www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Outcomes
of
external
septorhinoplasty
in
a
Turkish
male
population
夽
Gamze
Didem
Kilci,
Engin
Bas
¸er,
Ays
¸egül
Verim,
Ömer
Faruk
C
¸alim,
Bayram
Veyseller,
Orhan
Özturan,
Ahmet
Altintas
¸,
Mustafa
C
¸elik
∗ BakirköyDr.SadiKonukTrainingandResearchHospital,Istanbul,TurkeyReceived7February2017;accepted19April2017 Availableonline20May2017
KEYWORDS Septorhinoplasty; Ethnicfacial harmony; Columellarincision type; Rhinobaseprogram Abstract
Introduction:Thefirstandoneofthemostimportantstepsinfacialplasticsurgeryisaccurate preoperative facialanalysis andrecording ofdata thatmay helpthesurgeon to checkthe outcomesofhis/hertechniques,promotingasurgeon’sprofessionaldevelopment.
Objective:Toevaluatetheestheticoutcomesofexternalseptorhinoplastyrelevanttoethnic facialharmonyandtoinvestigatetherelationshipofthecolumellarincisionscarwiththetype ofskinandcolumellarincisiontypeinaTurkishpopulation.
Methods:Intotal,28consecutiveadultmalepatientswithameanageof32.14±10.66years (range:18---61years)wereincludedthestudy.Primaryoutcomeswerepreoperativeand postop-erativephotogrammetricfacialanalysesofthepatientsincludingmeasurementofnasofrontal angle,nasolabialangleandnasalprojectionratios(Gode)assessedaccordingtothedataderived fromtheRhinobaseprogram.ResultswerecomparedtofacialproportionsoftheTurkish popu-lation.ColumellarincisionscarscoresrelatedtotheFitzpatrickskintypeclassificationofthe patientsandcolumellarincisiontypesusedfortheexternalapproachweresecondaryoutcomes ofthestudy.
Results:Mean preoperative and postoperative nasofrontal angles were 148.04◦±8.18◦ and 144.50◦±7.15◦, respectively, whilemean preoperative and postoperative nasolabial angles were 87.59◦±14.01◦ and98.50◦±9.71◦,respectively.Meanpreoperative andpostoperative nasal tip projection ratios were 0.56±0.05 and 0.60±0.06, respectively. The differences
夽 Pleasecitethisarticleas:KilciGD,Bas¸erE,VerimA,¸alimC ÖF,VeysellerB,ÖzturanO,etal.Outcomesofexternalseptorhinoplastyin
aTurkishmalepopulation.BrazJOtorhinolaryngol.2018;84:426---34.
∗Correspondingauthor.
E-mail:dr.mcelik@yahoo.com(M.C¸elik).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2017.04.010
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
between pre- andpostoperative measurementswere all significantly differentand were in accordancewithTurkishnasalharmony.Columellarinverted‘‘V’’incisionswereperformedin 15(53.6%)patientswhile‘‘V’’incisionswereusedin13(46.4%)patients.FitzpatrickskinType4 wasseenin46.42%ofthepatients,FitzpatrickType3in46.42%andFitzpatrickType2in7.14% ofthepatients.Nosignificantdifferencewasseenbetweencolumellarscarscoresaccording toskintypeandcolumellarincisiontypeusedforexternalseptorhinoplasty.
Conclusions: Thisstudydemonstratedthatoutcomesfornasofrontalangle,nasolabialangleand nasaltipprojectionratiosanalyzedusingtheRhinobaseprograminpatientswhounderwent externalseptorhinoplastyweresimilartoreferencevaluesfortheTurkishpopulation. © 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Rinosseptoplastia; Harmoniafacial étnica; Incisãocolumelar; ProgramaRhinobase
Resultadosderinosseptoplastiaexternaemumapopulac¸ãoturcadosexomasculino Resumo
Introduc¸ão: Oprimeiroeumdosmaisimportantespassosnacirurgiaplásticafacialéaanálise pré-operatóriafacialprecisaeregistrodedadosquepodemajudarocirurgiãoaverificaros resultadosdesuastécnicas,promovendoseudesenvolvimentoprofissional.
