Endoscopic-Assisted Correction of the Deviated Nose

The approach to nasal bone classic corrective rhinoplasty is an almost-blind technique, where the results depends on feeling by the surgeon's hand. To overcome these drawbacks, endoscopic-assisted corrective rhinoplasty and septoplasty were performed for 16 cases of deviated noses between January 1995 and May 1997. The average follow-up period was 18 months. All patients were evaluated by symmetrical nasal pyramid, recurrence of the bony deflection, and septal deviation. The postoperative courses were satisfactory in most cases, with few complications. Compared with 28 cases of classic rhinoplasty, the patient satisfaction rate was high (87.5% in endoscopic-assisted rhinoplasty, 71.4% in classic rhinoplasty), and the complication and revision rate was low (0% in endoscopic assisted rhinoplasty, 14.3 and 7.1% in classic rhinoplasty). But extra time (about 40 min) and greater expense were required for endoscopic-assisted rhinoplasty. It appeared to us that endoscopic control during corrective rhinoplasty and septoplasty is a big step toward obtaining better results in bony and cartilage resection with extreme precision under monitor control and magnification. This technique is not an open approach but permits one to see more of the nasal skeleton and bony septum, the cause of the deformity, and the immediate effect of the corrective measures used. The use of an endoscope in corrective rhinoplasty for deviated noses provides an expanded field of vision, direct manipulation of lesions, and better aesthetic and functional results.     

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.     

Saddle Nose: Our Approach to the Problem

Saddle nose is usually caused by a trauma or by excessive resection of the septal cartilage. Nevertheless, there are other, less frequent causes of injury, such as congenital, syphilis, leishmaniosis, and leprosy. Within this context, it is very likely to see widening of the bony bridge and dropping of the tip of the nose. For this clinical status, we found extremely satisfactory a therapy in which we use a dorsum cartilage graft, followed by narrowing of the nasal bridge and shortening of the nose. To achieve this aim, different kinds of materials were employed. The authors usually prefer rehydrated (0.9% saline solution) human costal cartilage. This material was used in a study of a series of patients with saddle nose in which we used open rhinoplasty and cartilage homografts.     

Our Experience with Silicone in Rhinomentoplasty

Based on a review of the literature and our own experience, we propose criteria for the site of implantation that, in our eyes, is suitable for a silicon implant or a cartilage transplant. Special interest is focused on rhinoplasty and chin augmentation, as both determine the facial profile of the patient. During the last 17 years we have treated 443 patients with augmentation rhinoplasty, of whom 360 received autologous ear cartilage grafts and 83 received autologous rib cartilage grafts. At the same time we saw 30 patients requiring removal of artificial implant materials that were used by other surgeons for rhinoplasty augmentation purposes. Since 1986 we have performed 60 chin augmentations with anatomically shaped silicone implants (McGhan), of which 40 patients had a combined rhinomentoplasty done.     

Tragal cartilage grafts in rhinoplasty: a viable alternative in the graft-depleted patient.

OBJECTIVE: To describe a simple technique for harvesting tragal cartilage and describe its use in rhinoplasty. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: Rhinoplasties performed between January 2005 and June 2007 in which tragal cartilage grafts were utilized by the senior author (CSC) were reviewed to assess type of graft, preservation of tragal contour, and donor-site morbidity. RESULTS: Tragal cartilage grafts were used in three primary and three secondary rhinoplasty patients. Postoperative follow-up ranged from six months to 12 months. Tragal cartilage was used as five alar contour grafts, one lateral crural onlay graft, one dorsal onlay graft, and one infratip lobule graft. Tragal cartilage was used to close the septal perforation of one patient. Tragal contour was preserved in all patients, and there were no complications noted with this procedure. CONCLUSION: The tragus provides a simple, convenient alternative source of cartilage for rhinoplasty in graft-depleted patients.     

Augmentation of the Columella-Labial Angle to Prevent the ``Smiling Deformity' in Rhinoplasty

Aesthetic diagnosis of the smiling deformity, which is functional rather than anatomical, is essential to provide the best treatment in rhinoplasty. The nasal tip tends to rotate inferiorly during smiling, and the central upper lip moves superiorly. A posteriorly sloping upper lip with a retrodisplaced columella–labial junction gives an unaesthetic appearance. Downward movement of the tip and a sharper nasolabial angle are usually aesthetically unpleasant. In 28 nasal surgeries, augmentation of the columella–labial angle with cartilage strip grafts has been performed. The augmentation of the angle and additionally cutting of the depressor septi muscle created a wider nasolabial complex, and this angle looks full and more pleasant. This procedure has mainly been used as an additional procedure to standard reduction rhinoplasty in order to improve smiling deformity. Strip cartilage grafts were inserted subcutaneously into the upper lip extending half way to the columella and secured with a transcutaneous suture under the columella–labial angle to prevent misslocation. Augmentation by the cartilage graft together with cutting the depressor septi muscle prevented elevation and shortening of the upper lip, and also drooping of the nasal tip. This procedure provided an aesthetically pleasant appearance both at rest and during smiling.     

