长盾形和多层盖板耳廓软骨移植物在鼻尖整形中的应用

目的:探讨长盾形和多层盖板耳廓软骨移植物在鼻尖塑造中的应用。方法:在分离、修整、缝合下外侧软骨穹窿部的基础上,于耳后颅耳沟切口切取耳廓软骨,修剪成长盾形及2~3块盖板移植物,用于鼻尖的塑形。结果:共11例患者,随访时间6~24月,效果满意,无严重并发症发生。结论:长盾形和多层盖板耳廓软骨移植物可以良好的修饰鼻尖,取材方便,操作简单,效果肯定。     

Nasal Tip Plasty Using Various Techniques in Rhinoplasty

Rhinoplasty is one of the most common aesthetic surgical procedures in Korea today. However, simple augmentation rhinoplasty results often failed to satisfy the high expectations of patients. As a result, many procedures have been developed to improve the appearance of the nasal tip and nasal projection. However, the characteristics of Korean nasal tips including the bulbous appearance (attributable to the thickness of the skin), flared nostrils, and restriction of the nasal tip attributable to an underdeveloped medical crus of the alar cartilage and a short columella have made such procedures difficult. Currently, most plastic surgeons perform rhinoplasty simultaneously with various nasal tip plasty techniques to improve the surgical results. An important part of an aesthetically pleasing result is to ensure an adequate nasal tip positioned slightly higher than the proper dorsum, with the two tip defining points in close proximity to each other, giving the nose a triangular shape from the caudal view. From June 2002 to November 2003, the authors performed rhinoplasty with simultaneous nasal tip plasty using various techniques according to the tip status of 55 patients (25 deviated noses, 9 broad noses, 15 low noses, and 6 secondary cleft lip and nose deformities). The surgery included realignment of alar cartilage by resection and suture, fibroareolar and subcutaneous tissue resection, tip graft, and columellar strut. The postoperative results over an average period of 10 months were entirely satisfactory. There were no patient complaints, nor complications resulting from the procedures. Good nasal tip projection, natural columellar appearance, and improvement of the nasolabial angle were achieved for most patients. In conclusion, rhinoplasty with simultaneous nasal tip plasty, achieved by a variety of techniques according to patients tip status, is an effective method for improving the appearance of the nose and satisfying the desires of the patients.     

Augmentation of nasal tip projection using the inferior turbinate: review of technique and evaluation of long-term success

OBJECTIVES: To introduce the use of inferior turbinate bone as an alternative autograft for augmentation of nasal tip projection and to assess maintenance of nasal tip projection, bone remodeling, graft shaping, and ease of harvesting. METHODS: Thirteen consecutive patients in need of increased nasal tip projection underwent closed rhinoplasty during a prospective nonrandomized study in a university teaching hospital setting. An autologous demucosalized inferior turbinate bone graft was used as a columellar strut. Measurements of nasal tip projection were obtained using the Goode ratio. Photodocumentation and lateral soft tissue radiographs were obtained before surgery and between 30 and 38 months after surgery. RESULTS: In all patients, the results were as follows: (1) the inferior turbinate bone graft was easily harvested and molded into the appropriate-sized columellar strut; (2) the immediate postoperative nasal tip projection, as measured by the Goode ratio and visual assessment, was increased; and (3) the tip projections were maintained at the 30-month follow-up examination. Paired t tests revealed a statistically significant difference (P = .001 and P = .009) between preoperative and both immediate and long-term measurements. Comparison of immediate postoperative radiographs with those taken 2 years later demonstrated no remarkable change in appearance of the graft. CONCLUSIONS: The interior turbinate bone is a viable graft for augmenting nasal tip projection. Moreover, it maintains tip projection and needs little to no remodeling. The graft is easy to harvest, prepare, and place and can be used without requiring a second operative site.     

