When a flap's blood supply depends on a septal perforator, this flap is called a septal perforator flap. [ 1 ]


Due to confusion about the definition and nomenclature of perforator flaps, a consensus meeting was held in Gent, Belgium, on September 29, 2001. Regarding the nomenclature of these flaps, the authors stated the following:


" A perforator flap should be named after the nutrient artery or vessels and not after the underlying muscle. If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap should be based on its anatomical region or muscle. "  [ 1 ]


This so-called 'gent consensus' was needed because the lack of definitions and standard rules on terminology created confusion in communication between surgeons. [ 1 ]


Flaps can be transferred either free or pedicled. Regarding the nomenclature, one is free to add the type of transfer to the name of a flap. [ 1 ]


A free flap is defined as a tissue mass that has been taken away from the original site to be used in tissue transplantation. [ 11 ]  When a surgeon uses a free flap, the blood supply is cut and the pedicle reattached to recipient vessels, performing a microsurgical anastomosis. [ 12 ]


For more information on free flaps, see also  free flap .


Pedicled perforator flaps can be transferred either by translation or rotation. These two types will be discussed separately below. [ citation needed ]


This type of transfer is also called "advancement".The surgeon disconnects the flap from the body, except for the perforators. After this procedure, the flap is advanced into the defect. [ 13 ]


The subgroup of pedicled perforator flaps, transferred in the defect by rotation is the so-called "propeller flap".
Confusion concerning definition, nomenclature and classification of propeller flaps led to a consensus meeting similar to the "gent consensus meeting”. The consensus that was reached is named "the tokyo consensus". This article stipulates the definitions of propeller flaps and especially perforator propeller flaps. [ 14 ]  The definition that was set up is cited below:


"A propeller flap can be defined as an “island flap that reaches the recipient site through an axial rotation.” Every skin island flap can become a propeller flap. However, island flaps that reach the recipient site through an advancement movement and flaps that move through a rotation but are not completely islanded are excluded from this definition. "   [ 14 ]


Regarding the classification of propeller flaps, the surgeon should specify several aspects of these flaps. It is important that the type of nourishing pedicle, the degree of skin island rotation and, when possible, the artery of origin of the perforator vessel are mentioned. [ 14 ]


The perforator propeller flap is the propeller flap which is used most commonly. It is a perforator flap with a skin island, which is separated in a larger and smaller paddle by the nourishing perforator. These paddles can rotate around the perforator (pedicle), for as many degrees as the anatomical situation requires (90-180 degrees). This flap looks like a propeller when the two paddles are not too different in size. [ 14 ]


Trauma, oncological treatments or pressure ulcers can result in severe tissue defects. Those defects can be covered and closed by using autologe tissue transposition. The fact that each tissue defect is different makes it necessary for each tissue defect to be assessed individually. The choice of the type of tissue transposition depends on the location, nature, extent and status of the deformity. [ 15 ]


However, the health of the patient and possible contra-indications play an important role as well. Due to the development and improvement of cutaneous, myocutanous and fasciocutaneous tissue transpositions plastic surgeons are able to successfully restore the defect to its original shape. [ 15 ]  Nevertheless, functional recovery is not guaranteed in all patients. For the optimal renewal of shape and function, a suitable flap can be chosen to reconstruct the defect. In the case of using a so-called perforator flap, a reliable vascularization and the possibility of sensory (re) innervation can be combined with less donor-site morbidity and limited loss of function in the donor area. [ 15 ]


The surgical removal of both benign and  malignant tumors  often result in serious tissue defects involving not only soft tissue but also parts of the bone. [ 16 ]  Depending on the location aneligible flap can be selected. In breast reconstruction for example, perforator flaps have raised the standard by replacing like with like. [ 17 ]  When taking  breast reconstruction  into consideration, several surgical options are available to achieve lasting natural results with decreased donor-site deformities. The broad option of donor-sites makes practically all patients candidates for autogenous perforator flap reconstruction. [ 17 ]  Some examples include, Deep inferior epigastric perforator flap ( DIEP flap ), superior gluteal (SGAP) flaps and inferior gluteal (IGAP) flaps. [ citation needed ]


Treatment of tissue defects caused after a trauma present major surgical challenges especially those of the upper and lower limb, due to the fact that they often not only cause damage to the skin but also to bones, muscles/ tendons , vessels and/or  nerves . [ 18 ]


If there is extensive destruction a  fasciotomy  is needed, therefore it is generally accepted that the best way to cover these types of tissue defects is a  free flap transplantation. [ 18 ]
 [ 19 ] [ 20 ]  Nevertheless, over the years surgeons have tried to increase the application of perforator flaps, due to their proven advantages. In the case of upper limb surgery, perforator flaps are successfully used in minor and major soft tissue defects provided that in major defects the flap is precisely planed. [ 18 ] [ 21 ]


In lower limb surgery there have also been reports of successful use of perforator flaps. [ 22 ] [ 23 ]


Twenty three years after the first perforator flap was described by Koshima and Soeda, [ 3 ]  there has been a significant step towards covering tissue defects by using only cutaneous tissue. [ 24 ]  Results obtained from studies done on musculocutaneous and septocutaneous perforator flaps have shown a reduction of donor-site morbidity to a minimum  [ 24 ] [ 25 ]  due to refined perforator flap techniques that allow collection of tissue without scarifying the underlying muscles. [ 24 ] [ 26 ]  As a matter of fact, preventing damage to the underlying muscle including its innervation, has led to less cases of abdominal  hernia , [ 26 ]  the absence of postoperative muscle atrophy  [ 27 ]  and a better vascularised and functioning donor muscle. [ 17 ]  Furthermore, patients have shown decreased postoperative pain and accelerated rehabilitation  [ 17 ] [ 25 ]  Nevertheless, there will always be a chance that the displaced tissue partially or completely dies considering the fact that the perfusion of  the flap is difficult to assess intraoperatively. [ 28 ]  Furthermore, when using this technique additional scars are made. Thus considering the complexity and length of this procedure microsurgical expertise is required and patients need to undergo a longer period of anesthetics that of course could result in increased risk factors. [ citation needed ]  Microsurgical expertise in perforator flap dissection can be acquired using perforator flap training models in living tissue. [ 29 ]


Indications :


Contraindications : [ 30 ] [ 31 ]


Associated with the patient:


Any condition that probably increases the risk of intraoperative or postoperative complications: [ 32 ]


By inducing  thrombogenic  state through  vasoconstriction  of the microvasculature, tobacco influences  blood flow , wound healing and the survival of pedicled flaps. On the contrary there is no published data on damaging effects of cigarette smoke on free tissue transfer. [ 33 ] [ 34 ]


Permanent makeup , also known as  permanent cosmetics ,  derma-pigmentation ,  micro-pigmentation ,  semi-permanent makeup  and  cosmetic tattooing , [ 1 ]  is a  cosmetic  technique which employs  tattooing  techniques to replicate the appearance of traditional  makeup . By implanting pigments into the  dermis , long-lasting designs are created such as  eye liner , eyebrows, and lip color. This procedure appeals to a diverse range of people; from those who want to make their daily routines more simple to individuals with  medical conditions . By eliminating the need to apply traditional makeup regularly, permanent makeup has become a very convenient and effective solution. More than an aesthetic technique, permanent makeup plays a crucial role in procedures of  reconstructive  type.


Permanent makeup has evolved from a tattooing practice to a more widely accepted, sophisticated procedure. It has become very popular, not only because of its cosmetic advantages but also for its convenience and enhancing quality of life. However, it does come with risks. Complications include  allergic reactions , migration of pigment, or even  infections , which underscore the importance of high-quality materials and skilled technicians


As permanent makeup gradually gained popularity, its safety concerns, regulatory challenges, and options for removal also attracted attention. Whether selected for restoration, convenience, or other reasons, this technique represents a blend of science, personal care, and aesthetics.


The most widely documented first use of permanent makeup treatment was done by the famous U.K. tattoo artist  Sutherland MacDonald . [ 2 ]  In 1902, at his parlor, #76 Jermyn Str., London, he "perfected his method of giving a lasting complexion of the utmost delicacy to pale cheeks." [ 3 ]  The tattooist  George Burchett , a major developer of the technique in the 1930s, described in his memoirs how beauty salons tattooed many women without their knowledge, offering it as a "complexion treatment... of injecting vegetable dyes under the top layer of the skin." [ 4 ] [ 5 ]  Permanent makeup became much more commonplace beginning in the 1970s and 1980s, when it was used to address hair and pigment loss due to disease, [ 6 ]  and now it is considered very normal. [ 7 ]


One may opt for permanent makeup for a plethora of reasons. For some, it can replace the daily application of traditional  makeup  products in favor of a more lasting solution. [ 8 ]  This is especially useful for older women whose eyesight might not be good enough to apply the makeup [ 9 ]  or who have degenerative diseases such as  Parkinson's  which severely limits motor ability. [ 6 ]  Others may have the procedure to restore color areas that have lost it due to disease. This includes micro pigmentation for people with  alopecia  and  vitiligo , and areola recoloring for  breast cancer  patients. Permanent makeup is also a common practice in some African cultures, who use certain tattoos to signify status. [ 7 ] [ 10 ]


Some of the most common permanent makeup procedures for Americans are eyebrows and eyeliner. However, other types of permanent makeup include:


As with any  tattoo , there are cases of undesired results, whether that be from the initial application or degradation over time. [ 11 ]  Since this is the case, patients should come in with realistic expectations of what the  makeup  will look like. [ 9 ]  One factor that heavily influences how the cosmetic tattoo looks is  skin tone . This is because the same color may look different on different skin tones. Another factor that affects the appearance of these tattoos is sun exposure and lifestyle, which can fade the tattoos. [ 12 ]


As with any occupation, permanent makeup technicians need to complete required training in order to practice, although these requirements vary from state to state. The average technician completes an  apprenticeship  around nine months in length; however, certification programs vary from a single day to four years. [ 1 ] [ 9 ]  Once they complete their certification, the technician must submit various documents, including proof of certification, apprenticeship, and insurance, before practicing. [ 9 ]


Permanent cosmetics technicians are urged to comply with “standard precautions” and a uniform code of safe practice while performing cosmetic tattooing procedures. [ 13 ] [ 14 ]  This includes assessing whether the patient should receive permanent makeup at all and informing adequately informing them about the risks associated with the practice. [ 9 ]


In a study done regarding the possible complications of permanent makeup, the most common side effects were  itching , redness, and the occasional swelling, all of which tended to heal after a few days. [ 15 ]  While uncommon, permanent makeup can potentially come with more serious  complications , including  allergic reactions  to the pigments,  infection ,  granulomas ,  keloids , bleeding, crusting, loss of eyelashes, or general damage to the tattooed area. [ 11 ] [ 16 ]  Although properly trained technicians will maintain sterile conditions during application, [ 17 ]  the use of unsterilized tattooing instruments may also infect the patient with serious diseases such as  HIV  and  hepatitis .


