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PubMed2000

Techniques for the improvement of the internal nasal valve in functional-cosmetic nasal surgery.

The internal nasal valve (INV) refers to the slit-like region between the caudal end of the upper lateral cartilage (ULC) and the nasal septum. It is the narrowest portion and primary regulator of the nasal airway. Reduction rhinoplasty decreases the nasal airway cross-sectional area and may cause symptoms, unless additional surgical measures are taken. Rhinoplasty or septorhinoplasty was performed for 76 patients with a nasal hump, using an external approach. As a consequence of the nasal hump removal, the ULCs were separated from the septal cartilage. All patients underwent one of the three forms of cartilaginous nasal dorsum reconstruction: primary closure (PC) (50 patients); spreader graft (SG) (19 patients); or upper lateral splay graft (ULSG) (7 patients). At least 3 months postoperatively. INV obstruction was evaluated by asking the patients about nasal obstruction symptoms and visually examining the INV with an otoscope. Nasal obstruction complaints and INV constriction found among patients in the PC. SG and ULSG groups were 16 (32%), 2 (10.5%) and none, respectively. The results of the PC group were compared statistically with the combined results of the SG and the ULSG groups. The patients in the combined SG-ULSG group had significantly less nasal obstruction complaints and INV angle constriction compared with the PC group. Due to the higher rate of postoperative INV stenosis. PC should be avoided. The author uses ULSG when the septal cartilage appears straight and sturdy and SGs when the straightened septal cartilage looks weak and vulnerable, since SGs not only improve the INV, but also reinforce the septal cartilage.

Adolescent↗
PubMed1994

The role of preserved autogenous cartilage graft in septorhinoplasty.

Previous reports have established the role of fresh autogenous cartilage grafts harvested at the time of surgery. This report describes the value of autogenous preserved cartilage, removed and stored at the time of initial surgery, for use in secondary surgery. This study also compares fresh and preserved cartilage used in crushed and noncrushed states in secondary rhinoplasties. From 1983 to 1990, 256 of 1,185 patients who had undergone septorhinoplasty required a revision procedure. Cartilage graft was used in 186 (72.7%) patients. Cartilage removed during the primary surgery was stored in a saline and antibiotic solution at 0 degree F to 2 degrees F. The average time interval from primary to secondary surgery was 11.97 months (SD, 10.63 mo). Follow-up after graft placement averaged 44.71 months (SD, 26.21 mo). Two hundred seventy-seven pieces of cartilage were used, consisting of 16 noncrushed fresh, 136 crushed fresh, 8 noncrushed preserved, and 117 crushed preserved. Graft success rate was 93.8% for noncrushed fresh cartilage grafts, 87.5% for crushed fresh, 87.5% for noncrushed preserved, and 85.5% for crushed preserved graft. We conclude that preserved autogenous cartilage retains almost as much graft volume as fresh cartilage in rhinoplasties and eliminates the need for harvesting a graft. Cartilage removed during nasal surgery, particularly when a septoplasty is being performed, is valuable and should be stored for possible later use.

Adult↗
PubMed1998

Surgical correction of unilateral cleft lip nasal deformity.

Fifty-five patients with unilateral cleft lip nasal deformities were operated on from March 1992 to June 1996. Thirty-one patients were male and 24 were female. Three patients were 2 to 5 years of age, 7 patients were 6 to 10 years old, 12 patients were 11 to 15 years old, 13 were 16 to 20 years old, and 20 were greater than 21 years of age. The average follow-up period was 16 months. Combined operative procedures, depending on the severity of the cleft lip nasal deformity, were the following: (1) a reverse-U incision and Z-plasty for a mild vestibular web, (2) a reverse-U incision and V-Y plasty for a moderate vestibular web, (3) open rhinoplasty incision combined with a reverse-U incision and V-Y plasty for severe flattening or buckling of the cleft lower lateral cartilage, (4) lower lateral cartilage suspension or repositioning with or without an onlay cartilage graft, (5) alar base advancement, (6) bone graft on the piriform aperture, (7) septoplasty and corrective rhinoplasty, and (8) columella lengthening with an auricular composite graft. A nasal splint was applied for 3 to 6 months in every patient to maintain the corrected nostril contour. Most patients were satisfied with their surgical results. We suggest that to achieve a good contour of the nose, bony and cartilaginous deformities should be corrected simultaneously with correction of the soft tissue.

