Publications by authors named "Aaron M Kosins"

35 Publications

Preservation Rhinoplasty: Open or Closed?

Authors:
Aaron M Kosins

Aesthet Surg J 2022 Apr 20. Epub 2022 Apr 20.

Department of Plastic Surgery, University of California, Irvine, Irvine, CA.

Background: Preservation rhinoplasty (PR) is an evolving philosophy.

Objectives: The open approach was used initially, but the author felt a closed approach might be of benefit in certain patients.

Methods: One hundred sixty-two primary rhinoplasty cases were studied retrospectively between January and July 2020. One hundred cases had at least 1 year of follow-up. Patients had follow-up at 1 week, 1 month, 3 months, and 1 year after surgery. Technical details were recorded including dissection planes, preservation of the dorsum (DP) versus component reductions, surface versus foundational DP techniques, and open versus closed approach.

Results: One hundred patients had at least 1 year of follow-up. Fifty-six patients underwent an open approach, and 44 a closed approach. Eighty-three patients had preservation of the dorsal soft tissue envelope. All patients having a closed approach had preservation of the dorsal soft tissue envelope. Sixty-seven patients underwent DP with 38 having surface techniques and 29 having impaction techniques. Thirty-three patients underwent structural rhinoplasty with piezoelectric osteotomies and mid-vault reconstruction. All structural cases were performed using an open approach. Four revision surgeries were necessary.

Conclusions: Open and closed approaches have indications depending on the tip and dorsal deformities. A closed, PR is favored with thin skin, minimal dorsal modification, osseocartilaginous preservation (foundation techniques), less complex tip deformities, and overprojected noses. An open, PR is favored for extensive dorsal modification, S-shaped nasal bones, complex tip deformities, and tip augmentation. Structural, dorsal rhinoplasty is always done open and preferred for complex dorsal deformities and severe septal deviations.
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http://dx.doi.org/10.1093/asj/sjac074DOI Listing
April 2022

Structural Preservation Rhinoplasty: A Hybrid Approach.

Plast Reconstr Surg 2022 05 9;149(5):1105-1120. Epub 2022 Mar 9.

From Rush University Medical School and Toriumi Facial Plastics; private practice; and University of California, Irvine School of Medicine.

Summary: Structural preservation rhinoplasty merges two popular philosophies of rhinoplasty-structure rhinoplasty and preservation rhinoplasty-in an effort to maximize patient outcomes, aesthetics, and function. This allows the surgeon to both preserve the favorable attributes of the nose, and also to structure the nasal tip and dorsum with grafts to maximize contour and support. The concept of dorsal preservation is to preserve favorable dorsal aesthetic lines without the creation of an "open roof." However, the addition of some structure concepts can expand the utility of dorsal preservation in primary rhinoplasty patients. The authors discuss these structure concepts and their applicability to dorsal preservation.
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http://dx.doi.org/10.1097/PRS.0000000000009063DOI Listing
May 2022

Commentary on: A 3-Level Impaction Technique for Dorsal Reshaping and Reduction Without Dorsal Soft Tissue Envelope Dissection.

Authors:
Aaron M Kosins

Aesthet Surg J 2022 01;42(2):166-170

Department of Plastic Surgery, University of California, Irvine, Newport Beach, CA, USA.

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http://dx.doi.org/10.1093/asj/sjab321DOI Listing
January 2022

Optimization of the Soft Tissue Envelope of the Nose in Rhinoplasty Utilizing Fat Transfer Combined with Platelet-Rich Fibrin.

Facial Plast Surg 2021 Oct 26;37(5):590-598. Epub 2021 Feb 26.

HNO-Zentrum Rhein-Neckar, Mannheim, Germany.