New concepts in nasal tip contouring

Control of nasal tip contour has always been a key component of a successful rhinoplasty. Typically, this procedure is performed with an emphasis on narrowing the nasal tip structure. Creating a natural-appearing nasal tip contour is a complex task and requires a 3-dimensional approach. In an effort to identify the characteristics that make an ideal nasal tip, I evaluated numerous aesthetically pleasing nasal tips. After extensive study, I created a series of images to demonstrate how specific contours create highlights and shadows that will help guide the surgeon in creating a natural-appearing nasal tip contour. Many commonly used nasal tip techniques can pinch the tip structures if an overemphasis is placed on narrowing. These changes isolate the dome region of the nasal tip and can create an undesirable shadow between the tip lobule and alar lobule. Prior to contouring the nasal tip, the surgeon must stabilize the base of the nose with a columellar strut, suturing the medial crura to a long caudal septum, caudal extension graft, or an extended columellar strut graft. Stabilizing the nasal base will ensure that tip projection is maintained postoperatively. To contour the nasal tip, dome sutures are frequently used to flatten the lateral crura and eliminate tip bulbosity. Placement of dome sutures can deform the lateral crura and displace the caudal margin of the lateral crura well below the cephalic margin. This can result in a pinched nasal tip with the characteristic demarcation between the tip and the alar lobule. Alar rim grafts can be used to support the alar margin and create a defined ridge that extends from the tip lobule to the alar lobule. This form of restructuring can create a natural-appearing nasal tip contour with a horizontal tip orientation continuing out to the alar lobule. When dome sutures alone are inadequate, lateral crural strut grafts are used to eliminate convexity and prevent deformity of the lateral crura. Shield tip grafts can be used in patients with thick skin and an underprojected nasal tip. Whenever a shield tip graft is used, it must be appropriately camouflaged to avoid undesirable visualization of the graft as the postoperative edema subsides. When contouring the nasal tip, the surgeon should focus more on creating favorable shadows and highlights and less on narrowing. Nasal tips contoured in this manner will look more natural and will better withstand the forces of scar contracture that can negatively affect rhinoplasty outcomes.     

Simultaneous Open Rhinoplasty and Alar Base Excision for Secondary Cases

Background: Simultaneous open rhinoplasty and alar base excision are a very safe procedure for protecting the vascular supply of the nasal dip and the columellar skin in primary cases when surgical dissection is performed below the musculoaponeurotic layer of the nose. Major arteries of the external nose lie above the musculoaponeurotic layer. However, secondary cases may pose increased risks to the blood supply of the nasal tip and columella skin because of the decreased vascular supply and increased scar tissue from the previous rhinoplasty. We studied our secondary cases of simultaneous open rhinoplasty and alar base excision, to assess the real risk for necrosis of the nasal tip and columellar skin.Methods: A total of 12 secondary patients (6 men and 6 women) underwent simultaneous open rhinoplasty and alar base excision in the past 3 years. Their average age was 27 years (range, 21–35 years). The average follow-up period was 15 months (range, 1–35 moths). A modified grading system, originally described by Bafaqeeh and Al-Qattan, was used for assessment of the blood supply in the nasal tip and the columellar skin.Results: Satisfactory results were obtained for our patients, with the exception of one case. Grade 3 vascular compromise to the nasal tip and the columella was observed in one case, but the patient healed well with wound care treatment.Conclusion: Simultaneous alar base excision and open rhinoplasty can be performed safely in secondary cases. However some surgical maneuvers such as subcutaneous pocket preparation for the tip graft in closed rhinoplasty and subdermal defatting in the first rhinoplasty as well as previous scarring on the nasal lobule can disrupt the vascular supply of the nasal tip and columella skin. Under these conditions, alar base excision should be deferred and then performed as an isolated excision procedure.     

