Abstract
Introduction
Rhinoplasty, both functional and cosmetic, is one of the most demanded surgical procedures worldwide. In Mexico, this procedure occupies the third place in the list of the surgeries most performed by specialists. 1 Against this background, the procedure itself represents one of the most complex and variable surgical techniques used, with results that depend both on the patient's own characteristics (age, sex, race, skin quality, previous surgical, or traumatic background) and on the surgical technique chosen by the surgeon. 2
In this regard, the changes seen in the nasal tip are one of the most complex and demanding parts of this type of intervention because, lacking a radiological research tool to assess the shape, size and integrity of the tip cartilages, the surgeon's skills can often be compared to those of a skilled sculptor. Among the multiple structures that make up the nose, the configuration of those that form the nasal tip (projection and rotation) symbolize the cornerstone that determines the quality of the result, which is directly proportional to patient satisfaction. 3
To achieve the objective, several techniques have been developed based on the placement of autologous cartilage tissue grafts, obtained mainly from three sources: quadrangular cartilage of the nasal septum, auricular concha and costal cartilage.
For this research, we have considered particularly interesting to compare one of the most used techniques in aesthetic surgery, such as the intercrural strut type, against a technique less used that pretends to guarantee a greater stability of the projection and rotation of the nasal tip; we are talking about the septal extension graft technique.
Both techniques are commonly used nowadays; however, intercrural strut grafts have shown moderate efficacy in maintaining projection and unifying the tip complex, as their effect is very limited. 4 In contrast, there is evidence for septal extension grafts to effectively control tip projection, rotation and shape by securing the nasal tip to the septum. 5 It is important to emphasize that the type of graft used will always depend on the specific characteristics of the underlying tip structures.
As we have mentioned, health professionals understand that long-term results are unpredictable due to several factors related to the patient and the technique used, which is why the present study seeks to approximate real patient satisfaction, thus preventing the need for subsequent corrective reinterventions.
Materials and Methods
An ambispective analytical cohort study was designed in two parallel groups, with patients scheduled for rhinoplasty by the plastic, aesthetic and reconstructive surgery service at a tertiary care centre in the period from October 2021 to December 2022, with approval folio CEI/567/2022. The sample size calculation was carried out using the formula for cohort studies, 6 with a difference in the expected satisfaction of 10%, considering a confidence level of 95%, a power of 50%, which gives a minimum of 20 patients to be included in each study group. In light of the observational cohort nature of this study, it is imperative to underscore that the selection of patients remained beyond the purview of investigator intervention. Patient inclusion was executed through consecutive case enrolment in alignment with interventions pre-determined by the plastic surgery service. The specific surgical technique employed was determined by the on-call surgeon overseeing the respective cases.
Male and female patients, scheduled for rhinoplasty for the first time or who had previously undergone a similar procedure, over 18 years of age, were recruited and gave their authorization by signing an informed consent form with their autographic signature. Patients who missed any follow-up visit were excluded, as well as those who suffered any trauma after surgery involving the nasal tip. Elimination was based on individuals who withdrew their consent to participate in the study. All the patients involved were given a detailed explanation of their participation in the present study.
Patients were assigned as follows: Group A (Rhinoplasty with septal extension graft) and Group B or control group (Intercrural strut type rhinoplasty), included consecutively in order of scheduling.
Before surgery, the first evaluation of the case report form was completed to obtain baseline efficacy measurements (nasolabial/labial angle), as well as clinical and sociodemographic characterization variables.
The surgical techniques to be considered in this study are similar in terms of the approach route, order of dissection of nasal structures, technique for taking the septal cartilage portion and closure of the incisions. Both can be performed under balanced general anaesthesia + local infiltration or moderate sedation and analgesia + local infiltration.
All data were processed statistically in SPSS version 25 in Spanish. To determine if there are differences before and after surgery, we used Student's t-test for dependent samples and analysis of variance of one factor.
To evaluate patient satisfaction, two validated instruments were applied before surgery: the NOSE (Nasal Obstruction Symptoms Evaluation) questionnaire 7 and the ROE (Rhinoplasty Outcome Evaluation Scale) questionnaire. 8
Results
A total of 53 patients were recruited: 22 operated with the intercrural strut technique and 31 in the group operated with the septal extension graft technique. The age of the first group was established between 22 and 33 years, while the age of the second group oscillated between 26 and 39 years, without finding statistically significant differences between them. The majority of the study subjects belonged to the female sex (Table 1).
General Characteristics of the Population.
The difference between medians was determined by the Mann-Whitney U-test.
The difference between percentages was determined by the chi-square test.