A thin or damaged skin soft tissue envelope may cause concerns in primary and secondary rhinoplasty. During postoperative healing, unpredictable scarring and contraction may occur and lead to significant aesthetic and trophic sequelae. Besides a meticulous surgical technique, there are no reliable techniques to prevent long-term skin damage and shrinkage. Fat transfer with addition of platelet-rich fibrin (PRF) harbors the possibility of local soft tissue regeneration and skin rejuvenation through growth factors and mesenchymal stem cells. It may also facilitate the creation of a thin fat layer on the dorsum to prevent shrink-wrap forces and conceal small irregularities. The goal is to provide evidence for the feasibility, durability, and beneficial effect of diced macrofat transfer bonded with PRF on the nasal dorsum. We present the technique of fat transfer conjugated with PRF as a nasal dorsal graft. Clinical endpoints were the prevention of trophic disturbances and atrophy at a 1-year postoperative follow-up. We present the skin mobility test as a clinical indicator of a healthy soft tissue envelope. The presented case series consists of 107 rhinoplasties. Fat was harvested in the umbilical or costal region. PRF was created by centrifugation of autologous whole blood samples. Macrofat was diced, cleaned, and bonded with PRF. The compound transplants were transferred to the nasal dorsum. There were no perioperative complications or wound-healing issues. Mean follow-up was 14 months. Clinical inspection showed good skin quality and no signs of shrinkage, marked scarring, or color changes with positive skin mobility test in all patients. Survival of fat was confirmed by ultrasonography and magnetic resonance imaging. Diced macrofat transfer in conjunction with PRF to the nasal dorsum is a feasible and safe method. A beneficial effect on the soft tissue envelope is demonstrated as well as the prevention of shrink-wrap forces.
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http://dx.doi.org/10.1055/s-0041-1723785DOI Listing
October 2021

Incorporating Dorsal Preservation Rhinoplasty into Your Practice.

Authors:
Aaron M Kosins

Facial Plast Surg Clin North Am 2021 Feb;29(1):101-111

Plastic Surgery, UC Irvine School of Medicine, 1441 Avocado Avenue, Suite 203, Newport Beach, CA 92660, USA. Electronic address:

For rhinoplasty surgeons, surgery of the dorsum has never been so dynamic or as easily learned. Reproducible techniques offer excellent results that can be difficult to achieve in certain patients using component reduction. An expanding repertoire of dorsal preservation (DP) techniques is evolving. Each DP operation builds on the others. To understand DP requires a new appreciation of the cartilaginous septum, the perpendicular plate of ethmoid, nasal osteotomies, and anatomy of the nose where surgeons do not operate with traditional component reduction. The result is more beautiful noses where the normal anatomy is preserved.
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http://dx.doi.org/10.1016/j.fsc.2020.09.001DOI Listing
February 2021

Commentary on: Improvement of Alar Concavity With Scroll Ligament Preservation: Sandwich Technique.

Authors:
Aaron M Kosins

Aesthet Surg J 2020 09;40(10):1076-1079

University of California, Irvine School of Medicine, Irvine, CA.

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http://dx.doi.org/10.1093/asj/sjaa105DOI Listing
September 2020

Expanding Indications for Dorsal Preservation Rhinoplasty With Cartilage Conversion Techniques.

Authors:
Aaron M Kosins

Aesthet Surg J 2021 01;41(2):174-184

University of California, Irvine School of Medicine, Irvine, CA.

Background: Preservation rhinoplasty (PR) is a new and evolving philosophy in rhinoplasty surgery. As a surgeon becomes more experienced with preservation concepts, he/she begins to look for new ways to apply PR to an increasing percentage of primary cases.

Objectives: This article presents a series of 100 primary rhinoplasties that underwent dorsal preservation with an emphasis on the cartilage-only dorsal preservation.

Methods: A total of 226 primary rhinoplasty cases were studied retrospectively between July 2017 and August 2018. One hundred cases of dorsal preservation were included in the study. Data was collected in all cases regarding age, gender, ethnicity, and technical details of the operation. These 100 cases fall into the following 3 categories: (1) dorsal preservation employing a subdorsal strip; (2) dorsal preservation utilizing a cartilage-only pushdown with separate bony pyramid modification; and (3) dorsal preservation employing a cartilage reduction method with separate bony pyramid modification.

Results: Fifty-seven patients underwent subdorsal strip technique, 39 underwent cartilage-only pushdown technique, and 4 underwent cartilage modification. The average lowering was 4.5 mm (range, 2-10 mm), 2.5 mm (range, 1-3.5 mm), and 2 mm (range, 1-2.5 mm) for the subdorsal strip, cartilage-only pushdown techniques, and cartilage modification technique, respectively. No patients required revision surgery of their dorsum.

Conclusions: PR is a paradigm shift in rhinoplasty. With time, surgeons will find themselves asking in every situation whether they can preserve structures. Dorsal preservation is a reliable technique if patients are chosen properly. With bony cap modification, more dorsums can be preserved and dorsal aesthetics can be improved.

Level Of Evidence: 4:
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http://dx.doi.org/10.1093/asj/sjaa071DOI Listing
January 2021

Commentary on: Soft Tissue Thickness Variations of the Nose: A Radiological Study.

Authors:
Aaron M Kosins

Aesthet Surg J 2020 06;40(7):719-720

University of California, Irvine School of Medicine, Irvine, CA.

