Master Techniques in Rhinoplasty (2011) - Free ebook download as PDF File (.pdf), Text File (.txt) or read book online for free. Surgical technique in rhinoplasty. Daniel, Rod Rohrich, Bahman Guyuron, Tony Wolf, and. CHAPTER ONE A History of. Senior author (J.P.G.) devised a technique in which the larger costal. The best rhinoplasty candidate can describe his or her desired results, and has reasonable goals. Abbyy Finereader 12 Serial Number Cracking - The Supreme Philosophy Of Man The Laws Of Life Pdf Printer - Visual. Be A Dividend Millionaire Pdf - Eidos Championship Manager 03 04 Patch - Bahman Guyuron Rhinoplasty Pdf File.

• Dr Bahman Guyuron Migraine Surgery
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• Greg Guyuron

Introduction

Bahman Guyuron is recognized throughout the world for his superb lectures and expertise in rhinoplasty surgery. Every live presentation is insightful, beautifully illustrated, and often includes original techniques that are validated by impressive clinical results, usually with long-term follow-up. For many years, his colleagues have awaited a publication summarizing his personal philosophy and surgical techniques developed during the past 31 years. Rhinoplasty is that text.

Rhinoplasty is divided into 21 chapters, each clearly structured and ending with a “textbox” that summarizes the essential points. Each chapter begins with an outline of the contents both for the text and the specific video content, which means that information is easily found. Next, there is a list of 10 to 20 basic principles followed by a description of each technical step, with a list of the different surgical options.

Strengths

Instead of the more common inclusion of DVDs, this book is supplemented by an Internet-based series of detailed, educational surgical videos and case study animations that complement the text, along with illustrations. Together, these aspects render the principles of the surgical procedures quite clear. In the text, high-magnification, detailed clinical photos demonstrate Dr Guyuron's excellent documentation, with consistent pre- and postoperative positioning. The clinical photo legends often contain a precise list of the surgical steps, which makes it easy to follow and understand each procedure. Often, Dr Guyuron has included treatment algorithms, which are perfect learning tools that did not exist when I began my plastic surgery training.

At the beginning of the text, a very useful “Functional Nose Information Sheet” is presented, which emphasizes the principle that form and function are intrinsic to nasal surgery. Younger surgeons will find the detailed cephalometric examination very helpful in revealing even minor facial asymmetries, of which patients often are unaware. The chapter entitled “Dynamics of Rhinoplasty” is very important, as it emphasizes that the long-term result, rather than the short-term outcome, is the relevant criterion for measuring success. This fundamental principle is further validated in the “Rhinoplasty and Time Element” chapter, where the effects of postoperative swelling, gravity, and aging on the nose are discussed.

For surgeons seeking to improve their rhinoplasty results, there are numerous chapters addressing fundamental subjects (including osteotomies, tip sutures, optimal tip projection, alar base surgery, and alar rim deformities) that require both judicious preoperative decision making and intraoperative judgment. Of interest to experienced rhinoplasty surgeons, this book contains topics that are rarely discussed in other texts, including elongating the short nose, controlling nostril size, treating cleft lip nose deformity, and addressing the cocaine nose. Dr Guyuron reveals his personal approach and surgical techniques for each of these difficult conditions, validated with superb results.

The last chapter, about rhinogenic migraine headaches, is a specific highlight. It demonstrates the unique competence of Dr Guyuron. Most surgeons are not aware that migraine attacks are often triggered from within the nose, and the topic is rarely covered in surgical textbooks. The entire medical community is deeply indebted to Dr Guyuron for his advancement and dissemination of knowledge in this field.

Weaknesses

The “best” approach to rhinoplasty is a subject of much debate in our specialty. It is my personal opinion that Dr Guyuron's concept of correcting severe septal deformities—which include the s-shaped, anteroposterior, and cephalocaudal deformities—is not far-ranging enough and thus may fail in some cases. Specifically, scoring alone or in combination with spreader grafts does not guarantee long-term stability. Obviously, he is referring to his personal experience and he does not perform extracorporeal procedures, which are a proven alternative in such difficult cases. Also, the recommended use of prefabricated templates for planning rhinoplasty (found in the cephalometric examination section) seems a bit difficult. Readers should consider the information provided in this book within the context of their own experience and weigh the surgical options carefully.

