for the treatment of skeletal, dental, and facial abnormalities and obstructive sleep apnea (OSA) with maxillofacial surgery has catapulted surgical planning. Although reported for treating skeletal-dental abnormalities and dental implant surgery, a paucity of knowledge existed reporting the feasibility and resultant outcome measures when VSP was employed for planning maxillary and mandibular surgery for OSA patients. The surgery-first approach is at the forefront of advancing maxillofacial surgery. Case series reporting success with the surgery-first approach for patients with skeletal-dental and sleep apnea patients have been reported. In sleep apnea patients, clinically significant reductions in apnea-hypopnea index and improvement of low oxyhemoglobin saturation have been achieved. More so, significant improvement in the posterior airway space at the occlusal and mandibular planes were achieved, while preserving aesthetic norms as measured by tooth to lip measurements. VSP is a feasible tool used for predicting surgical outcome measures in maxillomandibular advancement surgery for patients with skeletal, dental, facial, and OSA derangements.

BackgroundEvaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). MethodsUsing previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. ResultsThe ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. ConclusionThis review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 1 Research LettersEquivocal Pain Scores One Week After Rhinoplasty: Synthetic Opioid Versus Neuropathic AnalgesicDanny Jandali and Jose E. BarreraDanny Jandali*Address correspondence to: Danny Jandali, MD, Texas Center for Facial Plastic and Laser Surgery, 14603 Huebner Road, Building 1, Suite 101, San Antonio, TX 78230, USA, E-mail Address: djandali@gmail.comTexas Center for Facial Plastic and Laser Surgery, San Antonio, Texas, USA.Search for more papers by this author and Jose E. BarreraTexas Center for Facial Plastic and Laser Surgery, San Antonio, Texas, USA.Department of Surgery, Uniformed Services, Bethesda, Maryland, USA.Department of Otolaryngology, University of Texas Health Sciences Center, San Antonio, Texas, USA.Search for more papers by this authorPublished Online:3 Jan 2022https://doi.org/10.1089/fpsam.2020.0350AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Equivocal Pain Scores One Week After Rhinoplasty: Synthetic Opioid Versus Neuropathic Analgesic." Facial Plastic Surgery & Aesthetic Medicine, 24(1), pp. 69–70FiguresReferencesRelatedDetailsCited byCommentary on “Opioid Prescribing Patterns Among Facial Plastic and Reconstructive Surgeons in the Medicare Population” by Barbarite et al: Shorter Duration Opioid Prescribing After Surgery—Moving Needles or Goalposts? Michael J. Brenner3 November 2021 | Facial Plastic Surgery & Aesthetic Medicine, Vol. 23, No. 6 Volume 24Issue 1Feb 2022 InformationCopyright 2022, American Academy of Facial Plastic and Reconstructive Surgery, Inc.To cite this article:Danny Jandali and Jose E. Barrera.Equivocal Pain Scores One Week After Rhinoplasty: Synthetic Opioid Versus Neuropathic Analgesic.Facial Plastic Surgery & Aesthetic Medicine.Feb 2022.69-70.http://doi.org/10.1089/fpsam.2020.0350Published in Volume: 24 Issue 1: January 3, 2022Online Ahead of Print:December 10, 2020PDF download

Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 3 CommentaryFree AccessIncreasing Levels of Evidence in Rhinoplasty: Stepping Up Our Role as Leaders in the SpecialtySam P. Most, José E. Barrera, and Wayne F. LarrabeeSam P. Most*Address correspondence to: Sam P. Most, MD, Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA 94305-6104, USA, E-mail Address: smost@stanford.eduhttps://orcid.org/0000-0002-7385-3149Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California, USA.Search for more papers by this author, José E. Barrerahttps://orcid.org/0000-0002-4817-3854Department of Surgery, Uniformed Services University, Washington, District of Columbia, USA.Facial Plastic Surgery, UT Health, San Antonio, Texas, USA.Search for more papers by this author, and Wayne F. Larrabeehttps://orcid.org/0000-0003-3680-6375The Larrabee Center, University of Washington School of Medicine, Seattle, Washington, USA.Search for more papers by this authorPublished Online:15 Jun 2022https://doi.org/10.1089/fpsam.2022.0147AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Over the past two decades, we have seen the growth, expansion, and maturation of the field of facial plastic surgery. The clinical breadth of our specialty is wide: we have