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http://dx.doi.org/10.1093/asj/sjz376DOI Listing
June 2020

Current Trends in Preservation Rhinoplasty.

Aesthet Surg J Open Forum 2020 Jan 1;2(1):ojaa003. Epub 2020 Feb 1.

Recently there has been a dramatic acceptance of the preservation principle in rhinoplasty surgery. Surgeons worldwide now preform preservation rhinoplasty, which has led to an expanding list of indications and techniques. Most rhinoplasty surgeons have accepted the fundamental principle that preservation is better than resection and that a natural result is superior to a fabricated or reconstructed structure, especially with regards to the nasal dorsum. Currently, the main emphasis is on defining the indications/contraindications, technical refinements, and minimizing complications. This paper provides an overview of the current trends in preservation rhinoplasty. In the 2 years following publication of the Editorial, "The Preservation Rhinoplasty: A New Rhinoplasty Revolution,"  there has been a dramatic acceptance of the preservation principle. Numerous surgeons throughout the world are preforming preservation rhinoplasty, which has led to an expanding list of indications and techniques. The majority of rhinoplasty surgeons have accepted the fundamental principle that preservation is better than resection, and that a natural result is superior to a fabricated or reconstructed structure, especially as regards the nasal dorsum. Currently, the main emphasis is on defining the indications/contraindications, technical refinements, and minimizing complications. The present paper is an overview of the current trends in preservation rhinoplasty.
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http://dx.doi.org/10.1093/asjof/ojaa003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671258PMC
January 2020

Decision Making in Preservation Rhinoplasty: A 100 Case Series With One-Year Follow-Up.

Aesthet Surg J 2020 01;40(1):34-48

Department of Plastic Surgery, University of California, Irvine School of Medicine, Irvine, CA.

Background: Preservation rhinoplasty (PR) is a new chapter in rhinoplasty history. The term was coined by Daniel in 2018 and represents a fundamental change in philosophy.

Objectives: The aim of this study is to discuss a single-surgeon case series utilizing PR techniques.

Methods: One hundred fifty-three primary rhinoplasty cases were studied retrospectively between December 2016 and August 2017. One hundred cases had at least 1 year of follow-up. Technical details were recorded, including dissection plane, ligament preservation, tip support, lateral crural maneuvers, alar contour grafts, and preservation of the dorsum vs traditional reduction. These 100 cases can be categorized as either complete preservation rhinoplasty (PR-C) or partial preservation rhinoplasty (PR-P).

Results: All patients had open rhinoplasty and the average follow-up time was 13 months. All patients had preservation of the dorsal soft tissue envelope, and in 36 the entire soft tissue envelope and ligaments were preserved. Fifty-four had preservation of the alar cartilages. Thirty-one had dorsal preservation. The combinations include: PR-C (skin, dorsum, and alars): 24; PR-P (skin and dorsum): 2; PR-P (alars and dorsum): 2; and PR-P (skin and alars): 7.

Conclusions: In most patients, the dorsal soft tissue envelope and nasal ligaments can be preserved. When possible, the lateral crura should be preserved and tensioning chosen over excision. Dorsal preservation is a versatile technique when proper patient selection is undertaken, and long-term issues with the middle vault and keystone area can be avoided. Some patients will benefit from total preservation where nothing is removed/disrupted and underlying structures are reshaped.

Level of Evidence: 4.
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http://dx.doi.org/10.1093/asj/sjz107DOI Listing
January 2020

Reassessing Surgical Management of the Bony Vault in Rhinoplasty.

Aesthet Surg J 2018 May;38(6):590-602

University of California, Irvine School of Medicine, Irvine, CA.

Level Of Evidence 5:
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http://dx.doi.org/10.1093/asj/sjx246DOI Listing
May 2018

Commentary on: Oculonasal Synkinesis: Video Report and Surgical Solution of a Rare Phenomenon.

Aesthet Surg J 2017 09;37(8):884-886

University of California, Irvine School of Medicine, Irvine, CA; Aesthetic Surgery Journal. Department of Plastic Surgery, University of Pécs Medical School, Pécs, Hungary.

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http://dx.doi.org/10.1093/asj/sjx141DOI Listing
September 2017

Comprehensive Diagnosis and Planning for the Difficult Rhinoplasty Patient: Applications in Ultrasonography and Treatment of the Soft-Tissue Envelope.

Authors:
Aaron M Kosins

Facial Plast Surg 2017 Oct 29;33(5):509-518. Epub 2017 Sep 29.

Department of Plastic Surgery, Irvine School of Medicine, University of California, Orange, California.

