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Nasal tip drooping following primary rhinoplasty often results secondary to disruption of nasal tip support. Predictable correction of this problem requires restoration of support within the destabilized nasal tip. This article highlights the use of structural augmentation and precise suture stabilization methods via the open rhinoplasty approach for repairing the postrhinoplasty droopy nasal tip.
This article reviews the case of a 45-year-old female who had undergone previous rhinoplasty in which there had been overaggressive resection of the nasal skeletal architecture. A revision rhinoplasty was preformed using available autogenous septal cartilage and various porous high-density polyethylene implants. One year after the procedure, the patient demonstrated restoration of nasal architecture and persistent aesthetic outcomes.
This article reviews the case of a 31-year-old female who had originally sustained a softball injury to her face and nose. Four years after the injury, she underwent her first rhinoplasty, which included spreader grafts. Unfortunately, a few months later, she sustained further nasal trauma, motivating her to seek a revision septo-rhinoplasty.
Among the complications of prolonged nasotracheal intubation in infants the possibility of pressure necrosis of the cartilaginous nose due to inadequate fixation or improper size of the tube is rarely mentioned. Three cases with postintubational alar defects and another child with a severe stenosis of the nasal entrance are reported. In the latter case a multi-staged reconstructive rhinoplasty had to be done in order to restore nasal breathing. While describing our surgical procedures the multiple difficulties and hazards of reconstructive rhinoplasty in early childhood are discussed.
One of the most difficult maneuvers in rhinoplasty is achieving a straight dorsum in the patient with a crooked nose. Often this deformity is a result of trauma involving the bony and cartilaginous vaults, resulting in nasal bone fractures and avulsion of the lateral cartilages into the nasal airway. Reduction of nasal bone fractures is fairly straightforward, but the repair of nasal cartilage trauma is more problematic. The cartilage of the nasal vault possesses fibrous attachments, which when disturbed, are difficult to reestablish. Overlay grafts are known to be effective in filling these defects and creating the illusion of a straight nose. In this series, during an 8-year period, 89 grafts were placed over lateral nasal wall concavities during rhinoplasty. Results after a minimum of 1 year follow-up are reviewed, as well as technique, materials, complications, revision rate, and patient satisfaction.
Currently popular transsphenoidal approaches to the pituitary include sublabial, external rhinoplasty, alotomy, and transnasal techniques. The conventional sublabial approach remains the workhorse method despite postoperative lip edema, potential difficulty for denture wearers, and troublesome persistent upper lip and incisor teeth numbness. We traced the courses of the nasopalatine, infraorbital, and anterior superior alveolar nerves in 41 cadaveric half-head dissection to determine the exact contribution to upper lip and incisor teeth innervation. We then conducted a retrospective patient survey of 25 sublabial, 28 external rhinoplasty, 23 alotomy, and 12 transnasal approaches to the hypophysis to assess the incidence of upper lip and incisor teeth paresthesias lasting longer than 1 month. We conclude that rhinoplastic techniques are superior to the sublabial approach in limiting upper lip and incisor teeth numbness without compromising neurosurgical exposure for hypophysectomy.
OBJECTIVE: To determine under which layer the silicone implants should be inserted into, the biomechanical properties of fascia and periosteum were investigated. DESIGN: Biomechanical testing of cadaveric tissues. BACKGROUND: In silicone augmentation rhinoplasty, most complications are closely related to the depth of implant and the mechanical character of the tissue surrounding the implant. METHODS: Biomechanical properties of human nasal periosteum and fascia were studied, including tensile strength, stress-strain relationship and stress relaxation under uniaxial elongation.Result. Although with less failure strain, the periosteum has more tensile strength than fascia. The slope of the linear part of stress-strain curve of the periosteum is bigger than that of fascia, which indicates the periosteum is stiffer than fascia. The stress-relaxation slope of periosteum is smaller than that of fascia. CONCLUSION: In the view of biomechanics, the periosteum is thicker, stronger and stiffer than fascia. Under periosteum the silicone implants are easier to be fixed at desired position, thus periosteum is more suitable for covering silicone implants. RELEVANCE: The periosteum is more suitable than fascia for covering silicone implants in augmentation rhinoplasty.
Mature adult rhinoplasty requires more sophisticated planning and flawless execution in order to achieve an optimal result. The improvement not only engenders a more pleasing feature, it also provides approximately 5 years' rejuvenation to the face. These patients possess thin skin, weak support structures, and vulnerable nasal function, rendering the rhinoplasty more enigmatic. The medical and emotional issues should be resolved prior to surgery.
