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PubMedDate not supplied

The quantification of surgical changes in nasal tip support.

OBJECTIVES: To quantify the changes in the strength of nasal tip support associated with various surgical modifications and to identify the procedures that best maintain or augment tip support. DESIGN: Case study in 2 phases. Phase 1 included 10 patients undergoing primary rhinoplasty, 5 undergoing secondary rhinoplasty, and 5 control patients. Fresh cadavers were used in phase 2. A purpose-built instrument (Beaty Tensegrometer; G. M. Tooling, Chamblee, Ga) was used to measure nasal tip support before and after surgical modifications. RESULTS: In the patients who underwent primary rhinoplasty, there was a 25% decrease in tip support when the ligamentous attachments between the lateral crura were divided. Reconstruction of these attachments increased tip support over baseline by 35%. With a columellar strut and ligament reconstruction, tip support was increased by 44%. In the secondary rhinoplasty group, reconstruction with the dynamic adjustable rotation tip-tensioning technique increased nasal tip support over baseline by 70%. In cadavers, intercartilaginous incisions and delivery of the lower lateral cartilages caused a loss of tip support, while raising the skin-soft tissue envelope with the open technique did not. Extensive resection of the lower lateral cartilages caused a loss of tip support. CONCLUSIONS: This study demonstrates that nasal tip support can be reliably quantified in a reproducible manner. Use of the open approach, reconstruction of the attachments between the lateral crura, conservative resection of the lower lateral cartilages, and the dynamic adjustable rotation tip-tensioning technique for secondary rhinoplasty best preserve nasal tip support.

Biomechanical Phenomena↗
PubMedDate not supplied

The extended columellar strut-tip graft.

The extended columellar strut-tip graft is a structural unit used in endonasal rhinoplasty that combines the attributes of the columellar strut and the tip graft. It is used to provide projection and contour to the nasal tip. Our goal with this study was to evaluate a 15-year experience with 155 patients who underwent rhinoplasty with the extended columellar strut-tip graft. Of these, 110 underwent secondary rhinoplasty, and 45 underwent primary rhinoplasty. There were 6 patients in the secondary rhinoplasty group who experienced complications: in 3, the graft became visible postoperatively, and 3 patients had graft placement asymmetry. These 6 patients underwent surgery in the initial years of graft development. One patient with graft edge visibility and 1 patient with graft asymmetry underwent revision surgery with satisfactory results. The extended columella strut-tip graft is a reliable method to provide nasal tip projection and contour. The successful use of the graft requires precise diagnosis and surgical technique.

Adult↗
PubMed1997

Lipogranulomas as complications of septorhinoplasty.

BACKGROUND: Nasal tumors caused by lipogranulomas are a rare complication of a rhinoplasty; only 1 report of this occurrence was found in the literature. OBJECTIVE: To present a series of 4 patients with subcutaneous nasal tumors after each had undergone a rhinoplasty, together with a review of the literature and the clinical consequences. DESIGN: Case series. SETTING: Hospitalized care at a university ear, nose, and throat department. PATIENTS: Four patients were referred within 6 months from a single department for consultation because of broad nasal pyramids after each patient had undergone a rhinoplasty. The origin of the deformities was not known. INTERVENTIONS: Ear, nose, and throat and ultrasound examinations and computed tomography (ie, bone and soft tissue examinations). Two patients had undergone revision surgery and histological examinations of subcutaneous fibrous tissue. MAIN OUTCOME MEASURE: Search for the origin of the nasal deformity. RESULTS: All 4 patients had wide nasal pyramids. One of the 4 patients also had subcutaneous tumors of the nasal dorsum, glabella, and medial canthus area; this patient had subcutaneous cystic lesions on computed tomography and ultrasound examination and a foreign body reaction around "empty spaces" on histological examination. The tumorlike lesions were the result of displaced ointment from the endonasal packings. Two of the 4 patients with minor deformities did not undergo any surgical revision, and they still had some moderate reduction of the cystic lesions within 1 year after the rhinoplasty. CONCLUSIONS: Lipogranulomas caused by ointments that are used together with nasal packings are most often reported in the orbit after endonasal sinus surgery. The incidence should be more frequent in patients who undergo a rhinoplasty because connections between the endonasal cavity and the extranasal subcutaneous layer are created routinely by osteotomies or removal of a hump. Thus, postoperative deformities (eg, inadequate narrowing of the bony pyramid or supratip thickening [permanent swelling of the nasal tip]) should be examined by use of computed tomography, if lipid ointments were used endonasally. For prevention, no lipid substances should be applied together with pressure from packings. In the case of a lipogranuloma, surgical removal via an open approach is the treatment of choice.