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http://dx.doi.org/10.1055/s-0037-1606639DOI Listing
October 2017

Response to "Contradictions in Piezosurgery".

Aesthet Surg J 2017 04;37(4):NP54-NP55

Clinical Assistant Professor, University of California, Irvine School of Medicine, Irvine, CA, USA.

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http://dx.doi.org/10.1093/asj/sjx017DOI Listing
April 2017

Commentary on: The Effect of Nasal Tip Rotation on Upper Lip Length.

Authors:
Aaron M Kosins

Aesthet Surg J 2017 05;37(5):511-514

Clinical Assistant Professor, University of California, Irvine School of Medicine, Irvine, CA, USA.

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http://dx.doi.org/10.1093/asj/sjx009DOI Listing
May 2017

Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery.

Aesthet Surg J 2017 Feb 13;37(2):143-157. Epub 2016 Dec 13.

Dr Kosins is a Clinical Assistant Professor, University of California, Irvine School of Medicine, Irvine, CA; and Rhinoplasty Section Co-editor for Aesthetic Surgery Journal. Dr Obagi is a dermatologist in private practice in Beverly Hills, CA.

Background: The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal skin and underlying soft tissue.

Objectives: This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures.

Methods: Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi "skin pinch test" was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue.

Results: Patients determined to have thin, normal, and thick skin by the "skin pinch test" were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer.

Conclusions: The "skin pinch test" is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively to treat patients with difficult soft tissue envelopes. LEVEL OF EVIDENCE 4.
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http://dx.doi.org/10.1093/asj/sjw160DOI Listing
February 2017

Rhinoplasty: The Asymmetric Crooked Nose-An Overview.

Facial Plast Surg 2016 Aug 5;32(4):361-73. Epub 2016 Aug 5.

Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, California.

There are three reasons why the asymmetric crooked nose is one of the greatest challenges in rhinoplasty surgery. First, the complexity of the problem is not appreciated by the patient nor understood by the surgeon. Patients often see the obvious deviation of the nose, but not the distinct differences between the right and left sides. Surgeons fail to understand and to emphasize to the patient that each component of the nose is asymmetric. Second, these deformities can be improved, but rarely made flawless. For this reason, patients are told that the result will be all "-er words," better, straighter, cuter, but no "t-words," there is no perfect nor straight. Most surgeons fail to realize that these cases represent asymmetric noses on asymmetric faces with the variable of ipsilateral and contralateral deviations. Third, these cases demand a wide range of sophisticated surgical techniques, some of which have a minimal margin of error. This article offers an in-depth look at analysis, preoperative planning, and surgical techniques available for dealing with the asymmetric crooked nose.
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http://dx.doi.org/10.1055/s-0036-1585421DOI Listing
August 2016

Response to "Comments on 'The Role of Piezoelectric Instrumentation in Rhinoplasty Surgery'".

Aesthet Surg J 2016 May;36(5):NP189

Dr Gerbault is a plastic surgeon in private practice in Paris, France. Dr Daniel is a Clinical Professor and Dr Kosins is a Clinical Assistant Professor, Department of Plastic Surgery, University of California, Irvine School of Medicine, Irvine, CA. Dr Daniel is also Rhinoplasty Section Editor for Aesthetic Surgery Journal.

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http://dx.doi.org/10.1093/asj/sjw017DOI Listing
May 2016

Commentary on: Double-Blind Comparison of Ultrasonic and Conventional Osteotomy in Terms of Early Postoperative Edema and Ecchymosis.

Aesthet Surg J 2016 Apr;36(4):402-3

Dr Gerbault is a plastic surgeon in private practice in Paris, France. Dr Kosins is a Clinical Assistant Professor, Department of Plastic Surgery, University of California, Irvine School of Medicine, Irvine, CA.

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http://dx.doi.org/10.1093/asj/sjw016DOI Listing
April 2016

The Role of Piezoelectric Instrumentation in Rhinoplasty Surgery.

Aesthet Surg J 2016 Jan 6;36(1):21-34. Epub 2015 Nov 6.

Dr Gerbault is a plastic surgeon in private practice in Paris, France. Dr Daniel is a Clinical Professor and Dr Kosins is a Clinical Assistant Professor, Department of Plastic Surgery, University of California, Irvine School of Medicine, Irvine, California.

Background: In rhinoplasty surgery, management of the bony vault and lateral walls is most often performed with mechanical instruments: saws, chisels, osteotomes, and rasps. Over the years, these instruments have been refined to minimize damage to the surrounding soft tissues and to maximize precision.

