Knorpeltransplantate bei der funktionell-ästhetischen Rhinoplastik

Complications after rhinoplasty could often be prevented if less of the support structures of the nose were resected and cartilage transplants were used to give stability. Long-term complications depend heavily on the nasal anatomy, Which is why the surgeon must be able to identify anatomical variants and adapt the surgical technique as necessary. Thus, rhinoplasty techniques have moved away from excisional methods and shifted toward repositioning and restructuring existing tissues. Conservative reduction and preservation of support structures will maximize the aesthetic and functional results. Checking the shape of the tip of the nose is the critical step, and stabilization of the nasal base in particular leads to a good long-term outcome with preservation of the nasal tip projection. The surgeon needs to stabilize the structure of the nose by building up the structure and must also anticipate the effects of scar contracture. This entails structural grafting with autologous cartilage. In this paper, the authors present the grafting techniques most commonly used to sculpt the nasal framework; in primary and secondary rhinoplasty. Tried and tested grafts are presented, with the appropriate nomenclature relating to each and also the anatomical locations of and clinical indications for each.     

External transcolumellar approach and cartilage grafting: a very complementary association

Two major facts have modified the philosophy of rhinoplasty: the desire to obtain more harmonious and balanced nose with conservative resections and a more frequent use of the open approach. This approach allows more accuracy in the diagnosis of the deformities and in the control and the preservation of the supports of the nose, namely the tip, alar and middle vault supports, and in the use of innovative techniques, specifically in the nasal tip: suture techniques and cartilage grafts. External transcolumellar approach and cartilage grafting go hand in hand and are frequently associated in the correction of under and overtip projection. Grafts can be use for improvement of aesthetic and function and the excellent exposure provided by the open approach permits a precise placement and stabilization of the grafts. Septal surgery benefits significantly from the excellent exposure for correction of all kind of deformities.     

Techniken der Nasenrückenkorrektur

Correction of the nasal dorsum ranks among the most common surgical procedures in rhinoplasty. Due to the involvement of nasal support structures such as septolateral cartilage and the K and scroll areas, these procedures have both aesthetic and functional impacts. In addition to spreader grafts and spreader flaps, the most important surgical methods currently include the split hump reduction technique, cartilage–fascia transplants and cartilage grafts from rib and ear. In addition to serving to correct deformities, the techniques described here help prevent complications such as inverted V, hourglass and saddle nose deformities, as well as nasal valve stenosis. The basic operative principle calls for reinforcement and reconstruction of the anatomical support structures, while avoiding overresection and mucosal lacerations.     

Rhinoplasty: morphodynamic anatomy of rhinoplasty. Interest of conservative rhinoplasty

OBJECTIVES: To highlight the morphodynamic anatomical mechanisms that influence the results of rhinoplasty. To present the technical modalities of nasal dorsum preservation rhinoplasties. To determine the optimized respective surgical indications of the two main techniques of rhinoplasty: interruption rhinoplasty versus conservative rhinoplasty. MATERIALS AND METHODS: Based on anatomical dissections and initial morphodynamic studies carried out on 100 anatomical specimens, a prospective study of a continuous series of 400 patients operated of primary reduction rhinoplasty or septo-rhinoplasty by one of authors (YS) has been undertaken over a period of ten years (1995-2005) in order to optimize the surgical management of the nasal hump. The studied parameters were: (1) surgical safety, (2) quality of early and late aesthetic result, (3) quality of the functional result, (4) ease of the technical realization of a possible secondary rhinoplasty. The other selected criteria were function of the different nasal hump morphotypes and the expressed wishes of the patients. RESULTS: The anatomical and morphodynamic studies made it possible to better understand the role of the "M" double-arch shape of the nose and the role of the cartilaginous buttresses not only as a function but also the anatomy and the aesthetics of the nose. It is necessary to preserve or repair the arche structures of the septo-triangular and alo-columellar sub-units. The conservative technique, whose results appear much more natural aesthetically, functionally satisfactory and durable over the long term, must be favoured in particular in man and in cases presenting a risk of collapse of the nasal valve. CONCLUSION: The rhinoplastician must be able to propose, according to the patient's wishes and in view of the results of the morphological analysis, the most adapted procedure according to his own surgical training but by supporting conservation of the osteo-cartilaginous vault whenever possible.     

Nasal deformity after bilateral cleft lip repair

Primary nasal deformity is characterized by apparent prolabio-columellar skin shortness due to alar cartilage dislocation worsened by lack of muscular support. The secondary deformation retains part of the initial deformity, sometimes even worsened by the primary lip repair. Multiple surgical lengthening techniques were used in nasal defect correction, suggesting both technical complexity and unsatisfactory results. Indeed, columellar insufficiency has more to do with abnormal columello-apical skin distribution due to alar mispositioning than an effective lack of skin. Secondary correction by open rhinoplasty allowing careful cartilage reconstruction of the nose tip seems to be widely accepted. However, the nasal defect can be limited by performing a primary intervention focusing on two principles: columellar lengthening by early alar repositioning and simultaneous lip and nose repair.     

