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Alar collapse may be developmental and can occur after trauma or tip rhinoplasty. This condition is often seen in elderly persons. Autogenous split costal bone that was grafted to the nasal bones proved effective in the treatment of alar collapse in three patients. This method changes the weakened alar wall into a noncollapsible extension of the nasal bones. Nasal inspiratory airflow was substantially increased after surgery.
Modification and refinement of the nasal tip has long been regarded as the most difficult and complicated procedure in rhinoplasty. The various procedures and approaches to this surgery have been characterized by removal of increasing amounts of lateral crus in an effort to develop greater definition of the tip. This has resulted in a number of iatrogenic deformities. In addition, it has resulted in undesirable and uncontrolled amounts of rotation and retrodisplacement. A technique with some variations that I have used for a number of years serves to overcome most of these problems while providing excellent definition to the tip. This method, with some variations, leaves 90% to 100% of the lower lateral cartilages of the nose that serves as a lateral strut. This limits the retrodisplacement and rotation that takes place when scar tissue replaces the excised lower lateral cartilages of the nose.
Although remodeling the nasal base is one of the most demanding and important parts of rhinoplasty, it is usually taught and performed in such a seemingly empirical manner that the entire process becomes bewildering and mysterious to many students. Because the cartilaginous skeleton of the nasal base bears a striking resemblance to a tripod, we have been using remodeling techniques for the past 25 years that employ mechanical principles that could be used if one desired to change the configuration of a tripod.
A stepwise study of nasal fractures includes an initial investigation that was carried out to discover why so many patients were awaiting rhinoplasty, which led us to find a 30% to 40% failure rate in nasal manipulation operations. We then studied the mechanics of nasal fracture by striking fresh cadaver noses. We found that if the nasal bones were deviated by more than half the bridge width, there was a concomitant C-shape fracture of the bony and cartilaginous septum. Two trials were performed, and patients with nasal deviation after trauma were allocated to either manipulation or manipulation plus excision of septal cartilage (closed or open reduction). Both trials were statistically significant, indicating that open reduction is the preferred treatment for patients with a deviation of more than half the bridge width of the nose.
Anatomic studies of the nose were done in 60 cadavers, both fresh and embalmed, allowing correlation of surgical anatomy and operative techniques. All septorhinoplasties were performed on fresh cadavers, using a clinical instrument set and head lamp. In addition, the alar cartilages were assessed in 25 patients undergoing external rhinoplasty. This multifaceted study provided an integrated approach to nasal anatomy.
When the cartilaginous framework in the tip of the nose fails to provide adequate support and definition, the rhinoplastic surgeon must create strength and refinement. To achieve these results, we advocate a new twist of an old concept that can be used to create a stronger, more triangular lobule in the wide, bulbous, or bifid tip. Morselizing, incising, and suturing alar cartilages have long been recognized as adjunctive procedures in tip rhinoplasty; however, the specific method described herein can provide results comparable to the classic Goldman tip while guarding against the possibility of cartilage displacement and mucous membrane entrapment.
One of the most important anatomic elements of successful rhinoplasty is nasal tip support and its influence on nasal tip projection, yet the medical literature is vague about what creates and maintains nasal tip support. During the years, 12 or more structures have been implicated that may be important. We believe the two controlling factors are the strength of the alar cartilages and the position of the septal angle.
Bossae formation is a common late complication seen following modification of the nasal tip during rhinoplasty. Prevention is our primary goal, and the incidence of this iatrogenic problem will decrease as the surgeon's understanding of the dynamics of healing in the altered nasal tip increases. We herein review the pertinent nasal anatomy, predisposing patient characteristics, and causative surgical maneuvers, concluding with our recommendations for prevention and treatment.
Preoperative computer-assisted video imaging was performed on 50 consecutive rhinoplasty candidates, along with routine preoperative photographs and assessment. Each patient then completed a questionnaire dealing with the imaging process. Patient acceptance of the imaging process was excellent. Responses indicated that most patients felt that video imaging improved communication between patient and surgeon, increased patient confidence in surgery and surgeon, and enhanced the patient-physician relationship. The future use of computer-assisted video imaging in teaching, preoperative planning, and improved post-operative patient satisfaction is discussed.