Secondary Rhinoplasty of the Asian Nose: Correction of the Contracted Nose

The contracted nose is a unique entity that follows primary rhinoplasty in the Asian patient. The proposed reasons for this complication are capsular contraction from a silicone nasal implant, pressure necrosis of the lower lateral cartilage resulting from the nasal implant, and infection after alloplastic implantation. The two principal anatomic constituents that must be addressed at the time of secondary rhinoplasty are the lower lateral cartilages and the skin envelope. The lower lateral cartilages should be derotated, projected, and transfixed with an extended spreader graft. Additional onlay grafting may be required to provide greater nasal tip derotation and projection. A transcolumellar incision situated at the columellar-labial angle permits undermining of the upper lip skin to release tension on the incision. If the nasal tip retraction is severe, then the skin envelope may be insufficient to provide coverage to the new cartilaginous framework. In this case, a paramedian forehead flap is recommended to provide adequate tissue coverage. Correction of alar–columellar disparity should be undertaken with composite grafting only after 6 months have transpired to gauge the ultimate relation between the alae and columella. Infection that arises after correction of the contracted nose can be devastating. It should be treated aggressively, but tailored to the severity of the infection. Wound tension along the columella may predispose to skin necrosis and consequent cartilage exposure, which should be managed in turn with prostaglandin emollients to accelerate wound healing and to prevent infection.     

The contoured auricular projection graft for nasal tip projection

In all rhinoplasty surgery, the universal need exists to increase, decrease, or preserve existing tip projection. When proper tip projection is lacking, a variety of techniques are useful for improving projection. We describe a valuable technique for tip projection, particularly useful and indicated in the Asian rhinoplasty, African American rhinoplasty, and in certain revision rhinoplasties. In the past 15 years, the senior author (M.E.T.) has used the contoured auricular projection graft in selected patients for achieving satisfactory tip projection in patients with blunted tips. The aesthetic outcomes have been predictable, pleasing, and reliable for the long term. Precision pocket preparation for auricular conchal cartilage graft placement is key to symmetry and projection of the final outcome. The results yielded a rounded nasal tip that may be more natural-appearing in Asians, African Americans, and selected patients with revision rhinoplasty. The contoured auricular projection graft provides a highly useful graft for the nasal tip.     

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.     

Open tip rhinoplasty.

An open tip rhinoplasty was used to correct moderate to severe secondary cleft lip nasal deformities in 122 patients from January 1986 to January 1988. The results of the surgery on 92 patients who were followed for 1 year or more were evaluated. When the surgery was performed after the age of 3 years, 60% of the patients had a satisfactory result. The pathology of the deformity included 32% with deficiencies of the nasal lining, 35% needed framework support such as a columellar strut, and 45% required correction of columellar deficiencies. Patients using a postoperative nasal stent had a 71% satisfactory result compared with a 37% satisfactory result when the stent was not used. The pathology and techniques to correct the nasal deformity are described.     

Apex columellar cartilage graft

The classical rhinoplasty techniques do not give the best results when used on thick skin noses. We have developed a new technique, apex columellar cartilage graft, for correcting nasal tip projection in thick skin noses.Presented at the ISAPS Meeting, New York, October 1987     

以鼻中隔软骨为鼻小柱支撑移植物在鼻尖整形中的应用

目的:探讨以鼻中隔软骨为鼻小柱支撑移植物在东方人鼻尖整形中的应用。方法:在50例鼻尖整形患者中,均以鼻中隔软骨为鼻小柱支撑移植物,使用固定悬浮型移植27例,延伸型移植13例,鼻中隔延伸型移植10例。结果:除1例因术后鼻尖突出度不足,经二次手术纠正外,余49例鼻尖成形良好,患者对手术效果满意。结论:根据不同情况,以鼻中隔软骨的不同植入形式进行鼻小柱支撑移植是鼻尖整形中一项良好的手术技术。     

Quantitative assessment of nasal changes after maxillomandibular surgery using a 3-dimensional digital imaging system

OBJECTIVE: To evaluate nasal changes after maxillomandibular surgery by means of images taken with a 3-dimensional digital camera. DESIGN: Thirty-two patients (26 female and 6 male) with preoperative and postoperative 3-dimensional photographs were studied. The patients underwent maxillary movement with impaction (upward rotation), maxillary movement with lengthening (downward rotation), or maxillary movement without rotation. With the 3-dimensional imaging software, preoperative and postoperative calculations were performed for interalar width, internostril width, nasal tip projection, and columellar length from the 3-dimensional digital images. The nasolabial angle was also measured. RESULTS: Postoperative interalar and internostril widening was significant (P<.05) for all 3 categories of maxillary movement. However, there was no statistically significant change in nasal tip projection and columellar length. Interestingly, movement of the maxilla with upward rotation did show a statistically significant decrease in the nasolabial angle. CONCLUSIONS: Changes to the nose clearly occur after orthognathic surgery. There was a statistically significant increase in postoperative interalar width and internostril width with maxillary movement. However, no clear correlation could be determined between amount of change and maxillary movement. Interestingly, maxillary advancement did not show any significant change in nasal tip projection or columellar length, with data showing both increases and decreases in measurements. The nasolabial angle in patients who underwent maxillary advancement with impaction (upward rotation) was the only measurement that showed a statistically significant increase.     