Adolescent↗
PubMed1997

Nasal dermoid sinus cysts in children.

Thirty-six children with nasal dermoid sinus cysts were treated in the Department Pediatric Otolaryngology, Armand Trousseau's Children's Hospital (Paris, France) between 1974 and 1994. Ten of the patients presented with a midline cyst only, eight had nasal pits only, and 18 had combined cases. In six of the 36 patients, presurgical imagery indicated signs of intracranial extension of the tract, reaching the foramen caecum without intracranial mass. Three surgical techniques were used: an external rhinoplasty approach with medial crura section in 23 cases, a direct median approach in seven cases, and a paracanthal approach in six cases. Only two cases had meningeal adherences. Two superficial recurrences occurred within the 7-year follow-up period. Widening of the scar occurred in four children after verticomedian approach or nasal pit excision. The external rhinoplasty procedure with medial crura section results in a wide surgical approach, low recurrence rate, and good aesthetic results.

Adolescent↗
PubMed2000

Arterial supply of the nasal tip in Asians.

OBJECTIVES: The blood supply to the nasal tip and columella was examined to determine whether it could be damaged as a result of transcolumellar incision during an external rhinoplasty approach in Asians. METHODS: The blood vessels that supply the nasal tip were examined by dissecting 51 cadavers, and their corresponding 102 nasal sections were injected with red latex before dissection. The size and distribution of the vessels were measured with the unaided eye and the primary supply vessels were determined. The subdermal layer in which the vessels lie and the course of the vessels were also investigated. RESULTS: The main blood supply source of the nasal tip proved to be the lateral nasal artery in 78% (80/102) of the cases examined, while the remaining cases (22%) received their blood supply via the dorsal nasal artery. Columellar branches were narrow in diameter and varied in size and appearance, and were therefore appeared insufficient as a main blood supply. These arteries passed through the musculoaponeurotic layer, but they were also in close proximity to the main surgical plane in the dome of the lower lateral cartilage. CONCLUSIONS: The authors speculate that the nasal tip blood supply in Asians is primarily derived from the lateral nasal or dorsal nasal arteries, with a variable contribution from the columella arteries. Therefore, it is important to correctly determine the surgical plane below the musculoaponeurotic layer in order to prevent skin flap necrosis or nasal tip deformity that may occur from damage to the main vessel during an external rhinoplasty approach.

Adult↗
PubMed1975

Valvular obstruction of the nasal airway.

Valvular nasal obstruction may occur in the postoperative rhinoplasty patient. One may anticipate a dropping of the tip, from residual redundant or inelastic skin, in some older patients with long noses. Measures to correct (or avoid) this may be undertaken at the time of the primary rhinoplasty. However, an overcorrection may be necessary if there is much redundant skin. Discretion may indicate the need for a secondary procedure. Lateral wall valving is unusual-but it may occur in the long, high, thin nose (where a suggestion of this action may be observed preoperatively). Maintenance of continuous cartilage along the alar rim, at the time of alar cartilage resection, appears to be important in prevention of postoperative valvular obstruction in these few patients.

Female↗
PubMed1983

The effects of nasal surgery on airflow.

Although nasal surgery for form and function is commonplace, knowledge of its effects on nasal airflow has been scanty. This study was undertaken to clarify that relationship. Prior to our investigation, we reviewed the pertinent physics of airflow. We noted that during laminar flow, the air in contact with the walls of a tube is motionless, whereas the air in the center moves. Moreover, according to Poiseuille's law, as the radius of the tube increases, the flow increases to the fourth power. Finally, tubes that are irregular, such as the nose, cause turbulent flow. When air passes through the nose, the flow is regulated by four values: the external valve, the internal valve (the angle formed by the junction of the upper lateral cartilages and the septal cartilages are the most important), the nasal turbinates, and the septum. Using anterior rhinomanometry, the nasal airflow was measured in 69 control subjects and in 329 patients who underwent a rhinoplasty, septoplasty, septectomy (submucous resection), or inferior turbinate resection, alone or in combination. We found that a rhinoplasty does not adversely affect the nasal airflow, and those patients who had procedures to improve their nasal airflow did indeed obtain it. These data were statistically significant. The data from our airflow studies frequently failed to correlate with patient assessments of their own nasal airways as well as our evaluations by rhinoscopy. Furthermore, rhinomanometric findings varied considerably even within the same testing session. At present, on the basis of our investigations, we cannot recommend rhinomanometry with enthusiasm because of its questionable reliability and validity.