Rhinoplasty

PURPOSE OF REVIEW: Successful rhinoplasty requires a detailed understanding of the nasal structure needed to produce a functional and aesthetically pleasing nose. Recent advances in surgical technique have focused on cartilage repositioning and reshaping, often with the use of cartilage grafting. RECENT FINDINGS: Newer techniques for strengthening the middle vault, stabilizing the base, and modifying the lateral crura are presented, as well as the M-arch model, a modification of the tripod concept. SUMMARY: Technical advances in rhinoplasty provide numerous options for reconstruction and reshaping of the nose.     

A new twist in nasal tip surgery. An alternative to the Goldman tip for the wide or bulbous lobule

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.     

Ethnic rhinoplasty

Rhinoplasty is one of the main facial plastic procedures performed worldwide. Ethnic patients today are mainly mixed-race patients. Diagnosis is based on anatomical findings and surgery should be planned based on patients’ needs and what they define as beautiful. Different surgical techniques are presented where a structural approach to rhinoplasty is explained. Very little tissue is resected and support structures of the nose are strengthened with sutures and grafts. A gradual approach to the nasal tip is also presented progressing from simple predictable techniques to more complex unpredictable ones. The final result should be noses with greater definition and refinement that are harmonious and blend in with patients’ faces.     

Evaluation of nasal tip surgery.

Nasal tip surgery has been evaluated with respect to correction of the lower lateral cartilages. Indications, techniques, results, and complications related to three generic approaches to the lower lateral cartilages are described. In 673 consecutive rhinoplasties the commonest type of nasal tip surgery was excisional, utilizing either a marginal or cartilage splitting technique. These techniques were utilized: 1. to accomplish debulking, and 2. to accomplish the installation of facets. The excisional technique found its greatest utility in primary rhinoplasties. The version technique, utilizing a change of direction of the thrust of the lower lateral cartilages was utilized in a variety of situations, particularly for the correction of moderately congenitally hypoplastic tip cartilages. It also found great utility in surgery of the Negro or cleft palate nose, increasing tip projection, correcting unacceptable bifidity, and in revision rhinoplasty. Augmentation rhinoplasty, utilizing conchal cartilage as an elastic strut was particularly useful for severe hypoplastic cartilage deficits, the Negro nose, columellar retraction, and alar rim deficits. The overall complication rate of lower lateral rhinoplasty was 17.4 percent. The rate of unacceptable complications related to lower lateral rhinoplasty was 2.7 percent.     

Die Schiefnase

The deviated nose represents a complex cosmetic and functional problem. Septal surgery plays a central role in the successful management of the externally deviated nose. This study included 800 patients seeking rhinoplasty to correct external nasal deviations; 71% of these suffered from variable degrees of nasal obstruction. Septal surgery was necessary in 736 (92%) patients, not only to improve breathing, but also to achieve a straight, symmetric external nose. A graduated surgical approach was adopted to allow correction of the dorsal and caudal deviations of the nasal septum without weakening its structural support to the nasal dorsum or nasal tip. The approach depended on full mobilization of deviated cartilage, followed by straightening of the cartilage and its fixation in the corrected position by using bony splinting grafts through an external rhinoplasty approach.     