In the evaluation of a patient for cosmetic surgery, an underlying congenital origin for the deformities noted, with possible expression in multiple organ systems, should always be considered. In this case, a 19-year-old woman requesting rhinoplasty exhibited facial anomalies: lack of quadrangular and lower lateral cartilages, small bony dorsum, underdeveloped aural cartilage, and infantile larynx and trachea. Otherwise healthy, she recalled having recurrent bouts of croup until she was 15 years old, exercise limitation secondary to stridor, and a family history of nasal hypoplasia. Genetic referral diagnosed her condition as Opitz-BBB/G compound syndrome (oculogenitolaryngeal syndrome), and we here review its head and neck manifestations. Suspected agenesis of nasal cartilage, unreported in previous literature (to our knowledge), was confirmed intraoperatively and presented a unique challenge for reconstruction, including a restricted choice of anesthesia and a need for banked cartilage.
Increasing nasal tip projection, rotation, and definition have classically been attempted through a variety of lobular cartilage incising or excising techniques. Resultant long-term complications, including bossing, alar notching, pinched tips, and alar collapse, have occasionally resulted from the use of these techniques. The majority of these complications have arisen secondary to a loss of structural support following the interruption of the lower lateral cartilages. This article describes the "lateral crural steal," a method of increasing nasal tip projection and nasal tip rotation while preserving the integrity of the lobular cartilage complex. The procedure uses the external rhinoplasty approach for exposure. By elevating both the dorsal and the vestibular skin from the domes of the lobular cartilages, the lateral crura may be advanced onto the medial crura to further project the nasal tip and to reorient the tip upward. This technique along with its philosophy and long-term follow-up results are presented.
Substantial premaxillary augmentation is necessary as an adjunctive treatment in most cleft rhinoplasties and in those patients exhibiting an acute nasolabial angle due to retrusion of the premaxila. We describe our technique of evaluation and treatment of this condition using a custom-carved piece of material made from a woven combination of Teflon and organic fibers (Proplast). Detailed technical illustrations as well as patient results are demonstrated. We have found this technique in our hands to be a simple, safe, and effective means of correction of significant premaxillary retrusion.
Nasal tip projection is an important defining feature of the nasal profile. Loss of projection is often the bane of the rhinoplastic surgeon. While augmentation techniques for maintaining or increasing tip projection are useful in selected patients, the majority of rhinoplasties rely on excision of cartilage, particularly cartilage of the cephalic border of the lower lateral crura, to produce the desired cosmetic result. The purpose of this study was to measure the effects of lower lateral cartilage excision on nasal tip projection resulting from three common forms of nasal tip surgery. These techniques included cephalic border resection without vertical dome division, cephalic border resection with vertical dome division, and cephalic border resection with dome division and suture reapproximation of the mesial crura, the so-called "Goldman tip." Despite the fact that overall excellent results were obtained and loss of projection was rarely a noticeable feature, a measurable loss of projection can be seen in all but one case in this series. Although loss of tip projection is usually acceptable due to the masking effect, the concurrent reduction in dorsal nasal height, loss of projection must be anticipated in excisional techniques of the lower lateral cartilage.
Nasal structural reconstruction is a formidable task in cases where there is loss of support to both the nasal dorsum and tip. A multitude of surgical approaches and materials have been used for the correction of the saddle-nose deformity with varying degrees of success. Articulated irradiated rib cartilage inserted through an external rhinoplasty approach was used to reconstruct nasal deformities in 18 patients over a 6-year period. Simultaneous use of a midline forehead flap to reconstruct the overlying soft tissue was required in four cases. Follow-up ranged from 1 to 6 years (mean, 2.8 years). Results were rewarding in most cases with marked improvement in nasal support and airway. Revision and/or replacement secondary to trauma or warping of the graft was required in four cases. None of the patients exhibited infection, extrusion, or noticeable resorption. A description of the surgical technique, review of all the cases, and recommendation for continued use of this graft material are discussed.