Summary

This book is a “must” for every physician performing rhinoplasty surgery and is of value for surgeons of all levels of expertise. As Dr Guyuron says in the Preface, all of us should learn something new every day that improves our results. This book is a valuable resource that can give any reader many new ideas and proven techniques to better treat his or her patients. I enjoyed reading this beautifully written book with its exciting, Internet-based educational tools.

Rating: 5

To purchase this book, visit: http://store.elsevier.com/Rhinoplasty/Bahman-Guyuron/isbn-9781416037514/

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Abstract

Current literature provides little information about the impact of environmental exposures on the severity of acquired blepharoptosis.

The authors assessed environmental factors that may contribute to eyelid ptosis in a population of identical twins.

Photographs of 286 sets of twins from a prospectively collected database from 2008 to 2010 were reviewed. The authors identified 96 sets of identical twins (192 individual persons) who had differing severity of ptosis. Digital photographs were analyzed, and the degree of ptosis was measured in each eye of every subject. The external factors that could potentially contribute to blepharoptosis were taken into consideration. The authors then assessed the correlations of 9 different environmental risk factors with ptosis. Generalized linear mixed model were constructed to determine the associations of ptosis measurements with environmental risk factors obtained from the subject survey database.

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The mean level of upper eyelid ptosis in the study population was 1.1 mm. The mean difference in ptosis between twins was 0.5 mm. Wearing contact lenses, either hard or soft, was significantly associated with ptosis. The mean ptosis measurement among twins who did not wear contact lenses was 1.0 mm; for those who wore soft contact lenses, the mean was 1.41 mm, and for those who wore hard contact lenses, the mean was 1.84 mm.

Acquired ptosis is not linked to body mass index, smoking behavior, sun exposure, alcohol use, work stress, or sleep. Wearing either hard or soft lenses was associated with an increased risk of ptosis. These influences are independent of genetic predisposition.

3 Diagnostic

Periorbital rejuvenation has long been a focus of aesthetic surgery. Common problems of the aging eye includes brow ptosis, excess upper eyelid skin, fat protrusion, and eyelid ptosis.^1,2 When an individual is in a resting straight gaze, the normal anatomic position of the upper eyelid margin should be 1 mm below the upper edge of the limbus. When the eyelid falls below this point, it is considered ptotic.¹ Eyelid ptosis creates a tired and aged appearance. When ptosis is severe, it can create a mechanical obstruction to the field of vision. Treatment for most cases of ptosis is surgical, but it is important to establish the cause before undertaking any intervention.

Ptosis has myriad listed causes that must be considered before any operative correction. These causes can be divided into 6 different subtypes: congenital (levator maldevelopment), myogenic, neurogenic, aponeurotic, mechanical, and pseudoptosic.³ Myogenic ptosis is the result of diseases such as myasthenia gravis and chronic progressive ophthalmoplegia. Causes of neurogenic ptosis include cerebral vascular accidents and multiple sclerosis. Mechanical ptosis can be related to tumors, cysts, and enlarged lacrimal glands. Severe facial trauma to the orbit or periocular tissues can also lead to ptosis.^4,5 Pseudoptosis can be caused by enophthalmos secondary to facial trauma or severe dermatochalasia that overlaps the upper eyelid margin. Elimination of the above causes of acquired ptosis or pseudoptosis leads one to the diagnosis of involutional or aponeurotic ptosis. Aponeurotic ptosis is presumed to result from the disinsertion or thinning of the levator muscle aponeurosis that has been considered part of the natural aging process. Microtraumatic influences, such as wearing contact lenses, eye rubbing, and having cataract surgery, have all been implicated as potential causes of aponeurotic ptosis, although no study has accounted for the influence of genetic predisposition.^6-8 Environmental factors, such as sun exposure, alcohol consumption, and smoking behavior, have been shown to affect signs of facial aging.^9,10 Currently, the literature is devoid of information about the influence of these environmental factors on ptosis. We designed a study to assess the influence of environmental factors on ptosis by analyzing and reviewing the histories of identical twins with varying severity of blepharoptosis.