Objetivo: Avaliarosresultadosestéticosdarinosseptoplastiaexternarelevantesparaa harmo-niaétnicafacialeinvestigaraassociac¸ãodacicatrizdeincisãocolumelarcomotipodepelee tipodeincisãocolumelaremumapopulac¸ãoturca.
Método: Nototal,28pacientesadultosconsecutivoscommédiadeidadede32,14±10,66anos (intervalo: 18-61anos) foramincluídosnoestudo.Osdesfechosprimários foramas análises faciaisfotogramétricaspré-operatóriasepós-operatóriasdospacientes,incluindoamedidado ângulonasofrontal,ângulonasolabialerazõesdaprojec¸ãonasal(Gode),avaliadosdeacordo comosdadosderivadosdoprogramaRhinobase.Osresultadosforamcomparadosàsproporc¸ões faciais dapopulac¸ãoturca.Osescores decicatriz de incisãocolumelarrelacionados coma classificac¸ãodeFitzpatrickdotipodepeledospacienteseostiposdeincisãocolumelarusados paraaabordagemexternaforamosdesfechossecundáriosdoestudo.
Resultados: Os ângulos nasofrontais pré- e pós-operatórios médios foram 148,04±8,18◦ e 144,50±7,15◦,respectivamente,enquantoosângulosnasolabiaispré-epós-operatóriosmédios foram87,59±14,01◦e98,50±9,71◦,respectivamente.Asrazõesmédiasdaprojec¸ãonasal pré-epós-operatóriaforamde0,56±0,05e0,60±0,06,respectivamente.Asdiferenc¸asentreas medidaspré-epós-operatóriasforamtodassignificativamentediferenteseestavamdeacordo comaharmonianasalturca.Aincisãocolumelarem‘‘V’’invertidofoiutilizadaem15(53,6%) pacienteseaincisãoem‘‘V’’foiutilizadaem13(46,4%)pacientes.PeleFitzpatricktipo4foi observadaem46,42%dospacientes,FitzpatrickTipo3em46,42%eFitzpatrickTipo2em7,14% dospacientes.Nãofoiobservadadiferenc¸asignificativaentreosescoresdecicatriz colume-lardeacordocomotipodepeleeotipodeincisãocolumelarutilizadosnarinosseptoplastia externa.
Conclusões: Este estudo demonstrou que os desfechos para ângulo nasofrontal, ângulo nasolabial e razões de projec¸ão nasal analisados pelo programa Rhinobase em pacientes submetidos àrinosseptoplastia externaforamsemelhantesaosvalores dereferênciapara a populac¸ãoturca.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Apart from its major role in the respiratory mechanism, the nose is a component of the face that substantially contributestofacialesthetics.Therefore,septorhinoplasty (SRP),withever-increasinginterest,appearstobeonethe mostcommonlyperformedsurgicaltechniquesforesthetic
andfunctionalpurposes.Regardingtheincisionalapproach, SRPmaybetechnicallyclassifiedaseitheropen(external)or closedrhinoplasty.Although,thetechnicalandprocedural aspectsof thesetwoapproaches aresimilar,the external approachispreferredovertheclosedtechniqueasitismore beneficialin terms of goodanatomical exposure enabling easy learning and teaching for the rhinoplasty surgeon.1
However,undesirablescarformationandunpredictablepoor healingofthecolumellarincisionarethemaindrawbacksof thistechnique.