On very rare occasions, people with permanent makeup have reported swelling or burning in the affected areas when they underwent  magnetic resonance imaging  (MRI). [ 18 ]  Nevertheless, most such cases indicated that poor quality pigments, pigments adulterated with heavy metals, and pigments with  diamagnetic  properties may have been the causative factors. [ 19 ] [ 20 ]  Permanent makeup can also reportedly affect the quality of an MRI image, however, complications can be avoided as long as medical professionals are previously informed. [ 11 ]


In the  United States , the inks used in permanent makeup are subject to approval as cosmetics by the  Food and Drug Administration . While certain pigments in tattoos lack  FDA  approval for use in permanent cosmetics, competing public health priorities and lack of safety problems have consequently caused loose regulations around what color pigments tattoo inks can contain. Thus, there is little regulation on the type of inks used, with some pigments not approved for skin contact or refined only to an industrial-grade level, i.e. printers’ ink, automobile paint, etc. . [ 21 ]


If a tattooist lacks proper training, patients run the risk of the artist injecting the ink too deep into their skin, causing the pigment to migrate into the surrounding tissue. As a result, the makeup may appear blurry and lack definition for thin line work. [ 11 ]  Due to their lymphatic distribution, older patients may have an increased risk for pigment migration following permanent eyelash makeup, [ 22 ]  Although migration is generally avoidable by not over-working swollen tissue. Removing migrated pigment is a difficult and complicated process, so it must be avoided if possible. [ 23 ]


As with tattoos, permanent makeup can be difficult, or even impossible, to remove. [ 12 ]  Common techniques used for this are laser  tattoo removal ,  dermabrasion  (physical or chemical  exfoliation ), and surgical removal. [ 23 ]  Different types of chemical removals have also become a popular option for permanent makeup removal.


Follicular unit transplantation  ( FUT ) is a  hair restoration  technique, also known as the strip procedure, where a patient's hair is transplanted in naturally occurring groups of 1 to 4 hairs, called  follicular units . Follicular units also contain  sebaceous (oil) glands , nerves, a small muscle, and occasional fine  vellus hairs . In follicular unit transplantation, these small units allow the surgeon to safely transplant thousands of grafts in a single session, which maximizes the cosmetic impact of the procedure. [ 1 ]


FUT is considered an advance over older  hair transplantation  procedures that used larger grafts and often produced a pluggy, unnatural look. In a properly-performed follicular unit transplant, the results will mimic the way hair grows in nature and will be undetectable as a hair transplant.


In recent history, FUT had been the most common procedure for hair restoration.  As of 2017, the newer  follicular unit extraction  (FUE) procedure has become the most common procedure. [ 2 ]


Follicular unit transplantation uses follicular units to accomplish a number of objectives critical to the hair restoration process:


Since the follicular unit is a distinct anatomic and physiologic entity, preserving it intact during the graft dissection is felt to maximize growth. In FUT, after hair is removed from the back of the scalp in a single strip, stereo-microscopic dissection allows the individual follicular units to be removed from this strip without being damaged. [ 3 ]


In the older mini-micrografting techniques, hair was harvested in multiple strips with the follicular units in each strip edge showing damage from the harvesting blades. The strips were then cut into smaller pieces, a process that would break up follicular units and risk additional damage to the follicles.
 [ 4 ]


Follicular Unit Transplantation enables the hair transplant to look natural both at the individual follicular unit level and in regards to the overall graft distribution. Since scalp hair normally grows in follicular units of 1 to 4 hairs, the exclusive use of these naturally-occurring units in FUT ensures that each graft will be identical to the surrounding follicular units. Thus, when the transplanted follicular units grow hair after a transplant, the overall results of the transplant will appear natural.


Additionally, by using individual follicular units, rather than larger grafts, the surgeon has a greater total number of grafts with which to work. This allows the surgeon to distribute the grafts more evenly over the scalp for a more natural overall distribution of hair.


The density of naturally-occurring follicular units in a normal scalp is relatively constant, measured at approximately 1 unit per mm 2 . [ 5 ]  This helps in the planning of a hair transplant in two ways:


In patients with high hair density, there are usually a sufficient number of follicular units in the donor area to accomplish the patient's goals. However, in the patient with low hair density, a compromise must be made, and this is guided by the follicular unit constant.  By transplanting a patient with low hair density using the same number and spacing of follicular units as in a patient with high density, the transplant surgeon will produce a thinner look, but will allow proper conservation of donor hair for future procedures. [ 6 ]


The key to a natural appearing hair transplant is to have the hair emerge from perfectly normal skin, so minimizing trauma to the scalp is an important aspect of follicular unit transplantation.  This can be accomplished by trimming away the excess tissue around the follicular units and then inserting them into small recipient sites on the patient's scalp.


Follicular units are relatively compact structures, but are surrounded by substantial amounts of non-hair bearing skin.  This extra tissue can be removed without injuring the follicles, using stereo-microscopic dissection.  These small, trimmed, follicular unit grafts can then be placed into tiny incisions in the patient's scalp; thereby minimizing damage to the scalp's connective tissue and blood supply. In contrast; the larger wounds produced by mini-micrografting and plug transplants caused cosmetic problems that included dimpling and pigment changes in the skin; depression or elevation of the grafts; and a thinned, shiny look to the scalp. These problems can be avoided using very small grafts and very small recipient wounds.


Another advantage of making small recipient wounds is the ability to create a "snug fit" for the follicular unit grafts. Unlike the punch grafts and some mini-grafting techniques; each of which removes a small bit of tissue in the recipient area; the trimmed follicular unit grafts used in FUT fit into small, needle-made incisions without any need for removing tissue. This preserves the elasticity of the scalp and holds the tiny grafts snugly in place. After surgery, the snug fit facilitates wound healing and helps to ensure that the grafts will get enough oxygen from the surrounding tissue in order to maximize their survival. [ 3 ]


There are four reasons why the follicular unit transplantation procedure allows a hair transplant surgeon to transplant large numbers of grafts in each session:


The " platelet-rich fibrin matrix " ( PRFM ) method is a  cosmetic surgery  procedure involving  plasma needling . It is a way of extracting  platelets  from the patient's own blood and using them as a  dermal filler  – that is, as a substance injected under the skin of the face to try to fill out  wrinkles . [ 1 ]


PRFM is an  outpatient  procedures that, as of March 2011 [update] , costs about $900 to $1,500 in the U.S. and takes less than half an hour. Blood is drawn from the patient's arm and spun in a  centrifuge  to separate out the platelets, which are then injected back under the patient's facial skin. It can also be combined in a specific way with other fillers. A procedure using this combination has been marketed as the "Vampire facelift"." [ 1 ]


PRFM has been available on the U.S. market since 2009. It was developed and is marketed by the  Aesthetic Factors  corporation. [ 1 ]  While a platelet extraction centrifuge was cleared by the U.S.  Food and Drug Administration  (FDA) in 2002 As of March 2011 [update]  platelets extracted in this centrifuge have not been cleared or approved by the FDA for facial rejuvenation. [ 1 ]  Nonetheless, Selphyl has been described as a "FDA approved dermal filler" in YouTube videos and trade publications. [ 1 ]


The  efficacy  of PRFM is contested. As of March 2011 [update] , according to a  New York Times  report, it is attested by several plastic surgeons who use it but remains unproven by research. [ 1 ]   Phil Haeck , the president of the  American Society of Plastic Surgeons , dismissed the procedure as "creepy", "a gimmick" and as "antiquated as  bloodletting ". [ 1 ]  It is marketed as Selphyl, TruPRP, Emcyte, Regen, and Pure Spin.


Platysmaplasty , commonly referred to as a neck lift, is a form of cosmetic  plastic surgery  involving tightening and removing  skin  from the human  neck . [ 1 ] [ 2 ]


Because it doesn't often follow a predictable pattern of aging, neck lift surgery must be tailored to each patient's specific needs. Loss of collagen is a major contributor to facial aging, and the neck is certainly no exception. [ 3 ]  As the aging process progresses, collagen production declines and the skin becomes lax, sags, and looks wrinkled. With time, neck muscles also weaken causing a "turkey wattle" appearance. The thin skin of the neck is also especially vulnerable to creases and lines. Neck lifts tend to last 7-10 years and can be repeated in the future if necessary. [ 4 ] [ citation needed ]


Pollicization  (or  pollicisation ) is a  hand surgery  technique in which a  thumb  is created from an existing finger. Typically this consists of surgically migrating the index finger to the position of the thumb in patients who are either born without a functional thumb (most common) or in patients who have lost their thumb traumatically and are not amenable to other preferred methods of thumb reconstruction such as toe-to-hand transfers. [ 1 ] [ 2 ]


During pollicization the index finger  metacarpal  bone is cut and the finger is rotated approximately 120 to 160 degrees and replaced at the base of the hand at the usual position of the thumb. The arteries and veins are left attached. If nerves and tendons are available from the previous thumb these are attached to provide sensation and movement to the new thumb ("neopollex"). If the thumb is congenitally absent other tendons from the migrated index finger may be shortened and rerouted to provide good movement.


The presence of an  opposable thumb  is considered important for manipulation of most objects in the physical world. Children born without thumbs often adapt to the condition very well with few limitations, so the decision to proceed with pollicization lies with the child's parents with the recommendation of their surgeon. Persons who have grown to adulthood with functional thumbs and then lost a thumb find it highly beneficial to have a thumb reconstruction, not only from a functional but from a mental and emotional standpoint.


Other cases for pollicization are:


Prison plastic surgery  is  plastic surgery  or cosmetic surgery (often the terms are used interchangeably) offered and performed to people who are incarcerated, as a means of social rehabilitation. These services were normally provided as part of a larger package of care that may include work  training ,  psychological services , and more. Popular surgeries included  rhinoplasties ,  blepharoplasty ,  facelifts ,  scar removal  and  tattoo removal . These programs began in the early 20th century and were commonplace up till the early 1990s. They took place across the US (in 42+ states), the UK, Canada, and Mexico. [ 1 ]


"Incarceration itself is famously  hard on the body ," reports journalist and author  Zara Stone  in her book,  Killer Looks: The Forgotten History of Plastic Surgery In Prisons ; [ 2 ]  in 2017, facial injuries accounted for 33% of all inmate hospitalizations in New York City, compared to  0.7 percent of the general population. "The existence of prison plastic surgery programs is America’s dirty little secret."