Complications Associated With Isotretinoin Use After Rhinoplasty

Background This study aimed to evaluate the association between the postoperative use of isotretinoin and the formation of nasal tip deformities after rhinoplasty.Methods A retrospective study investigated a case series of patients who presented with nasal tip deformities subsequent to the use of isotretinoin after rhinoplasty. Patients who had taken isotretinoin after rhinoplasty were identified from a single surgeon’s case log. Clinic charts and operative reports were reviewed. Predisposing factors and time intervals to complications were identified.Results Three patients were found to have undergone isotretinoin therapy after rhinoplasty. Nasal tip deformities included bossa formation, asymmetry, and prominence of a composite graft. All three patients required subsequent procedures to repair soft tissue nasal tip deformities. In all three cases, isotretinoin was started within 2 years of the primary rhinoplasty. The nasal tip deformities were first observed within 6 months after isotretinoin was started.Conclusions Three cases are described in which postoperative use of isotretinoin was associated with nasal tip deformities after rhinoplasty. Further studies are needed to investigate this possible causative relationship and to describe the risks involved.     

Combined use of triple cartilage grafts in secondary rhinoplasty.

Secondary rhinoplasty on a patient with a middle vault deformity is one of the most challenging procedures for a plastic surgeon. In order to achieve proper nasal aesthetics and airway function, a surgeon most commonly chooses to engraft the nose with a spreader, dorsal onlay, or columellar graft. This paper examines the aforementioned techniques in the management of 25 patients who presented with a severe middle nasal vault deformity. METHODS: During the last 5 years, 25 patients received secondary rhinoplasty using triple cartilage grafts to repair severe middle vault deformities. Patients were then questioned at least 3 months postoperatively about both airway problems and cosmetic satisfaction. RESULTS: All the 25 patients indicated cosmetic satisfaction with 23 of the patients also achieving complete nasal airway function. Only two patients persisted to have an insufficient nasal airway. An endonasal examination revealed a slight nasal synechiae in one patient, while no anatomic problem was identified in the second patient. From a cosmetic standpoint, a straight dorsum with improved dorsal aesthetic lines and nasal profile, along with nasal-facial balance were achieved. When indicated, secondary rhinoplasty to repair a middle vault deformity using the combination of spreader, dorsal onlay, and columellar grafts to augment the nose has shown to have both functional and cosmetic benefits.     

Aesthetic rhinoplasty: Avoiding unfavourable results

Rhinoplasty is one of the most challenging surgical procedures in plastic surgery. It is not surprising that a significant number of patients end up with unfavourable outcomes. Many of these unfavourable outcomes could be the result of poor judgment and wrong decision making. Most frequently, the unfavourable outcome is the result of errors in surgical technique. In this paper, unfavourable outcomes resulting from errors in surgical technique are discussed under the heading of each operative step. Poor placement of intra-nasal incision can result in internal valve obstruction. Bad columellar scars can result from errors during open rhinoplasty. Unfavourable results associated with skeletonisation are mentioned. Tip plasty, being the most difficult part of rhinoplasty, can result in lack of tip projection, asymmetry and deformities associated with placement of tip grafts. Over-resection of the lower lateral cartilages during tip plasty can also result in pinched nose, alar collapse causing external valve obstruction and other alar rim deformities. Humpectomy can result in open roof deformity, inverted V deformity and over-resection resulting in saddle nose. The so-called poly beak deformity is also a preventable unfavourable outcome when dealing with a large dorsal hump. Complications resulting from osteotomies include narrowing of nasal airway, open roof deformity, inverted V deformity and asymmetry of the bony wall resulting from incomplete or green stick fractures. Judicious use of grafts can be very rewarding. By the same token, grafts also carry with them the risk of complications. Allografts can result in recurrent infection, atrophy of the overlying skin and extrusion resulting in crippling deformities. Autografts are recommended by the author. Unfavourable results from autografts include displacement of graft, visibility of the graft edges, asymmetry, warping, and resorption.KEY WORDS: Aesthetic rhinoplasty, hump resection, osteotomy, radix, unfavourable results     

