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PubMedDate not supplied

Alar expansion and reinforcement: a new technique to manage nasal valve collapse.

OBJECTIVE: To describe the new technique of alar expansion and reinforcement as a comprehensive approach to the surgical management of nasal valve collapse. METHODS: Alar expansion and reinforcement expands the narrow nasal valve and reinforces the floppy nasal sidewall. Forty-one patients underwent rhinoplastic surgery for nasal valve collapse between May 1, 2002, and April 30, 2005, using an external rhinoplasty approach; of these, 32 responded to our postoperative questionnaire. Twenty-four patients (75%) underwent primary surgery and 8 (25%) had undergone previous rhinoplasty. All patients had permanent adjustable expansion sutures. Twelve patients (38%) had an excessively floppy nasal sidewall that required a high-density porous polyethylene alar batten implant to anchor the expansion sutures. Patients underwent clinical review from 6 months to 3 years after surgery, and a telephone survey was used to evaluate their functional and cosmetic satisfaction rates. RESULTS: Thirty patients (94%) experienced good improvement in their nasal airway. The improvement in nasal airway patency was statistically significant (P<.001). Two patients (6%) reported no improvement. There were no complications. Cosmetic outcome was satisfactory in all 8 patients who also requested cosmetic improvement. Of the 24 patients who had surgery for nasal obstruction only, 10 (42%) rated their cosmetic appearance as better, with the remaining 14 (58%) indicating that they did not identify any significant change in their nasal appearance. CONCLUSION: Alar expansion and reinforcement is a safe, reliable, and effective technique to manage nasal valve collapse.

Adult↗
PubMedDate not supplied

Measurement of preoperative and postoperative nasal tip projection and rotation.

OBJECTIVE: To measure the effect of columellar struts and cephalic trim on tip projection and tip rotation using digitized photographs. METHODS: Using photographs of 62 patients who underwent external rhinoplasty, we retrospectively analyzed nasal tip projection (the Goode method) and rotation (nasolabial angle) before and after surgery. A cartilaginous strut was used in 36 patients, whereas 26 patients did not receive a strut. Patients were categorized into 4 subgroups, depending on the placement of a strut (placement, strut+ vs nonplacement, strut-) and the removal of the cephalic margin (removal, cephalic+ vs nonremoval, cephalic-) of the lateral crus: strut-/cephalic-, n = 17; strut+/cephalic-, n = 23; strut-/cephalic+, n = 9; strut+/cephalic+, n = 12. RESULTS: Nasal tip projection, measured with the Goode method, increased from 0.58 to 0.60 (P = .02) in the strut+ group; in the strut- group, nasal tip projection did not change significantly. Nasolabial angle increased from 93.96 degrees to 100.92 degrees in the strut+/cephalic- group and from 88.30 degrees to 95.06 degrees in the strut+/cephalic+ group. Removal of the cephalic margin alone (strut-/cephalic+) hardly affected tip rotation (P = .05). CONCLUSIONS: The external rhinoplasty approach did not lead to a decrease in nasal tip projection. A cartilaginous strut slightly increased nasal tip projection and also increased nasal tip rotation. This effect was accentuated by the removal of the cephalic margin of the lateral crus.

Female↗
PubMed1999

Lateral crural steal and lateral crural overlay: an objective evaluation.

OBJECTIVE: To assess objectively the effect of 2 cartilage-modifying techniques, lateral crural steal (LCS) and lateral crural overlay (LCO), on the degree of nasal tip projection and rotation. DESIGN: A prospective trial using computer imaging techniques for assessment. SETTINGS: Half of the patients were seen at a university hospital and the other half at a private practice. PATIENTS: A selected series of 30 patients seeking rhinoplasty mainly for nasal tip repositioning. Only patients with no history of previous nasal operations were included. INTERVENTION: All patients were operated on using an external rhinoplasty approach. Only 1 of the 2 techniques was adopted for each patient. The technique selected depended purely on clinical judgment. MAIN OUTCOME MEASURES: The nasofacial angle and the Goode ratio were used to assess tip projection, and the nasolabial angle and rotation angle were used to assess tip rotation. RESULTS: The use of the LCS technique resulted in an increase in both nasal tip projection and rotation, but the use of the LCO technique resulted in an increase in tip rotation and a decrease in tip projection (P<.001). Additionally, the LCO technique resulted in significantly higher degrees of rotation than the LCS technique (P<.001). CONCLUSIONS: The LCS procedure is indicated when a moderate increase in nasal tip projection and rotation is desired. The LCO technique is useful in patients where severe underrotation is associated with overprojection.