surgeons who are well known in virtually all aspects of aesthetic and reconstructive surgery of the face. Our excellence in clinical care is evident in our busy practices, our adherence to high moral and ethical standards, as well as in the presentations of excellent results we see at our meetings. Facial plastic surgery fellowship programs continue to expand and adhere to the highest of training standards. We attract the best and brightest to our fellowship programs.Although attracting strong candidates to the field ensures a future generation of highly talented and motivated surgeons, it alone does not ensure our future as leaders in a clinical field that overlaps with other clinical specialties. To maintain the leadership role of our specialty, our mission has been and should continue to be threefold: to provide excellent clinical care to our patients, to educate the next generation of surgeons, and to engage in cutting-edge research and innovation.Over the past two decades, with support from the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), we have created a new generation of surgeons who are adept at clinical and basic science research. This journal and its predecessors have been an invaluable asset, providing a venue for publishing what we hope will ultimately lead to improved outcomes for our patients. We believe the next step for our continued position as leaders in the field includes increasing adoption of evidence-based medicine (EBM).Facial plastic surgeons have already made great strides in this arena, particularly in the field of rhinoplasty. Over 20 years ago, Alsarraf published one of the first proposals for measuring outcomes in facial plastic surgery.1 The concept of using psychometrically validated questionnaires, or patient-reported outcome measures (PROMs), to evaluate results was new to our field but not to medicine. Subsequently, Stewart et al. published the Nasal Obstructive Symptoms Evaluation (NOSE) scale, which has been used broadly to evaluate nasal obstruction in rhinoplasty patients.2–5Outcomes instruments such as the NOSE, the Sinonasal Outcome Test (SNOT-22), and Epworth Sleepiness Scale, widely used in other subspecialties of otolaryngology, allow examination quality of life of our patients, a metric that we can use to evaluate treatment effectiveness and examine cost-effectiveness of various procedures.6–10 Studies such as these can influence policy and thus have a large impact on our specialty and the lives of our patients. However, the science of PROMs, particularly psychometric validation, has continued to become more rigorous.The Standardized Cosmesis Health Nasal Outcomes Survey (SCHNOS) for rhinoplasty was developed specifically to provide a more highly validated easy-to-use PROM for widespread adoption.11 This instrument has been extensively studied, characterized, and even used for psychiatric screening.12–17 It has been translated into multiple languages and is being adopted worldwide as a standard for rhinoplasty outcome measurement.18–22PROMs are not meant for use only in academic settings. The Clinical Practice Guideline for rhinoplasty suggests that every clinician should document patient satisfaction with the nasal appearance as well as function pre- and postoperatively.23 Furthermore, a multispecialty group of rhinoplasty surgeons, representing the AAFPRS, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAOHNSF), and the American Society of Plastic Surgeons (ASPS) created evidence-based performance measures for rhinoplasty, which includes the strong recommendation for the use of PROMs in documentation for all surgeons performing rhinoplasty.24All measures in this report were approved by the ASPS Quality and Performance Measures Work Group and Executive Committee, and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the AAFPRS, The Rhinoplasty Society, and the American Association of Oral and Maxillofacial Surgeons. Thus our collective leadership has already suggested that we use PROMs in our practices, academic or private. So why have these and other aspects of EBM not been adopted widely?There may simply be a fear that we as clinicians may be forced to practice "cookbook medicine," with little regard for clinical experience or individual patient needs. Ten years ago, Dr. John Rhee, who was at the time the editor-in-chief of this journal, published an article entitled "No Need to Fear Evidence-Based Medicine".25 One of the major points of this article was that EBM exists at the intersection of clinical expertise, individual patient