Adult↗
PubMed1983

History of total nasal reconstruction with particular emphasis on the folded forehead flap technique.

The history of plastic surgery is identified throughout the centuries with the history of rhinoplasty. The Indian Koomas first and later the Italian surgeons found valid solutions to the problems caused by partial loss of the nasal pyramid. However, the idea of rebuilding, with a single forehead flap, the tip and columella and providing at the same time a lining of skin for the newly formed nose goes back to the middle of the nineteenth century. The Italian Natale Petrali (1842) and the Germans Johann Friedrich Dieffenbach (1845) and Ernst Blasius (1848) contend for precedence in carrying out this important procedure still used today, which, barring postoperative contracture, represented a great advance in successful total rhinoplasty.

Germany↗
PubMed1987

Nasal tip projection: counterpoint.

The achievement of tip projection in rhinoplasty has been overemphasized in recent programs and publications. The normal spring support of the tip by the medial crura will ordinarily give adequate tip projection in a well-executed rhinoplasty. If additional tip projection is required, the simplest procedures are advancement of the columella and tip upward on the end of the septum and similar advancement of the alar cartilages toward the bridge. For additional support, a cartilage strut is inserted between the medial crura. Retrusion of the distal nasal complex requires maxillary advancement or support beneath the base of the alae and columella. If a tip graft is required, one achieves a more natural tip by a posterior conchal graft, utilizing its natural curve, rather than by a building-block support.

Cartilage↗
PubMed1994

Oculonasal synkinesis.

A phenomenon the authors have termed oculonasal synkinesis has been observed in 13 individuals in two independent practices. This complex presents as simultaneous contraction of the orbicularis oculi and the compressor narium minor muscles. When the patient blinks, the compressor narium minor muscle contracts, causing depression of the ala. Its etiology is postulated as the formation of anomalous connections between the temporal and zygomatic branches of the facial nerve, innervating the orbicularis oculi muscle, and the buccal branches of the facial nerve, innervating the compressor narium minor muscle. All 13 individuals who exhibited this phenomenon are female. This anomaly was displayed bilaterally in 7 patients, on the right side in 2 patients, and on the left side in 4 patients. A 2-month-old daughter of one of the patients who had bilateral presentation, also displayed the phenomenon. In 6 patients who underwent rhinoplasty, resection of the compressor narium minor muscle resulted in complete elimination of the abnormal muscle movement. The plastic surgeon who performs rhinoplasty should be cognizant of the synkinesis and discuss its presence with the patient, since a patient may consider this a surgical sequela upon discovering the condition postoperatively. Furthermore, this unintentional muscle function is aesthetically displeasing.

Adolescent↗
PubMed1994

Columella lengthening in nasal tip plasty of Orientals.

To elevate the nasal tip in Orientals, two simple adjunctive procedures are presented. Either V-Y advancement or earlobe composite graft can be used after the open rhinoplasty incision on the columella-labial junction. Over the past 6 years, 62 Oriental patients with short columella were treated with one of the above procedures. The nasal tip projection as well as nasal tip appearance greatly improved. The scar in the columellar base posed no problems, and none of the patients complained about the scar. The procedures are particularly useful for cosmetic rhinoplasty in Orientals as well as in cleft lip nasal deformity.

Cleft Lip↗
PubMed1998

Footplates of the medial crura.