Pathologies underlying the nose, the patient’s expec-tation for surgery, age, gender, race, facialharmony and her/his ethnic characteristics may present considerable variabilities between populations.2---6 Besides all of these
factorswhich should be carefully examined, facial analy-sisincludingnasofrontal,nasolabial,nasomentalangles,tip projection ratios and tip deviation angles should be per-formedpreoperativelyusingcertainobjectivemeasuresand methodstoobtainsuccessfulresults.7,8
Within this context, photographic techniques are pre-ferredascommonlyusedmethodsinthepreoperative plan-ning and postoperative assessment of theselandmarks.7,9
Portraitphotographstakenfromsixdifferentdirectionsare uploadedtovariousdigitalsoftwareprogramsdevelopedfor facialanalysisanddatadrawnfromthesesoftwareareused inoutcomeassessment.
Inthisstudy,usingtheRhinobaseBorlandDelphisoftware program, we aimed to critically examine pre- and post-operativefacialanalyses ofpatients whounderwentopen (external)approachSRPandtocomparetheestheticresults withtheethniccharacteristicsoftheTurkishpopulation.10
Columellar scar formation wasalsoanalyzed according to ethnicskintypesandcolumellarincisiontype.
Methods
Thiswasaprospective,observationalstudyconductedatthe Otorhinolaryngology Department of our hospital between 2008 and 2011 with the approval of the local institu-tionalethics committee (StudyID B:30.2.BAV.0.05.05/31). Allvolunteerswereprovidedwithinformationaboutthe pro-cedures,andwritteninformedconsentwasobtainedbefore thestudy.Twenty-eightconsecutiveadultmalepatientswho underwent primary external SRP witha diagnosis of sep-tonasaldeformitywereincludedinthestudy.
Patientswereexcludediftheyhadahistoryofprevious SRP,additionalsinonasalpathologies(chronicrhinosinusitis withor withoutpolyposis),andfemale patientswerealso excludedtominimizevariabilitybecauseof gender differ-ences.
Demographicinformation, anamnesis,previous medica-tion, systemic diseases, detailed endoscopic examination andFitzpatrickskintypeclassificationofthepatientswere enteredintothehospitaldatabase.11,12
Portraitphotographsfromtheanterior,basal,right lat-eral,leftlateral,right obliqueandleftobliqueviews (six directions) were taken preoperatively by a professional expertinrhinoplastyphotographyandwereuploadedtothe RhinobaseBorlandDelphisoftwareprogram(version4.0for Windows;InpriseCorp,ScottsValley,CA,USA).10Anatomical
Figure2 Preoperativebasalfacialanalysis.
landmarks(tip,supratip, subnasale, nasion, rhinion,etc.) were marked on the photographs and in the appropriate boxseenontherightsideofthescreen.Measurementsof correspondinglengths,heights,distances,ratios(tip projec-tionratio)andangles(Nasofrontal Angle(NFA),Nasolabial Angle (NLA), etc.), automatically calculated in the Rhi-nobaseprogram,weredisplayedonthescreen andstored intheprogram(Figs.1and2).
Surgeryandpostoperativecare
External SRP under general anesthesia was preferred for theprocedure. Patientsweredividedintoeither columel-larinverted‘‘V’’or‘‘V’’incisiongroupsusingacointoss. Incisionswere closedusing 4/0absorbablepolyglactin for thesubdermallayer,and5/0nonabsorbablepolypropylene fortheskinlayer.Topicalantibioticointmentwasappliedto thesuturesuntiltheirremovalonpostoperativeday5.
Follow-upassessmentsandoutcomemeasures
Patients were all followed up for a mean of 9.82±6.15 months (range6---30 months) after surgery. Similarto the procedureforpreoperativephotogrammetricmeasurements with the Rhinobase software program, patients’ portrait photographs wereall reuploaded and NLA, NFA and nasal tip projection ratios were reevaluated at postoperative
follow-up(Figs.3and4).Photogrammetricfacialanalyses were accepted as the primary outcome measures of the presentstudy.