preferences/needs, and current best evidence, rather than the former alone (Fig. 1).Fig. 1. The overlapping components of EBM. EBM, evidence-based medicine.Indeed, the labeling of evidence levels in studies does not discount the value of studies of "lower evidence" levels. Rather, it simply points out that such studies are more subject to bias and should be understood as such. Furthermore, a randomized controlled trial provides high evidence for a given technique, but only in rare cases (such as drug trials in cancer, or in instances wherein a treatment can be blinded to patient and practitioner, for example) it dictates that a particular treatment stands above all others. Thus EBM should encourage us to add current best levels of evidence to the other factors we use to make clinical decisions.Some may feel that the use of a questionnaire adds a burden to an already busy clinical practice. In fact, some outcome measures are quite brief and easy to use (Fig. 2). In practice, PROMs such as the SCHNOS provide invaluable information to the clinician regarding what a patient seeks at initial consultation, before ever entering the room, and may even help predict the likelihood a patient will be satisfied postoperatively.17,26 For those in private practice, these measures can also be used to address quality assurance requirements for state and national accreditation.Fig. 2. The SCHNOS. This is one example of a validated PROM for rhinoplasty. Note that the questionnaire covers functional as well as aesthetic concerns. PROM, patient-reported outcome measure; SCHNOS, Standardized Cosmesis Health Nasal Outcomes Survey.At this moment we have an opportunity to enhance our role as leaders in the field of rhinoplasty, and it is one we can all participate in. Although basic science requires a laboratory, and randomized controlled trials require much administrative help, we as a group can collectively move the field of rhinoplasty forward with widespread adoption of PROMs in our clinical practices. For example, a recent systematic review on the use of autospreaders versus spreader grafts found 1129 relevant studies, but only 17 (<2%) included quantifiable data that would be useful in the meta-analysis.27 Imagine the increased power of such analysis if even 25% of these studies had included such data.We encourage the use of the SCHNOS or other widely available free-to-use PROMs in your daily practice. We would also encourage the fellowship committee of the AAFPRS Foundation and the Accreditation Council for Post-Residency Specialty Education (ACPSE) to consider requiring this tool in all fellowship programs. Inclusion of this additional data point in studies of techniques will allow us, over time, to increase the quality of our specialty's publications. Ultimately this will lead to improved patient care. As a group, let us lead by example by adopting PROMs into our practices and move the field forward together.References1. Alsarraf R, Larrabee WFJr., Anderson S, Murakami CS, Johnson CMJr. Measuring cosmetic facial plastic surgery outcomes: a pilot study. Arch Facial Plast Surg. 2001;3(3):198–201. Link, Google Scholar2. Lindsay RW. Disease-specific quality of life outcomes in functional rhinoplasty. Laryngoscope. 2012;122(7):1480–1488. Crossref, Medline, Google Scholar3. Most SP. Analysis of outcomes after functional rhinoplasty using a disease-specific quality-of-life instrument. Arch Facial Plast Surg. 2006;8(5):306–309. Link, Google Scholar4. Rhee JS, Poetker DM, Smith TL, Bustillo A, Burzynski M, Davis RE. Nasal valve surgery improves disease-specific quality of life. Laryngoscope. 2005;115(3):437–440. Crossref, Medline, Google Scholar5. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004;130(2):157–163. Crossref, Medline, Google Scholar6. Hopkins C, Gillett S, Slack R, Lund VJ, Browne JP. Psychometric validity of the 22-item Sinonasal Outcome Test. Clin Otolaryngol. 2009;34(5):447–454. Crossref, Medline, Google Scholar7. Johns MW. Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep. 1992;15(4):376–381. Crossref, Medline, Google Scholar8. Lipan MJ, Most SP. Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg. 2013;15(5):358–361. Link, Google Scholar9. Rudy SF, Kandathil C, Spataro EA, Moubayed SP, Most SP. Effect of nasal steroids on nasal obstruction in septal deviation: a double-blind randomized controlled trial. Facial Plast Surg Aesthet Med. 2020;22(4):243–248. Link, Google Scholar10. Teti VP, Akdagli S, Most SP. Cost-effectiveness of corticosteroid nasal spray vs surgical therapy in patients with severe to extreme anatomical nasal obstruction. JAMA Facial Plast Surg. 2016;18(3):165–170. Link, Google Scholar11. Moubayed SP, Ioannidis JPA, Saltychev M, Most SP. The 10-item standardized cosmesis and health nasal outcomes survey (SCHNOS) for functional and cosmetic rhinoplasty. JAMA Facial Plast Surg. 2018;20(1):37–42. Link, Google Scholar12. Kandathil CK, Saltychev M, Abdelwahab M, Spataro EA, Moubayed SP, Most SP. Minimal clinically important difference of the standardized cosmesis and health nasal outcomes survey. Aesthet Surg J. 2019;39(8):837–840. Crossref, Medline, Google Scholar13. Kandathil CK, Saltychev M, Patel PN, Most SP. Natural history of the standardized cosmesis and health nasal outcomes survey after rhinoplasty. Laryngoscope. 2021;131(1):E116–E123. Crossref, Medline, Google Scholar14. Patel PN, Wadhwa H, Okland T, Kandathil CK, Most SP. Comparison of the distribution of standardized cosmesis and health nasal outcomes survey scores between symptomatic and asymptomatic patients. Facial Plast Surg Aesthet Med. 2021 [Online ahead of print]; DOI: 10.1089/fpsam.2021.0054. Link, Google Scholar15. Saltychev M, Kandathil CK, Abdelwahab M, Spataro EA, Moubayed SP, Most SP. Psychometric properties of the standardized cosmesis and health nasal outcomes survey: item response theory analysis. JAMA Facial Plast Surg. 2018;20(6):519–521. Link, Google Scholar16. Saltychev M, Kandathil CK, Abdelwahab M, Spataro EA, Moubayed SP, Most SP. Confirmatory factor analysis of the standardized cosmesis and health nasal outcomes survey. Plast Reconstr Surg. 2019;143(2):454e–456e. Crossref, Medline, Google Scholar17. Spataro EA, Kandathil CK, Saltychev M, Olds CE, Most SP. Correlation of the standardized cosmesis and health nasal outcomes survey with psychiatric screening tools. Aesthet Surg J. 2020;40(12):1373–1380. Crossref, Medline, Google Scholar18. Abdelwahab M, Saltychev M, Elkholy NA, Elsisi H, Moubayed SP, Most SP. Arabic validation of the standardized cosmesis and health nasal outcome survey for Arabic-speaking rhinoplasty patients. Plast Reconstr Surg. 2019;143(3):673e–675e. Crossref, Medline, Google Scholar19. Atallah MR, Milad D, Benamer YH, Saltychev M, Most SP, Moubayed SP. Translation, cultural adaptation and validation of the SCHNOS in French. J Otolaryngol Head Neck Surg. 2019;48(1):17. Crossref, Medline, Google Scholar20. Battista RA, Ferraro M, Piccioni LO, et al. Translation, cultural adaptation and validation of the standardized cosmesis and health nasal outcomes survey (SCHNOS) in Italian. Aesthetic Plast Surg. 2021 [Online ahead of print]; DOI: 10.1007/s00266-021-02677-7. Crossref, Medline, Google Scholar21. Perez-Garcia IC, Penaranda A, Cobo R, Hernandez AV, Moubayed SP, Most SP. Spanish translation, cultural adaptation, and validation of the standardized cosmesis and health nasal outcomes survey questionnaire. Plast Reconstr Surg Glob Open. 2019;7(3):e2153. Crossref, Medline, Google Scholar22. Rahavi-Ezabadi S, Most SP, Saltychev M, Sazgar AA, Moubayed SP, Saedi B. Validation of the persian language version of the standardized cosmesis and health nasal outcomes survey (SCHNOS). JAMA Facial Plast Surg. 2018;20(6):521–523. Link, Google Scholar23. Ishii LE, Tollefson TT, Basura GJ, et al. Clinical practice guideline: improving nasal form and function after rhinoplasty executive summary. Otolaryngol Head Neck Surg. 2017;156(2):205–219. Crossref, Medline, Google Scholar24. Manahan MA, Fedok F, Davidson C, et al. Evidence-based performance measures for rhinoplasty: a multidisciplinary performance measure set. Plast Reconstr Surg. 2021;147(2):222e–230e. Crossref, Medline, Google Scholar25. Rhee JS, Daramola OO. No need to fear evidence-based medicine. Arch Facial Plast Surg. 2012;14(2):89–92. Link, Google Scholar26. Okland TS, Patel P, Liu GS, Most SP. Using nasal self-esteem to predict revision in cosmetic rhinoplasty. Aesthet Surg J. 2021;41(6):652–656. Crossref, Medline, Google Scholar27. Buba CM, Patel PN, Saltychev M, Kandathil CK, Most SP. The safety and efficacy of spreader grafts and autospreaders in rhinoplasty: a systematic review and meta-analysis. Aesthetic Plast Surg. 2022 [Online ahead of print]; DOI: 10.1007/s00266-021-02735-0. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetailsCited byInvited Discussion on: Comparison of Dorsal Preservation and Dorsal Reduction Rhinoplasty: Analysis of Nasal Patency and Aesthetic Outcomes by Rhinomanometry, NOSE and SCHNOS Scales18 January 2023 | Aesthetic Plastic Surgery, Vol. 24 Volume 24Issue 3Jun 2022 InformationCopyright 2022, American Academy of Facial Plastic and Reconstructive Surgery, Inc.To cite this article:Sam P. Most, José E. Barrera, and Wayne F. Larrabee.Increasing Levels of Evidence in Rhinoplasty: Stepping Up Our Role as Leaders in the Specialty.Facial Plastic Surgery & Aesthetic Medicine.Jun 2022.162-164.http://doi.org/10.1089/fpsam.2022.0147Published in Volume: 24 Issue 3: June 15, 2022Online Ahead of Print:May 23, 2022PDF download

Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 4 Surgical PearlStep-by-Step Let Down Preservation Rhinoplasty TechniqueJeanie Sozansky Lujan and Jose Enrique BarreraJeanie Sozansky Lujan*Address correspondence to: Jeanie Sozansky Lujan, MD, Austin Face and Body, 7004 Bee Caves Rd, Building 2, Ste 100, TX 78746, USA. E-mail Address: sozansjm@gmail.comhttps://orcid.org/0000-0003-3387-2676Texas Center for Facial Plastic and Laser Surgery, San Antonio, Texas, USA.Search for more papers by this author and Jose Enrique BarreraTexas Center for Facial Plastic and Laser Surgery, San Antonio, Texas, USA.Search for more papers by this authorPublished Online:29 Jul 2022https://doi.org/10.1089/fpsam.2020.0612AboutSectionsView articleView Full TextSupplemental MaterialPDF/EPUBView Supplemental Data Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Step-by-Step Let Down Preservation Rhinoplasty Technique." Facial Plastic Surgery & Aesthetic Medicine, 24(4), pp. 314–315FiguresReferencesRelatedDetailsCited byFunctional and Aesthetic Outcomes of Let Down Dorsal Preservation Rhinoplasty Jeanie Sozansky Lujan, Jared M. Goldfarb, and Jose Enrique Barrera3 March 2023 | Facial Plastic Surgery & Aesthetic Medicine, Vol. 25, No. 2Application of Ultrasonic Piezoelectric Technology for Rhinoplasty José Enrique Barrera15 June 2022 | Facial Plastic Surgery & Aesthetic Medicine, Vol. 24, No. 3 Volume 24Issue 4Aug 2022 Information© 2022, American Academy of Facial Plastic and Reconstructive Surgery, Inc.To cite this article:Jeanie Sozansky Lujan and Jose Enrique Barrera.Step-by-Step Let Down Preservation Rhinoplasty Technique.Facial Plastic Surgery & Aesthetic Medicine.Aug 2022.314-315.http://doi.org/10.1089/fpsam.2020.0612Published in Volume: 24 Issue 4: July 29, 2022Online Ahead of Print:July 15, 2021PDF download

Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 3 ViewpointFree AccessApplication of Ultrasonic Piezoelectric Technology for RhinoplastyJosé Enrique BarreraJosé Enrique Barrera*Address correspondence to: José Enrique Barrera, MD, Texas Center for Facial Plastic and Laser Surgery, 14603 Huebner Road, Building 1, San Antonio, TX, USA, E-mail Address: jose@drjosebarrera.comE-mail Address: admin@drjosebarrera.comhttps://orcid.org/0000-0002-4817-3854Texas Center for Facial Plastic and Laser Surgery, LLC, San Antonio, Texas, USA.Search for more papers by this authorPublished Online:15 Jun 2022https://doi.org/10.1089/fpsam.2022.0029AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Ultrasonic surgery for rhinoplasty has been previously described.1–4 The utility of ultrasonic techniques has been modified and expanded into the fields of craniofacial, maxillofacial, and neurosurgery. We present our experience as an introduction to techniques gained over the past 3 years of using the piezoelectric system (DePuy Synthes, Raynham, MA).5The piezoelectric system is an ultrasonic surgical system consisting of handpieces and associated tips for cutting bone and bone substitutes. It can be used for osteotomy, osteoplasty, decorticating, drilling, shaping, and smoothing of bones and teeth in a variety of surgical procedures. Alternatives to the piezoelectric system include the Sonopet (Stryker Neuro Spine ENT).6 The Sonopet, as described by its manufacturer, emulsifies bone with ultrasonic vibration technology. The mechanism of action works by vibration with torsional oscillation. This technology allows for smooth bone cuts that are smaller than standard osteotomies while minimizing trauma to surrounding and underlying soft tissue.Benefits of Ultrasonic SurgeryWith either the piezo or Sonopet, the degree of bone removal is dependent on the surgical tip configuration, the power setting of the console, the density of the bone, and the amount of time the surgical tip spends in contact with the bone.5–7There is no loss of power regardless of the environment and/or treatment performed.The system actively demineralizes tissue, with reduced risk to soft tissue.Minimum pressure is required, resulting in higher precision and reduced hand fatigue for the clinician.The use of ultrasonic