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Biomedical subjects

M B Constantian

Publications and source records attributed to M B Constantian.

At least 19 recordsLinked to original sources
PubMed1999

Elaboration of an alternative, segmental, cartilage-sparing tip graft technique: experience in 405 cases.

Despite the value of tip grafting in many rhinoplasty patients, adequate donor cartilage may be unavailable in secondary and even primary patients whose donor sites have been harvested previously or whose septal cartilage is calcified. Furthermore, by enlarging the lobule, tip grafts can create undesirable postoperative disproportions in some patients. These two observations have stimulated the elaboration of a tip graft method (which evolved from the Sheen technique) that uses small amounts of autogenous donor material to augment only those lobular segments that require increased contour or support, without necessarily increasing overall lobular volume. This article reports experience with; the technique in a 405-patient study group. Segmental tip grafting is performed endonasally through access incisions along the caudal edge of one alar cartilage. Grafts augment each third of the tip lobule and anterior columella (corresponding to each of the alar cartilage crura) depending on the aesthetic objective; multiple grafts are always placed. Selective augmentation limits the overall increase in lobular size. The method is not suitable for those patients needing substantial augmentation (58 of 463 tip-grafted patients in the 6-year study period), in which case the author still prefers the Sheen technique. The records of the 405-patient study group (40 percent primary rhinoplasty, 60 percent secondary rhinoplasty) indicate a total nasal revision rate of 14 percent; 6 percent were tip revisions. Tip revisions were more frequent in secondary patients but not in patients with thin skin. Reoperation percentages decreased during the study term, so that the tip revision rate was 12 percent in the first 12 months of study but only 4 percent in the last 12 months (p < 0.0008). The primary indication for tip grafting has evolved since the author's earlier practice experience: in the past 3 years of the study, 77 percent of primary patients and 80 percent of secondary patients underwent grafting principally to improve lobular contour, not tip projection (p < 0.0005). A segmental, cartilage-sparing tip graft technique can provide both projection and contour for primary and secondary rhinoplasty patients. Nevertheless, tip imperfections remain the most common reason for revision in the author's practice.

Adolescent↗
PubMed1998

An alar base flap to correct nostril and vestibular stenosis and alar base malposition in rhinoplasty.

Nostril and vestibular stenoses can be properly reconstructed by composite grafts from the alar lobule or ear. However, when alar base malposition accompanies the nostril stenosis, composite grafting will enlarge the nostril but not correct the alar base displacement. An alar base flap designed as a crescent adjacent to the alar base, elevated, and transposed on subcutaneous and musculocutaneous perforators corrects the nostril stenosis and repositions the alar base simultaneously. Anterior, active rhinomanometry demonstrates a substantial increase in mean nasal airflow from this reconstructive maneuver alone. The author has used the flap successfully in 29 secondary rhinoplasty patients; survival has been uniformly complete even when the donor tissue has been scarred or burned. All rhinoplasties were performed endonasally, however; the survival of this flap performed simultaneously with open rhinoplasty has not been established.

Adult↗
PubMed1996

The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty.

Despite the apparent association of nasal airway obstruction with septal deviation and/or inferior turbinate hypertrophy, increasing clinical evidence suggests that incompetence of the internal or external nasal valves may also affect airflow. But how much? What is the relative importance of the valves and septum in causing nasal airway obstruction? One-hundred and sixty consecutive patients (88 primary rhinoplasty, 72 secondary rhinoplasty) without turbinate hypertrophy or septal perforation and operated on for correctable nasal airway obstruction were evaluated prospectively by anterior active mask rhinomanometry preoperatively and from 1 to 43 months (mean 8.4 months) postoperatively after 1% phenylephrine decongestion to eliminate mucosal factors. Patients were stratified according to the site(s) of preoperative obstruction at the internal valves, the external valves, the septum, or any combination of the three. Geometric mean nasal airflow was calculated from independent measurements of each nasal airway. Surgical treatment consisted of submucous septal resection, internal valvular reconstruction with dorsal or spreader grafts, and external valvular reconstruction with cartilage or bone grafts; inferior turbinectomy was not performed. All procedures were performed endonasally. In the entire 160 patient study group, septal and/or valvular surgery corrected the airway in 152 patients (95 percent); 8 patients had partial residual obstruction. Our data support the prior rhinologic data in showing only a modest (and statistically insignificant, p < 0.4, n = 25) improvement in (geometric) mean nasal airflow following septal surgery alone. However, external valvular reconstruction alone increased airflow 2.6 times over preoperative values (n = 10). Internal valvular reconstruction alone by dorsal grafts (n = 17) or spreader grafts (n = 29) increased nasal airflow 2.0 times; spreader grafts and dorsal grafts were equally effective in supporting the internal valves. The largest improvement in postoperative airflow was seen in the patients with septal plus internal and external valvular incompetence (n = 21), in which flow increased 4.9 times over preoperative values (p < 0.0003). Patients in whom valvular incompetence alone was corrected experienced as much relative improvement as patients in whom valvular plus septal obstruction was corrected. Finally, valvular reconstruction in 54 secondary rhinoplasty patients who had previously undergone septoplasty corrected the airway obstruction in 49 patients (91 percent). Notably, 110 of 160 patients (69 percent) had a lateralized preoperative obstruction; however, the septum was deviated toward the clinically obstructed side in only 51 of these patients (46 percent); in the other 54 percent, the subjectively obstructed side was contralateral to the side toward which the septum was deviated. Nasal valvular function should be assessed in all preoperative rhinoplasty patients with airway obstruction; in many individuals, valvular effects may equal or surpass septal deviation as the primary cause of nasal airflow obstruction.