Secondary outcome measures were columellar scar assessmentsbasedontheStonyBrookScarEvaluationScale (SBSES) modified by Verim et al. for use with columellar scars.13,14Thepresenceorabsenceofscarsofwidth>2mm,
elevationordepression,discoloration,notching,and over-allappearancewereassigned0or1pointforeachofthese items.Totalscores werecategorizedintofive groups ran-ging from 0 (worst), 1 (poor), 2 (mild), 3 (moderate), 4 (good)to5 (best--- no scar). Columellar scars were eval-uated with regard to Fitzpatrick skin type classification of the patients and columellar incision type used in the SRP.
Statisticalanalysis
NCSS(Number CruncherStatistical System)2007 andPASS (PowerAnalysisandSampleSize)2008StatisticalSoftware (NCSS LLC, Kaysville, UT, USA) has been used for statis-tical analysis of the results. Descriptive statistics (mean, standard deviation, frequency, median) were used in the evaluationofthestudydata.Datawerecomparedusingthe Chi-squaredtest and PairedSample t-test. Statistical sig-nificancewasacceptedatp<0.05withp<0.01beingvery significant.
Figure3 Postoperativelateralfacialanalysis(sixthmonth).
Results
Twenty-eightconsecutiveadultmalepatientswithamean ageof32.14±10.66years(range:18---61years)completed thestudy.Postoperativefollow-uprangedbetween6and30 monthswithameanof9.82±6.15months.Thecolumellar inverted‘‘V’’incisionwasperformedin15(53.6%)patients while thecolumellar ‘‘V’’incisionwasusedin 13(46.4%) patients.
TheFitzpatrickskintypeclassificationofthepatientswas asfollows:2(7.1%)patientshadType2,13(46.4%)patients Type3,and13(46.4%)patientsType4.Demographicsand Fitzpatrickskinclassificationofthepatientsaredetailedin
Table1.
Mean preoperative NFA, NLA and tip projection ratios of the patients retrieved from the Rhinobase program were respectively 148.04◦±8.18◦, 87.59◦±14.01◦, and 0.56±0.05.However,meanpostoperativeNFA,NLAandtip projectionratioswere144.50◦±7.15◦,98.50◦±9.71◦,and 0.60±0.06,respectively.MeanNFA,NLAandtipprojection ratios all improved significantly after SRP (Paired Sample
t-test;p<0.01;p=0.001,0.001, and0.003,respectively). DetailedanalysesofNFA,NLAandtipprojectionratiosare displayedinTable2.
Columellar scar assessments at long-term follow-up demonstratedthat8(28.6%)patientshadacolumellarscar depressed in relation to the surrounding skin; 3 (10.7%) patients had a scar darker than the surrounding skin; 5
(17.9%)patientshadnotching;2(7.1%)hadascarwithpoor overallappearance;1(3.6%)patienthadascarwiderthan 2mm.ColumellarscarassessmentsaccordingtoStonyBrook Scar Evaluation Scores disclosed 2 (7.1%) patients with a poor (1/5)columellar scar,3 (10.7%)patients withamild (2/5) columellarscar, 4 (14.3%)patients witha moderate (3/5) scar, and 19 (67.9%) patients without scar forma-tion(5/5).Patients’columellarscarsclassifiedaccordingto StonyBrookScarEvaluationScoresarepresentedinTable3. EvaluationofStonyBrookscarscoresinrelationto Fitz-patrickskintypeclassificationdemonstratednostatistically significant differencebetween scar scores of the patients andFitzpatrickSkin Type2, Type3,or Type4(Chi-Square test;p>0.05)(Table4).Likewise,evaluationofStonyBrook scar scoresinrelationtocolumellarincisiontypeusedfor external approach SRP (Inverted ‘‘V’’ vs. ‘‘V’’ incision) demonstratednostatisticallysignificantdifferencebetween scar scoresofthepatientsandtypeofcolumellarincision employedforexternalSRP(Table5).