piezoelectric technology has significantly improved the patient recovery experience after rhinoplasty. The device uses an ultrasonic low frequency that only cuts bone and spares soft tissues—vessels, nerves, mucosa, and soft cartilage.8 The cutting tip vibrates within a very narrow range, allowing for precise bone incisions.8 These qualities make this technology ideal for osteotomies in rhinoplasty. Furthermore, animal studies comparing piezoelectric technology vs traditional osteotomes found the osteotomy gap produced to be half the size.In addition, the regenerated bone area with respect to total osteotomy area is doubled when using the piezoelectric saw.9 These histological findings translate into reduced postoperative recovery times for patients. Our study patients experienced little to no bruising, minimal pain, and only 1–2 weeks of obvious facial edema. The author's step-by-step preservation rhinoplasty technique can be referenced for review.10DiscussionStudies comparing the piezoelectric system and the Sonopet have yet to be done. The technologies, cost, and utility vary between the two systems. It would be beneficial to evaluate the utility of these systems in a cross-sectional study.The author has had no major complications with ultrasonic technology; however, epidermal burns can occur if the proper irrigation protocol necessary to keep the equipment cool is not utilized.Greywoode et al. described ultrasonic technology as an expensive equipment that may best serve surgeons who can split the cost within a surgical group or within a hospital setting.4–7 Many hospital systems have the technology available in their neurosurgery or oral maxillofacial departments. The device has been used in dacryocystorhinostomy, endoscopic transorbital decompression, and functional endoscopic sinus surgery.7 The multifunctionality of ultrasonic technology can be cost-effective depending on the surgeon's application.There are many applications for ultrasonic technology in rhinoplasty surgery. Many applications have been investigated using an ultrasonic bone aspirator such as the Sonopet. Sonopet's newer “Payner 360” handpiece tip utilizes a 360° tip that provides an easier ability to precisely contour the bony and cartilaginous aspects of the dorsal hump with an ability to move the handpiece side to side. Piriform aperture enlargement can also be done to improve the nasal valve. The ultrasonic bone aspirator can also be used for inferior turbinate reduction, sculpting of upper and lower lateral cartilages, and septal and costal cartilage grafts.7Dorsal preservation rhinoplasty offers advantages over the traditional and widely practiced component resection of the bony and cartilaginous dorsal hump. Rhinoplasty practices are moving from historically reductive techniques to more preservation surgery. However, the literature has a paucity of material on the topic of preservation rhinoplasty as well as the use of ultrasonic piezoelectric technology.Our center is currently evaluating the functional and aesthetic outcomes of a let down dorsal preservation rhinoplasty performed with the piezoelectric system. Figure 1 shows our 1-year outcomes in a patient after dorsal preservation rhinoplasty based on the validated assessment tools Nose Obstruction Symptom Evaluation, Sinonasal Outcome Test, Standardized Cosmesis and Health Nasal Outcomes Survey, Epworth Sleepiness Scale, and before and after photographs.Fig. 1. (A–J) Before and 16 months after photos of patient who desired a sloped dorsal profile with a more feminine supratip break, implementing the modified Z plasty dorsal preservation rhinoplasty technique. Overall percentage improvement and average change in patient-reported Nose Obstruction Symptom Evaluation (10–2), Sinonasal Outcome Test (37–2), Standardized Cosmesis and Health Nasal Outcomes Survey (32–0), and Epworth Sleepiness Scale (4–2) scores.Figure 2 is a photograph of the piezoelectric system and attachments used at Texas Center for Facial Plastic and Laser Surgery, LLC, San Antonio, Texas.Fig. 2. Photograph of piezoelectric system and attachments used at Texas Center for Facial Plastic and Laser Surgery, LLC, San Antonio, Texas.There are three accepted dorsal preservation rhinoplasty procedures that utilize ultrasonic technology: the push down, let down, and resurfacing dorsal preservation rhinoplasty techniques. Impacting the nasal bones into the pyriform aperture as in the push down approach potentiates nasal airway narrowing and thus the possibility of increased airway obstruction. In