In  San Quentin prison , California, the prison's chief medical doctor Dr.  Leo L. Stanley  was one of the first people to develop a prison plastic surgery practice, focused on reforming the faces of convicts. [ 3 ]  "Considerable plastic surgery has been done, particularly that done for deformed noses,” Dr. Leo Stanley wrote in his 1918 report to the warden. [ 4 ]  “This work has been of benefit in that it has improved the appearance of many of the men and removed a deforming feature. Some work has been done on ears which were very prominent." Stanley reported long waiting lists, noted researcher Ethan Blue. [ 5 ]  Dr. Stanley's "typical prison malingerer," [ 6 ]  had a fractured nose or scarred face, and was treated with crude methods: for nose surgery, a six-inch length of broomstick was placed against the nose and hit with a mallet. "The physician of the future will be an increasing powerful antagonist in the war against crime," Stanley wrote. [ 7 ]


New York was an early adopter, with attention to prisoner beautification baked in from the early 1900s. In 1915, NYC police commissioner Arthur Woods referred to a 15-year-old inmate's appearance in relation to his crime. “He was an inferior looking lad, small and flabby...mild  acne  on the face...forehead broad, nose small, eyes rather sly…chin pointed and  receding ,” wrote Woods. [ 8 ]


Prison plastic surgery became more prevalent throughout the 20th century. In 1954  the American Correctional Association added prisoner plastic surgery to its manual, stating: “elective surgery…[for] especially repulsive facial disfigurements has a definite place in the rehabilitation of prisoners. [ 9 ] ” Many states followed suit, including Texas, North Carolina, and Hawaii.


Some of these early surgeries fell in the  eugenics  bracket, the idea that criminality could be  seen and displayed on the face , reports social Psychologist  Ray Bull  and Nichola Rumsey. [ 10 ]  An examination of some of the mid-20th century prison programs suggested that by and large, plastic surgeries did reduce recidivism—in some cases, dropping it from 76% to 33%. Some findings: Plastic surgery is effective in enhancing the outcome for non-addict prisoners. In 1970, the former director of the Federal Bureau of Prisons from 1937 to 1964, James Van Benschoten Bennett, analyzed these programs. [ 11 ]  "One of the more fruitful areas of research now under way in the federal prisons concerns plastic surgery: the way to rehabilitate a misshapen prisoner."


" Discriminatory practices based on physical appearance  perpetuate social inequalities and hinder individuals' opportunities for reintegration into society," noted author Zara Stone, in a Rockefeller research paper. [ 12 ]


The scholar and feminist critic  Jessica Mitford  was one of the first to question the ethics of performing plastic surgery on prisoners, and if in such a circumstance the prisoners could really consent to such treatment. In her book,  Kind and Usual Punishment , she wrote that one doctor told her that inmates had become “our companions in medical science.. . . . This has been a rewarding experience both for the physician and for the subjects.” This was in regards to a  scurvy  experiment where inmates suffered hemorrhages in the skin and whites of the eyes, excessive loss of hair, mental depressions, and abnormal emotional responses... at a time when scurvy was already curable and treatable." [ 13 ]


The writer  Allen M. Hornblum  explored the issue of consent  [ 14 ]  in his book,  Acres Of Skin , where he reported of strips of skin being flayed off the back of inmates that participated in dermatological trials in the Eastern Penitentiary, Pennsylvania. [ 15 ]  Ostensibly, they were volunteers, but a payment incentive was the reason for their volunteerism and abuse. [ 16 ]


In the movie  Dark Passage , Humphrey Bogart plays the role of Vincent Parry, a man sentenced for murder. [ 17 ]  Parry escapes San Quentin and undergoes plastic surgery to change his appearance and hide from the law while he tries to clear his name. In the 1996 movie  A Face to Die For ,  Yasmine Bleeth plays the part of a scarred young woman that is conned into participating in a crime. [ 18 ]  In prison she gets plastic surgery as part of a reform program, and when released sets out to seek her revenge.


The  reconstructive ladder  is the set of levels of increasingly complex management of wounds in reconstructive  plastic surgery . [ 1 ]  The surgeon should start on the lowest rung and move up until a suitable technique is reached.


There are several small variations in the reconstructive ladder [ 2 ] [ 3 ]  in the scientific literature, but the principles remains the same:


Rhinoplasty  ( Ancient Greek :  ῥίς ,  romanized :  rhī́s ,  nose  +  Ancient Greek :  πλάσσειν ,  romanized :  plássein ,  to shape ), commonly called  nose job , medically called  nasal reconstruction , is a  plastic surgery  procedure for altering and reconstructing the  nose . [ 1 ]  There are two types of plastic surgery used –  reconstructive surgery  that restores the form and functions of the nose and  cosmetic surgery  that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal  injuries  caused by various  traumas  including  blunt , and  penetrating trauma  and trauma caused by  blast injury . Reconstructive surgery can also treat  birth defects , [ 2 ]   breathing problems , and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a  deviated nasal septum  or a sinus condition. [ citation needed ]  Surgery only on the septum is called a  septoplasty .


In  closed rhinoplasty  and  open rhinoplasty  surgeries – a plastic surgeon, an  otolaryngologist  (ear, nose, and throat specialist), or an  oral and maxillofacial surgeon  (jaw, face, and neck specialist), creates a functional, aesthetic, and facially proportionate nose by separating the nasal skin and the  soft tissues  from the  nasal framework , altering them as required for form and function,  suturing  the incisions, using  tissue glue  and applying either a package or a  stent , or both, to immobilize the altered nose to ensure the proper healing of the surgical incision.


Treatments for the plastic repair of a broken nose are first mentioned in the  Edwin Smith Papyrus , [ 4 ]  a transcription of text dated to the  Old Kingdom  from 3000 to 2500  BCE . [ 5 ]


The  Ebers Papyrus  ( c.  1550 BC), an  Ancient Egyptian   medical papyrus , describes rhinoplasty as the  plastic surgical  operation for reconstructing a nose destroyed by rhinectomy. Such a mutilation was inflicted as a criminal, religious, political, and military punishment in that time and culture. [ 6 ]


Rhinoplasty techniques are described in the  ancient Indian  text  Sushruta samhita  by  Sushruta , where a nose is reconstructed by using a flap of skin from the cheek. [ 7 ]


During the  Roman Empire  (27 BC – 476 AD) the encyclopaedist  Aulus Cornelius Celsus  ( c.  25 BC – 50 AD) published the 8-tome  De Medicina  (On Medicine,  c.  14 AD), which described plastic surgery techniques and procedures for the correction and the reconstruction of the nose and other body parts. [ 8 ]


At the  Byzantine  Roman court of the Emperor  Julian the Apostate  (331–363 AD), the royal physician  Oribasius  ( c.  320–400 AD) published the 70-volume  Synagogue Medicae  (Medical Compilations, 4th century AD), which described facial-defect reconstructions that featured loose  sutures  that permitted a  surgical  wound to heal without distorting the facial flesh; how to clean the bone exposed in a wound;  debridement , how to remove damaged tissue to forestall  infection  and so accelerate healing of the  wound ; and how to use  autologous skin flaps  to repair damaged cheeks, eyebrows, lips, and nose, to restore the patient's normal  visage . [ 9 ]


In Italy,  Gasparo Tagliacozzi  (1546–1599), professor of  surgery  and  anatomy  at the  University of Bologna , published  Curtorum Chirurgia Per Insitionem  (The Surgery of Defects by Implantations, 1597), a technico–procedural manual for the  surgical  repair and reconstruction of facial wounds in soldiers. The illustrations featured a  re-attachment  rhinoplasty using a  biceps muscle  pedicle flap; the graft attached at 3-weeks post-procedure; which, at 2-weeks post-attachment, the surgeon then shaped into a nose.


In Great Britain,  Joseph Constantine Carpue  (1764–1846) published the descriptions of two rhinoplasties: the reconstruction of a battle-wounded nose, and the repair of an  arsenic -damaged nose. (cf.  Carpue's operation ). [ 10 ] [ 11 ]


In Germany, rhinoplastic technique was refined by surgeons such as the  Berlin University  professor of surgery  Karl Ferdinand von Gräfe  (1787–1840), who published  Rhinoplastik  (Rebuilding the Nose, 1818) wherein he described 55 historical plastic surgery procedures, and his technically innovative free-graft nasal reconstruction (with a tissue-flap harvested from the patient's arm), and surgical approaches to eyelid,  cleft lip , and  cleft palate  corrections. Dr. von Gräfe's  protégé , the  medical  and  surgical   polymath   Johann Friedrich Dieffenbach  (1794–1847), who was among the first surgeons to anaesthetize the patient before performing the nose surgery, published  Die Operative Chirurgie  (Operative Surgery, 1845), which became a foundational medical and plastic surgical text (see  strabismus ,  torticollis ). Moreover, the  Prussian   Jacques Joseph  (1865–1934) published  Nasenplastik und sonstige Gesichtsplastik  (Rhinoplasty and other Facial Plastic Surgeries, 1928), which described refined surgical techniques for performing nose-reduction rhinoplasty via internal incisions. [ 12 ]


In the United States, in 1887, the otolaryngologist John Orlando Roe (1848–1915) performed the first modern endonasal rhinoplasty (closed rhinoplasty) in order to treat  saddle nose  deformities. [ 13 ] [ 14 ]


In the early 20th century, Freer, in 1902, and Killian, in 1904, pioneered the  submucous resection  septoplasty (SMR) procedure for correcting a deviated  septum ; they raised mucoperichondrial tissue flaps, and resected the  cartilaginous  and  bony   septum  (including the  vomer bone  and the  perpendicular plate  of the  ethmoid bone ), maintaining septal support with a 1.0-cm margin at the dorsum and a 1.0-cm margin at the caudad, for which innovations the technique became the foundational, standard  septoplastic  procedure. In 1929, Peer and Metzenbaum performed the first manipulation of the caudal septum, where it originates and projects from the forehead. In 1934, Aurel Rethi introduced the open rhinoplasty approach featuring an incision to the nasal septum to facilitate modifying the tip of the nose. [ 15 ]  In 1947, Maurice H. Cottle (1898–1981) endonasally resolved a septal deviation with a minimalist hemitransfixion incision, which conserved the septum; thus, he advocated for the practical primacy of the closed rhinoplasty approach. [ 6 ]  In 1957, A. Sercer advocated the "decortication of the nose" ( Dekortication des Nase ) technique which featured a columellar-incision open rhinoplasty that allowed greater access to the  nasal cavity  and to the nasal septum.