Therefore,skintype(FitzpatrickType2,Type3,orType 4)andcolumellarincisiontypeused(inverted‘‘V’’or‘‘V’’ incision) werenotfactorsinfluencing scarformation after externalSRP.
Discussion
The first and one of the most important steps in facial plasticsurgeryisaccuratepreoperativefacialanalysisand
Figure4 Postoperativebasalfacialanalysis(sixthmonth).
recordingof datathatmayhelp thesurgeontocheckthe outcomesofhis/hertechniques,promotingasurgeon’s pro-fessionaldevelopment.7,15,16
Photogrammetric facial analysis, a method commonly used in facial analysis, enables objective substantiation and archiving of the outcomes of SRP.7,9 This method is
more reliable than cephalometric analysis in soft tissue profileanalysis,andfor determiningthe racialandethnic
differencesin normal facial profiles. Moreover, angle and ratio measurements, which are independent of image dimensions,arethemajoradvantagesofthismethodover cephalometricanalysis.9,17
Varioussofttissuefacialanalysisprogramsbasedon2Dor 3Dphotographicdocumentationhavebeenreportedinthe literature.18---20Fromthese,Rhinobase,afreeprogramwith
anautomatedphotographicanalysistoolachievingcomplete
Table1 Distributionofpatients’age,follow-upperiod,Fitzpatrickskintypes,andcolumellarincisiontypes.
Min-Max Mean±SD
Age(years) 18---61 32.14±10.66
Postoperativefollow-up(months) 6---30 9.82±6.15
Numberofpatients %
Fitzpatrickskintypes
Type2 2 7.1
Type3 13 46.4
Type4 13 46.4
Columellarincisiontypes
InvertedV 15 53.6
Table2 Preoperative,postoperativenasofrontalangle,nasolabialangle,andtipprojectionratiosofthepatients.
Mean±SD p-Value
Nasofrontalangle(NFA;degrees)
Preoperative 148.04±8.18 0.001a
Postoperative 144.50±7.15
Nasolabialangle(NLA;degrees)
Preoperative 87.59±14.01 0.001a
Postoperative 98.50±9.71
Tipprojectionratios
Preoperative 0.56±0.05 0.003a
Postoperative 0.60±0.06
Pairedsamplet-test.
ap<0.01.
Table3 Distributionofscarevaluationparametersandscoresofthepatients.
StonyBrookScarEvaluation Numberofpatients %
Depressedcomparedwithsurroundingskin 8 28.6
Darkerthanthesurroundingskin 3 10.7
Notching 5 17.9
Pooroverallappearance 2 7.1
Width≥2mm 1 3.6
DistributionofScarScores
Poor(1/5) 2 7.1
Mild(2/5) 3 10.7
Moderate(3/5) 4 14.3
NoScar(5/5) 19 67.9
Table4 EvaluationofStonyBrookScarScoresaccordingtoFitzpatrickskintype.
StonyBrookScarScores Fitzpatrickskintype p-Value
Type2 Type3 Type4
n(%) n(%) n(%) 1/5(poor) 0(0) 2(15.4) 0(0) 0.587 2/5(mild) 0(0) 1(7.7) 2(15.4) 3/5(moderate) 0(0) 1(7.7) 3(23.1) 5/5(noscar) 2(100) 9(69.2) 8(61.5) Chi-Squaredtest.p<0.05.
Table5 EvaluationofStonyBrookScarScoresaccordingtocolumellarincisiontype.