Objectives: This article will present the evolution of the authors' current operative technique based on 185 clinical cases performed over an 19-month period using piezoelectric instrumentation (PEI).

Methods: A two-part study of cadaver dissections and clinical cases was performed using PEI. Evolution of the authors' clinical technique and the operative sequence were recorded.

Results: Thirty cadaver dissections and 185 clinical cases were performed using PEI, including 82 primary and 103 secondary cases. An extended subperiosteal dissection was developed to visualize all aspects of the open rhinoplasty including the osteotomies. Ultrasonic rhinosculpture (URS) was utilized in 95 patients to shape the bony vault without osteotomies. To date, 11 revisions (6%) have been performed. There were no cases of bone asymmetry, irregularity, or excessive narrowing requiring a revision.

Conclusions: Based on the authors' experience, adoption of PEI is justified and offers more precise analysis and surgical execution with superior results in altering the osseocartilaginous vault. With extensive exposure, surgeons can make an accurate diagnosis of bony deformity and safely contour the bones to achieve narrowing and symmetry of the bony dorsum. Stable osteotomies can be performed under direct vision with precise mobilization and control. As a result of PEI, the upper third of the rhinoplasty operation is no longer shrouded in mystery. LEVEL OF EVIDENCE 4: Therapeutic.
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http://dx.doi.org/10.1093/asj/sjv167DOI Listing
January 2016

Analysis and Treatment of the Plunging Tip Illusion.

Authors:
Aaron M Kosins

Plast Reconstr Surg 2016 Jan;137(1):243e

University of California, Irvine Medical Center, Orange, Calif.

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http://dx.doi.org/10.1097/PRS.0000000000001916DOI Listing
January 2016

The plunging tip: analysis and surgical treatment.

Aesthet Surg J 2015 May;35(4):367-77

Dr Kosins is a Volunteer Clinical Assistant Professor and Dr Daniel is a Volunteer Clinical Professor, University of California, Irvine Medical Center, Irvine, CA. Dr Lambros is a plastic surgeon in private practice in Newport Beach, CA.

Background: The plunging tip refers to a deformity in which the nasal tip plunges on smiling.

Objectives: To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling.

Methods: Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose.

Results: Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip.

Conclusions: This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation.
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http://dx.doi.org/10.1093/asj/sju110DOI Listing
May 2015

Rhinoplasty: the nasal bones - anatomy and analysis.

Aesthet Surg J 2015 Mar;35(3):255-63

Dr Lazovic is Clinical Assistant Professor of Plastic Surgery, University of Belgrade, School of Medicine, Belgrade, Serbia; and Clinic of Burns, Plastic, and Reconstructive Surgery, Clinical Center of Serbia, Belgrade, Serbia. Dr Daniel is Clinical Professor of Plastic Surgery and Dr Kosins is Clinical Assistant Professor, Aesthetic and Plastic Surgery Institute, University of California, Irvine, Orange, California. Dr Janosevic is Professor of Otorhinolaryngology, University of Belgrade, School of Medicine, Belgrade, Serbia; and Clinic of ENT and MFS, Clinical Center of Serbia, Belgrade, Serbia. Dr Kosanovic is a Professor of Otorhinolaryngology, Faculty of Stomatology, University of Belgrade, Belgrade, Serbia; and Clinic of ENT and MFS, Clinical Center Zvezdara, Belgrade, Serbia. Dr Colic is a plastic surgeon in private practice in Belgrade, Serbia.

Background: The analysis of nasal anatomy, and especially the nasal bones including the osseocartilaginous vault, is significant for functional and aesthetic reasons.

Objectives: The objective was to understand the anatomy of the nasal bones by establishing new descriptions, terms, and definitions because the existing parameters were insufficient. Adequate terminology was employed to harmonize the anthropometric and clinical measurements.

Methods: A two-part harvest technique consisting of resecting the specimen and then creating a replica of the skull was performed on 44 cadavers to obtain specific measurements.

Results: The nasal bones have an irregular, variable shape, and three distinct angles can be found along the dorsal profile line beginning with the nasion angle (NA), the dorsal profile angulation (DPA) and the kyphion angulation (KA). In 12% of cases, the caudal portion of the nasal bones was straight and without angulation resulting in a "V-shape" configuration. In 88% of cases, the caudal portion of the bone was angulated, which resulted in an "S-shape" nasal bone configuration. The intervening cephalic bone, nasion to sellion (N-S), represents the radix while the caudal bone, sellion to r (S-R), represents the bony dorsum.

