Trending Topics in Rhinoplasty

In the era of Web-based social relations, people who share interests and/or activities log into the same social networking service, create profiles with his or her social links, and interact using e-mail and instant messaging. Social networking sites allow users to share activities, ideas, events, and interests within their individual networks.

Twitter is an online social networking and microblogging service that enables its users to send and read text-based posts of up to 140 characters, known as “tweets.” Twitter quickly achieved worldwide popularity, with 200 million users as of 2011, generating over 200 million tweets and handling over 1.6 billion search queries per day.¹ When a word, phrase, or topic is posted (tweeted) multiple times on Twitter, it becomes a “trending topic.”

Trending topics become popular through an event that prompts people to talk about one specific topic. These topics help users to understand what is happening in the world. And what are the trending topics in rhinoplasty? The Archives, other journals, and our facial plastic meetings are our social networking, our “rhinoplasty twitter.” From these sources we have picked #IrradiatedRibGraft, #DicedCartilage, and #LateralCruraOrientation as the top 3 trending topics in the last years to discuss herein.

Autologous costal cartilage graft is considered one of the main grafts for rhinoplasty. It was popularized after the concept of structural rhinoplasty. Rib grafts can be harvested as a composite osseocartilaginous segment or just a cartilaginous graft.² Ribs provide the advantages of a large volume of graft material with excellent structural support. The disadvantages are warping and the potential donor site morbidities (pneumothorax, scar visibility, and chest wall deformity). McCarn and Weber³ recommend the use of intraoperative ultrasonography for rapid detection of iatrogenic pneumothorax after costal cartilage harvest instead of chest radiography because of lower cost, improved sensitivity, and lack of exposure to ionizing radiation.

The use of irradiated costal cartilage graft is another option to avoid these donor site morbidities. However, the lack of reliability of this graft in rhinoplasty that was associated with poor studies with inconsistent design, small number of patients, and short follow-up period prevented the acceptance by the surgeons' community. The article by Kridel et al⁴ on irradiated homologous costal cartilage in 357 patients with follow-up extending to 24 years helped change this concept. The authors showed that the rate of complications was no greater than rhinoplasty complication rates when autologous cartilage grafts are used. This was an important article that will be referred to for a long time.

Menger and Nolst Trenité⁵ also added relevant information on this topic. They studied 66 patients with follow-up extending to 9 years (average of 51 months) in 9 specific recipient sites in the nose. They suggest that irradiated homologous rib grafts are safe, but in cases requiring a shield graft, they should be avoided because of resorption. Overall, it seems that irradiated costal cartilage graft now has a favorable position.

The use of diced cartilage in reconstructive surgery was first described in the 1940s. However, the technique has never achieved widespread use owing to the lack of long-term reliability. Diced cartilage offers obvious advantages like greater flexibility and minimal risk of warping and obviates the need for a long and straight cartilage graft donor site.

In recent years, articles on the use of diced cartilage rather than a solid piece of cartilage graft have made fans all over the world, especially in dorsum augmentation. Daniel⁶ has shown that excellent outcomes can be accomplished using temporal fascia to wrap the diced cartilage and augment the dorsum. The temporal fascia prevents problems of palpability and visibility of diced grafts. Furthermore, it seems to prevent resorption, since some of Daniel's patients required removal of excess amounts of cartilage because of overcorrection for anticipated volume loss. He presented adequate results at 1- to 2-year follow-up evaluations. We have been using this same technique for over 2 years with excellent results. Apparently, diced cartilage wrapped in temporal fascia has solved most of the problems of dorsum augmentation and radix grafting.

Bullocks et al⁷ presented the use of diced cartilage combined with autologous tissue glue (platelet-rich plasma + fibrin glue). The authors have introduced an innovative technique for delivering diced cartilage that may reduce the potential disadvantages of the temporal fascia (elevated costs, additional donor sites, and complications). The authors reported maintenance of dorsal height in all cases, but this was not objectively studied.