The beauty and allure of rhinoplasty rests in its unending mystery of challenges. It is an operation that demands the surgeon's attention, and it is a procedure in which technical skill alone seldom assures successful outcomes. Following a 40-year involvement with rhinoplasty, the author awaits his next case with as much enthusiasm as the first. Few operations in the repertoire of the facial plastic surgeon can be thus characterized.
Normal topographic anatomy of the distal nose is a reflection of the delicate integration between the lower lateral cartilage, the upper lateral cartilage, the sep-tum, and skin. Understanding these relationships will help the rhinoplasty surgeon diagnose and treat con-cavities of the distal nose. Most patients present with a hybrid of these defects. For example, the patient in Fig. 19 presented for a primary rhinoplasty. A variety of concavities can be noted and include dorsal septal deflection, upper lateral cartilage avulsion on the left,bilateral lower lateral complete concavities, and the beginning of a dorsal depression (Fig. 19A-I). The nasal skeleton and the skin and soft tissue are normally in equilibrium, but trauma and reduction rhino-plasty disrupts this equilibrium. Skeletal distortion can lead to septal deflection, middle vault collapse, or alar buckling [20]. It is important to realize that correction of deflection or depression by excision needs to be balanced with augmentation, which provides balance for the previously disequilibrated skeletal and soft tissue forces. Augmentation can be done with spreader grafts, tip grafts, columellar strut, and dorsal grafts. A patient's soft tissue envelope will also play a major role in the success of a septorhinoplasty. The surgical principles of septorhinoplasty such as judicious resculpting of the cartilaginous framework, respect of major tip support, tip grafting technique, and postoperative tissue contraction still apply and must be placed in conjunction with repairing a pathological topographic concavity.
Out of the numerous implant materials that have been used for augmentation of the nasal dorsum, autogenous cartilage is considered to be the optimal grafting material due to its versatility and long-term survival. However, in the case of extensive augmentation often an alternative grafting material is needed. Homologous cartilage seems an attractive option, but is not commonly used because of the fear of disease transmission, the long-term unpredictability and the possibility of warping. Alloplastic grafts have offered varying degrees of success in rhinoplasty, but have resulted in significant complications as well. Lately, expanded polytetrafluorethylene (Gore-Tex(R)) has proven to be a promising synthetic material in nasal dorsal augmentation. However, convincing long-term success compared to autogenous cartilage grafts is still lacking and numbers are insufficient. This paper consists of a prelimary report about the use of Gore-Tex(R) soft-tissue patches in nasal dorsal augmentation in 66 patients over a 6-year period, which forms the largest European series so far. No complications were observed in either primary (29%) or revision rhinoplasties (71%).
The aesthetic facial surgeon's evaluation of the patient seeking cosmetic surgery must be thorough. Those with emotional disturbances and overt psychiatric disorders are considered to be poor candidates for elective cosmetic surgery. In patients with nasal deformity, the prevalence of subclinical psychological morbidity and the role of cosmetic surgery in these circumstances are uncertain. This study investigates the use of the CORE questionnaire in assessing the psychological status of patients awaiting rhinoplasty or septorhinoplasty and compares this with the psychological status of patients awaiting septoplasty. A prospective trial of 27 rhinoplasty patients and 16 septoplasty patients revealed that in terms of life functioning, patients with nasal deformity have significantly higher psychological morbidity compared with patients without nasal deformity. However, there was no significant difference in global psychological status. In addition, female patients with nasal deformity are more distressed in terms of general wellbeing than male patients with nasal deformity and there is a tendency for higher global psychological impairment in women. These results may have implications in terms of health care rationing in patients with nasal deformity and preoperative psychological screening.
Several studies in facial plastic surgery have suggested that changes in body image that initiate a positive psychological cycle play an important role in a successful outcome. The change in the patient's self-perception leads to a sense of well-being, rather than there being a direct impact from the changed features. One area in which this change in self-perception may be manifest is in the development and maintenance of interpersonal relationships. Due to the impact of negative body image preoperatively, we hypothesized that patients with nasal deformity may have problems with their interpersonal relationships. This theory was tested using the IIP-32: a short version of the inventory of interpersonal problems. A prospective trial was undertaken of 27 rhinoplasty patients with nasal deformity and 16 septoplasty patients without nasal deformity, the latter group used as a control. The results show that the null hypothesis that the two groups are from the same population on all dimensions of the IIP-32 cannot be rejected (total mean score 0.753). From this data, it seems that patients with nasal deformity have no more difficulties in their interpersonal relationships and, as such, this particular issue cannot be used in support of rhinoplasty surgery.