The endonasal rhinoplasty was the usual approach to nose surgery until the 1970s, when Padovan presented his technical refinements, advocating the open rhinoplasty approach; he was seconded by Wilfred S. Goodman in the later 1970s, and by Jack P. Gunter in the 1990s. [ 16 ] [ 17 ]  Goodman impelled technical and procedural progress and popularized the open rhinoplasty approach. [ 18 ] [ secondary source needed ]  In 1987, Gunter reported the technical effectiveness of the open rhinoplasty approach for performing a secondary rhinoplasty; his improved techniques advanced the management of a failed nose surgery. [ 19 ] [ secondary source needed ]


In early 2021, it was reported that a trend that involved getting a rhinoplasty had emerged on the social media platform  TikTok . The trend became known as the #NoseJobCheck trend and involved users of the platform posting videos that showed how their noses looked before and after their rhinoplasty surgeries, with a specific audio soundtracking the video. From October 2020 to January 2021, the #NoseJobCheck audio had been used in over 120,000 videos and videos with the #NoseJobCheck hashtag had accumulated over one billion views. [ 20 ]


For plastic surgical correction, the structural anatomy of the nose comprises:  A.  the nasal soft tissues;  B.  the aesthetic subunits and segments;  C.  the blood supply arteries and veins;  D.  the nasal lymphatic system;  E.  the facial and nasal nerves;  F.  the nasal bone; and  G.  the nasal cartilages.


To plan, map, and execute the surgical correction of a nasal defect or deformity, the structure of the external nose is divided into nine  aesthetic nasal subunits , and six  aesthetic nasal segments , which provide the plastic surgeon with the measures for determining the size, extent, and topographic locale of the nasal defect or deformity.


In turn, the nine aesthetic nasal subunits are configured as six aesthetic nasal segments; each segment comprehends a nasal area greater than that comprehended by a nasal subunit.


Using the co-ordinates of the subunits and segments to determine the topographic location of the defect on the nose, the plastic surgeon plans, maps, and executes a rhinoplasty procedure. The unitary division of the nasal topography permits minimal, but precise, cutting, and maximal corrective-tissue coverage, to produce a functional nose of proportionate size, contour, and appearance for the patient. Hence, if more than 50 percent of an  aesthetic subunit  is lost (damaged, defective, destroyed) the surgeon replaces the entire  aesthetic segment , usually with a regional  tissue graft , harvested from either the face or the head, or with a tissue graft harvested from elsewhere on the patient's body. [ 21 ]


Like the face, the human nose is well vascularized with arteries and veins, and thus supplied with abundant  blood . The principal arterial blood-vessel supply to the nose is two-fold:  (i)  branches from the  internal carotid artery , the branch of the  anterior ethmoidal artery , the branch of the  posterior ethmoidal artery , which derive from the  ophthalmic artery ;  (ii)  branches from the  external carotid artery , the  sphenopalatine artery , the  greater palatine artery , the  superior labial artery , and the  angular artery .


The  external nose  is supplied with blood by the  facial artery , which becomes the angular artery that courses over the superomedial aspect of the nose. The sellar region ( sella turcica , "Turkish chair") and the dorsal region of the nose are supplied with blood by branches of the internal  maxillary artery  ( infraorbital artery ) and the  ophthalmic arteries  that derive from the internal  common carotid artery  system.


Internally, the  lateral nasal wall  is supplied with blood by the sphenopalatine artery (from behind and below) and by the anterior ethmoid artery and the posterior ethmoid artery (from above and behind). The  nasal septum  also is supplied with blood by the sphenopalatine artery, and by the anterior and posterior ethmoid arteries, with the additional circulatory contributions of the superior labial artery and of the greater palatine artery. These three vascular supplies to the internal nose converge in the  Kiesselbach plexus  ( the Little area ), which is a region in the anteroinferior-third of the nasal septum, (in front and below). Furthermore, the nasal vein vascularisation of the nose generally follows the arterial pattern of nasal vascularisation. The nasal veins are biologically significant, because they have no vessel-valves, and because of their direct, circulatory communication to the  cavernous sinus , which makes possible the potential intracranial spreading of a bacterial infection of the nose. Hence, because of such an abundant nasal blood supply,  tobacco smoking  does therapeutically compromise post-operative healing.


The pertinent nasal  lymphatic system  arises from the superficial mucosa, and drains posteriorly to the  retropharyngeal nodes  (in back), and anteriorly (in front), either to the upper  deep cervical nodes  (in the neck), or to the  submandibular glands  (in the lower jaw), or into both the nodes and the glands of the neck and the jaw.


The sensations registered by the human nose derive from the first two branches of  cranial nerve V , the  trigeminal nerve . The  nerve  listings indicate the respective innervation (sensory distribution) of the trigeminal nerve branches within the nose, the face, and the upper jaw (maxilla).


The supply of  parasympathetic  nerves to the face and the upper jaw (maxilla) derives from the  greater superficial petrosal  (GSP) branch of  cranial nerve VII , the  facial nerve . The GSP nerve joins the  deep petrosal nerve  (of the sympathetic nervous system), derived from the carotid plexus, to form the  vidian nerve  (in the vidian canal) that traverses the  pterygopalatine ganglion  (an autonomic ganglion of the maxillary nerve), wherein only the parasympathetic nerves form synapses, which serve the  lacrimal gland  and the glands of the nose and of the palate, via the (upper jaw) maxillary division of  cranial nerve V , the  trigeminal nerve .


In the upper portion of the nose, the paired  nasal bones  attach to the  frontal bone . Above and to the side (superolaterally), the paired nasal bones connect to the  lacrimal bones , and below and to the side (inferolaterally), they attach to the ascending processes of the  maxilla  (upper jaw). Above and to the back (posterosuperiorly), the bony nasal septum is composed of the  perpendicular plate of the ethmoid bone . The  vomer  bone lies below and to the back (posteroinferiorly), and partially forms the choanal opening into the nasopharynx, (the upper portion of the  pharynx  that is continuous with the nasal passages). The floor of the nose comprises the  premaxilla bone  and the  palatine bone , the roof of the mouth.


The nasal septum is composed of the quadrangular cartilage, the vomer bone (the perpendicular plate of the ethmoid bone), aspects of the premaxilla, and the palatine bones. Each lateral nasal wall contains three pairs of  turbinates  (nasal conchae), which are small, thin, shell-form bones: (i) the  superior concha , (ii) the  middle concha , and (iii) the  inferior concha , which are the bony framework of the turbinates. Lateral to the turbinates is the medial wall of the  maxillary sinus . Inferior to the nasal conchae (turbinates) is the meatus space, with names that correspond to the turbinates, e.g. superior turbinate, superior meatus, et alii. The internal roof of the nose is composed by the horizontal, perforated  cribriform plate  (of the ethmoid bone) through which pass sensory filaments of the  olfactory nerve  ( cranial nerve I ); finally, below and behind (posteroinferior) the cribriform plate, sloping down at an angle, is the bony face of the  sphenoid sinus .


The cartilaginous  septum  ( septum nasi ) extends from the nasal bones in the midline (above) to the bony septum in the midline (posteriorly), then down along the bony floor. The septum is quadrangular; the upper half is flanked by two triangular-to-trapezoidal cartilages: the upper lateral-cartilages, which are fused to the dorsal septum in the midline, and laterally attached, with loose ligaments, to the bony margin of the  pyriform (pear-shaped) aperture , while the inferior ends of the upper lateral-cartilages are free (unattached). The internal area (angle), formed by the septum and upper lateral-cartilage, constitutes the internal valve of the nose; the  sesamoid cartilages  are adjacent to the upper  lateral-cartilages  in the fibroareolar connective tissue.


Beneath the upper lateral-cartilages lay the lower lateral-cartilages; the paired lower lateral-cartilages swing outwards, from medial attachments, to the caudal septum in the midline (the medial crura) to an intermediate crus (shank) area. Finally, the lower lateral-cartilages flare outwards, above and to the side (superolaterally), as the lateral crura; these cartilages are mobile, unlike the upper lateral cartilages. Furthermore, some persons present anatomical evidence of nasal scrolling—i.e., an outward curving of the lower borders of the upper lateral-cartilages, and an inward curving of the cephalic borders of the alar cartilages.


The form of the nasal subunits—the dorsum, the sidewalls, the lobule, the soft triangles, the alae, and the columella—are configured differently, according to the race and the ethnic group of the patient, thus the nasal physiognomies denominated as: African, platyrrhine (flat, wide nose); Asiatic, subplatyrrhine (low, wide nose); Caucasian, leptorrhine (narrow nose); and Hispanic, paraleptorrhine (narrow-sided nose). The respective  external nasal valve  of each nose is variably dependent upon the size, shape, and strength of the lower lateral cartilage. [ 22 ]


In the midline of the nose, the  septum  is a composite (osseo-cartilaginous) structure that divides the nose into two similar halves. The lateral nasal wall and the  paranasal sinuses , the superior concha, the middle concha, and the inferior concha, form the corresponding passages, the superior meatus, the middle meatus, and the inferior meatus, on the lateral nasal wall. The  superior meatus  is the drainage area for the posterior  ethmoid bone  cells and the sphenoid sinus; the middle meatus provides drainage for the anterior ethmoid sinuses and for the maxillary and frontal sinuses; and the inferior meatus provides drainage for the  nasolacrimal duct .


The  internal nasal valve  comprises the area bounded by the upper lateral-cartilage, the septum, the nasal floor, and the anterior head of the inferior turbinate. In the narrow (leptorrhine) nose, this is the narrowest portion of the nasal airway. Generally, this area requires an angle greater than 15 degrees for unobstructed breathing; for the correction of such narrowness, the width of the nasal valve can be increased with spreader grafts and flaring sutures.