StonyBrookScarScores Columellarincisiontype p-Value
InvertedVincision Vincision
n(%) n(%) 1/5(poor) 2(13.3) 0(0) 0.066 2/5(mild) 3(20) 0(0) 3/5(moderate) 3(20) 1(7.7) 5/5(noscar) 7(46.7) 12(92.3) Chi-Squaretest;p<0.05.
facialanalysisinlessthan15min,isourpreferredprogram forpre-andpostoperativeanalyses.10
Several studieshave reportedthat ethnicity,race, and gender arefactorsdetermining facialratios andanglesin populations.7,9,16,21,22 However, although endorsed in the
study by Biller and Kim in 2009, ethnicity and age were pointedouttobeofsecondaryimportancetotheevaluation ofindividualfacialharmony.23
Knowledgeof facialestheticmeasurementsofpatients inaparticularpopulationisaprerequisiteforprecisefacial analysis.24Thenasion,oneoftheconspicuouslandmarksin
facialharmony,andtheangle derivedfromthisreference point(nasofrontalangle)shouldbecarefullyconsideredin lateralprofilesinanattempttogainmeasurementsspecific totheethnicityofthepatient.
In2011,inastudybyGodeetal.inTurkeycomprising40 controlsand40patientswhoweretoundergoSRP,meanNFA measurementsdeterminedafter softtissue facialanalysis wereabout143.3◦±8.3◦incontrolswhowerepleasedwith their facialappearance. The authorsstated nosignificant differenceswithregardtopatients’gender.7
In 2008, standard photogrammetric facial analysis of anotherTurkishpopulationincluding111controlsrevealed NFAmeasurementsofmales(mean±SD139.5◦±11◦)tobe unrelated to gender.However, when considering the very largerangeofNFAs,theauthorsconcludedthatNFA mea-surementsvariedsubstantiallybetween Turks.25 Inastudy
covering100Turksin2009,Malkoc¸etal.alsoreportedmean maleNFAs(146◦±8.19◦)tobeunrelatedtogender.26
Mean nasofrontal angles of our patients were 148.04◦±8.18◦ preoperatively and 144.50◦±7.15◦ in postoperative follow-up. The decrease in the mean measurement of nasofrontal angles was very significant (p=0.001). Moreover, mean postoperative NFAs of our patients were within the range of mean NFAs, varying between 139.5◦±11◦ and 146◦±8.19◦, in Turkish peo-ple who were satisfied with the appearance of their nose.7,25,26
In a recent study evaluatingmean nasal anthropomet-ric measurements in young Turkish males in 2006, Turks living on the Black Sea coast were found to have a NFA (134.96◦±7.7◦)moreacutethaninourcohort.22Mostlikely,
thisdiversityoriginatesfromfacialstructuresdifferingfrom one region to another in Turkey. In our opinion, hetero-geneityof thepopulation shouldbebornein mindbefore interpretingaveragefacialanalysismeasurements.Indeed, thedemographiccompositionofAnatolianTerritorypresents considerablevariationsasaresultofbeingoccupiedby mul-tipleimmigrationsinthepast.
Nasal tip contouring has always been a critical factor in achieving successfulrhinoplasty.27 Projection, rotation,
shape,andsofttissuethicknessarethemaincharacteristics ofanidealnasaltip.28Rhinoplastyisknowntorequire
elab-orationoftipprojectionandrotationaskeycomponentsof surgicalsuccess.29
In an effort to identify the improvement in tip pro-jection, preoperative and postoperative tip projection ratios were compared in our study. The very significant increase that we identified after surgery (0.56±0.05 vs. 0.60±0.06; p<0.003) was consistent with tip projection ratios(0.55---0.60ofthedistancefromthenasiontothenasal tip)definedbyGoode.30
Inourstudy,NLA wasselectedtobethethird parame-terfor analyzingtheTurkishmaleprofilebeforeandafter SRP. As mentioned before,when considering NFA and tip projection ratios, NLA has proved to differ among vari-ous ethnicities and races.22,25,26 Similar to the outcomes
forNFAandtipprojectionratios,preoperativeand postop-erativeNLA valueswereverysignificantlyimprovedinour patients(87.59◦±14.01◦vs.98.50◦±9.71◦;p=0.001). Fur-thermore,NLAmeasurementsofourcohortwereinkeeping withthemeanNLAsoftheTurkishpopulationreportedby Kale-Varlık25andMalkocetal.26(98◦±13.7◦and101◦±10◦,
respectively).