Four suture tip rhinoplasty: a powerful tool for controlling tip dynamics.

OBJECTIVE: To evaluate the short-term effectiveness of using a 4-suture technique to control nasal tip dynamics. The 4 sutures include a medial crural suture, bilateral intradomal sutures, and an interdomal suture. STUDY DESIGN AND SETTING: Retrospective photograph analysis of preoperative and postoperative photographs of 77 patients with respect to 7 dynamic variables: supratip break, projection, rotation, tip shape, tip definition, tip symmetry, and the presence of a double columellar break. RESULTS: Seventy-four patients underwent primary rhinoplasty and had an overall average score of 5.2 on a -7 to +7 scale, with a mean follow-up period of 3.8 months. The 3 patients undergoing revision rhinoplasty had an overall average score of 5.0 and a mean follow-up of 8.7 months. CONCLUSION: The 4-suture technique worked best with respect to projection and tip symmetry, although the technique proved to be an effective tool overall in controlling all 7 variables mentioned above. EBM rating: C-4.     

The decision process in choosing costal cartilage for use in revision rhinoplasty

The aims of rhinoplasty reconstruction include maintaining or augmenting long-term tip projection, restoring rigid dorsal stability, and restoring optimum respiratory function. The methods set forth to obtain these objectives are inherently based on the intrinsic nasal principles at the time of the rhinoplasty. Because of the excellent and consistent results autologous costal cartilage grafts provide when faced with problems such as the traumatic saddle deformity, defects after neoplastic resection, congenital nasal deformities, severe tip weakness or underprojection, rhinoplasty in the ethnic patient, and revision rhinoplasty, they are an invaluable resource to the rhinoplasty surgeon. Once the surgeon becomes comfortable and proficient at harvesting this graft, it inevitably will become the graft of choice when substantial amounts of cartilage are required.     

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. Presented at The XVI. Congress of ISAPS, 26–29 May 2002, Istanbul, Turkey, and should be attributed to Department of Plastic and Reconstructive Surgery, Cerrahpasa School of Medicine, Istanbul University, and Haseki Hospital, Department of Otolaryngology Istanbul, Turkey.     

Management of the Long Nose: Review of Techniques for Nasal Tip Supporting Structures

The long nose with a “plunging” tip is a deformity that involves an inferiorly rotated nasal tip, leading to an increase in the length of the nose. The anatomic basis of the long nose with a plunging tip may be divided into two types. Type 1 presents a normal alar–cartilage complex inferiorly displaced by a long nasal septum and long upper lateral cartilages. Type 2 is caused by a dislocation of the alar cartilages downward from the aponeurotic attachments to the septal angle. During the study period, the authors identified 60 patients with long noses and plunging tips. For 22 patients with type 1 long noses, the high septal incision technique was used in 12 cases and the step technique in 10 cases. The invagination procedure alone was used for 22 of 38 patients with type 2 plunging noses. Also, an extension graft with the invagination procedure was used for 6 patients, and a columellar strut graft was used for 10 patients. A high septal incision increased tip rotation without significantly changing the amount of tip projection. However, the step procedure, the invagination technique alone, septal extension graft with the invagination technique, and columellar strut grafts increased nasal tip rotation and projection. During the study period, 38 patients were identified as having a smiling deformity, which was improved using the authors’ modification procedure. On the basis of the results, the authors recommend that the appropriate treatment for each patient with a long nose and a plunging tip must be determined by preoperative and intraoperative examination findings with the patient at rest and while smiling.