Adult↗
PubMed1976

The nasal bony dorsum and cartilaginous vault. Pitfalls in management.

Our literature is replete with technical descriptions of rhinoplasty techniques designed to avoid certain complications. Analysis of 153 secondary rhinoplasties indicates that no procedure is immune to undesirable results and no specific technique can be employed to manage all potential problems. Critical scrutiny of these cases both preoperatively and intraoperatively indicated a decided recurrence of certain complications in the nasal bony dorsum and cartilaginous vault. Fifty-eight defects of the bony dorsum were encountered. These defects included open vault, wide dorsum, asymmetry, excessive or inadequate hump removal, abnormal nasofrontal angle, step deformities, and bony irregularities. Defects in the cartilaginous middle third of the nose occurred 91 times. These consisted to supratip prominence, valve collapse, asymmetry, and saddle deformity.

Humans↗
PubMed1979

Profile contouring including cheiloplasty.

Profile disharmony exists when there is an unattractive forehead-to-chin contour. An indication for correction arises when the appearance disturbs the patient. Often the patient believes rhinoplasty alone will improve the unpleasant profile. The surgeon must appreciate other deformitied and enlighten the patient of concurrent osseous and soft tissue abnormalities. Profile evaluation and treatment rarely requires complicated diagnostic and corrective measures. Complex mathematical evaluations followed by multistaged surgical procedures are impractical for most patients. My experience with augmentation of the nose and mentum with polyamide mesh in more than 200 cases indicates that it is a simple and safe material for implantation. Modification of the nasofrontal angle and cheiloplasty are minor adjunctive procedures and are readily combined with the basic rhinoplasty.

Chin↗
PubMed1996

Anthropometric analysis of the female Latino nose. Revised aesthetic concepts and their surgical implications.

OBJECTIVE: To determine whether the present aesthetic concepts set forth for rhinoplasty in white patients can be applied to the ethnic variations seen in Latino women and, if not, to develop a reproducible means of analysis to serve as a guide for surgical correction. DESIGN: Cohort analytic study; criterion standard analysis of nasal aesthetics. PARTICIPANTS: Ninety-seven Latino women and 40 white women. INTERVENTIONS: Patients were separated according to geographic area of origin, either the Caribbean, Central America, or South America. Anthropometric measurements were obtained and nasal indexes were calculated. Results were compared with previously reported data for African Americans and whites. All patients underwent complete nasal photographic analysis. RESULTS: Caribbean subjects showed the greatest divergences from whites and resembled African-American anthropometric norms, whereas Central and South American subjects more closely resembled white norms. Two new aesthetic concepts were developed, the dorsal nasal breakpoint and the horizontal nasal axis, which have implications for aesthetic rhinoplasty. The breakpoint is a pivotal point along the nasal dorsum, structurally determined, which was found at different locations in all the groups studied. Caribbean subjects had breakpoints approximately halfway down the dorsum. Central and South Americans had breakpoints about two thirds of the way down the dorsum, and whites had breakpoints three fourths of the way down the dorsum. The horizontal rotation axis is present along a plane that connects the top of the ala with the tip. Rotation of the tip about this axis affects both the characteristics of the dorsal breakpoint and the final appearance of the nose. CONCLUSIONS: In general, Latino noses can be anthropometrically categorized as mesorrhine. When the geographically derived groups were examined individually, the Latino nose ranged from subplatyrrhine to paraleptorrhine. Surgical correction should be individualized, as each group requires correction of different nasal features. The dorsal breakpoint and the horizontal axis plane can act as nasal profile guides for surgical modifications that would achieve the current concept of the aesthetic nose.