Adult↗
PubMed2001

Extracorporeal septoplasty with paramarginal incision.

To reconstruct the airways in the case of serious nasoseptal deviation it is preferable to remove the cartilaginous septum, reshape it, and put it back. This may be done through an open rhinoplasty approach with a transcolumellar scar resulting in wide visual access to the septal structures. As the transcolumellar scar may give problems in some cases, it might be helpful to use an extended paramarginal incision. A traditional open rhinoplasty approach was used in eight patients and the extended paramarginal incision technique in 19 patients. Two of the eight patients who had the open rhinoplasty technique developed unsatisfactory transcolumellar scars. Of the 19 patients who had paramarginal incisions no patient developed late problems. The paramarginal approach was superior to the traditional open rhinoplasty approach despite the slightly better visualisation with open rhinoplasty.

Adult↗
PubMed1999

One-stage correction of complex facial disproportion.

Patients with facial disharmony frequently have abnormal nasal form and disordered jaw relationships. Both orthognathic surgery and rhinoplasty are required to correct such facial disproportions. During a 10-year period 100 patients with a spectrum of indications have had concomitant orthognathic and rhinoplasty surgery by a team consisting of the same plastic surgeon, oral and maxillofacial surgeon, and orthodontist. Of this group 51 patients were operated on solely for aesthetic reasons, the majority being long face syndrome. All had a rhinoplasty usually with septal surgery. Depending on the deformity, the jaw surgery varied: 5 patients had mandibular surgery only, 12 had maxillary surgery alone, and the remaining 34 patients had both mandibular and maxillary procedures. Patients were followed for between 1 and 62 months by the plastic surgeon and for at least 2 years by the orthodontist. There was no orthognathic relapse or other major complications, but 4 patients required secondary minor nasal tip surgery under local anesthesia and 2 patients had persisting unilateral inferior alveolar nerve damage. Orthognathic surgery and rhinoplasty are not routinely performed concomitantly due to the difficulty in predicting the outcome of the soft-tissue relationships and increased morbidity. In this series, a one-stage approach was used to provide facial harmony. This reduces the overall surgical and anesthetic morbidity, inconvenience, and expense, and has resulted in good cosmetic and functional results. Therefore, it is suggested that with a competent team, orthognathic surgery and rhinoplasty can be performed concomitantly with dependable results and without significant complications.

Adolescent↗
PubMed2001

Computer-aided prototype system for nose surgery.

Rhinoplasty, or surgery to reshape the nose, is one of the most common of all plastic-surgery procedures. Rhinoplasty can enhance a patient's appearance and self-confidence, may also correct a birth defect or injury, or help relieve some breathing problem. In this paper, we present a three-dimensional (3-D) surgical simulation system, which can assist surgeons in planning rhinoplasty procedures. This system employs computer graphics and image-processing techniques for the simulation of a rhinoplasty. Although the presented algorithms themselves are not new, the proposed system exploits the new idea to apply 3-D morphing for rhinoplasty, and simulation results are useful for the physicians. According to patients' expectation of what they would like their noses to look like, our system simulates expected results. Our tools provide quantitative measurements of a nose structure. Using these quantitative results, surgeons can arrange appropriate preoperative plans for patients. Finally, experimental results and experiences are reported to evaluate the usefulness of the proposed system.