Adolescent↗
PubMed1994

The incompetent external nasal valve: pathophysiology and treatment in primary and secondary rhinoplasty.

The size of any nasal airway depends not only on the width and contour of the septal partition and inferior turbinates but also on the position and stability of the lateral nasal wall under the pressure changes that occur during the dynamic process of ventilation. Thus any congenital or acquired weakness of the upper or lower lateral cartilages or their investing soft tissues may profoundly affect the ability to draw adequate volumes of air through the nose. Sixty-one surgical patients treated for incompetence of the external nasal valves (comprising the cutaneous and skeletal support of the mobile alar walls) are the subjects of this paper. Rhinomanometric data on 16 patients with "pure" external valvular incompetence showed a twofold increase in total mean nasal airflow following valvular reconstruction with septal cartilage or bone grafts or with composite conchal cartilage-skin grafts for patients with associated vestibular skin deficiencies. Seven patients with combined external valvular and septal pathology derived most of their postoperative airflow improvement from correction of the valvular defect. The external nasal valve may be a substantial cause of nasal airway obstruction in some patients; its pathophysiology and treatment are discussed in primary and secondary rhinoplasty.

Adolescent↗
PubMed1993

Experience with a three-point method for planning rhinoplasty.

Three aesthetic parameters, based entirely on nasal surface soft tissue morphology, can be used to formulate a practical rhinoplasty strategy. They are, in order of ascending importance: (1) skin thickness and distribution, (2) tip lobular configuration, and (3) the balance between nasal base size and bridge height. These three parameters, chosen because of their broad ramifications for a successful rhinoplasty result, help determine the need and method for dorsal and tip reduction or augmentation, and recognize the constancy of preoperative skin sleeve distribution, particularly at the nasal base. The strategy is equally useful in primary and secondary rhinoplasty. Because their effects are regional, all other decisions (e.g., osteotomies, alar wedge resection, nasal shortening, valvular reconstruction) are secondary and can be made independently.

Adult↗
PubMed1993

Functional effects of alar cartilage malposition.

Nasal airway obstruction is frequently synonymous with septal deviation or inferior turbinate hypertrophy. Less readily appreciated is the fact that the mobile lateral nasal wall caudal to the bony arch can obstruct the airway, particularly at the internal or external nasal valves. External valvular incompetence can result from postsurgical or congenital causes, among the most common of which is alar cartilage malposition. Twenty-seven patients with alar cartilage malposition in a series of 61 patients (44%) treated for airway obstruction from external nasal valvular incompetence comprise this report. Rhinomanometric data demonstrate an increase in total nasal airflow from 99 +/- 17 ml (mean +/- SEM) to 190 +/- 37 ml per 14 seconds after valvular correction. Patients in whom additional septal pathology was corrected nevertheless had no significant airflow improvement over patients with external valvular reconstruction alone. Treatment principles of valvular incompetence from alar cartilage malposition are given for primary and secondary rhinoplasty patients, among which is a composite conchal cartilage/skin graft that can reconstruct a functioning lateral crus and replace a vestibular skin deficiency. Interestingly, alar cartilage relocation to correct the malposition also narrows the alar base, even when no alar wedge resection is performed.

Cartilage↗
PubMed1993

The middorsal notch: an intraoperative guide to overresection in secondary rhinoplasty.

A notch commonly appears at the midpoint of the nasal dorsum when the bridge has been resected beyond the ability of the soft tissues to contract. This notch, commonly seen in secondary rhinoplasty patients, occurs at the cephalic end of the supratip convexity and appears whether or not the tip has been overresected. The notch corresponds to the center of the "inverted V" deformity that signals middle vault collapse and may occur even when the middle vault has been reconstructed by spreader grafts. The middorsal notch also appears intraoperatively and therefore can guide the surgeon in determining the limits of dorsal skeletal resection. Ablation of the mid-dorsal notch by dorsal grafting is effective in both primary and secondary rhinoplasty patients.

Cartilage↗
PubMed1992

Distant effects of dorsal and tip grafting in rhinoplasty.

Grafts to the nasal dorsum and tip, whose local effects are well known, also have distant effects that may not be as readily obvious but that nevertheless are just as real. Dorsal and tip grafts can shorten or lengthen the nose (relatively and absolutely), affect nasal symmetry, preserve or alter nasal ethnic characteristics, and alter dorsum/tip relationships. Each of these properties increases the utility of cartilage and bone grafts in treating a variety of nasal configurations.

Adult↗
PubMed1989

An alternate strategy for reducing the large nasal base.

The position of the dorsum directly influences the apparent size of the nasal base: the higher the bridge, the smaller the nasal base seems. This powerful optical illusion provides the surgeon with an alternate strategy for creating harmony in the nose with a low, straight dorsum and a disproportionately large nasal base. Instead of reducing the lower nose, the surgeon can augment the upper nose (and make whatever nasal base changes are independently necessary). This alternate strategy limits the amount of nasal skeletal reduction necessary, thereby limiting the potential for postoperative change and soft-tissue distortion and directly increasing the surgeon's control over the result.

Adult↗