Conclusions: By standardizing and measuring existing nasal landmarks and understanding the different anatomic configurations of the nasal bones, rhinoplasty surgeons can better plan their operations within the radix and bony and osseocartilaginous vaults.
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http://dx.doi.org/10.1093/asj/sju050DOI Listing
March 2015

The osseocartilaginous vault of the nose: anatomy and surgical observations.

Aesthet Surg J 2015 Mar;35(3):242-51

Dr Daniel is a Clinical Professor and Dr Kosins is a Clinical Assistant Professor in the Department of Plastic Surgery at the University of California, Irvine. Dr Palhazi is a PhD student in the Department of Medicine at Semmelweis University in Budapest, Hungary.

Background: The dorsal hump and dorsal aesthetic lines have been considered bony and cartilaginous structures. Knowledge of the anatomy of the osseocartilaginous vault is essential for obtaining aesthetically pleasing results of rhinoplasty.

Objectives: The authors described the morphology, embryology, and clinical relevance of the nasal vault and the changes that occur in this area during rhinoplasty.

Methods: Dissections were performed on 15 fresh adult cadavers to examine the anatomy of the osseocartilaginous vault. Intraoperative endoscopic examination of the vault also was performed in 9 rhinoplasty patients before and after dorsal hump reduction.

Results: In the cadaver study, the average length of the dorsal keystone area, measured along the dorsal septum, was 8.9 mm, and the average width was 4.9 mm. No significant difference in length was observed between cadaver subgroups with straight or humped nasal profiles. The extent of lateral overlap of the nasal bones with the cephalic portion of the upper lateral cartilages varied. In rhinoplasty patients, the average length of the cartilaginous vault exposed during dorsal reduction was 7.6 mm.

Conclusions: The aesthetic lines and profile of the nose before dorsal reduction are dictated by the cartilaginous vault. After reduction, the dorsal lines are determined by the bony vault edges. In routine rhinoplasty, reduction of dorsal height generally corresponds to removal of the dorsal cartilaginous septum.
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http://dx.doi.org/10.1093/asj/sju079DOI Listing
March 2015

Rhinoplasty: the lateral crura-alar ring.

Aesthet Surg J 2014 May 28;34(4):526-37. Epub 2014 Mar 28.

Dr Daniel is a Clinical Professor and Dr Kosins is a Clinical Assistant Professor in the Department of Plastic Surgery, University of California, Irvine, Orange, California.

Background: Rhinoplasty surgeons routinely excise or incise the lateral crura despite nostril rim retraction, bossa, and collapse. Given recent emphasis on preserving the lateral crura, a review of the lateral crura's anatomy is warranted.

Objectives: The authors quantify specific anatomical aspects of the lateral crura in cadavers and clinical patients.

Methods: This was a 2-part investigation, consisting of a prospective clinical measurement study of 40 consecutive rhinoplasty patients (all women) and 20 fresh cadaver dissections (13 males, 1 female). In the clinical phase, the alar cartilages were photographed intraoperatively and alar position (ie, orientation), axis, and width were measured. Cadaver dissections concentrated on parts of the lateral crura (alar cartilages and alar ring) that were inaccessible clinically.

Results: Average clinical patient age was 28 years (range, 14-51 years). Average cadaver age was 74 (range, 57-88 years). Clinically, the distance of the lateral crura from the mid-nostril point averaged 5.9 mm, and the cephalic orientation averaged 43.6 degrees. The most frequent configuration of the axis was smooth-straight in the horizontal axis and a cephalic border higher than the caudal border in the vertical axis. Maximal lateral crura width averaged 10.1 mm. In the cadavers, average lateral crural dimensions were 23.4 mm long, 6.4 mm wide at the domal notch, 11.1 mm wide at the so-designated turning point (TP), and 0.5 mm thickness. The accessory cartilage chain was present in all dissections.

Conclusions: The lateral crura-alar ring was present in all dissections as a circular ring continuing around toward the anterior nasal spine but not abutting the pyriform. The lateral crura (1) begins at the domal notch and ends at the accessory cartilages, (2) exhibits a distinct TP from the caudal border, (3) has distinct horizontal and vertical vectors, and (4) should have a caudal border higher than the cephalic border. Alar malposition may be associated with position, orientation, or configuration.
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http://dx.doi.org/10.1177/1090820X14528464DOI Listing
May 2014

The plunging tip: illusion and reality.

Aesthet Surg J 2014 Jan;34(1):45-55

Dr Kosins is a Volunteer Clinical Assistant Professor WOS and Dr Daniel is a Clinical Professor, University of California, Irvine Medical Center, Irvine, California.

Background: The plunging tip is defined as a nasal deformity where the nasal tip descends or "plunges" during smiling.