Adult↗
PubMed1994

Calibrated nasal tip: review of 100 cases.

Asymmetry of the alar cartilages is a common finding in primary rhinoplasty in Caucasian patients. The "delivery" technique provides good exposure of the alar cartilages which allows examination and tailoring in better surgical conditions than those of the "closed" technique and also avoids the "open" nose approach in the majority of rhinoplasty cases.

Anthropometry↗
PubMed1992

External skin excision in the sebaceous nose and supratip deformity.

Some sebaceous noses cannot be properly reduced in size because of redundant skin. After standard rhinoplasty some noses develop a supratip deformity that recurs even after subcutaneous removal of the scar tissue. These noses can be corrected only by wedge-shaped skin excision. Most patients much prefer a pleasantly shaped nose, even at the cost of a midline scar on the nose. Most surgeons are hesitant to add scars to the face. However, the vast experience with wounds following accidents, tumor excisions, or corrections of malformations has shown that generally scar formation on the nose is inconspicuous. Nineteen patients were treated successfully by skin excision at the time of primary rhinoplasty or by a second operation.

Adult↗
PubMed1988

The comma-shaped tip cartilage graft.

Conventional onlay grafts of cartilage to the tip, columella, and alar margin provide valuable techniques for the refinement of minor deformities in both primary and secondary rhinoplasty. However, they cannot produce a full restoration of the dynamic anatomy of the lower lateral cartilages, which give forward thrust and arch support to the tip and nostril margins. For these grosser problems another graft design has been devised by the author. A report is given of the successful use of a comma-shaped septal graft used for over five years in selected cases of secondary rhinoplasty. The graft replaces the deficient lateral crus and alar dome and is sculpted and then sprung into position so that it restores function and gives the desired aesthetic effect.

Cartilage↗
PubMed1993

Nostril and alar reshaping.

The authors recommend, when necessary, the use of external excisions for correcting variations in the shape of the nostrils and alae in the cleft lip-nose deformity, in primary rhinoplasties, and in secondary rhinoplasties. Their experience in the use of external incisions was originally stimulated by Millard's paper of 1960 which recommended different types of remodeling external excisions in his analysis of how to handle variations in the shape of the nostrils and alae.

Adolescent↗
PubMedDate not supplied

Management and aesthetic results of support grafts in saddle nose surgery.

To define the surgical management and long-term aesthetic results of patients undergoing rhinoplasty with support graft for saddle nose, 147 patients have been included in this retrospective study. One hundred forty-four autogenous grafts (bone or cartilage) and three processed irradiated bovine cartilage grafts have been used during the period 1980-1997. Two approaches have been employed: open rhinoplasty and endonasal approach. Most of cases have been treated with bony grafts (116 bone graft versus 26 cartilage grafts). Global follow-up after surgery for long-term aesthetic study was 8.5 years. Among the different autogenous that have been used in our series, the calvarial bone had the most interesting results in terms of resorption. In patients with important saddle nose deformity, we recommend calvarial bone as a material of choice for dorsonasal reconstruction. It provides excellent and natural long-term feel to the nasal complex.

Adult↗
PubMedDate not supplied

Umbrella graft of columella tip: 20 years' experience.

We present our experience with nasal grafts over 20 years. The nose, located centrally, always plays a key role in facial aesthetics. Public recognition of this makes rhinoplasty the most popular operation. From the traditional aesthetic point of view, propogated by the media, the nose must be narrow and straight and have correct nasolabial and forehead angles. It is the desire of every surgeon to obtain permanent and satisfactory cosmetic results. However, it is not always possible to obtain good cosmetic appearance using conventional methods when the nose is small or large, when the columella is short, or when the skin is thick. Mostly, nasal tip projection cannot be achieved. In the present article, we report our experiences in primary asthetic rhinoplasty using cartilaginous grafts obtained from septum, costa, and ear as umbrella grafts of columella type.

Cartilage↗
PubMedDate not supplied

The use of lower turbinate bone grafts in the treatment of saddle nose deformities.