Some controversy currently exists about the optimal substance or scaffold for delivering diced cartilage, thus new studies are required to determine the best technique.

Since the earliest descriptions of Anderson's tripod theory,⁸ the lateral crura have gained more and more importance in rhinoplasty. Its 3-dimensional shape, position, and strength are very important to nasal tip refinement, projection, and rotation. In spite of having several techniques to modify the lateral crus, we still have lots to discover about its dynamics.⁹ The concept of cephalically positioned lateral crura was introduced by Sheen¹⁰ in the 1970s, and since then other authors like Constantian¹¹ and Toriumi¹² have contributed to the understanding of this topic. Nevertheless, the effect of cephalic position on the form and function of the nasal tip remains controversial.

Recently, a landmark article was published Sepehr et al.¹³ They used a mathematical model to evaluate the relative effectiveness of various tip-plasty maneuvers while the lateral crura are in cephalic position compared with orthotopic position. They showed that the directionality of the change in projection, rotation, and nasal length produced by the various tip-plasty maneuvers is largely the same as that expected and observed clinically. They emphasized that the surgeon should consider the variable range in lateral crura orientation when choosing the rhinoplasty maneuvers.

Several other authors published techniques that address these malpositioned lateral crura, attempting to correct aesthetic defects and concurrently prevent functional problems. Gruber et al¹⁴ created an “island” of cephalic lateral crus that was slipped under the main body of the lateral crus to stiffen and straighten it. They suggest that the cephalic part of the lateral crus can act as a lateral crural strut to maintain the ala in a more caudal position. Similar to this, Murakami et al¹⁵ described the turn-in flap of the cephalic portion of the lateral crus as an alternative to cephalic resection of the alar cartilage. This technique reduces tip volume and reinforces the durability of the lateral crus, giving support to the external nasal valve and the desirable shape of the nasal tip.

To enhance tip rotation, other lateral crura repositioning techniques were published. Sazgar¹⁶ used the same cephalic turn-in flap in association with a lateral crural setback to treat the drooping nose. He suggests that this technique allows for an increase in nasal tip rotation in an incremental fashion, with preservation of nasal valve function. Zuliani and Silver¹⁷ used lower lateral to upper lateral cartilage suspension to correct nasal ptosis. They found that this technique corrects even the droopiest noses, while also providing a moderate degree of bulk and strength over the area of the external nasal valve.

The lateral crus has achieved tremendous respect among surgeons. We now have a better understanding of its importance and how to manage it to achieve stable and predictable aesthetic and functional outcomes. We believe that lots of new techniques will be published in the following years to address this topic.

Of course, many other trending topics are popping up every day in our meetings and journals. In different parts of the world there are new discussions on the present and the future of rhinoplasty. Apaydin¹⁸ and Rowe-Jones¹⁹ have given us an update of the rhinoplasty status in the Middle East and Europe, respectively. Simons²⁰ showed us a great perspective of the future of rhinoplasty in America and in the world. He commented on the future based on lessons of the past. As we all agree, he thinks rhinoplasty will continue to attract interest and evolve.

That is the same opinion of Dayan and Kanodia²¹ and Palma and Khodaei,²² who believe that we might be forgetting the techniques and lessons from the past and are not teaching our fellows and residents different approaches to rhinoplasty. In their articles, they defend that in the future a mixture of approaches and techniques tailored to patient needs will be more suitable than a single surgical approach.

As Larrabee²³ stated in this Editorial, rhinoplasty is the operation facial plastic surgeons like the most. It is the most intriguing, defying, and challenging operation. We all search for a consensus,²⁴ a perfect body of research and a final protocol that will guide us for all types of noses. At present, we do not have such consensus and maybe we will not have it soon. But we should keep looking forward to this. That is why we should always be a part of this social networking, which is our “rhinoplasty twitter.”