Objective: The authors prospectively measure a series of 25 patients with a focus on the anatomic changes of the nose before and after the patient smiles.

Methods: Twenty-five women who presented for cosmetic primary rhinoplasty and complained of a plunging tip were included in the study. Three angles were measured on lateral view (tip angle, nasolabial angle, and columella inclination angle), along with changes in tip, subnasale, and alar crease. The Simon tip rotation angle (STRA) measured tip position in relation to the static tragus. The alar rim angle measured the angle of the alar rim at the nostril. Changes in static and smiling positions were compared.

Results: Tip, nasolabial, and the columella inclination angles decreased between static and smiling positions by 10.9, 11.8, and 11.9 degrees, respectively. Tip position dropped by 0.9 mm, while the subnasale and alar crease junction elevated by 1.3 and 3.7 mm, respectively. The STRA, an angle independent of alar base movement, decreased by less than 1 degree. The alar rim angle increased by 9.9 degrees.

Conclusions: Our data demonstrate that the nasal tip changes its position less than 1 mm with a full smile. The concept of a "plunging tip" is an optical illusion. In reality, the alar crease and subnasale elevate and the alar rim straightens, while the tip position changes minimally. Objectively, the tip moves less than 1 mm and less than 1 degree using the STRA.
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http://dx.doi.org/10.1177/1090820X13515482DOI Listing
January 2014

Rhinoplasty: congenital deficiencies of the alar cartilage.

Aesthet Surg J 2013 Aug 9;33(6):799-808. Epub 2013 Jul 9.

Division of Plastic Surgery, School of Medicine, University of California-Irvine, CA, USA.

Background: Congenital deficiencies of the alar cartilages are rare and often visible at birth but can occasionally present later.

Objectives: The authors review the anatomical development and discuss the incidence and treatment of congenital defects within the alar cartilages seen in rhinoplasty cases.

Methods: The charts of 869 consecutive patients who underwent open rhinoplasty were retrospectively reviewed, and 8 cases of congenital defects of the alar cartilage within the middle crura were identified. Intraoperative photographs were taken of the alar deformities, and each patient underwent surgical correction. To simplify analysis, a classification of the defects was developed. A division was a cleft in the continuity of the alar cartilage with the 2 ends separate. A gap was a true absence of cartilage ranging from 1 to 4 mm, which can be accurately assessed in unilateral cases. A segmental loss was a defect greater than 4 mm.

Results: The 8 cases of deformity could be classified as 4 divisions, 3 gaps, and 1 segmental loss. None of the patients had a history of prior nasal trauma or nasal surgery. Six patients were women and 2 patients were men. In all cases, adequate projection and stability were achieved with a columellar strut. Asymmetry was minimized through concealer or tip grafts. There were no complications.

Conclusions: Surgeons performing rhinoplasty surgery will encounter and should be prepared to deal with unexpected congenital defects of the alar cartilage. These defects within the middle crura will require stabilization with a columellar strut and, often, coverage with a concealer tip graft. We speculate that the cause of these defects is a disruption of the hedgehog signals that may arrest the condensation or block the differentiation of the underlying neural crest cells.
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http://dx.doi.org/10.1177/1090820X13495692DOI Listing
August 2013

Evidence-based value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis.

Plast Reconstr Surg 2013 Aug;132(2):443-450

Orange, Calif.; and Durham, N.C. From the Aesthetic and Plastic Surgery Institute, University of California, Irvine, and the Department of Statistical Sciences, Duke University. The first two authors should be considered co-first authors.

Background: The purpose of this study was to determine the evidenced-based value of prophylactic drainage of subcutaneous wounds in surgery.

Methods: An electronic search was performed. Articles comparing subcutaneous prophylactic drainage with no drainage were identified and classified by level of evidence. If sufficient randomized controlled trials were included, a meta-analysis was performed using the random-effects model. Fifty-two randomized controlled trials were included in the meta-analysis, and subgroups were determined by specific surgical procedures or characteristics (cesarean delivery, abdominal wound, breast reduction, breast biopsy, femoral wound, axillary lymph node dissection, hip and knee arthroplasty, obesity, and clean-contaminated wound). Studies were compared for the following endpoints: hematoma, wound healing issues, seroma, abscess, and infection.

Results: Fifty-two studies with a total of 6930 operations were identified as suitable for this analysis. There were 3495 operations in the drain group and 3435 in the no-drain group. Prophylactic subcutaneous drainage offered a statistically significant advantage only for (1) prevention of hematomas in breast biopsy procedures and (2) prevention of seromas in axillary node dissections. In all other procedures studied, drainage did not offer an advantage.