The most frequent consideration of previous importance (antecedent) for rhinoplasty was aesthetic discomfort (58.5%) (Figure 1).
Graph of frequency of reason for rhinoplasty.
Regarding the source of the cartilage, in the case of the intercrural strut, all were taken from the septum, while, for the patients with septal extension grafting, cartilage from the septum was used in 87.1% and from the rib in 12.9% (Table 2). Surgical time was statistically lower in the intercrural strut group compared to that used in the septal extension grafting technique.
Clinical Characteristics of Patients Undergoing Rinoplasty. Differences Between Techniques.
The difference between percentages was calculated with the Chi-square test.
The difference between means was determined with the Student's t-test.
A statistical exercise was performed to determine if any of the antecedents identified in the patients (nasal obstruction, trauma or rhinomodeling) made any difference in the surgical time. It was identified that the median surgical time was lower in the obstruction group (median 143 min; q25-275, 121-171 min) and the longest surgical time was recorded in the group with a history of rhinomodeling (median 171 min; 148-190 min), these differences were not statistically significant (P = 0.155) (Figure 2).
Graph of evaluation of the surgical time based on the important background of the studied population.
In all cases, it was observed that, at the initial evaluation, the nasolabial angle in both men and women was less than 90° (Table 3), with no statistically significant differences between the groups. At the end of surgery, immediately after surgery, an increase in the nasolabial angle was identified in both groups, which was very similar between the techniques used. At 6 months after surgery, we observed that the nasolabial angle decreased slightly in all cases, although this decrease in the nasolabial angle was greater in the intercrural post group (100° to 97°, in women and 98° to 91°, in men) compared to the septal extension group (100° to 99°, in women and 96° to 94°, in men), these differences did not prove to be statistically significant between groups (Table 3).
Differences Between the Nasolabial Angle due to Time, Gender and Surgical Technique.
The difference between means was determined using analysis of variance (ANOVA); the Bonferroni correction indicates that the difference is established by the pre-surgical versus post-surgical groups at 6 months.
All values correspond to a p-value of less than 0.001.
Figures 3 and 4 show the differences in the nasolabial angle evaluated at 6 months after surgery between each technique; Figure 3 shows the results in the female sex (P = 0.076) and Figure 4 in the male sex (P = 0.236).
Graph of evaluation of the nasolabial angle, after 6 months of the rhinoplasty in female gender.
Graph of evaluation of the nasolabial angle, after 6 months of the rhinoplasty in male gender.
It is also observed, in both groups, that the nasolabial angle is within the ideal level described by Katira et al, 9 without statistical differences between groups for the female sex (Figure 5a, b, c and d), although in the male group, where the nasolabial angle, in the septal extension graft technique, is greater in relation to the intercrural strut technique (P = 0.236). (Figure 6a, b, c, and d)
(a) Front projection before surgery, (b) lateral projection before surgery, (c) basal projection before surgery, (d) front projection after surgery, (e) lateral projection after surgery and (f) basal projection after surgery. Septal extension graft technique.
(a) Front projection before surgery, (b) lateral projection before surgery, (c) basal projection before surgery, (d) front projection after surgery, (e) lateral projection after surgery and (f) basal projection before surgery. Intercrural strut technique.
Two main parameters were used to evaluate the effectiveness of the technique: first, the final nasolabial angle, taking as successful the intervention that achieved an angle of 90° to 95° in men and 95° to 100° in women (Figure 7), and second, the level of satisfaction expressed by each of the study subjects at the final visit (Figure 8).
Graph of success evaluation of the intervention according to the nasolabial angle achieved at 6 months.
Graph of final satisfaction level among patients who underwent rhinoplasty, evaluation at 6 Months.
Regarding the first indicator, the intercrural strut technique obtained a 72.7% success rate while the septal extension graft technique obtained a 67.7% success rate; these differences are not statistically significant (P = 0.469).
However, in the satisfaction survey, only 59.1% of the subjects who underwent surgery with the intercrural strut technique expressed satisfaction with the result, in contrast to those who underwent surgery with the septal extension graft technique, where 100% of the patients reported being satisfied with the result (P = 0.000).