Saddle nose reconstruction is based on the use of support grafts to manage aesthetic and functional problems. Bone (calvarial, iliac crest, costal, nasal hump, ulnar, and heterogeneous origin), cartilage (septal, costal, heterogeneous), and synthetic materials (silicon, silastic, polyethylene) were used as support grafts. Three patients have been included in this study to define the surgical management and long-term aesthetic and functional results of patients undergoing rhinoplasty with support grafts for a saddle nose deformity. Open rhinoplasty was employed. Both the lower turbinates were excised and the bone dissected from the soft tissues in two cases and in one case, only mucosa was removed. The amount of support needed was measured by using bone wax. The bone was used shaped in layers, according to the defect, and sutured to each other by vycril suture, and wrapped around by surgicell. The graft was then inserted in its place and fixed with external prolene sutures. Results were satisfactory in both function and aesthetics. Ten to 16-month follow-ups had no complications. Saddle nose surgery basically requires the use of a support graft to repair the nasal dorsum. A lower turbinate bone graft procedure has some advantages: it is cheap and safe, it is ready to use and not time-consuming, there is no donor area and no additional donor site morbidity, and it enlarges the airway and the passage to prevent nasal airway obstruction.

Adult↗
PubMed2004

Labiocolumellar graft combined with tip graft in the management of inadequate tip projection.

The short distance of the nasal tip from the alar crease indicates inadequate projection. Tip grafts are commonly used for the management of this problem. In addition to tip grafts, labiocolumellar augmentation by cartilage grafts also provides further elevation of the tip complex for patients with poor tip definition, excessive alar base width, inadequate tip projection, or plunging nasal tip. In addition to standard rhinoplasty procedure and tip grafting for nasal tip augmentation, a linear cartilage graft was inserted centrally just behind the labiocolumellar angle for further tip elevation. The graft was placed in the subdermal plane just anterior to the orbicularis oris muscle to prevent graft displacement and clicking during muscle motion. This procedure was performed for 45 rhinoplasty patients, only three of whom underwent tip plasty procedures alone. During 1 year, 43 patients were followed up. Most of the patients (75%) were satisfied with the results of the procedure. Tip graft combined with labiocolumellar graft is an effective technique for obtaining satisfactory tip projection and correcting the acute labiocolumellar angle.

Adult↗
PubMed2004

Implications for nasal recontouring: nasion position preferences as determined by a survey of white North Americans.

White North American men (n = 75) and women (n = 75) were surveyed to investigate gender specific preferences of nasion position, which may aid plastic surgeons in nasal shaping during rhinoplasty. The subjects were asked to rank preferences of various nasion positions from life-size, scaled, sketched male and female profiles. Nasion positions with regard to height (anterior projection) and level (vertical position) were altered, whereas all other facial and nasal anthropometric measurements were held constant. The nasion heights were drawn at 7, 10, and 13 mm anteriorly to the corneal plane, and the nasion levels were drawn at the supratarsal fold (ST), upper lid ciliary margin (CM), midpupil (MP), and lower limbus (LL). The rank selections made by the female and male subjects of both gender profiles demonstrated statistical significance, as demonstrated by one-way analysis of variance (ANOVA) of ranks (p < 0.001). Further analysis using a post-Dunn test was completed to delineate significant gender specific preferences for the aesthetic nasion level and height. Female nasion levels were preferred at CM or MP over LL or ST on the basis of female ranks, and at ST, CM, or MP over LL on the basis of male ranks (p < 0.05 for all comparisons). Additionally, female nasion heights were preferred at 10 mm > 13 mm > 7 mm anterior to the corneal plane on the basis of both female and male ranks (p < 0.05 for all comparisons). Male nasion levels were preferred at ST, CM, or MP over LL on the basis of both male and female ranks ( p < 0.05 for all comparisons). Male nasion heights were preferred at 10 mm > 13 mm > 7 mm anterior to the corneal plane by both male and female ranks (p < 0.05 for all comparisons). In summary, both the male and female subjects strongly disliked a low nasion height of 7 mm and a low nasion level placed at LL for both gender profiles. Both the male and female subjects were most particular concerning nasion height, preferring a 10-mm projection and strongly disliking a deeper 7-mm height for both male and female profiles. Both the male and female subjects were more tolerant of nasion level alterations. Whereas the male subjects tolerated nasion levels at ST, CM, or MP for either gender profile, the female subjects preferred only nasion levels at CM and MP for the female gender. Overall, these findings may lend support to recent trends in radix augmentation during rhinoplasty, especially among male patients.