Pronounced nasal tip ptosis is generally regarded as an unattractive facial feature. Besides its aesthetic ramifications, marked inferior displacement of the nasal tip adversely affects nasal function by restricting airflow through the nares. We present a new technique that is a modification of a lateral crural flap procedure that was described in 1975. This technique, which is performed using an open rhinoplasty approach, predictably rotates the nasal tip upward by restructuring the alar cartilages via controlled overlay of the lateral crura. When overprojection accompanies tip ptosis, the controlled lateral crural overlay technique permits graduated retrodisplacement of the tip, in addition to rotation, giving the surgeon full control for reliably and accurately repositioning the nasal tip superiorly and posteriorly.
The platyrrhine nose is characterized by a hypoplastic nonprojected nasal tip, wide flaring alae, underdeveloped premaxilla, and lack of nasal dorsal support. Aesthetic nasal reconstruction is performed utilizing the external rhinoplasty technique. Precise placement of nasal augmentation grafts is facilitated by this technique. The harvesting and utilization of a large autogenous nasal fibrofatty graft for finesse dorsal contouring is described. Seventy-five patients underwent aesthetic reconstruction of the platyrrhine nose. Follow-up ranged from 2 to 7 years. No major complications, including extrusion or significant resorption of augmentation grafts, have been observed. Minor complications included notching of the transverse columella incision in 5% (4/75) of cases, observable suture tract marks along the alar closure incision in 4% (3/75) of cases, and alar incision granuloma in 1% (1/75). A modification of our technique, utilizing a two-layer tension-free closure of the columella and alar incisions, has alleviated these complications.
The nasal base is very complex secondary to the dynamic relationship between the skin, underlying muscle, and cartilaginous structures. Recently, we have employed a new method for refinement of the nasal base, which we name reduction columelloplasty. This procedure employs a full-thickness diamond-shaped tissue excision between the feet of the medial crura. The incision is carried down through the skin, depressor septi muscle, and adjacent soft tissue. Following en bloc removal, the defect is carefully closed in a vertical orientation, approximating the medial crura of the lower lateral cartilages. As in the open rhinoplasty approach, the scar produced by this technique is of negligible importance if it is closed using proper techniques of skin eversion and early suture removal. We have found this procedure to be an extremely reliable method for narrowing splayed medial crura, increasing the nasolabial angle, modifying the shape of the nares, and for increasing tip projection.
OBJECTIVE: To identify refinements in forehead flap nasal reconstruction that consistently provide better esthetic and functional results. DESIGN: Case series of patients undergoing forehead flap nasal reconstruction from July 1, 1987, to May 31, 1994. SETTING: University hospital ambulatory surgery department. PATIENTS: Thirty-two patients with various nasal defects. INTERVENTIONS: Modifications of currently accepted techniques of paramedian forehead flap nasal reconstruction, namely, flap harvest and contouring, W-plasty closure of the superior forehead donor site, and creation of soft-tissue triangles. The principles of open-structure rhinoplasty are incorporated into cartilaginous reconstruction of the nasal tip and columella. The alar rim is reconstructed with cartilage grafts placed at the nasal rim. MAIN OUTCOME MEASURES: Esthetic and functional results of nasal reconstruction were subjectively graded by three otolaryngologists (V.C.Q., D.A.S., and M.F.R.) and the patients. RESULTS: Improved esthetic and functional nasal reconstruction. The most common nasal subunits reconstructed were as follows: ala, 27 patients (84%); side-wall, 22 patients (69%); dorsum, 18 patients (56%), and tip, 15 patients (47%). The esthetic results ranged from average to excellent (3 to 5 on a scale of 5), the functional results ranged from improved to much improved over preoperative breathing (4 to 5). Two patients required unplanned surgical revisions. Forty-seven percent of patients chose to undergo dermabrasion. Five patients required postoperative intradermal injection of triamcinolone acetonide (Kenalog). Three patients required preoperative tissue expansion. Flap or graft loss, infection, or hematoma did not occur. CONCLUSIONS: The predictability of the techniques in providing excellent results in patients undergoing nasal reconstruction decreases the need for revision procedures and helps the patient and the surgeon achieve the desired outcome.