Computer Simulation↗
PubMed2001

Three-dimensional Z-plasty in the correction of the unilateral cleft lip nasal deformity.

OBJECTIVE: Numerous methods have been introduced for correction of the cleft lip nasal deformities, but no single procedure has given sufficiently satisfactory results to provide a surgical standard. Much effort has been put on restoring cartilaginous structures using alar cartilage modification and suspension. But even after the cartilage framework is repositioned well, redundant alar webbing is still unsightly and frequently conspicuous. This paper presents a procedure combining the usual open rhinoplasty technique and three-dimensional Z-plasty in an external approach to remove the alar web and to lengthen the columella at the same time. METHODS: Open rhinoplasty was performed in 26 consecutive patients with unilateral cleft lip nasal deformity from 1991 to 1996. We used an open rhinoplasty approach, which is a combination of the usual infracartilaginous incision on the noncleft side and a small triangular flap on the cleft side. RESULTS AND CONCLUSIONS: This external rhinoplasty incision can provide a wide surgical field for the handling of the whole cartilage framework. The three-dimensional Z-plasty utilizing redundant alar skin not only removes the alar web but also helps lengthen the columella and provides soft tissue to the nasal vestibule. This technique is easy, and the postoperative result is very consistent. Our open rhinoplasty approach has several advantages and can be a useful approach in the correction of the unilateral cleft lip nasal deformity.

Adolescent↗
PubMedDate not supplied

Management of severe bilateral nasal wall collapse.

OBJECTIVE: The aim of this study was to examine and analyze the pathology contributing to severe bilateral nasal wall collapse seen in certain revision rhinoplasty patients and identify those surgical maneuvers in the previous nasal surgery, which may have contributed to this complication; suggest alternatives or modifying steps in nasal surgery to prevent lateral wall collapse; analyze consecutive revision rhinoplasties and identify those patients who have complete bilateral nasal collapse at the internal nasal valve; and analyze the results achieved after surgical reconstruction of complete bilateral nasal collapse. PATIENTS: We identified 49 patients, who presented from 1990 to 2000 for revision surgery, who had bilateral collapse of the upper lateral cartilage. All patients had at least one previous rhinoplasty and all but 14 patients had undergone two or more procedures. The patients were reconstructed with a conchal cartilage graft placed through an external rhinoplasty approach. RESULTS: All patients complained of nasal obstruction with forced nasal inspiration. The collapse was visualized on inspiration and when prevented with intranasal positioning of a bayonet, all patients experienced an immediate improvement in nasal breathing. Postoperatively, all patients experienced this same improvement in their nasal airway. Collapse was not identified in any of the patients after surgery. Two patients underwent revision because of cosmetic asymmetries. CONCLUSION: We strongly recommend a cartilage overlay to reconstitute the rigid midline continuity of the upper lateral cartilages. Unfortunately, with any significant hump removal, this structural interruption is, to varying degrees, inevitable in most rhinoplasty techniques. The upper lateral cartilages can be sutured to circumvent some of the inferior drift, but this will not reconstitute the rigid lateral cantilever effect of the intact cartilage.

Adult↗
PubMed2001

Alar setback technique: a controlled method of nasal tip deprojection.