Alongwiththeprimaryoutcomeparametersusedfor pro-fileanalysisinSRP,columellarincisionscarswereincludedin thescopeofsecondaryoutcomesinthepresentstudy.The effectsofincisiontypeusedintheexternal approachand pigmentationof the skin wereinvestigated oncolumellar scaroutcome assessed usingtheStony BrookScar Evalua-tionScale.13Inthepresentstudy,7.1%ofpatientshadpoor
scarformation, 10.7%hadmild scar formationand 68%of patientshadnocolumellarscar.Insummary,ourfailurerate incolumellarscarformationwasabout7.1%.Theseresults werepoorerthanforsomeauthorswhosescarratedidnot exceed2%.31,32 However,when comparedto the
columel-larscarevaluationofBafaqeehandAl-QattaninanArabian population,ourresultswereseen tobebetterthanthose reportedbytheseauthorswhoattributedthehighrateof scarformationtothethickanddarkskinoftheirpatients.33
IncontrasttotheassertionsofBafaqeehandAl-Qattan, wewere notable toconfirm arelationship between poor scarformationandhighpigmentconcentrationoftheskin. Infact,wepreferredthewidelyusedFitzpatrickskintype classificationfor examining the relationship between scar formationandskintone,andfoundnocorrelationbetween thesetwoparameters.Fromthispoint,ourstudywasrather in line withthe opinions of Adamsonwho considered the columellatobeapreferredsiteforhealing,evenindarker skins.34
Thelackofcorrelation betweencolumellarscar forma-tionand columellarincision typeis thefinal point of our study.Controversyexistsontherelationship betweenscar formationandthetypeofcolumellarincisionusedin exter-nalSRP.Therearesomewhosuggestthat,withtheinverted ‘‘V’’incision,theremaybeamoresatisfactoryscarinterms of visibility. However, some do not agree, based on the opinionthatfinesseshouldberequiredforsuturingincision lines.31,32,35,36
Ourobservationsdidnotconfirmthesuperiorityofa par-ticularincisiontypeoveranotherintermsofpreventingpoor healing.Indeed,53.6%ofourpatientswereoperatedusing aninverted‘‘V’’incisionand46.4%witha‘‘V’’incisionand nocorrelationwasfoundbetweencolumellarscarformation andincisiontechniqueemployed.
Althoughweachievedinterestingresults,thereare lim-itationstoourstudy.Thesizeofthestudypopulationmay alsobealimitation.Wecouldnotassertedthatcolumellar scarformationwasnotrelatedtothetypeofcolumellar inci-sionusedortopigmentconcentrationoftheskin because ofthesmallstudypopulation.Theotherlimitationsofthe present study arethat the limited numberof parameters analyzed.However,consideringthedifferencesinNLA,NFA andtipprojectionratiosbetweengenders,wepreferredto
studymalepatientstoavoidanypossiblebias.Furthermore, thisstudy was ratherbuilt onthe pre- andpostoperative profileanalysisof aparticular population. Furtherstudies involvinglargernumbersofpatientsareneededtoconfirm theseinitialfindings.
Conclusion
Inconclusion,theresultsofthepresentstudydemonstrated thatthemeanNFA,NLAandtipprojectionratiosofTurkish men who required improvement in their nasal appear-ance and symptoms were, respectively, 148.04◦±8.18◦, 87.59◦±14.01◦ and 0.56±0.05, whereas postoperative evaluation of the same parameters used in profile analy-sisyielded144.50◦±7.15◦,98.50◦±9.71◦ and0.60±0.06. Postoperativeprofilemeasurementswereinlinewiththose ofTurkish menwhowerepleased withthe appearanceof theirnose:7.1%ofpatientshealedwithapoorcolumellar scar,while68%healedwithnoscar.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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