contrast, the let down approach removes a wedge of maxillary bone, essentially Webster's triangle, negating the need for impaction and potential airway obstruction. Removing this wedge of maxillary bone also prevents medialization of the inferior bony segment that could narrow the airway.Cadaveric studies led by Patel PN and Abdelwahab M et al. have shown that the push down preservation rhinoplasty technique narrows the internal nasal valve, whereas the let down preservation rhinoplasty technique does not.11,12 Another type of dorsal preservation rhinoplasty not included in this study is a resurfacing technique. For patients with smaller dorsal humps and underrotated tips, only small changes need to be made to the dorsum to achieve the desired aesthetic profile once the tip is elevated. A diamond file attachment on the piezoelectric can be used to reduce the bony cap without violating the keystone.The main appeal of a dorsal preservation rhinoplasty compared with a traditional structural rhinoplasty is that the dorsal aesthetic contours are preserved and the middle vault is generally not violated avoiding an “open roof” deformity. This mitigates the potential for irregularities at the rhinion as well as produces a more natural aesthetic result.Data collection for patients in our center's experience is ongoing and is needed to adequately assess long-term outcomes of ultrasonic rhinoplasty techniques.ConclusionThe application of piezoelectic technology can achieve not only excellent aesthetic outcomes but also significant improvement in nasal breathing. The technique can address variable dorsal hump sizes and midvault deviations, consistently delivering the desired aesthetic dorsal profile and improvement in nasal breathing. The recovery process involves minimal to no bruising, a low level of pain, and limited edema. Piezoelectric technology should be more widely utilized in rhinoplasty.Author Disclosure StatementConsultant, Stryker, LLC. No competing financial interests exist.Funding InformationNo funding was received for this article.References1. Pribitkin E, Greywoode JD. Sonic rhinoplasty: innovative applications. Facial Plast Surg. 2013;29(02):127–132. Crossref, Medline, Google Scholar2. Greywoode JD, Pribitkin EA. Sonic rhinoplasty: histologic correlates and technical refinements using the ultrasonic bone aspirator. Arch Facial Plast Surg. 2011;13(05):316–321. Link, Google Scholar3. Pribitkin EA, Lavasani LS, Shindle C, Greywoode JD. Sonic rhinoplasty: sculpting the nasal dorsum with the ultrasonic bone aspirator. Laryngoscope. 2010;120(08):1504–1507. Crossref, Medline, Google Scholar4. Greywoode JD, Van Abel K, Pribitkin EA. Ultrasonic bone aspirator turbinoplasty: a novel approach for management of inferior turbinate hypertrophy. Laryngoscope. 2010;120(Suppl. 4):S239. Crossref, Medline, Google Scholar5. Synthes. Piezoelectric System. https://www.jnjmedicaldevices.com/en-US/product/piezoelectric-system. Accessed March 1, 2022. Google Scholar6. Stryker. Sonopet. https://www.stryker.- com/us/en/nse/products/sonopet-ultrasonic-aspirator.html. Accessed March 1, 2022. Google Scholar7. Hjelm N, Goldfarb J, Krein H, Heffelfinger RN, Pribitkin E. Sonic rhinoplasty: review and updated uses. Facial Plast Surg. 2021:37(1):107–109. Crossref, Medline, Google Scholar8. Gerbault O, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthet Surg J. 2016;36(1):21–34. Crossref, Medline, Google Scholar9. Anesi A, Ferretti M, Cavani F, et al. Structural and ultrastructural analyses of bone regeneration in rabbit cranial osteotomy: piezosurgery versus traditional osteotomes. J Craniomaxillofac Surg. 2018;46(1):107–118. Crossref, Medline, Google Scholar10. Sozansky JL, Barrera JE. Step by step let down preservation rhinoplasty technique. Facial Plast Surg Aesthet Med. 2021. [Epub ahead of print]; DOI: 10.1089/fpsam.2020.0612. Link, Google Scholar11. Patel PN, Abdelwahab M, Most SP. A review and modification of dorsal preservation rhinoplasty techniques. Facial Plast Surg Aesthet Med. 2020;22(2):71–79. Link, Google Scholar12. Abdelwahab M, Most SP, Patel PN. Impact of dorsal preservation rhinoplasty versus dorsal hump resection on the internal nasal valve: a quantitative radiological study. Aesthetic Plastic Surgery. 2020;44(3):879–887. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 24Issue 3Jun 2022 InformationCopyright 2022, American Academy of Facial Plastic and Reconstructive Surgery, Inc.To cite this article:José Enrique Barrera.Application of Ultrasonic Piezoelectric Technology for Rhinoplasty.Facial Plastic Surgery & Aesthetic Medicine.Jun 2022.165-167.http://doi.org/10.1089/fpsam.2022.0029Published in Volume: 24 Issue 3: June 15, 2022Online Ahead of Print:May 13, 2022PDF download