The surgical management of nasal defects and deformities divides the nose into six  anatomic subunits : (i) the dorsum, (ii) the sidewalls (paired), (iii) the hemilobules (paired), (iv) the soft triangles (paired), (v) the alae (paired), and (vi) the columella. Surgical correction and reconstruction comprehend the entire anatomic subunit affected by the defect (wound) or deformity, thus, the entire subunit is corrected, especially when the resection (cutting) of the defect encompasses more than 50 percent of the subunit. Aesthetically, the nose—from the nasion (the midpoint of the nasofrontal junction) to the columella-labial junction—ideally occupies one-third of the vertical dimension of the person's face; and, from ala to ala, it ideally should occupy one-fifth of the horizontal dimension of the person's face. [ 23 ]


The  nasofrontal angle , intersection of the line from the  nasion  to the nasal tip with the line from the  nasion  to the  glabella , usually is 115-130 degrees; the nasofrontal angle is more acute in the male face than in the female face. The  nasofacial angle , intersection of the line from the  nasion  to the nasal tip with the line from the  nasion  to the pogonion, is approximately 30–40 degrees. The  nasolabial angle , the slope between the columella and the  philtrum , is approximately 90–95 degrees in the male face, and approximately 100–105 degrees in the female face. Therefore, when observing the nose in profile, the normal show of the columella (the height of the visible nasal aperture) is 2 mm; and the dorsum should be rectilinear (straight). When observed from below (worm's-eye view), the alar base configures an isosceles triangle, with its apex at the infra-tip lobule, immediately beneath the tip of the nose. The facially proportionate projection of the nasal tip (the distance of the nose's tip from the face) is determined with the Goode Method, wherein the projection of the nasal tip should be 55–60 percent of the distance between the nasion (nasofrontal junction) and the tip-defining point. A columellar double break might be present, marking the transition between the intermediate crus of the lower-lateral cartilage and the medial crus.


The  Goode Method  determines the extension of the nose from the facial surface by comprehending the distance from the alar groove to the tip of the nose, and then relating that measurement (of nasal-tip projection) to the length of the nasal dorsum. The nasal projection measurement is obtained by delineating a right triangle with lines parting from the nasion (nasofrontal juncture) to the alar–facial–groove. Then, a second, perpendicular delineation, that traverses the tip-defining point, establishes the ratio of projection of the nasal tip; hence, the range of 0.55:1 to 0.60:1, is the ideal nasal-tip-to-nasal-length projection. [ 24 ]


Systematic approaches to nasal analysis have been described. For example, the 10-7-5 method allows for methodical analysis of the nose. It describes 10 features from the frontal view, 7 features from the lateral view, and 5 features from the basal view. [ 25 ]


3D simulations and planning  can be used to communicate the patients existing deformities, and plan or propose the desired approach. [ 26 ] [ 27 ] [ 28 ]   3-dimensional cameras allow photographic capture, inspection, analysis, and modification to understand the existing nasal anatomy, and communicate a potential result to the patient. [ 29 ]


To determine the patient's suitability for undergoing a rhinoplasty procedure, the surgeon clinically evaluates them with a complete  medical history  ( anamnesis ) to determine their physical and  psychological health . The prospective patient must explain to the physician–surgeon the functional and aesthetic nasal problems that they have. The surgeon asks about the ailments' symptoms and their duration, past surgical interventions, allergies, drugs use and drugs abuse (prescription and commercial medications), and a general medical history. Furthermore, additional to physical suitability is psychological suitability—the patient's psychological motive for undergoing nose surgery is critical to the surgeon's pre-operative evaluation of the patient. [ 6 ]


The complete physical examination of the rhinoplasty patient determines if he or she is physically fit to undergo and tolerate the physiologic stresses of nose surgery. The examination comprehends every existing physical problem, and a consultation with an anaesthesiologist, if warranted by the patient's medical data. Specific facial and nasal evaluations record the patient's skin-type, existing surgical scars, and the symmetry and asymmetry of the  aesthetic nasal subunits . The external and internal nasal examination concentrates upon the  anatomic thirds  of the nose—upper section, middle section, lower section—specifically noting their structures; the measures of the nasal angles (at which the external nose projects from the face); and the physical characteristics of the naso-facial bony and soft tissues. The internal examination evaluates the condition of the nasal septum, the internal and external nasal valves, the  turbinates , and the nasal lining, paying special attention to the structure and the form of the nasal dorsum and the tip of the nose. [ 6 ]


Furthermore, when warranted, specific tests—the mirror test, vasoconstriction examinations, and the Cottle maneuver—are included to the pre-operative evaluation of the prospective rhinoplasty patient. Established by Maurice H. Cottle (1898–1981), the  Cottle maneuver  is a principal diagnostic technique for detecting an internal nasal-valve disorder; whilst the patient gently inspires, the surgeon laterally pulls the patient's cheek, thereby simulating the widening of the cross-sectional area of the corresponding internal nasal valve. If the maneuver notably facilitates the patient's inspiration, that result is a positive  Cottle sign —which generally indicates an airflow-correction to be surgically effected with an installed spreader-graft. Said correction will improve the internal angle of the nasal valve and thus allow unobstructed breathing. Nonetheless, the Cottle maneuver occasionally yields a  false-positive Cottle sign , usually observed in the patient affected by alar collapse, and in the patient with a scarred nasal-valve region. [ 30 ]


There is limited evidence that a single dose of corticosteriods decreases oedema and bleeding first two days post operation but the difference is not maintained after this. [ 31 ]   Swelling and edema can take at least 1-year to diminish. [ 32 ]   Certain adjuncts, including fat grafting may help quicken the time to edema and bruising resolution. [ 33 ]


The plastic surgical correction of  congenital  and acquired abnormalities of the  nose  restores functional and aesthetic properties by the surgeon's manipulations of the nasal skin, the subcutaneous (underlying) cartilage-and-bone support framework, and the  mucous membrane  lining. Technically, the plastic surgeon's incisional approach classifies the  nasal surgery  either as an  open rhinoplasty  or as a  closed rhinoplasty  procedure. In open rhinoplasty, the surgeon makes a small, irregular incision to the  columella , the fleshy, exterior-end of the nasal septum; this columellar incision is additional to the usual set of incisions for a nasal correction. In closed rhinoplasty, the surgeon performs every procedural incision endonasally (exclusively within the nose), and does not cut the columella. [ 6 ]


Except for the columellar incision, the technical and procedural approaches of open rhinoplasty and of closed rhinoplasty are similar; yet closed rhinoplasty procedure features:


The open rhinoplasty approach affords the plastic surgeon advantages of ease in securing grafts ( skin ,  cartilage ,  bone ) and, most importantly, in securing the nasal cartilage properly, and so better to make the appropriate assessment and remedy. This procedural aspect can be especially difficult in revision surgery, and in rhinoplastic alteration of the thick-skinned "ethnic nose" of the person of color. The study,  Ethnic Rhinoplasty: a Universal Preoperative Classification System for the Nasal Tip  (2009), reports that a nasal-tip classification system, based upon skin thickness, has been proposed to aid the surgeon in determining if an open rhinoplasty or a closed rhinoplasty can best correct the defect or deformity affecting the patient's nose. [ 35 ]


Cause, the open and closed approaches to rhinoplastic correction resolve: (i) nasal pathologies (diseases intrinsic and diseases extrinsic to the nose); (ii) an unsatisfactory aesthetic appearance (disproportion); (iii) a failed primary rhinoplasty; (iv) an obstructed airway; and (v) congenital nose defects and deformities.


Recently, ultrasonic rhinoplasty [ 36 ]  which was introduced by Massimo Robiony in 2004 has become an alternative to traditional rhinoplasty. [ 37 ]  Ultrasonic rhinoplasty uses  piezoelectric  instruments [ 38 ]  to reshape atraumatically nasal bones, also known as rhinosculpture. Ultrasonic rhinoplasty uses piezoelectric instruments (scrapers rasps, saws) that affect only the bones and the stiff cartilages through ultrasonic vibrations, as the instruments used in  dental surgery . [ 39 ]  The use of piezoelectric instruments requires a more extended approach than the isial one, allowing to visualize the whole bony vault, to reshape it with rhinosculpture or to mobilize and stabilize bones after controlled osteotomies. [ 40 ]


A rhinoplastic correction can be performed on a person who is under  sedation , under  general anaesthesia , or under  local anaesthesia ; initially, a  local anaesthetic  mixture of  lidocaine  and  epinephrine  is injected to numb the area, and temporarily reduce vascularity, thereby limiting any bleeding. Generally, the  plastic surgeon  first separates the nasal skin and the  soft tissues  from the  osseo - cartilagenous  nasal framework, and then reshapes them, sutures the incisions, and applies either an external or an internal stent, and tape, to immobilize the newly reconstructed nose, and so facilitate the healing of the surgical cuts. Occasionally, the surgeon uses either an  autologous  cartilage graft or a bone graft, or both, in order to strengthen or to alter the nasal contour(s). The autologous grafts usually are harvested from the  nasal septum , but, if it has insufficient cartilage (as can occur in a revision rhinoplasty), then either a costal cartilage graft (from the  rib cage ) or an auricular cartilage graft ( concha  from the  ear ) is harvested from the patient's body. Homologous (donor) rib cartilage is also sometimes used if the patient's own cartilage is unsuitable. [ 41 ] [ 42 ]  When the rhinoplasty requires a bone graft, it is harvested from either the  cranium , the hips, or the rib cage; moreover, when neither type of autologous graft is available, a synthetic graft ( nasal implant ) is used to augment the nasal bridge. [ 43 ]   The main types of grafts to support and reposition the nasal tip (or the central/medial limb of the tripod) are either columellar strut, or the septal extension graft.  Both are useful and effective, but the septal extension graft (SEG) is shown to impart greater control, and less changes over time. [ 44 ]


For the benefit of the patient and the physician–surgeon, a photographic history of the entire rhinoplastic procedure is established; beginning at the pre-operative consultation, continuing during the surgical operation procedures, and concluding with the post-operative outcome. To record the "before-and-after" physiognomies of the nose and the face of the patient, the specific visual perspectives required are photographs of the nose viewed from the anteroposterior (front-to-back) perspective; the lateral view (profiles), the worm's-eye view (from below), the bird's-eye view (overhead), and three-quarter-profile views. [ 6 ]


In  plastic surgical  praxis, the term  primary rhinoplasty  denotes an initial (first-time) reconstructive, functional, or aesthetic corrective procedure. The term  secondary rhinoplasty  denotes the revision of a failed rhinoplasty, an occurrence in 5–20 per cent of rhinoplasty operations, hence a  revision rhinoplasty . The corrections usual to secondary rhinoplasty include the cosmetic reshaping of the nose because of a functional breathing deficit from an over aggressive rhinoplasty, asymmetry, deviated or crooked nose, areas of collapses, hanging columella, pinched tip, scooped nose and more. Although most revision rhinoplasty procedures are "open approach", such a correction is more technically complicated, usually because the nasal support structures either were deformed or destroyed in the primary rhinoplasty; thus the surgeon must re-create the nasal support with cartilage grafts harvested either from the  ear  (auricular cartilage graft) or from the  rib cage  (costal cartilage graft).


A  functional rhinoplasty  refers to a rhinoplasty performed to alleviate nasal obstruction, whereas a  cosmetic rhinoplasty  refers to a rhinoplasty performed for aesthetic reasons. Procedures performed as part of a functional rhinoplasty typically include septoplasty, inferior turbinate reduction, and spreader graft placement.