Conclusions: Many surgical operations can be performed safely without prophylactic drainage. Surgeons can consider omitting drains after cesarean section, breast reduction, abdominal wounds, femoral wounds, and hip and knee joint replacement. Furthermore, surgeons should consider not placing drains prophylactically in obese patients. However, drain placement following a surgical procedure is the surgeon's choice and can be based on multiple factors beyond the type of procedure being performed or the patient's body habitus.

Clinical Question/level Of Evidence: Therapeutic, II.
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http://dx.doi.org/10.1097/PRS.0b013e3182958945DOI Listing
August 2013

Immunological demyelination enhances nerve regeneration after acute transection injury in the adult rat sciatic nerve.

Ann Plast Surg 2012 Mar;68(3):290-4

Reeve-Irvine Research Center, Irvine, CA, USA.

Introduction: Our recent experiments demonstrate that demyelination enhances peripheral nerve regeneration after contusion injury in the adult rat sciatic nerve. The role of demyelination in peripheral nerve regeneration in a sciatic nerve transection model has yet to be elucidated. We hypothesize that (1) axon regeneration within a region of injury increases after experimental, immunologic demyelination, and (2) regenerated axons are partially derived from the proximal motor axons.

Methods: Sciatic nerves of adult female Sprague-Dawley rats (n = 20) were injected with a demyelinating agent immediately after transection injury. The sciatic nerves were harvested 1 month (n = 5) and 2 months (n = 5) after surgery. In the control groups, the cut nerves were reapproximated without demyelination therapy. The lesion containing length of nerve was cut into 1-mm transverse blocks and processed to preserve orientation. Specimens were evaluated using structural and immunohistochemical analyses.

Results: A single epineural injection of complement proteins plus antibodies to galactocerebroside resulted in demyelination followed by Schwann cell remyelination. At 1 month, remyelination was clearly shown throughout the injured sciatic nerve segment. At 2 months, there was a statistically significant increase in peripheral nerve regeneration following demyelination therapy as evidenced by total axon count, axon density, and fiber diameter.

Conclusion: This study demonstrates enhanced histomorphologic nerve regeneration in the rat sciatic nerve after local delivery of experimental, immunologic demyelination following transection injury. It highlights the utility of demyelination in peripheral nerve regeneration. This therapy may be applicable for tissue-engineered constructs, cell-based systems, and nerve transfers to improve outcomes in peripheral nervous system injuries.
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http://dx.doi.org/10.1097/SAP.0b013e31823dce7eDOI Listing
March 2012

Improvement of peripheral nerve regeneration following immunological demyelination in vivo.

Plast Reconstr Surg 2011 May;127(5):1813-1819

Orange and Irvine, Calif. From the Reeve-Irvine Research Center, Sue and Bill Gross Stem Cell Research Center, and the Department of Tissue Engineering and Regenerative Medicine, Aesthetic and Plastic Surgery Institute, University of California at Irvine.

Background: To improve regeneration of the peripheral nervous system, a therapy was utilized in the adult rat sciatic nerve in which nerve regeneration is enhanced following acute crush injury. The authors hypothesized that (1) axon regeneration within a region of injury increases following experimental, immunological demyelination; and (2) regenerated axons partially derive from the proximal motor axons.

Methods: The sciatic nerves of 10 Sprague-Dawley rats were injected with a demyelinating agent following crush injury, while the nerves of 10 control rats received a crush injury without therapy. The sciatic nerves were harvested at 14 and 28 days. The lesion containing length of the nerve was cut into 1-mm blocks, and specimens were fixed and evaluated using structural and immunohistochemical analyses. A Flouro-Ruby tracer was injected into the sciatic nerves of a separate group of rats to determine the source of axonal regrowth.

Results: An epineural injection of complement proteins plus antibodies to galactocerebroside resulted in demyelination followed by Schwann cell remyelination. At 14 days, remyelination was demonstrated spanning the injured sciatic nerve segment. At 28 days, peripheral nerve regeneration was quantified by total axon count, axon density, and nerve fiber diameter. Tracers demonstrated that regeneration arose partially from proximal motor axons.

Conclusions: This study demonstrates enhanced regeneration in the peripheral nervous system using experimental, immunological demyelination. Findings indicate that axon count, axon density, and nerve fiber diameter within a region of acute crush injury in the rat sciatic nerve can be improved using a demyelinating treatment.
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http://dx.doi.org/10.1097/PRS.0b013e31820cf2b0DOI Listing
May 2011
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