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Inadequate nasal tip projection is the most common problem of primary and secondary rhinoplasty. Inadequate nasal tip projection with inadequate septal support requires an umbrella graft. The umbrella graft consists of a vertical cartilaginous strut between the medial crura and a horizontal onlay graft overlying the alar domes. The umbrella graft supports the nasal tip pyramid and reestablishes nasal tip projection. The statistics included in this report involve 1252 cases from 1986 to 1996, and it was discovered that 22 percent of the patients required an umbrella graft. Most of these patients had secondary rhinoplasties. The revision rate was 5 percent; the most common complication was cartilaginous show. Cartilage graft loss or significant absorption was not observed. A closed rhinoplasty approach with autologous tissue to reconstruct nasal tip projection was used. The umbrella graft technique is time proven, successful, and reproducible.

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The distribution of sebaceous glands in nasal skin is of interest because the presence of these adnexal structures significantly influences the outcome of healing. Using whole nasal skins dissected from cadavers, we prepared tissue sections from the nasal bridge to the nasal tip, both from the midline and lateral aspects. The sebaceous glands in these sections were analyzed for the following parameters: (1) size of the glands, (2) width of luminal cross-sections, and (3) depth of the glands. These parameters were studied using a Leitz Quantimet 500 Plus image analyzer and software to quantify the results. We found that the superior or proximal nasal skin contains fewer, smaller, more superficially located sebaceous glands. The inferior or distal nasal skin contains increased numbers of sebaceous glands which are markedly larger in size. The glands in the distal nose have larger lumina, are situated both superficially and deep in the dermis, and also occupy a greater percentage of the dermis. We identified an anatomical breakpoint on the nasal skin, marking the transition from superficial, small sebaceous glands to superficial-and-deep, enlarged glands. The columella was found to be similar to the proximal nasal skin.

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External shaving is an accepted technique in the treatment of rhinophyma. The application of external shaving to aesthetic rhinoplasty is also valuable in the treatment of a thick, sebaceous nasal tip that does not respond to standard reduction rhinoplasty. External shaving will reduce the thickness of the nasal tip skin and enhance tip definition. Fifty consecutive patients undergoing external shaving were followed over a 5-year period. The majority of the cases were secondary rhinoplasties. The results reveal a very high success rate, with one significant complication, a hypertrophic scar, and two minor complications. Proper diagnosis, patient selection, and surgical technique produce predictable and favorable aesthetic results.

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This article presents the guest editor's views on basic primary rhinoplasty at this time, and explains changes in techniques during the past 30 years of his practice.

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During the past 15 years the guest editor has developed new and better procedures for secondary rhinoplasty. These techniques, including ear cartilage grafts, are discussed in this article.

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The nose is divided anatomically into its component aesthetic parts. The preoperative examination of each of these parts, as well as techniques to modify them, have been reviewed. It is stressed that the nose is aesthetically more than the sum of its parts. No component may be completely ignored, because the result we strive for must take into account the effect of each upon its counterparts.

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A method is presented for supplementing local anesthesia with intravenous diazepam and fentanyl. Ease of administration and high patient acceptance in over 1500 cases is discussed.

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The National Survey of Hospital Data Processing contains a great wealth of information that the hospitals have contributed in respect to the trends and changes that are now occurring within our hospital data-processing environment. 2-5 We wish to thank all of those hospitals that have participated in this study and have been willing to provide the kind of information that is so essential in tabulating these results. It is our hope that this report will provide some measure of return on your investment and that it will supply some answers to you as you face the difficult questions of planning and projecting for the future. A great deal more information is contained within the study, but it cannot be presented because of the sheer volume of information that remains. For this reason, the survey has been structured as an on-line database rather than a report. We ask that those who have interests in seeking more in-depth information from these files contact our publishing office so that we can advise you of ways that this information can be conveniently made available to you for your special project. There will be a follow-up report for 1986 when that database is complete. For those who wish to do longitudinal studies, a parallel volume was published in August 1985 that should provide a 4-year perspective on the field of hospital data processing.

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