A total of 45 patients with cleft lip nasal deformities were operated on between September 1997 and December 1999. We reviewed 35 of them. Out of these, 31 patients had unilateral cleft lip nasal deformities and four patients had bilateral cleft lip nasal deformities. The age range of the patients was from 3 years to 56 years. A reverse-U incision with V-Y plasty was used in 20 patients with mild to moderate unilateral cleft lip nasal deformities. An open rhinoplasty incision combined with the reverse-U incision and V-Y plasty was used in 11 patients with severe unilateral cleft lip nasal deformities. A bilateral reverse-U incision and a trans-columellar incision were used in the four patients with bilateral cleft lip nasal deformities. After advancement of the mucochondrial flap, alar transfixion sutures were used to ensure firm contact between the nasal skin and the redraped reverse-U flap. A composite graft for columellar lengthening was used in six cases of severe unilateral cleft lip nasal deformity and the four cases of bilateral cleft lip nasal deformity. Ancillary procedures included correction of a lateral displacement of the alar base, lip scar revision, a cartilage graft for tip augmentation, iliac bone grafting for correction of hypoplasia of the maxilla or for an alveolar cleft and corrective rhinoplasty. A self-made nasal retainer was applied for 6 months in all patients to maintain the corrected contour of the nostril. The follow-up period ranged from 11 months to 26 months, with an average of 18 months. The final results were evaluated based on the degree of symmetry of the nostrils, the redraping of the alar-columellar web and the exposure of the nostrils. Good results were obtained in 29 patients where alar-columellar web deformities were either absent or minimal and a satisfactory symmetry of the nostrils was achieved. Four patients had fair results and two patients had poor results. In conclusion, we suggest that the reverse-U incision with V-Y plasty is a useful method for achieving symmetry of the nostrils in cleft lip nasal deformities in Orientals. In addition, this technique provides ample advancement and repositioning of the mucochondrial flap and simultaneous correction of the nasal vestibular web.
Successful surgical repair of the unilateral cleft lip and nose deformity, defined as normal orbicularis oris function and near-perfect symmetry of the repaired lip and nose, demands that the surgeon possess complete understanding of the embryology and anatomy of the midfacial defects. The surgical approach to repair of the unilateral cleft lip/nose should place great emphasis on achieving symmetry, not only with the lip segments but also perhaps even more importantly with the nasal tip. The reconstruction should recreate an intact fully functional orbicularis oris muscle across the cleft and camouflage the scar optimally. We have found that modification of the Millard rotation-advancement flap technique, with particular attention to the primary nasal repair, provides the best outcomes. In patients who have undergone primary repair of the lip and/or nose deformity, secondary rhinoplasty is generally required, regardless of the technique used at the primary repair. The degree of nasal deformity, however, is less severe following primary repair of the asymmetric nasal tip. We have found that the sliding flap cheliorhinoplasty, Wang's modification of the Vissarionov technique, provides excellent results for most secondary cleft rhinoplasties.
Silicone rubber has been used safely and effectively for facial augmentation for nearly 5 decades in eastern Asia. We have used silicone rubber nasal implants in primary ethnic rhinoplasty and have found consistent and long-lasting results with low complication rates. Silicone dorsal nasal augmentation in primary rhinoplasty avoids donor site morbidity and implant resorption as seen with autogenous implants. Silicone nasal implants have a low extrusion and infection rate. In the appropriate patient with proper placement, silicone nasal implant is nearly the ideal implant material.
The septo-rhinoplasty is a standard procedure in head and neck surgery. Only slight modifications have been developed during the last years concerning especially the surgery of the septum, the tip of the nose and the osteotomies. The presently well favored "external rhinoplasty" is not of any advantage and should be restricted to only few indications. In the present paper the different surgical approaches are described for the various nose deformities of adults and especially for those problems related to children.
The authors stress that conservative correction should be the main goal in rhinoplasty in general and in the surgical treatment of the nasal tip in particular. After outlining contemporary concepts and criteria relating to the modeling of an aesthetically pleasing nasal tip and the consequent surgical planning for its achievement as well as the specific indications for tip plasty, they go on discuss the technical aspects of tip projection and rotation. A personal technique is proposed for reshaping and sculpturing the tip, completed by a double interdomal suture with different application points during closed rhinoplasty. The technique also involves ancillary procedures consisting in the execution of a series of incisions with a radial pattern at the domal level and, when necessary, in the undersurface of the lateral crus. The procedure is explained in detail and the results are illustrated and discussed.