自体鼻中隔软骨在鼻背凹陷充填术中的应用

目的 介绍用自体鼻中隔软骨充填鼻背凹陷的方法。方法 按常规鼻中隔矫正术切取鼻中隔软骨，根据鼻背凹陷的不同程度和部位，将充填软骨修削成单层卵圆形，或将软骨分割成2～3块叠加后缝合在一起，或将软骨制成倒“V”形，根据鼻背凹陷的大小和形状进行鼻背部充填。结果 43例患者短期效果全部满意，30例经6个月至5年随访，其中3例软骨有轻度吸收，鼻背稍凹陷，其余均较满意。结论 自体鼻中隔软骨充填鼻背整形，取材在同一手术野内完成，方法简便易行，软骨能与周围组织融合在一起，无排斥反应，长期效果较好，可作为鼻背美容整形的选择材料。     

Use of Autologous Costal Cartilage Combined with Expanded Polytetrafluoroethylene in Asian Rhinoplasty

BackgroundThe corresponding author's experience and recent methods employed in autologous costal cartilage grafts combined with expanded polytetrafluoroethylene (ePTFE) in Asian rhinoplasty were presented in this study.ObjectivesThe purpose of this study was to assess the outcomes of rhinoplasty performed on patients using autogenous costal cartilage grafts combined with an ePTFE implant.MethodsSeventy-five rhinoplasty cases with autologous costal cartilage grafts and an ePTFE implant were retrospectively reviewed. Graft types, complications associated with the graft itself or graft harvesting, surgical outcomes, and patient satisfaction were assessed.ResultsThe mean follow-up time post-operation was 13.5 months. A total of 42/75 patients underwent revision surgeries. Graft-related complications were found in 8% of cases, including two warped graft and four infection cases. Three individuals with infections had mild graft resorption. One patient with an infection removed the implant. Graft exposure, mobility, and substantial resorption were not recorded. A total of two cases underwent revision procedures for infection and perforation, respectively. Chest incision lengths for graft harvesting averaged 2.1 cm. No pneumothorax or significant donor-site pain was found. Donor-site scars were negligible, although two cases had hypertrophic chest scars. In general, functional and esthetic outcomes were mostly satisfactory among the assessed patients.ConclusionsRhinoplasty using autologous rib cartilage provides adequate support and sufficient cartilage amounts for correcting nasal contouring. Meanwhile, ePTFE alone for nasal dorsum augmentation safely achieves satisfactory outcomes. Rib cartilage rhinoplasty performed by an experienced surgeon yields excellent, long-lasting results with minimal risk; however, the potential for infection should be considered following revision surgery.     

Open Rhinoplasty Through a Forked Flap Incision

Surgical elongation of the short columella is a challenging problem for the surgeon. Although some flaps from the upper lip are successfully used to correct this deformity on cleft lip patients with a scarred upper lip, these methods cannot be applied to noncleft patients with a smooth upper lip. Distant flaps and composite grafts do not give the best aesthetic results. The use of an external approach for rhinoplasty is preferred by many surgeons, especially for difficult or secondary cases. Most incisions for open rhinoplasty are placed on the columella. This report describes a new incision for open rhinoplasty to be used on patients with a short columella. The incision is a standard forked flap with a columellar base but the legs of the flap extend to the nostril bases instead of to the upper lip. This method was used on eight aesthetic rhinoplasty patients with a short columella between March 1995 and March 1998. The results of the method are discussed.     

Short columella nasolabial complex in aesthetic rhinoplasty

Many papers describe different approaches for short columella in cleft lip or Negroid noses. Very little has been found in international literature related to these aesthetic rhinoplasties. The scarce skin of the columella, the firm union between the nasal tip and the lip, due to the hypertrophy of the depressor septi nasi muscle, and the low projection of the nasal tip, consequence of the open position of the caudal part of the medial crura, are the cause of this problem. Therefore, the skin, muscle, and cartilage were treated simultaneously. Herein is described a VY composite advanced flap for projecting the tip, suturing both divergent medial crura together and adding the skin and muscle tissues of the lip to the columella. With this flap the tip was projected, the columella was narrowed, the nasolabial angle improved, and the upper lip elongated. Good results could be achieved without using any other cartilage graft or silastic strut. Standard rhinoplasty and septumplasty could be combined with this technique. Inconspicuous scars were observed.     