OBJECTIVES: To describe an alar cartilage-modifying technique aimed at decreasing nasal tip projection in cases with overdeveloped alar cartilages and to compare it with other deprojection techniques used to correct such deformity. DESIGN: Selected case series. SETTINGS: University and private practice settings in Alexandria, Egypt. PATIENTS: Twenty patients presenting for rhinoplasty who had overprojected nasal tips primarily due to overdeveloped alar cartilages. All cases were primary cases except for one patient, who had undergone 2 previous rhinoplasties. INTERVENTION: An external rhinoplasty approach was used to set back the alar cartilages by shortening their medial and lateral crura. The choice of performing a high or low setback depended on the preexisting lobule-to-columella ratio. Following the setback, the alar cartilages were reconstructed in a fashion that increased the strength and stability of the tip complex. MAIN OUTCOME MEASURES: Subjective evaluation included clinical examination, analysis of preoperative and postoperative photographs, and patient satisfaction. Objective evaluation of nasal tip projection, using the Goode ratio and the nasofacial angle, was performed preoperatively and repeated at least 6 months postoperatively. RESULTS: A low setback was performed in 16 cases (80%) and a high setback in 4 (20%). The mean follow-up period was 18 months (range, 6-36 months). The technique effectively deprojected the nasal tip as evidenced by the considerable postoperative decrease in values of the Goode ratio and the nasofacial angle. No complications were encountered and no revision surgical procedures were required. CONCLUSIONS: The alar setback technique has many advantages; it results in precise predictable amounts of deprojection, controls the degree of tip rotation, preserves the natural contour of the nasal tip, respects the tip support mechanisms, increases the strength and stability of nasal tip complex, preserves or restores the normal lobule-to-columella proportion, and does not lead to alar flaring. However, the technique requires an external rhinoplasty approach and fine technical precision.

Adolescent↗
PubMed2002

Management of the keel nose and associated valve collapse.

OBJECTIVES: To analyze the anatomical abnormality of the keel nose and correlate the findings with etiologic maneuvers of a routine rhinoplasty procedure; to identify the contributing factors and offer suggestions to avoid or decrease the severity of these surgical complications; and to present an effective revisional procedure to correct the functional and cosmetic consequences of this deformity. PATIENTS AND METHODS: A total of 47 patients (31 women and 16 men; age range, 18-71 years) with a keel-appearing nose presented for revision rhinoplasty. All had undergone at least 1 rhinoplasty procedure, and 39 had undergone 2 or more previous nasal procedures. All patients had bilateral lateral nasal wall collapse and an associated severely compromised internal nasal valve. All patients underwent reconstruction with a conchal cartilage overlay graft. RESULTS: All patients had a moderate to excellent cosmetic improvement; the subjective improvement in nasal airway was more dramatic. Since patients with a keel nose have an associated internal valve collapse, both abnormalities are addressed simultaneously with the conchal cartilage overlay repair, which results in minimal morbidity with no major complications. CONCLUSIONS: Conchal cartilage overlay repair uses a cartilage graft from the auricle with a recommended external rhinoplasty for placement. Appropriate sizing and fashioning precede the precise placement and suture fixation. This technique addresses both functional and cosmetic abnormalities.

Adolescent↗
PubMed2003

Analysis of nasal and labial deformities in cleft lip, alveolus and palate patients by a new rating scale: preliminary report.

INTRODUCTION: In this study the nasal deformities in patients with cleft lip, alveolus and palate (CLAP) were analysed and the relevant role of the perinasal-perioral muscular balance, and the inborn dislocation of the alar cartilages is presented. PATIENTS AND METHODS: 50 CLAP patients were analysed in whom 29 primary cheiloplasties, 12 lip revisions and 9 rhinoplasties were performed. The lip repair was done by a modification of Millard's technique, the nose by either a closed or open-sky rhinoplasty. The severity of the cleft appearance was evaluated pre- and postoperatively, according to a pre-agreed visual rating scale. There were 4 degrees of severity of the deformity preoperatively (mild, moderate, severe and very severe), and postoperatively 5 categories of outcome (excellent, very good, good, satisfactory and poor) depending on the scores obtained by summing up the points corresponding to different types of deformity. This scale is closely related to the American Cleft Palate classification of clefts. RESULTS: 17 excellent, 4 very good, 2 good, 5 satisfactory and 1 poor result were obtained in the group of primary cheiloplasty. Eight excellent, 4 very good results were obtained by the lip revisions. Seven excellent and 2 satisfactory results were obtained following rhinoplasty. CONCLUSIONS: During the primary lip repair, it is important to correct the abnormal position of ala nasi, the nasal floor and the base of the columella. When correct insertion of m. transversus nasi to the nasal spine is achieved and a good repair of m. orbicularis oris, symmetry of the alae and normal growth of lip and columella was obtained even in most severe bilateral cases. In cases of diastasis of the orbicularis and transversus nasi muscles, in combination with other soft tissue deformities or scars, a secondary musculo-periosteal revision is recommended. The defect of the soft tissue triangle of the nose is best corrected via an open rhinoplasty.