The purpose of this combined prospective and retrospective study was to review the abnormalities of the footplates of the medial crura, their surgical correction, and the dynamic changes that result from footplate alteration. Prospectively, measurements of 40 footplates were obtained during 20 consecutive primary rhinoplasties. The distance between the footplates at their most posterocaudal position was measured, along with the thickness, length, and width of the footplates. The shape of the nostrils was also observed and correlated to the form of the footplates. The distance between the footplates ranged from 7.5 to 15 mm, the average being 11.4 mm. The length of the footplates ranged from 4 to 7.5 mm, the average being 5.81 mm. The thickness of the footplates averaged 1.06 mm, ranging from 0.80 to 1.5 mm. The width of the footplates ranged from 2.5 to 7.0 mm, averaging 4.48 mm. In a retrospective review of 295 consecutive rhinoplasties, footplates were altered in 76 cases (25.8 percent). Of these cases, 29 procedures (9.8 percent) were performed to narrow the columella base and to advance the subnasale: on 24 patients (8.1 percent), the goal of this maneuver was to narrow the columella base only; on 5 patients (1.7 percent), the operation was conducted to aid in increasing the tip projection, provide a better foundation for the tip, advance the subnasale caudally, and narrow the alar base. Asymmetry of the columella was corrected in 16 patients (5.4 percent), and footplates were resected primarily to reduce the tip projection in 2 patients (0.7 percent). A detailed analysis of the nasal base will dictate one of the following courses pertaining to footplate alteration. If the patient exhibits an overprojected tip and divergent footplates, the lateral portion of the footplates will be resected partially, then approximated. If the tip is underprojected or has normal projection, the divergent footplates will be approximated without resection. Should the subnasale and the base of the columella be protruding, the soft tissue between the footplates will be removed to avoid excess fullness in this site as a result of the approximation of the footplate. However, when the footplates are divergent, the columella base and nasal spine area are often retracted, setting an auspicious stage for approximation of the footplates without having to excise the soft tissue. This maneuver not only narrows the columella base, it also advances it caudally. Longstanding caudal deviation of the septum may also create asymmetry of the footplates, which will not respond to mere repositioning of the septum, and often requires repositioning of the footplates with mobilization and fixation to the contralateral footplates.

Cartilage↗
PubMed1998

Correction of the crooked nose.

Correcting the crooked nose remains one of the most challenging problems in rhinoplasty. When faced with a twisted nose, rhinoplasty surgeons tend to be divided into those who perform an anatomic reconstruction and those who prefer camouflage techniques. Regardless of the approach used, the revision rate remains fairly high. An anatomic correction of the twisted nose through an open approach was performed. The septum was freed from the extrinsic forces of the deformed nasal bones and upper and lower lateral cartilages. The residual true septal injury was then evaluated. The septal deformity was addressed through quadrangular cartilage resection, repositioning of the caudal septum in the anatomic midline, and correction of the dorsal septal deformity with horizontal control sutures. The skeletal support was then reconstructed with the use of a spreader-extension graft on the concave side and a batten graft on the opposite side. The nasal tip was set relative to the dorsum by fixation to the extension grafts. Residual lateral crus deformities were corrected by a combination of lateral crural spanning sutures or alar spreader grafts. With this approach, straightening the crooked nose without compromising skeletal support or nasal aesthetics was successful.

Adult↗
PubMed2000

Sonography of nasal tip anatomy and surgical tip refinement.

The amorphous or wide nasal tip is the most commonly encountered nasal tip deformity, but little has been done to measure the effect of standard rhinoplasty techniques on nasal tip width. In the clinical routine, nasal tip width and soft-tissue cover thickness are estimated by inspection and palpation rather than by measurement. In this study, a B-mode sonograph with a 12-MHz transducer was used in a noncontact mode to measure tip width 0.5 cm occipital to the tip defining point, distance between the alar cartilage domes, and thickness of the soft-tissue cover overlying the lower lateral cartilages. These parameters were measured 3 to 8 weeks before and 56 days to 19 months after a transdomal suture tip plasty in 18 patients. The distance between the alar cartilage domes seemed to be an important factor for tip width because interdomal distance, not soft-tissue cover thickness, correlated with tip width before surgery (correlation: 0.53). Conversely, the degree of tip refinement correlated with preoperative soft-tissue cover thickness (correlation: 0.75), but not with interdomal distance. Ultrasonic imaging of nasal soft tissues may help to assess the effect of different tip refining procedures and other soft-tissue changes after rhinoplasty.