Intraoperative measurements of harvestable septal cartilage in rhinoplasty

The aim of this study was to assess the dimensions of the septal cartilage available for grafting in patients undergoing open rhinoplasty and analyze whether the size of the external nose might be a useful indicator of the size and amount of harvestable septal cartilage. A prospective study was conducted on 55 Korean rhinoplasties. Intraoperative measurement of the harvested septal cartilage with preservation of 10 mm width l-strut was performed. The correlation between the quantity and size of the septal cartilage in situ with anthropometric measurements were evaluated. The mean caudal length of the harvested septal cartilage was 15.1 mm, the mean dorsal length was 18.2 mm, and the mean area was 520.9 mm2. Only 5 patients (9.1%) had cartilage sufficient for full-length dorsal onlay grafts, whereas 10 patients (18.2%) had septal cartilages of length >25 mm that could be used as spreader grafts. Dimensions of the septal cartilage in situ did not correlate with preoperative external nose measurements. The amount of harvested septal cartilage is usually insufficient for simultaneous use for multiple grafts in Korean. External nose size may not be a useful indicator of the availability of adequate septal cartilage for rhinoplasty. The need to harvest additional graft material should be kept in mind during preoperative planning for rhinoplasty procedures.     

Postauricular cartilage storage in rhinoplasty

In the past decade, the number of patients demanding rhinoplasty has increased, and this has increased the use of grafts. Although different materials are used as grafts, cartilage is the most popular one. In secondary rhinoplasties the need for cartilage is very frequent. The most suitable cartilage grafts are the ones extracted during primary rhinoplasty. These grafts are disposed of after the operation and in a secondary operation, grafts are obtained from a new donor site. In our department, the surplus cartilages obtained during primary rhinoplasties of the patients who are thought to be probable secondary rhinoplasty candidates are stored in a postauricular pocket after their volumes are measured and marked down. In the secondary operations the volume of the grafts are measured again and the grafts are used. We have found out that there is no significant difference between the initial and secondary volumes of lower lateral cartilages (3.6% of initial volume is lost), but the difference between the initial and secondary volumes of septal cartilages is significant (6.9% of initial volume is lost), and the stored cartilages are sufficient qualitatively and quantitatively for the secondary rhinoplasties.     

Allogenous Cartilage Graft Versus Autogenous Cartilage Graft in Augmentation Rhinoplasty: A Decade of Clinical Experience

Cartilage grafts have great value in augmentation rhinoplasty. For most surgeons, an autogenous cartilage graft is the first choice in rhinoplasty because of its resistance to infection and resorption. On the other hand, an allogenous cartilage graft might be preferred over an autogenous graft to avoid additional morbidity and lengthened operating time. Allogenous cartilage grafts not only have the advantage of averting donor site morbidity but also are resistant to infection, resembling autogenous cartilage grafts. The authors present their experience with 41 patients who underwent augmentation rhinoplasty using 22 autogenous and 19 allogenous cartilage grafts between June 1994 and August 2004. For evaluation of adequate augmentation rates, photographic analyses were performed on preoperative, early postoperative, and late postoperative photographs from all the patients. To assess patient satisfaction, the Facial Appearance Sorting Test (FAST) was applied preoperatively and late postoperatively in both groups. These results were compared, and it was concluded that in terms of resorption, there was no difference in the early and late postoperative follow-up data between allogenous and autogenous cartilage grafts. Evaluation of the preoperative and early postoperative photographic outcomes showed statistically significant differences with respect to adequate augmentation rates between the two groups. The FAST scores showed statistically significant differences between preoperative and late postoperative outcomes. There were no infections in the two groups of patients. Commentary to DOI: .     

Augmentation Rhinoplasty Using an L-Shaped Auricular Cartilage Framework Combined with Dermal Fat Graft for Cleft Lip Nose

We prepared an L-shaped framework using autogenous auricular cartilage and combined this with dermal fat, according to each patient, to graft it in 12 patients with cleft lip nose. Although auricular cartilage is weak on its own, by our method we obtained a strong columella strut and nasal dorsum augmentation at the same time. Dermal fat graft provided camouflage for cartilage irregularities and was useful for increasing the graft volume. Although absorption caused a decreased volume to a certain extent, there were no other complications such as cyst formation, and a natural nasal contour was achieved in all patients.     