Projectile injuries to the face deserve particular attention to evaluate for involvement of critical structures and functional elements and treat the devastating effects on facial aesthetics. Ballistic trauma to the maxillofacial region often has significant soft tissue and bony defects, creating a greater challenge to the reconstructive surgeon. The main goals of treatment of projectile injuries to the face are decreasing the amount of contaminants and nonviable tissue at the site, ensuring functionality, and restoring aesthetic appearance. There exists a lack of robust research on the subject. Soft tissue injuries from high-velocity projectiles have changed the perspective on treating acute injuries to the face and neck. Injuries encountered during both Operation Iraqi Freedom and Operation Enduring Freedom give the author pause to reflect upon a different wounding pattern than that encountered in stateside trauma centers. Given the dissemination of high-velocity weaponry by enemy combatants such as the improvised explosive device, mortar round, and high-velocity rifles, a higher incidence of facial wounds has been reported. The mechanism of injury and a stepwise approach for surgical repair are discussed incorporating advanced trauma life support principles and a reconstructive ladder of repair.

Purpose: An absorbable nasal implant for the treatment lateral nasal wall collapse was approved for use in patients with nasal obstruction. It remains to be seen whether this treatment is equivalent to open techniques for the treatment of nasal valve incompetence from collapsibility. Materials and methods: Two groups were analyzed for the study. One group had surgery which included the implant, septoplasty, and inferior turbinate submucous reduction and the other group had a variety of functional rhinoplasty techniques for lateral wall insufficiency in addition to septoplasty and inferior turbinate submucous reduction. NOSE and SNOT-22 were used to demonstrate pre and post-operative changes. Results: Ninety total patients were identified. Fifty patients underwent insertion of an absorbable nasal implant and 40 underwent a traditional open technique to stabilize the LNW. For the implant group the mean NOSE score was 63.4 (SD 24) and post-operative was 22.9 (SD 19.9), in addition, the SNOT-22 score was 38.8 (SD 19.8) and post-operative was 18.5 (SD 15.2). For the open rhinoplasty group, the mean NOSE score was 57.9 (SD 23.2) and post-operative was 17.6 (SD 16.4). The SNOT-22 score was 33.6 (SD 14.9) and post-operative score was 11.5 (SD 15.2) The delta between pre and post-operative NOSE and SNOT-22 test were not different at an average of 3.95 months post-operatively between the groups (NOSE, P = 0.94 and SNOT-22, p = 0.53). Conclusion: In patients with multiple structural causes of nasal obstruction, including lateral wall insufficiency, insertion of an absorbable nasal implant, to support the LNW, seems to be equally effective as functional rhinoplasty techniques over a 4 month timeframe.

Purpose of review The aim of this article is to review the recent literature on orthognathic surgery for treatment of malocclusion and obstructive sleep apnea (OSA). The discussion outlines the refinements of the procedure and advances in technology. Recent findings Maxillomandibular advancement (MMA) may be performed for complex malocclusion and OSA. Although orthodontic management followed by MMA has been the gold standard in managing complex cases, the surgery first approach for treatment of malocclusion has increased in popularity because of decreased treatment time and improved patient quality of life. MMA continues to be the gold-standard for treatment of refractory sleep apnea. Technological advancements, including 3D printing and virtual surgical planning, have enhanced the patient experience and provided more efficiency to this surgery. First introduced in the 19th century, orthognathic surgery has continuously been refined. Over the last few decades, there has been increasing support for a surgery first approach in the treatment of malocclusion. MMA has revolutionized the surgical treatment of OSA and provides the best opportunity for success or cure in patients with complex obstructive patterns. Technology has enhanced the surgical process and created more efficiency for the surgeon and patient. Video abstract .