Adult↗
PubMed2000

Segmental bone and cartilage reconstruction of major nasal dorsal defects.

This article describes the results of segmental bone and cartilage reconstruction of significant nasal dorsal defects. Solid bone graft reconstructions frequently lead to an unnatural hardness of the nasal tip. Rib cartilage reconstructions are pliable and soft but are a problem because they easily undergo warpage. The operation is performed using the open approach. Outer cranial bone graft is used for the bone component and extends at least two-thirds of the length of the dorsum. It is secured in place with a compression screw and a Kirschner wire. The cartilage component consists of an abbreviated L strut constructed of septal or conchal cartilage. It is slotted into the cranial bone in a tongue-in-groove manner and is sutured to it through a drill hole in the bone. The dorsal profile is completed with a single cartilage onlay graft or multiple sagittal cartilage grafts secured to the sides of the L strut. Twelve patients underwent segmental reconstruction of nasal deformities. Within this group, five patients underwent secondary rhinoplasty, five underwent posttraumatic rhinoplasty, and two underwent nose augmentation for Oriental features. There were seven men and five women. In all cases, good nasal tip mobility was maintained, and the nasal tips were soft. The interface between the bone graft and cartilage graftwas well camouflaged. The two did not separate. This procedure follows the principle of replacing lost tissue with like materials.

Adult↗
PubMed2000

The true hanging columella: simplified diagnosis and treatment using a modified direct approach.

An imbalance between the alar rim and the columella border can be a disturbing aesthetic deformity. If the cause is a pseudohanging columella, the therapy should be directed to the alar rims. When the deformity is a true hanging columella with unusually wide medial crural cartilages, balance can be restored by excising a C-shaped crescent of cartilage from the cranial border of the medial crura of the alar cartilages in a direct approach. This condition was present in approximately 15 percent of the patients reviewed. The treatment of a true hanging columella adds a subtle beneficial enhancement to the results of a rhinoplasty. The authors describe a simplified diagnostic method and present their experience treating the true hanging columella using a modified "direct approach" through a closed endonasal rhinoplasty.

Adult↗
PubMed2000

Primary correction of the unilateral cleft nasal deformity.

An 18-year experience with the management of the unilateral cleft nasal deformity in 1200 patients is presented. A primary cleft nasal correction was performed at the time of lip repair in infancy; a secondary rhinoplasty was done in adolescence after nasal growth was complete. The technical details of the authors' primary cleft nasal correction are described. Exposure was obtained through the incisions of the rotation-advancement design. The cartilaginous framework was widely undermined from the skin envelope. The nasal lining was released from the piriform aperture, and a new maxillary platform was created on the cleft side by rotating a "muscular roll" underneath the cleft nasal ala. The alar web was then managed by using a mattress suture running from the web cartilage to the facial musculature. In 60 percent of cases, these maneuvers were sufficient to produce symmetrical dome projection and nostril symmetry. In the other 40 percent, characterized by more severe hypoplasia of the cleft lower lateral cartilage, an inverted U infracartilaginous incision and an alar dome supporting suture (Tajima) to the contralateral upper cartilage were used. Residual dorsal hooding of the lower lateral cartilage was most effectively managed with this suture. This primary approach to the cleft nasal deformity permits more balanced growth and development of the ala and domal complex. Some of the psychological trauma of the early school years may be avoided. Also, because of the early repositioning of the cleft nasal cartilages, the deformity addressed at the time of the adult rhinoplasty is less severe and more amenable to an optimal final result.

Cleft Lip↗
PubMed2001

A new technique in nasal-tip reduction surgery.

This article presents a technique for the reduction of the overprojected nasal tip with a proportional reduction of the nostril-margin circumference. To achieve these reductions, a modified open rhinoplasty technique is used, which is unique in that it involves the total transection of the columella through the medial crura of the alar cartilage. The alar cartilage is raised with the flap. The technique was first developed and introduced by the senior author (R.A.S.) 25 years ago and has since been refined through the execution of several thousand rhinoplasties. The results continue to be consistent and pleasing from both the patients' and the surgeon's points of view.

Female↗