Adult↗
PubMedDate not supplied

The use of high-density porous polyethylene as a custom-made nasal spreader graft.

The concept and technique of using high-density porous polyethylene (HDPP), a nonresorbable synthetic material, for nasal spreader grafts, are presented. This material is thought to be particularly useful in revision (secondary or tertiary) rhinoplasty, in which internal valve collapse frequently is confronted and septal cartilage often is unavailable because it has been harvested for spreader or other grafts. Sold as a thin plain sheet (0.85 x 38 x 50 mm) that can be cut to an appropriate size for spreader grafts, HDPP is a ready-to-use material commercially available on the market. Because HDPP permits ingrowths of fibrous tissue inside and around, it is a nonabsorbable material that stabilizes the upper lateral cartilages in their new position and maintains the appropriate internal valve angle. The authors used this material for 15 patients undergoing secondary (n = 12) and tertiary (n = 3) rhinoplasty because of valvular collapse. During the mean follow-up period of 16 months (range, 8-30 months), neither complication nor recurrence of airway obstruction occurred.

Adult↗
PubMed2005

Aesthetic septorhinoplasty in the burned nose.

Patients who have survived thermal injuries to the face suffer severe disfigurement from the devastating deformities of full-thickness facial burns. The nose is the prominent central organ of the face, which has crucial effect on Aesthetic appearance. The plastic surgeon's role to deal with such cases is to undertake procedures to produce a more pleasant look although the target organ could be the non-burned areas of the face. It is a common belief that surgical intervention under the scarred or grafted nose is risky and may result in skin or covering graft necrosis. For this reason, plastic surgeons are cautious and hesitate to perform Aesthetic surgery on burn scarred tissue. We present 13 cases, 10 women and three men with complete or subtotal nasal burn. Classic Aesthetic Rhinoplasty operations were performed to create a better appearance and correct any internal or external deviations. These procedures are carried out under severely burned skins, or previously grafted and reconstructed noses. Cases were followed for about a one-year period. There was no necrosis in any part of skin after surgery. We believe that Aesthetic rhinoplasty can be done safely in these victims with pleasing outcome. The problems that we encountered in these cases were irregularities of burned alar margins, multiple operations and intractable nasal deviation in severe cases.

Adolescent↗
PubMed2004

Nasal tip support and its surgical modification.

As noted by Drs. Johnson and Toriumi, "The keyto successful rhinoplasty lies in the restructuring of the lower third of the nose. The modified skeletal elements must have both proper form and sufficient skeletal strength to give shape to the overlying skin-soft tissue envelope. A skeleton that lacks this load-bearing integrity becomes distorted or collapses under the weight of overlying tissues and the forces of scar contracture" [6]. All facial plastic surgeons have seen (or caused)a weakened nasal tip and have been frustrated at attempts to correct the resultant aesthetic and functional deformities. In a well-reasoned plea for surgical conservatism Dr. Tardy states that "Tip cartilage reorientation and repositioning often produce more favorable and predictable appearances. Notching, pinching, cephalicalar retraction, over-rotation, asymmetries, and tip support loss are all almost entirely eliminated in long-term healing when this conservative philosophy is embraced" [3]. Though conservation of surgical injury will certainly improve rhinoplasty results, a midline tensegrity rebuild using the time-honored surgical technique of layered wound closure will provide the maximum level of surgical control presently available overnasal tip modification. The basic knowledge of architecture and engineering presented here, along with the application of these concepts to nasal tip support,will benefit all of our patients through improvement of surgical results. As surgical architect/engineers we should all em-brace the concept that "The resistant virtue of the(nasal tip) structure that we seek depends on its (architectural) form; it is through its form that it is stable,not because of an awkward accumulation of material. There is nothing more noble and elegant from an intellectual viewpoint than this: to resist through form" [12].

Esthetics↗