METHODS

We obtained institutional review board approval from University Hospitals, Case Medical Center, Cleveland, Ohio, to evaluate which environmental factors affect signs of aging in twins in a retrospective cohort study. We analyzed photographs and social/medical history questionnaires from a database that contained information collected at the annual Twins Days Festival in Twinsburg, Ohio, from 2008 to 2010. The questionnaires provided data on contact lens use, alcohol consumption, sun exposure, smoking behavior, work stress rating, and sleep habits (Supplementary Material). A full series of facial photographs was taken of each subject at the time of the survey. Photographs were taken with a Nikon SRL camera (Tokyo, Japan) using a Nikon ring flash from an approximate distance of 4 feet using a 16 f-stop, 1/60 shutter speed, ISO 100 with manual focus. The camera was calibrated and white balanced on the spot to suit the lighting conditions that day. Twin sets had photographs taken only minutes apart and were exposed to the same relative environmental lighting factors. All subjects provided informed consent.

Photographs of 286 twin sets were screened by 2 independent reviewers to identify twins with different levels of ptosis noticeable on frontal view. These frontal-view photographs were compared with photographs of the subjects smiling to evaluate change in brow position and with lateral photographs to evaluate overall globe position. Twins sets in which one twin had a significantly different brow position when smiling compared with resting were excluded to eliminate the impact of brow compensation on the ptosis measurement. Twins with evidence of a significant positive vector or enophthalmos were excluded to eliminate the effect that globe position may have on eyelid position. Additionally, subjects with a history of congenital ptosis, neurogenic disorders, ocular disorders, or past ocular surgery were excluded.

Photographs of patients who met the above criteria underwent detailed evaluation. The typical limbus is 11 mm in diameter. In a patient without ptosis, the upper eyelid will overlap the upper edge of the limbus by 1 mm. Ptosis was measured by first assessing the digital photograph pixel count from the midpupil to the edge of the lower limbus. This pixel count was set to 5.5 mm. If the lower limbus was not visible, the contralateral eye was used for both eyes. A second measurement was taken from the midpupil to the upper eyelid margin. The distance was converted to millimeters based on a ratio comparison to the previously defined midpupil–to–lower limbus distance. Eyes with distances less than 4.5 mm were defined as ptotic, with the severity measured in millimeters (Figure 1). The mean of both measurements was used for statistical analysis.

This photograph of a 39-year-old woman was analyzed to measure. The blue horizontal line represents the midpupil axis. The red line is drawn from the midpupil to the inferior edge of the limbus. This distance was set at 5.5 mm. The green line shows the distance from midpupil to the upper eyelid margin. Ptosis was measured by comparing the green line to the red line and subtracting this from 4.5 mm.

This photograph of a 39-year-old woman was analyzed to measure. The blue horizontal line represents the midpupil axis. The red line is drawn from the midpupil to the inferior edge of the limbus. This distance was set at 5.5 mm. The green line shows the distance from midpupil to the upper eyelid margin. Ptosis was measured by comparing the green line to the red line and subtracting this from 4.5 mm.

Statistical analyses were performed using Microsoft Excel 2010 (Microsoft, Redmond, WA). Environmental factors were correlated with trends in ptosis using a univariate generalized linear mixed model in SAS, version 9.3 (SAS Institute, Inc., Cary, NC). Significance was defined at a level of P < .05.

Dr Bahman Guyuron Migraine Surgery

RESULTS

We identified a total of 96 twin sets (192 subjects) who met the inclusion criteria and had appreciably different levels of ptosis (Figure 2). The subjects included 44 men and 148 women who had a mean age of 48.5 years (range, 18-82 years). The mean body mass index (weight in kilograms divided by height in meters squared) was 26.4 (range, 16.4-52.7). There were 70 patients who reported a history of smoking (mean, 18.7 pack-years; range, 1-66 pack-years). Ninety-nine patients who reported drinking alcohol, with a mean consumption of 2.4 drinks per week. The mean calculated sun score was 117.9.