Results


Can be good if performed by an experienced practitioner.  As in all plastic surgery procedures, there can be some unpredictability, and biologic systems can heal in different ways.


In reconstructive rhinoplasty, the defects and deformities that the  plastic surgeon  encounters, and must restore to normal function, form, and appearance include broken and displaced nasal bones; disrupted and displaced nasal cartilages; a collapsed bridge of the nose;  congenital defect ,  trauma  ( blunt ,  penetrating ,  blast ),  autoimmune disorder ,  cancer , intranasal drug-abuse damages, and failed primary rhinoplasty outcomes. Rhinoplasty reduces bony humps, and re-aligns the nasal bones after they are cut (dissected, resected). When  cartilage  is disrupted,  suturing  for re-suspension (structural support), or the use of cartilage grafts to camouflage a depression allow the re-establishment of the normal nasal contour of the nose for the patient. When the bridge of the nose is collapsed, rib-cartilage, ear-cartilage, or cranial-bone grafts can be used to restore its anatomic integrity, and thus the aesthetic continuity of the nose. For augmenting the nasal dorsum, autologous cartilage and bone grafts are preferred to (artificial)  nose prostheses , because of the reduced incidence of  histologic  rejection and medical complications. [ 45 ]


The  human nose  is a sensory organ that is structurally composed of three types of tissue: (i) an  osseo - cartilaginous  support framework (nasal skeleton), (ii) a mucous membrane lining, and (iii) an external skin. The anatomic  topography  of the human nose is a graceful blend of convexities, curves, and depressions, the contours of which show the underlying shape of the nasal skeleton. Hence, these anatomic characteristics permit dividing the nose into  nasal subunits : (i) the midline (ii) the nose-tip, (iii) the dorsum, (iv) the soft triangles, (v) the alar lobules, and (vi) the lateral walls. Surgically, the borders of the nasal subunits are ideal locations for the scars, whereby is produced a superior aesthetic outcome, a corrected nose with corresponding skin colors and skin textures. [ 46 ] [ 47 ]


Therefore, the successful rhinoplastic outcome depends entirely upon the respective maintenance or restoration of the anatomic integrity of the nasal skeleton, which comprises (a) the nasal bones and the ascending processes of the maxilla in the upper third; (b) the paired upper-lateral cartilages in the middle third; and (c) the lower-lateral, alar cartilages in the lower third. Hence, managing the surgical reconstruction of a damaged, defective, or deformed nose, requires that the plastic surgeon manipulate three anatomic layers:


The technical principles for the  surgical  reconstruction of a  nose  derive from the essential operative principles of  plastic surgery : that the applied procedure and technique(s) yield the most satisfactory functional and aesthetic outcome. Hence, the rhinoplastic reconstruction of a new nasal subunit, of virtually normal appearance, can be done in a few procedural stages, using intranasal tissues to correct defects of the  mucosa ;  cartilage  battens to brace against  tissue  contraction and depression (topographic collapse); axial  skin flaps  designed from three-dimensional (3-D) templates derived from the topographic subunits of the nose; and the refinement of the resultant correction with the subcutaneous sculpting of  bone , cartilage, and flesh. Nonetheless, the physician-surgeon and the rhinoplasty patient must abide the fact that the reconstructed nasal subunit is not a nose proper, but a  collagen -glued collage—of forehead skin, cheek skin, mucosa, vestibular lining, nasal septum, and fragments of  ear  cartilage—which is perceived as a nose only because its contour, skin color, and skin texture are true to the original nose. [ 47 ]


In nasal reconstruction, the plastic surgeon's ultimate goal is recreating the shadows, the contours, the skin color, and the skin texture that define the patient's "normal nose", as perceived at conversational distance (c. 1.0 metre). Yet, such an aesthetic outcome suggests the application of a more complex surgical approach, which requires that the surgeon balance the patient's required rhinoplasty, with the patient's  aesthetic ideal  (body image). In the context of surgically reconstructing the patient's physiognomy, the "normal nose" is the three-dimensional (3-D) template for replacing the missing part(s) of a nose (aesthetic nasal subunit, aesthetic nasal segment), which the plastic surgeon re-creates using firm, malleable, modelling materials—such as  bone ,  cartilage , and  flaps of skin and of tissue . In repairing a partial nasal defect (wound), such as that of the alar lobule (the dome above the nostrils), the surgeon uses the undamaged, opposite (contralateral) side of the nose as the 3-D model to fabricate the anatomic template for recreating the deformed nasal subunit, by molding the malleable template material directly upon the normal, undamaged nasal anatomy. To effect a total nasal reconstruction, the template might derive from quotidian observations of the "normal nose" and from photographs of the patient before they sustained the nasal damage.


The surgeon replaces missing parts with tissue of like quality and quantity; nasal lining with  mucosa , cartilage with cartilage, bone with bone, and skin with skin that best match the native skin color and skin texture of the damaged nasal subunit. For such surgical repairs, skin flaps are preferable to skin grafts, because skin flaps generally are the superior remedy for matching the color and the texture of nasal skin, better resist tissue contracture, and provide better vascularisation of the nasal skeleton; thus, when there is sufficient skin to allow tissue harvesting, nasal skin is the best source of nasal skin. Furthermore, despite its notable  scarring  propensity, the nasal skin flap is the prime consideration for nasal reconstruction, because of its greater verisimilitude.


The most effective nasal reconstruction for repairing a defect (wound) of the nasal skin, is to re-create the entire nasal subunit; thus, the wound is enlarged to comprehend the entire nasal subunit. Technically, this surgical principle permits laying the scars in the  topographic  transition zone(s) between and among adjacent aesthetic subunits, which avoids juxtaposing two different types of skin in the same aesthetic subunit, where the differences of color and texture might prove too noticeable, even when reconstructing a nose with  skin flaps . Nonetheless, in the final stage of nasal reconstruction—replicating the "normal nose" anatomy by subcutaneous sculpting, the surgeon does have technical allowance to revise the scars, and render them (more) inconspicuous. [ 48 ]


Reconstruction rhinoplasty is indicated for the correction of defects and deformities caused by:


The effectiveness of a rhinoplastic reconstruction of the  external nose  derives from the contents of the surgeon's  armamentarium  of skin-flap techniques applicable to correcting defects of the nasal skin and of the mucosal lining; some management techniques are the  bilobed flap , the  nasolabial flap , the  paramedian forehead flap , and the  septal mucosal flap .


The design of the bilobed flap derives from the creation of two adjacent random transposition flaps (lobes). In its original design, the leading flap is applied to cover the defect, and the second flap, is emplaced where the skin flexes more, and fills the donor-site wound (from where the first flap was harvested), which then is closed primarily, with  sutures . The first flap is oriented geometrically, at 90 degrees from the long axis of the wound (defect), and the second flap is oriented 180 degrees from the axis of the wound. Although effective, the bilobed flap technique did create troublesome "dog ears" of excess flesh that required trimming and it also produced a broad skin-donor area that was difficult to confine to the nose. In 1989, J. A. Zitelli modified the bilobed flap technique by: (a) orienting the leading flap at 45 degrees from the long axis of the wound; and (b) orienting the second flap at 90 degrees from the axis of the wound. Said orientations and emplacements eliminated the excess-flesh "dog ears", and thus required a smaller area of donor skin; resultantly, the  broad-based, bilobed flap  is less prone to the "trap door" and the "pin cushion" deformities common to skin-flap transposition procedure. [ 50 ]


The design of the bilobed flap co-ordinates its lobes with the long axis of the nasal defect (wound); each lobe of the flap is emplaced at a 45-degree angle to the axis. The two lobes of the bilobed flap rotate along an arc, of which all points are equidistant from the apex of the nasal defect.


In the 19th century, the surgical techniques of  J.F. Dieffenbach  (1792–1847) popularized the nasolabial flap for nasal reconstruction, for which it remains a foundational nose surgery procedure. The nasolabial flap can be either superiorly based or inferiorly based; of which the superiorly based flap is the more practical rhinoplastic application, because it has a more versatile arc of rotation, and the donor-site scar is inconspicuous. Depending upon how the defect lay upon the nose, the flap pedicle-base can be incorporated either solely to the nasal reconstruction, or it can be divided into a second stage procedure. The blood supply for the flap pedicle are the transverse branches of the contralateral  angular artery  (the facial artery terminus parallel to the nose), and by a confluence of blood vessels from the angular artery and from the  supraorbital artery  in the medial canthus, (the angles formed by the meeting of the upper and lower eyelids). Therefore, the incisions for harvesting the nasolabial flap do not continue superiorly beyond the medial canthal tendon. The nasolabial flap is a random flap that is emplaced with the proximal (near) portion resting upon the lateral wall of the nose, and the distal (far) portion resting upon the cheek, which contains the main angular artery, and so is perfused with retrograde arterial flow. [ 51 ]


The pedicle of the nasolabial flap rests upon the lateral nasal wall, and is transposed a maximum of 60 degrees, in order to avoid the "bridge effect" of a flap emplaced across the nasofacial angle.


The paramedian forehead flap is the premier  autologous  skin graft for the reconstruction of a nose, by replacing any of the aesthetic nasal subunits, especially regarding the problems of different tissue thickness and skin color. The forehead flap is an axial skin flap based upon the  supraorbital artery  (an ophthalmic artery branch) and the supratrochlear artery (an ophthalmic artery terminus), which can be thinned to the subdermal plexus in order to enhance the functional and aesthetic outcome of the nose. Restricted length is a practical application limit of the paramedian forehead flap, especially when the patient has a low frontal hairline. In such a patient, a small portion of scalp skin can be included to the flap, but it does have a different skin texture and does continue growing hair; such mismatching is avoided with the transverse emplacement of the flap along the hairline; yet that portion of the skin flap is random, and so risks a greater incidence of  necrosis .


The paramedian forehead flap has two disadvantages, one operational and one aesthetic: Operationally, the reconstruction of a nose with a paramedian forehead flap is a two-stage surgical procedure, which might a problem for the patient whose health (surgical suitability) includes significant, secondary medical risks. Nonetheless, the second stage of the nasal reconstruction can be performed with the patient under local anaesthesia. Aesthetically, although the flap donor-site scar heals well, it is noticeable, and thus difficult to conceal, especially in men. [ 48 ]


The surgeon designs the paramedian forehead flap from a custom-fabricated three-dimensional metal foil template derived from the measures of the nasal defect to be corrected. Using an  ultrasonic scanner , the flap-pedicle is centre-aligned upon the Doppler signal of the supraorbital artery. Afterwards, the distal one-half of the flap is dissected and thinned to the subdermal plexus.