Adolescent↗
PubMed1997

Surgery of the nasal tip.

One of the most challenging aspects of cosmetic rhinoplasty is nasal tip refinement. In efforts to control tip rotation, projection and architecture, surgeons face constant tradeoffs between tip position and dorsal reduction. Open structure rhinoplasty allows direct visualization of bony-cartilaginous deformities, preservation of nasal structural integrity and precise nasal tip alteration. The open rhinoplasty technique involves, control of tip projection and rotation, reshaping of nasal tip cartilage, minimal resection of the nasal dorsum and lower lateral cartilage and preservation or reinforcement of major tip supports. The advantage of open structure rhinoplasty includes preservation of inherent nasal supporting elements and precise nasal reshaping which are essential for aesthetically pleasing and predictable postoperative results.

Cartilage↗
PubMed2002

Correction of the cleft-lip nasal deformity.

Correction of the cleft-lip nasal deformity is a difficult task that requires a clear understanding of the associated complex anatomic abnormalities. These deformities tend to accentuate as nasal growth continues. Primary tip rhinoplasty in the unilateral deformity improves nasal tip symmetry and decreases the need for intermediate surgery. Intermediate rhinoplasty in the bilateral deformity is performed when nasal tip projection is markedly diminished. In both the unilateral and bilateral deformity, definitive rhinoplasty utilizing the open-structure rhinoplasty approach allows maximum exposure for placement of structural grafts to improve tip projection, definition, support, and function. In this article, the pathologic anatomy of the unilateral and bilateral cleft nasal deformity is described. The philosophy and timing of repair are discussed. Finally, the techniques used by the authors to address both the aesthetic and functional problems are outlined.

Adolescent↗
PubMed2003

The ethnic nose.

There are distinctive anatomical differences between the non-Caucasian (platyrrhine, mesorrhine) nose and the Caucasian (leptorrhine) nose. In general, non-Caucasian patients requesting aesthetic rhinoplasty desire improvement and refinement of their noses with preservation of defining ethnic characteristics. Surgeons who perform rhinoplasty in this patient population must be familiar with the variations in nasal anatomy and implement augmentation rather than reduction techniques to achieve the desired aesthetic and functional outcomes. We provide a brief review of recent historical trends in ethnic rhinoplasty, highlight relevant anatomical differences, and describe our strategy for addressing the challenges of ethnic rhinoplasty.

Esthetics↗
PubMed1995

Surgery of the internal nasal valve.

Over the past 25 years external rhinoplasty has become increasingly popular. Some rhinosurgeons recommend its use widely, even in routine cases. In our view, however, the classical endonasal approaches remain the first choice. Open rhinoplasty offers an excellent visualization and therefore facility of precise correction, but causes a larger area of wound and scarring. It should, therefore, be restricted to cases of particular difficulties. In the era of minimal invasive surgery, external rhinoplasty advocated as a standard procedure seems to be a drawback, particularly if the aesthetic problem is the leading one. Every facial plastic surgeon should master closed and external rhinoplasty to be able to decide which approach is the most suitable in each situation from the patient's point of view.

Airway Resistance↗
PubMed1994

Shaping and positioning the nasal tip without structural disruption: a new, systematic approach.