These 39-year-old female identical twins had differing levels of ptosis. These patients were visually identified from a twins database and had individual ptosis measured in each eye. (A) This twin did not wear contact lenses. (B) This twin did wear contact lenses.

These 39-year-old female identical twins had differing levels of ptosis. These patients were visually identified from a twins database and had individual ptosis measured in each eye. (A) This twin did not wear contact lenses. (B) This twin did wear contact lenses.

The mean ptosis measurement was 1.1 mm. The distribution of ptosis severity demonstrated 89 subjects with 0-1 mm of ptosis, 73 subjects with 1-2 mm of ptosis, and 27 subjects with 2-3 mm of ptosis. Three subjects had greater than 3 mm of ptosis. The mean differential ptosis between the more and less ptotic twin was 0.5 mm. There were 59 sets of twins that had difference in ptosis of <1 mm, 35 sets who had a difference of 1-2 mm, and 2 sets who had difference of >2 mm (Table 1).

Blepharoptosis Data

DISCUSSION

Blepharoptosis, which can result in stigma as people age, can cause both functional and cosmetic changes to the eyes. Ptosis is often recognized in patients who are seeking aesthetic blepharoplasty, and it is important to correct the problem during that procedure; otherwise, preoperative ptosis will be more apparent postoperatively. Surgical interventions for the treatment of ptosis have been well described and include levator suspension and the Fasanella-Servat, the Putterman, and the modified Putterman procedures.^11-13 Ptosis can stem from a variety of causes, and before surgical intervention it is important to rule out all systemic or medical causes of acquired ptosis. Elimination of all other causes during a work-up for ptosis leaves the surgeon with the diagnosis of aponeurotic ptosis. Unless there is a specific, identifiable traumatic event, the ptosis is attributed to attenuation of the levator aponeurosis. Attenuation of the levator has been considered part of the natural aging process, although in multiple studies, researchers found ptosis in younger individuals that was not attributed to any commonly identifiable cause or traumatic event.^6,7,14 We eliminated subjects who had undergone previous eye or eyelid surgery because these types of surgeries could have a significant impact on ptosis and would introduce too much variability into the present study. To our knowledge, this was the first study to broadly evaluate environmental factors known to impact facial aging specifically to determine an influence on ptosis.^9,10,15,16

Ptosis can be visualized and measured on an anterior to posterior view photograph taken with subjects in repose, but care must be taken to eliminate other influencing factors. All subjects with potential medical causes, neurological causes, and previous ocular trauma or surgery were eliminated from the study. Additionally, careful analysis of multiple photographs was used to identify and exclude subjects with evidence of enophthalmos, significant dermatochalasia obstructing the upper eyelid, eyebrow ptosis, or ptosis compensation with activation of the frontalis. This allowed us to account for most factors that could potentially influence ptosis in our evaluation. Excluding all other causes of ptosis and accurately assessing the severity of ptosis were of paramount importance to the analysis.

This study is the first to demonstrate that sleep duration, sun exposure, alcohol consumption, work stress, and smoking do not significantly impact acquired ptosis after controlling for genetic influence. One could hypothesize that lack of sleep and irritation of the eyes that leads to rubbing could result in stretching of the levators of the upper eyelid. This would have the potential to induce ptosis over time. However, in the present study, we found no significant link between these factors and eyelid ptosis.