The septal mucosal tissue flap is the indicated technique for correcting defects of the distal half of the nose, and for correcting almost every type of large defect of the mucosal lining of the nose. The septal mucosal tissue flap, which is an anteriorly based pedicle-graft supplied with blood by the septal branch of the superior labial artery. To perform such a nasal correction, the entire septal mucoperichondrium can be harvested. [ 52 ] [ 53 ]


The surgeon cuts the anteriorly based septal mucosal tissue-flap as widely as possible, and then releases it with a low, posterior back-cut; but only as required to allow the rotation of the tissue-flap into the nasal wound.


A technical variant of the septal mucosal flap technique is the  trap-door flap , which is used to reconstruct one side of the upper half of the nasal lining. It is emplaced in the contralateral  nasal cavity , as a superiorly based septal mucosal flap of rectangular shape, like that of a "trap-door". This septomucosal flap variant is a random flap with its pedicle based at the junction of the septum and the lateral nasal skeleton. The surgeon elevates the flap of septal mucosa to the roof of the nasal septum, and then traverses it into the contralateral (opposite) nasal cavity through a slit made by removing a small, narrow portion of the dorsal roof of the septum. Afterwards, the septomucosal flap is stretched across the wound in the mucosal lining of the lateral nose. [ 48 ]


The following rhinoplastic techniques are applied to the surgical management of: (i) partial-thickness defects; (ii) full-thickness defects; (iii) heminasal reconstruction; and (iv) total nasal reconstruction.


A partial-thickness defect is a wound with adequate soft-tissue coverage of the underlying nasal skeleton, yet is too large for primary intention closure, with sutures. Based upon the locale of the wound, the surgeon has two options for correcting such a wound: (i) healing the wound by secondary intention (re-epithelialisation); and (ii) healing the wound with a full-thickness skin graft. Moreover, because it avoids the patched appearance of a skin-graft surgical correction, healing by secondary intention can successfully repair nasal wounds up to 10 mm in diameter; and, if the resultant scar proves aesthetically unacceptable, it can be revised later, after the wound has healed.


In the event, larger nasal wounds (defects) do successfully heal by secondary intention, but do present two disadvantages. First, the resultant scar often is a wide patch of tissue that is aesthetically inferior to the scars produced with other nasal-defect correction techniques; however, the skin of the medial canthus is an exception to such scarring. The second disadvantage to healing by secondary intention is that the contracture of the wound might distort the normal nasal anatomy, which can lead to a pronounced deformity of the alar rim area. For this reason, healing by secondary intention generally is not recommended for defects of the distal third of the nose; nonetheless, the exception is a small wound directly upon the nasal tip.


Full-thickness skin grafts are the effective wound-management technique for defects with a well-vascularized, soft-tissue bed covering the nasal skeleton. The patient's  ear  is the preferred skin-graft donor site from which to harvests grafts of pre-auricular skin and grafts of post-auricular skin, usually with an additional, small amount of adipose tissue to fill the wound cavity. Yet, nasal correction with a skin graft harvested from the patient's neck is not recommended, because that skin is low-density pilosebaceous tissue with very few follicles and sebaceous glands, thus is unlike the oily skin of the nose.


The technical advantages of nasal-defect correction with a skin graft are a brief surgery time, a simple rhinoplastic technique, and a low incidence of tissue  morbidity . The most effective corrections are with a shallow wound with sufficient, supporting soft-tissue that will prevent the occurrence of a conspicuous depression. Nonetheless, two disadvantages of skin-graft correction are mismatched skin color and skin texture, which might result in a correction with a patch-work appearance; a third disadvantage is the natural  histologic  tendency for such skin grafts to contract, which might distort the shape of the corrected nose.


Full-thickness nasal defects are in three types: (i) wounds to the skin and to the soft tissues, featuring either exposed bone or exposed cartilage, or both; (ii) wounds extending through the nasal skeleton; and (iii) wounds traversing all three nasal layers: skin, muscle, and the osseo-cartilaginous framework. Based upon the dimensions (length, width, depth) and topographic locale of the wound and the number of missing nasal-tissue layers, the surgeon determines the rhinoplastic technique for correcting a full-thickness defect; each of the aesthetic nasal subunits is considered separately and in combination.


The skin between the nasal dorsum and the medial canthal tendon is uniquely suited to healing by secondary intention; the outcomes often are superior to what is achieved with either skin grafts or skin-flaps and tissue-flaps. Because the medial canthal tendon is affixed to the facial bone, it readily resists the forces of  wound contracture ; moreover, the animation (movement) of the medial brow also lends resistance to the forces of wound contracture. Furthermore, the medial canthal region is aesthetically hidden by the shadows of the nasal dorsum and of the supraorbital rim, thereby obscuring any differences in the quality of the color and of the texture of the replacement skin (epithelium).


Healing by secondary intention (re-epithelialisation) occurs even when the wound extends to the nasal bone. Although the rate of healing depends upon the patient's wound-healing capacity, nasal wounds measuring up to 10 mm in diameter usually heal in at 4-weeks post-operative. Nonetheless, one potential, but rare, complication of this nasal correction approach is the formation of a medial canthal web, which can be corrected with two opposing  Z-plasties , technique which relieves the disfiguring tensions exerted by the scar tissue's contracture, its shape, and location on the nose.


The size of the nasal defect (wound) occurred, in either the dorsum or the lateral wall, or both, determines the reconstructive skin-flap technique applicable to the corresponding aesthetic nasal subunits.


The width of the human nasal-tip ranges 20–30 mm; the average width of the nasal tip, measured between the two alar lobules, is approximately 25 mm.


The appropriate surgical management of an alar lobule defect depends upon the dimensions (length, width, depth) of the wound. Anatomically, the nasal skin and the underlying soft tissues of the alar lobule form a semi-rigid aesthetic subunit that forms the graceful curve of the alar rim, and provides unobstructed airflow through the nostrils, the  anterior nares .


The reconstruction rhinoplasty of an extensive heminasal defect or of a total nasal defect is an extension of the plastic surgical principles applied to resolving the loss of a regional aesthetic subunit. The skin layers are replaced with a paramedian forehead flap, but, if forehead skin is unavailable, the alternative corrections include the  Washio retroauricular-temporal flap  and the  Tagliacozzi flap . The nasal skeleton is replaced with a rib-graft nasal dorsum and lateral nasal wall; septal cartilage grafts and conchal cartilage grafts are applied to correct defects of the nasal tip and of the alar lobules. [ 55 ] [ 56 ]


The nasal lining of the distal two-thirds of the nose can be covered with anteriorly based septal mucosal flaps; however, if bilateral septal-flaps are used, the septal cartilage does become devascularized, possibly from  iatrogenic  septal perforation. Furthermore, if the nasal defect is beyond the wound-correction scope of a septal mucosal flap, the alternative techniques are either an inferiorly based pericranial-flap (harvested from the frontal bone) or a free flap of temporoparietal fascia (harvested from the head), either of which can be lined with free grafts of mucosa to achieve the nasal reconstruction.


Illustration 1:  The surgeon cuts the excessively wide bones of the upper nasal  dorsum  (violet) with an  osteotome  (bone chisel), then detaches, corrects, and relocates them inwards, to a position, between the ocular orbits (red), that narrows the width of the nasal dorsum.


Illustration 2:  The surgeon chisels two cuts (incisions) to the nasal bones, each incision begins at the nasal cavity. The first incision begins at the yellow dot and extends upwards, along the green arrow, until meeting the zig-zag line (red). The second incision begins at the blue dot and extends upwards, along the black arrow, until meeting the zig-zag line (red). Once cut and loosened from the face, the nasal bone pieces are corrected, then pushed inwards and re-set, thus narrowing the nose.


The rhinoplasty patient returns home after surgery, to rest, and allow the nasal cartilage and bone tissues to heal the effects of having been forcefully cut. Assisted with prescribed medications— antibiotics ,  analgesics ,  steroids —to alleviate pain and aid wound healing, the patient convalesces for about 1-week, and can go outdoors. Post-operatively, external sutures are removed at 4–5 days; the external cast is removed at 1-week; the stents are removed within 4–14 days; and the "panda eyes"  periorbital bruising  heal at 2-weeks. If an alar base reduction is performed conjunctively within the Rhinoplasty, these sutures need to be removed within 7–10 days post operatively. Throughout the first year post-operative, in the course of the rhinoplastic wounds healing, the tissues will shift moderately as they settle into being a new nose.  Furthermore, as rhinoplasty climbs the ladder of surgical procedures performed to achieve an aspired appearance, especially amongst women, the relationship between body image and mental state must be examined in order to destigmatize motives behind the surgical intervention. [ 61 ] [ 62 ]


Rhinoplasty is safe, yet  complications  can arise; post-operative bleeding is uncommon, but usually resolves without treatment.  Infection  is rare, but, when it does occur, it might progress to become an  abscess  requiring the surgical drainage of the  pus , whilst the patient is under  general anaesthesia . Adhesions,  scars  that obstruct the airways, can form a bridge across the nasal cavity, from the  septum  to the  turbinates , and lead to difficulty breathing and may require surgical removal. If too much of the osseo-cartilaginous framework is removed, the consequent weakening can cause the external nasal skin to become shapeless, resulting in a "polly beak" deformity, resembling the beak of a  parrot . Likewise, if the septum is unsupported, the bridge of the nose can sink, resulting in a "saddle nose" deformity. The tip of the nose can be over-rotated, causing the nostrils to be too visible, resulting in a  porcine  nose. If the cartilages of the nose tip are over-resected, it can cause a pinched-tip nose. If the columella is incorrectly cut, variable-degree numbness might result, which requires a months-long resolution. Other deformities that may result from a rhinoplasty include Rocker deformity, inverted V deformity, and open room deformity. [ 63 ]  Furthermore, in the course of the rhinoplasty, the surgeon might  accidentally  perforate the septum (septal perforation), which later can cause chronic nose bleeding, crusting of nasal fluids, difficult breathing, and whistling breathing. A  turbinectomy  may result in  empty nose syndrome .


Non-surgical rhinoplasty  is a medical procedure in which injectable fillers, such as  collagen  or  hyaluronic acid , are used to alter and shape a person's nose without  invasive surgery . The procedure fills in depressed areas on the nose, lifting the angle of the tip or smoothing the appearance of bumps on the bridge. [ 64 ]  The procedure does not alter nose size, though it can be used to correct some functional  birth defects .