This paper presents a new, comprehensive, and systematic approach to analysis, planning, and techniques of primary nasal tip rhinoplasty, emphasizing techniques that limit uncontrollable variables before proceeding to techniques which increase uncontrollable variables and risk secondary deformity, including (1) maintenance of structural integrity of the alar rim strips, limiting use of scoring or morselization techniques which reduce support and introduce potential secondary deformities, (2) shaping and positioning the lateral and medial crura in a reversible, nondestructive manner using permanent suture and nonvisible control graft techniques, (3) minimizing uncontrollable postoperative variables by decreasing the need for visible grafts to shape the tip complex in primary rhinoplasty, achieving the same results with existing alar structural elements, (4) integrating these concepts with specific sequences of surgical techniques--bilateral alar arch components individually positioned, then shaped and unified for symmetry, and finally positioned for rotation and projection--and (5) introducing an integrated set of surgical techniques and sequencing of tip surgery to achieve the objectives listed above in most primary and some secondary rhinoplasties. The concepts and techniques of this approach are based on the principle that preservation of structural integrity of alar complex elements (medial and lateral crural arch elements) preserves support and reduces the incidence of secondary deformities (kinking, buckling, discontinuity) that can result from shaping techniques which disrupt that integrity. If shaping and positioning of the tip can be achieved with reversible, nondestructive techniques, the need for placement of visible grafts (with their additional variables) is greatly reduced. Shaping and positioning can be performed incrementally and reversibly without jeopardizing structural integrity and support in the surgical process. Ten fresh cadaver dissections were utilized in the development of the surgical techniques. A total of 233 rhinoplasties (220 primary and 13 secondary) with 1 to 9 years of follow-up have been performed using this approach. Only two secondary procedures for tip deformity have been performed.

Cadaver↗
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↗
PubMed2000

Supratip deformity: a closer look.

Supratip deformity, a hallmark of a poorly executed rhinoplasty or an inauspicious healing, continues to plague the novice often and the experts on occasion. A clinical and histopathologic study was conducted to search for the surgical causes of this deformity and its histologic presentation. An organized, logical management program was then developed. Clinically, supratip fullness was observed in both primary (26 of 298 patients; 9 percent) and secondary (40 of 112 patients; 36 percent) rhinoplasty candidates. In primary patients, the deformity was the result of inadequate tip projection (pseudodeformity), an overprojected caudal dorsum, a combination of both, or cephalically oriented lower lateral cartilages. In secondary patients, the deformity was caused by an underresected or overresected caudal dorsum, overresected midvault, underprojected tip (pseudodeformity), or a combination of some of these factors. The histopathologic evaluation demonstrated significant fibrosis in the supratip soft tissue of 14 of 16 patients undergoing secondary rhinoplasty without the injection of triamcinolone acetonide and in only 13 of 23 patients who underwent primary rhinoplasty (p<0.05). A supratip deformity can be eschewed by proper resection of the caudal dorsum, avoidance of dead space, restoration of adequate projection to the nasal tip, and an approximation of the supratip subcutaneous tissue to the underlying cartilage using a supratip suture, hence eliminating the dead space. If the problem is noted shortly after surgery, in the presence of collapsible consistency of the supratip tissue and adequate projection, the treatment is taping the supratip tissue as often as it is practical. If no favorable response is elicited in 6 to 8 weeks, thejudicious injection of a small amount of triamcinolone acetonide (0.2 to 0.4 cc of 20 mg/cc) in the deep subcutaneous tissue (not in the dermis) is done. The injection is repeated in 4-week intervals until the desired effect is achieved. If supratip fullness is the consequence of inadequate cartilage resection or inadequate tip projection, surgical correction is needed. The recalcitrant soft-tissue excess in the supratip area is resected, and the subcutaneous soft tissue is approximated to the underlying cartilage. If the dorsum was previously overresected, a cartilage graft to the caudal dorsum or midvault will create an optimal dorsal frame and reduce the potential for a recurrent supratip deformity.

Humans↗