Contact lens wear has previously been implicated in acquired ptosis. In 1891, Epstein and Putterman⁷ showed evidence of ptosis in a case series of 5 contact lens wearers. Kersten et al¹⁴ and van den Bosch and Lemij¹⁷ found rates of eyelid ptosis in hard contact lens wears that ranged from 23% to 43%. In a study of 46 subjects and an age-matched control group, van den Bosch and Lemij found a mean of 0.5 mm more ptosis with contact lens wearers. Bleyen et al¹⁸ and Reddy et al¹⁹ have also shown a association between ptosis and wearing soft contact lenses. Very recently, Kitazawa²⁰ published a case-control study in a Japanese population and found a higher prevalence of contact use among patients with ptosis. The present study further validates the findings of those authors with an objective reproducible method that establishes the significant impact of contact lens use on ptosis.

The exact mechanism of contact lens–induced ptosis has not been fully elucidated. It is theorized that pulling of the upper eyelid for contact placement and removal may lead to chronic microtrauma, laxity, and discontinuity of the levator. Watanbe et al²¹ studied biopsies from 30 subjects with ptosis, 15 of whom wore contact lenses and 15 of whom did not. They found that wearing contact lenses use associated with fibrosis within Mueller's muscle, whereas age-related ptosis showed discontinuity within the muscle. They postulated that fibrosis within Mueller's muscle leads to decreased contractility.

This study has several identifiable advantages over the previously reported literature. Directly comparing identical twins creates the ideal case-control comparison. Our study with 192 subjects, 47 of whom wore contact lenses, represents one of the largest population-based studies of acquired eyelid ptosis. Although multiple studies have specifically focused on the impact of wearing contact lenses, the present study was designed with a broader focus in an attempt to determine whether any other environmental factors contribute to ptosis. Additionally, in most studies, patients are categorized as either having or not having ptosis. We measured the amount of ptosis and determined the associations of those measurements with various environmental factors. Not all acquired ptosis between twins can be explained by contact lens use. In our population, the mean ptosis measurement was 1.1 mm. Approximately 15.2% of subjects had a measurement >2 mm. There are likely other unidentified factors that play a role in the development of ptosis. Although we tested 9 different environmental factors that were hypothesized to be involved, the present study is not comprehensive. The mean age of our population was 48.5 years, and it is possible that environmental factors, such as sun exposure, smoking, lack of sleep, and alcohol consumption, might take several years to cause significant changes in ptosis severity, which would therefore be apparent in older subjects. Murchison et al²² commented that different ethnicities have variability in the normative margin reflex distance (MRD1). In their study population, white subjects had a mean of MRD1 of 5.1 mm, whereas black subjects had a mean MRD1 of 4.5 mm. We did not adjust for ethnicity; however, the difference in ptosis measurements between twins would not have changed regardless of the normative values used to measure absolute ptosis. Most of our subjects were white population, and using above normative values would have increased the overall amount of ptosis reported.

In the senior author's practice, many patients with detectable ptosis have had no identifiable cause other than wearing contact lenses. Acquired ptosis of this kind is highly responsive to surgical treatment, and the Guyuron and Davies²³ have shown the value of the modified Putterman technique.

The primary disadvantage to the present study is the reliance on data from photographs. Life-sized photos were not taken, but a detailed analysis process allowed us to make a ratio-based comparison and calculate ptosis severity. In the repose position, the body will do many things to compensate for ptosis, including activating the frontalis and raising the eyebrows. Hering's law of equal innervation may also mask the presence and severity of ptosis. A person with unilateral ptosis that is visible in repose may have suffered from bilateral ptosis that was masked by the increased work of the eyelid elevators. Standardized photographs have been used to evaluate and measure ptosis in several studies.^11,20 Lastly, more information about the length of contact lens use, reason for contact lens use, and specific visual correction in each eye might have provided more insight into the characterization of contact lens–induced ptosis.

CONCLUSIONS

Wearing either hard or soft contact lenses was the only environmental factor that we found to be associated with acquired blepharoptosis. No others factors were identified as having a significant impact. The actual mechanism of contact lens–induced ptosis is still poorly understood, although recurrent traction on the eyelid during placement and removal likely leads to changes in the levator aponeurosis and Mueller's muscle. This type of ptosis is amenable to correction using the modified Putterman technique.

Supplementary Material

This articles contains supplementary material located online at www.aestheticsurgeryjournal.com.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

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Supplementary data