Originally developed at the turn of the twenty-first century, early attempts used biologically harmful soft-tissue fillers such as  paraffin wax  and  silicone . After 2000, physicians use  minimally invasive  techniques using modern fillers. [ 65 ]


A  rotation flap  is a semicircular  skin flap  that is rotated into the defect on a  fulcrum point . Rotation flaps provide the ability to mobilize large areas of tissue with a wide vascular base for reconstruction. The flap must be adequately large, and a large base is necessary if a back-cut will be needed to lengthen the flap. If the flap is too small, the residual defect can be covered by mobilizing the surrounding tissue.


A drawback of rotation flaps is the extended cutting and undermining needed to create the flap, thus increasing the risk of  hemorrhage  and  nerve damage .


This term is often used in contrast with the term " free flap " where the transferred tissue is completely detached.


Skin grafting , a type of  graft surgery , involves the  transplantation  of  skin  without a defined circulation. The transplanted  tissue  is called a  skin graft . [ 1 ]


Surgeons may use skin grafting to treat:


Skin grafting often takes place after serious injuries when some of the body's skin is damaged. Surgical removal (excision or  debridement ) of the damaged skin is followed by skin grafting.  The grafting serves two purposes: reducing the course of treatment needed (and time in the hospital), and improving the function and appearance of the area of the body which receives the skin graft.


There are two types of skin grafts:


A full-thickness skin graft is more risky, in terms of the body accepting the skin, yet it leaves only a scar line on the donor section, similar to a Cesarean-section scar. In the case of full-thickness skin grafts, the donor section will often heal much more quickly than the injury and causes less pain than a partial-thickness skin graft. A partial thickness donor site must heal by re-epithelialization which can be painful and take an extensive length of time.


Two layers of skin created from animal sources has been found to be useful in  venous leg ulcers . [ 3 ]


Grafts can be classified by their thickness, the source, and the purpose. By source:


Allografts, xenografts, and prosthetic grafts are usually used as temporary skin substitutes, that is a wound dressing for preventing infection and fluid loss. They will eventually need to be removed as the body starts to reject the foreign material. Autologous grafts and some forms of treated allografts can be left on permanently without rejection. [ 5 ]  Genetically modified pigs can produce allograft-equivalent skin material, [ 6 ]  and  tilapia  skin is used as an experimental cheap xenograft in places where porcine skin is unavailable and in veterinary medicine. [ 7 ] [ 8 ]


By thickness:


When grafts are taken from other animals, they are known as heterografts or xenografts. By definition, they are temporary biologic dressings which the body will reject within days to a few weeks. They are useful in reducing the bacterial concentration of an open wound, as well as reducing fluid loss.


For more extensive tissue loss, a full-thickness skin graft, which includes the entire thickness of the skin, may be necessary. This is often performed for defects of the face and hand where contraction of the graft should be minimized. The general rule is that the thicker the graft, the less the contraction and deformity.


Cell cultured  epithelial   autograft  (CEA) procedures take skin cells from the person needing the graft to grow new skin cells in sheets in a laboratory; because the cells are taken from the person, that person's immune system will not reject them. However, because these sheets are very thin (only a few cell layers thick) they do not stand up to trauma, and the "take" is often less than 100%.  Newer grafting procedures combine CEA with a dermal matrix for more support. [ clarify ] Research is investigating the possibilities of combining CEA and a dermal matrix in one product.


Experimental procedures are being tested for burn victims using stem cells in solution which are applied to the burned area using a  skin cell gun . Recent [ when? ]  advances have been successful in applying the cells without damage. [ citation needed ]


In order to remove the thin and well preserved skin slices and strips from the donor, surgeons use a special surgical instrument called a  dermatome . This usually produces a split-thickness skin graft, which contains the  epidermis   with only a portion of the  dermis . The dermis left behind at the donor site contains  hair follicles  and  sebaceous glands , both of which contain epidermal cells which gradually proliferate out to form a new layer of epidermis. The donor site may be extremely painful and vulnerable to infection. There are several ways to treat donor site pain. These include subcutaneous anesthetic agents, topical anesthetic agents, and certain types of wound dressings. [ 10 ]


The graft is carefully spread on the bare area to be covered. It is held in place by a few small  stitches  or  surgical staples .  The healing process for skin grafts typically occurs in three stages: plasmatic imbibition, capillary  inosculation , and  neovascularization .


During the first 24 hours, the graft is initially nourished by a process called  plasmatic imbibition  in which the graft "drinks  plasma " (i.e., absorbs nutrients from the underlying recipient bed).


Between 2–3 days, new blood vessels begin growing from the recipient area into the transplanted skin in a process called  capillary inosculation .


Between 4–7 days,  neovascularization  occurs in which new blood vessels form between the graft and the recipient tissues.


To prevent the accumulation of fluid under the graft which can prevent its attachment and revascularization, the graft is frequently  meshed  by making lengthwise rows of short, interrupted cuts, each a few millimeters long, with each row offset by half a cut length like bricks in a wall. In addition to allowing for drainage, this allows the graft to both stretch and cover a larger area as well as to more closely approximate the contours of the recipient area. However, it results in a rather pebbled appearance upon healing that may ultimately look less aesthetically pleasing. [ 11 ]


An increasingly common aid to both pre-operative wound maintenance and post-operative graft healing is the use of  negative pressure wound therapy  (NPWT). This system works by placing a section of foam cut to size over the wound, then laying a perforated tube onto the foam. The arrangement is then secured with bandages. A vacuum unit then creates negative pressure, sealing the edges of the wound to the foam, and drawing out excess blood and fluids. This process typically helps to maintain cleanliness in the graft site, promotes the development of new blood vessels, and increases the chances of the graft successfully taking. NPWT can also be used between debridement and graft operations to assist an infected wound in remaining clean for a period of time before new skin is applied. Skin grafting can also be seen as a skin transplant. [ medical citation needed ]


This is based upon the principle of mobilizing a full segment of skin from an area to the site needing tissue replacement. The flaps are triangularly shaped opposite each other. It can be used in direct excision and closure of a contracted scar to produce a better looking and healing scar. It helps to elongate and break up a linear scar. It also gives a good result in the release of linear contractures. [ 12 ] [ 13 ] [ 14 ] [ 15 ]  Z-plasty is of paramount importance to the plastic surgeon and a frequently used method in both single multiple forms. [ 16 ]


Risks for the skin graft surgery are:


Rejection may occur in  xenografts . To prevent this, the person receiving the graft usually must be treated with long-term  immunosuppressant  drugs.


Most skin grafts are successful, but in some cases grafts do not heal well and may require repeat grafting. The graft should also be monitored for good circulation.


Recovery time from skin grafting can be long.  Graft recipients wear compression garments for several months and are at risk for depression and anxiety consequent to long-term pain and loss of function. [ 17 ]


Skin grafting, in more rudimentary forms, has been practiced since ancient times. The  Ebers Papyrus  of  ancient Egypt  contains a brief treatise on xenografting. [ 18 ]  Around 500 years later, members of the  Hindu   Kamma  caste are described as performing skin grafts which included the usage of subcutaneous fat. [ 19 ]  The 2nd century AD Greek philosopher  Celsus  is also known to have developed a method to reconstruct the foreskins of  Jewish  men using skin grafts, as  circumcision  was considered barbaric in Greek and Roman society. [ 20 ]


More modern uses of skin grafting were described in the mid-to-late 19th century, including Reverdin's use of the pinch graft in 1869; Ollier's and Thiersch's uses of the split-thickness graft in 1872 and 1886, respectively; and Wolfe's and Krause's use of the full-thickness graft in 1875 and 1893, respectively.  John Harvey Girdner  demonstrated skin graft transplant from a deceased donor in 1880. [ 21 ]  Today, skin grafting is commonly used in dermatologic surgery. [ 22 ]  Recently Reverdin's technique is used but with very small (less than 3 mm diameter). Such small wounds heal in a short time without scars. This technique is called  SkinDot . [ 23 ]


There are alternatives to skin grafting including skin substitutes using cells from patients, [ 24 ]  skin from other animals, such as pigs, known as Xenograft and medical devices that help to close large wounds. Xenograft was originally known as "zoografting." Other animals that can be used include dogs, rabbits, frogs, and cats, with the greatest success achieved with porcine skin. [ 12 ] [ 13 ]  Other skin substitutes include Allograft, Biobrane, TransCyte, Integra, AlloDerm, Cultured epithelial autografts (CEA).


There are medical devices that help close large wounds. The device uses skin anchors that are attached to healthy skin. An adjustable tension controller then exerts a constant pulling tension on sutures looped around the skin anchors. The device gradually closes the wound over time. [ 25 ]


“Microcolumn grafting” is a new grafting method being researched that uses needles to take autologous skin biopsies from the patient & implant them in the wound site. [ 26 ] [ 27 ] [ 28 ]


Snapchat dysmorphia , also known as " selfie  dysmorphia", is a trending phenomenon used to describe patients who seek out  plastic surgery  in order to replicate and appear like their filtered selfies or altered images of themselves. [ 1 ]  The increasing availability and variety of  filters  used on social media apps, such as  Snapchat  or  Instagram , allow users to edit and apply filters to their photos in an instant – blemish the skin, narrow the nose, enlarge the eyes, and numerous other edits to one's facial features. These heavily edited images create unrealistic and unnatural expectations of one's appearance, showing users a "perfected" view of themselves. [ 2 ]  The disconnection between one's real-life appearance and the highly filtered versions of oneself manifest into body insecurity and dysmorphia. [ 3 ]  The distorted perception of oneself can potentially evolve into an obsessive preoccupation with perceived flaws in one's appearance, a mental disorder known as  body dysmorphic disorder  (or BDD). [ 4 ]  BDD has been classified as part of the obsessive-compulsive spectrum and it is currently affecting one in 50 Americans. [ 5 ]


In 2018, many newspaper outlets questioned the rising impact of social media applications on the choice of plastic surgeries for users. [ 5 ]  Researchers from the  Boston Medical Center  (BMC) wrote in a  JAMA Facial Plastic Surgery  essay that with the rise of Snapchat in 2011, there has been increasing cases of patients going into the cosmetic doctors’ offices to request for surgeries to look like filtered versions of themselves, similar to how they appear through Snapchat filters. [ 3 ]  These filters create a dysmorphic illusion in which the unattainable filters establish a disconnection from the realities of how individuals look like and what they desire to look like. Hence, the filtered photos from social media apps encourages users to drive for constant improvements to their appearance based on the filters. The pressure to achieve this impossible aesthetic look may be a casual factor in triggering BDD, [ 2 ]  and individuals with BDD tend to engage in heavy plastic surgery use. Based on a 2022 survey results from the  American Academy of Facial Plastic and Reconstructive Surgery  (AAFPRS), 79% of plastic surgeons reported a trend of patients seeking improvement in their physical appearances with the desire to look better in selfies. [ 6 ]