λ-Shaped Implant for Augmentation of Anterior Nasal Spine in Asian Rhinoplasty as an Ancillary Procedure

There is often a preexisting acute columella-labial angle in Asian noses and in most of these cases, the nasal spine is underdeveloped or sometimes even absent. Moreover, nasal tip projection by a tip graft or cephalic rotation of the nasal tip may get worse at the retracted columella-labial junction in the Asian nose with an underdeveloped anterior nasal spine, thus requiring the use of a maxillary spine graft or an implant. In many instances, however, the ideal source of autogenous tissue may not be available or the donor site for these tissues may be objectionable. So I have designed the λ-shaped silicone implant for augmenting the underdeveloped anterior nasal spine (ANS) to correct the acute columella-labial angle. From March, 1996 until September, 1999, I have done ANS augmentations using the λ-shaped silicone implant in Asian rhinoplasty on 37 female patients. The correction of an acute columella-labial angle was readily accomplished by application of the λ-shaped implant using the unilateral intranasal approach. The author suggests that ANS augmentation with the λ-shaped implant is a simple and effective method as an ancillary procedure in Asian rhinoplasty providing esthetically pleasing results in properly selected Asian patients.     

Use of Porous High-Density Polyethylene in Revision Rhinoplasty and in the Platyrrhine Nose

Nasal reconstruction presents a significant challenge to the facial plastic surgeon. Reestablishment of the desired aesthetic nasal contour and restoration of respiratory function are the dual goals of this endeavor. While autologous cartilage or bone is considered optimal grafting material, the supply is often limited and harvesting entails additional morbidity. Many synthetic materials have been introduced for use in nasal reconstruction, but high infection and extrusion rates have left most surgeons dissatisfied with conventional implants. Porous polyethylene (Medpor) implants were used for nasal reconstruction in 187 patients; 66 (35.3%) patients underwent primary rhinoplasty, while revision surgery was performed in 121 (64.7%) patients. Most patients required multiple implants, including columella struts, plumper grafts, dorsal tip implants, and nasal valve battens. Postoperative follow-up ranged from 6 months to 3.5 years. Complications occurred in five (2.6%) patients. Three early and two delayed infections necessitated implant removal in five patients, all of whom had compromised skin–soft tissue envelopes secondary to heavy smoking, cocaine abuse, or prior surgery. One case of an overly augmented nasal dorsum and tip required implant removal, reduction, and reinsertion. All implants were easily removed. No other complications including implant extrusion or skin erosion have been noted. Porous polyethylene (Medpor) implants allow for fibrovascular ingrowth, which lends stability to the implant. Porous polyethylene implants are well tolerated and provide an ideal material for nasal reconstruction.     

Dorsal nasal augmentation with "open sandwich" graft consisting of conchal cartilage and retroauricular fascia

Background: Augmenting the nasal dorsum with conchal grafts can cause visible irregularities over time due to the morphological qualities of that material. Objectives: This study describes the senior authors' technique of dorsal nasal augmentation with chondrofascial "open sandwich" grafts consisting of pieces of conchal cartilage and retroauricular fascia. The authors assess the efficiency and reliability of this graft in nasal dorsal augmentation. Methods: The authors retrospectively reviewed the cases of 19 patients who underwent dorsal augmentation rhinoplasty with chondrofascial grafts. Both cartilage and fascia were harvested through the same incision in the retroauricular sulcus. The conchal graft was cut in 2 to 4 pieces and slightly crushed with tissue forceps. The pieces of cartilage were arranged and fixed to the fascia in different patterns according to the nasal dorsum contour. Results: The follow-up period ranged from 12 to 35 months in 16 patients who qualified for inclusion in the final data. The maximal thickness of the chondrofascial graft was 4.5 mm. There were no major complications in the recipient area, except 1 case of undercorrection. There were 2 complications in the donor area. In 1 case, a hematoma was treated conservatively. In another case, a strip of skin necrosis in the conchal area occurred and was treated by excision and direct suture with satisfactory resolution. Conclusions: The autologous chondrofascial graft is appropriate for slight to mild dorsal nasal augmentation. The method, as with most rhinoplasty techniques, requires careful and judicious preoperative examination, planning, and execution. The postoperative scar is inconspicuous and the donor site morbidity is minimal. Level of Evidence: 4.     

Pitanguy's Method of Protruding Ear Correction from Our Own Experience: Review of 80 Cases

A recent review of the literature revealed more than 20 methods of correction of protruding ears. Pitanguy's cartilage island flap technique is still not widespread. However, it is extraordinarily versatile and effective from our own experience. The aim of this study is to present our own experience in the correction of prominent ears using this method. According to Pitanguy's cartilage island flap technique, 80 patients were operated on at the Private Plastic Surgery Clinic from 1992 to 1999. There were 45 (56%) female and 35 (44%) male patients, aged from 9 to 37 years (22 years on average). All procedures were performed under local anesthesia. In the follow-up period of 1 to 8 years the final aesthetic results were estimated as very good in 68 (85%) patients and good in 12 (15%) patients. Early complications in the form of bleeding occurred in three (3.75%) patients. Asymmetry in the ears' position was qualified as a late complication and occurred in four (5%) patients.