Discussion
Plastic surgery is the most artistic part of medicine. The conception and perception of a beautiful result will be the product of the balance between knowledge, technical skill, the surgeon's experience and the patient's expectations, as well as the patient's basic physical characteristics. 2 One of the most frequently performed techniques is rhinoplasty, considered by the American Association of Plastic Surgery as the fourth most frequently performed procedure by plastic surgeons. According to the latest published results of the International Society of Aesthetic Plastic Surgery 2021 global survey, 995 149 rhinoplasties were performed worldwide, an increase of 16.7% over the previous year's figures. 1
Septal extension grafting is a method of controlling nasal tip projection, shape and rotation. Since its introduction, SEG has been widely used as the primary choice for correcting a small nose and iatrogenic nasal foreshortening, especially in Asian rhinoplasty. 10
It has been reported that, with age, the appearance of the nose can be greatly affected, altering the quality of the cartilage, generating a possible muscular atrophy, affecting the thickness and elasticity of the skin, which can result in a much longer nose with a very drooping tip. 11 In our study, the overall median age of the patients was between 22 and 39 years. Although the age of the group operated with the septal extension graft technique was higher (P = 0.009), the results achieved, as well as the patient satisfaction identified in the final evaluation, were better compared to the intercrural strut technique.
In terms of obtaining the ideal angles, the projection of the nasal tip, as well as its position regarding the dorsum and upper lip, frequently differ in the postoperative period after rhinoplasty. This variation depends on multiple factors conditioned by the surgical technique as well as individual factors.
According to Ortiz Monasterio, the features of the ‘Hispanic face’ depend on the percentage of features of each ethnicity in each individual. The facial skeleton is characterized by a large bizygomatic diameter, resulting in prominent cheekbones. A large bigonial diameter may also be present. The mouth projects anteriorly, resulting in an acute columellar-labial angle. 12 Today's ideal nose is straight with a well-defined tip, covered with thin skin under which the osteocartilaginous support protrudes, giving an impression of angularity. The radix should be located at the level of the upper edge of the tarsal cartilage of the upper eyelid, and the nasolabial angle should be between 90° and 100°. In our study, the final evaluation revealed an angle of 99 ± 3 in the septal extension graft group and 97 ± 3 in the intercrural strut group, both of which yielded satisfactory results based on the clinical metrics’ parameters. However, the satisfaction outcomes favoured the septal extension graft technique over the intercrural strut graft technique. This preference may stem from the clinical significance of the achieved angle, despite the lack of statistical significance. Furthermore, the absence of statistical significance might be attributed to a type two error. Therefore, future research should aim to augment the sample size to accentuate the differences between the two techniques.
Floris V et al discuss the importance of ‘normality’ in the human being; in other words, Floris states that the human being likes normal noses. The aesthetic ideal of the nose eludes a clear definition. Average features may be an important determinant of ideal nasal shape: research has shown that being average plays an important role in human perception of facial attractiveness. 13 To reach these conclusions, Floris V et al obtained photographic series of the faces of 80 Caucasian female volunteers aged 25 to 40 years. A mathematically averaged composite image was created using the top 40 female volunteers. Forty-one members of a panel were recruited to judge the attractiveness of the nose of each original and composite image, using a 5-point Likert scale, ranging from 1 (very ugly) to 5 (very pretty). The deviation of nasal shape from the mean was calculated by principal component analysis of standardized nasal landmarks. Analysing this information, Floris V et al determined that, in Caucasian women, a mathematically averaged nose is an attractive nose. Furthermore, the more the shape of a nose resembles the average shape, the more attractive it is considered. Calculation of the deviation from the mean, before and after rhinoplasty, can help to objectively measure the aesthetic result of rhinoplasty.
Serap Koyabsi, on the other hand, clarifies the existing disparities between the results that the surgeon pursues and the patient's appreciation, in a study carried out on 53 rhinoplasty patients where the main objective was to elucidate the factors that influence patient satisfaction. From that study, patient satisfaction was shown to be correlated with functional outcome, but not with surgeon satisfaction. 3
Study Limitations
One constraint inherent in observational studies is the researcher's inability to manage potential biases, such as the randomization of intervention groups or the oversight of interventions. Additionally, we acknowledged that another constraint in this study pertained to the sample size. For future research, it is advisable to conduct a randomized clinical trial with a sample size that minimizes the risk of type 2 errors, ensuring a robust demonstration of differences between techniques.
Conclusions
The results obtained indicate that the patients who undergo rhinoplasty are more frequently women, between the second and third decade of life, presenting aesthetic nonconformity as the most relevant antecedent. Rhinomodeling, on the other hand, is presented as the most relevant antecedent that influenced the surgical time employed. At the end of the project, a final modification of the nasolabial angle was achieved in all patients. Finally, both the intercrural strut technique and the septal extension graft technique showed a similar result in relation to the nasolabial angle achieved; however, the second technique was superior in terms of patient satisfaction.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical Statement
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the ethics and research committee of the Valentín Gómez Farías Hospital with registration number CEI/567/2022.
Informed Consent
A signed informed consent was obtained. Likewise, we have the authorization to use and present the data obtained, as well as the photographs exhibited in this article.