Postoperative sequelae and complications of rhinoplasty

This article has overviewed complications of rhinoplasty. Generally, these complications fall into two categories: aesthetic (that is, cosmetic sequelae that may require a revision rhinoplasty) and nonaesthetic. Of the nonaesthetic complications, infection has the widest span of severity. A localized Staphylococcus aureus abscess or Pseudomonas infection of the nose may occur postoperatively. Owing to the proximity of the nose to the cranium, a cavernous sinus thrombosis or basilar meningitis may result. Postoperative toxic-shock syndrome is a rare occurrence that surgeons should be aware of; most cases have occurred with the presence of nasal packing, but a case using only plastic nasal splints has been reported also. Bacteremia seems to be uncommon during rhinoplasty. Infection after rhinoplasty is generally much less frequent than one would expect from an operation in an unsterile field. Antibiotics are frequently utilized electively. Postoperative nasal-periorbital edema and ecchymosis are regarded as unavoidable but may be lessened significantly by postoperative head elevation and cold packs. The possibility of postoperative bleeding must be evaluated by the surgeon preoperatively. This sequela usually occurs either within 72 hours postoperatively or at around 10 days postoperatively. Many different causes exist for chronic postoperative nasal obstruction, from poorly supported nasal valves closing upon inspiration to an enhanced allergic rhinitis leading to chronic nasal mucosal edema. The latter may be treated by injection of steroid into the turbinates. Among aesthetic complications, supratip prominence, saddle deformity, and persistent hump are among the more commonly reported. Supratip prominence--"polly-beak"--can be caused by inadequate reduction of tip cartilaginous or soft-tissue elements, especially in relation to the reduction of the dorsum. An over-reduced dorsum will leave an otherwise normal nasal tip with a relative prominence. An accumulation of blood or a mucous cyst occurring under the skin of the tip will produce a prominence. Poor tip projection, tip ptosis, and alar collapse are the result of overreduction of tip elements. A dislocated alar cartilage can appear as an asymmetric nasal bossa. Saddle-nose deformity occurs after overaggressive bony and/or cartilaginous hump removal. Infractured nasal bones that subsequently drop into the piriform aperture can create a bony saddle. Persistent hump is due to inadequate reduction of a bony or cartilaginous hump. If the septal cartilage reduction is disproportionate to the bony septum reduction, the appearance of either a hump or a saddle is possible.(ABSTRACT TRUNCATED AT 400 WORDS)     

External rhinoplasty: a critical analysis of 500 cases

The study presents a comprehensive statistical analysis of a series of 500 consecutive rhinoplasties of which 380 (76 per cent) were primary and 120 (24 per cent) were secondary cases. All cases were operated upon using the external rhinoplasty technique; simultaneous septal surgery was performed in 350 (70 per cent) of the cases. Deformities of the upper two-thirds of the nose that occurred significantly more in the secondary cases included; dorsal saddling, dorsal irregularities, valve collapse, open roof and pollybeak deformities. In the lower third of the nose; secondary cases showed significantly higher incidences of depressed tip, tip over-rotation, tip asymmetry, retracted columella, and alar notching. Suturing techniques were used significantly more in primary cases, while in secondary cases grafting techniques were used significantly more. The complications encountered intra-operatively included; septal flap tears (2.8 per cent) and alar cartilage injury (1.8 per cent), while post-operative complications included; nasal trauma (one per cent), epistaxis (two per cent), infection (2.4 per cent), prolonged oedema (17 per cent), and nasal obstruction (0.8 per cent). The overall patient satisfaction rate was 95.6 per cent and the transcolumellar scar was found to be unacceptable in only 0.8 per cent of the patients.     

Auricular cartilage grafts and nasal surgery

OBJECTIVE: To illustrate the safety, effectiveness, and versatility of auricular cartilage grafts in nasal surgery. STUDY DESIGN: Retrospective chart review of the author's nasal surgery experience for an 8-year period. METHODS: Five hundred eight rhinoplasties were performed over an 8-year period. One hundred one of these cases used auricular cartilage grafts as donor material. RESULTS: Donor cartilage was used in a wide range of grafting techniques: tip grafts, dorsal onlays, spreader grafts, septal replacements, alar battens, composite grafts, etc. The average follow up was 12 months. The complication rate was low. Five patients experienced complications involving the auricular cartilage graft or its donor site. No patients experienced graft resorption or infection. Donor site morbidity was limited. No auricular infections or hematomas were observed. CONCLUSION: Septal cartilage is usually the first choice as donor material in nasal surgery; however, when indicated, auricular cartilage grafts can serve as a safe, effective, and versatile alternative. This conclusion is supported by their successful use in a wide variety of surgical techniques, with long-term follow-up. The author feels strongly that autografts should be favored over alloplastic material. Alloplastic grafts continue to present a risk of infection over the entire life of their use. When a rhinoplasty is performed skillfully with a cartilage autograft, time becomes an ally of the surgeon rather than an enemy.     

自体鼻中隔软骨联合耳廓软骨的鼻中隔延伸物移植术在鼻尖整形中的应用

目的:探讨运用鼻中隔软骨联合耳廓软骨构建鼻中隔延伸物复合体重置鼻尖位置和重塑鼻尖形态的可行性。方法:2018年9月至2019年10月,以中国医学科学院整形外科医院17例低鼻患者为研究对象,17例患者中男2例,女15例;年龄19~39岁,平均27岁。17例患者均为初次鼻整形病例。术中在全身麻醉下行鼻整形术。切取鼻中隔软骨...     

鼻内镜下自体软骨鼻整形同期鼻中隔偏曲矫正治疗外伤性歪鼻畸形的临床分析

目的对鼻内镜下自体软骨（鼻中隔软骨、耳软骨和肋软骨）鼻整形同期行鼻中隔偏曲矫正治疗外伤性歪鼻畸形的临床分析。方法收集2017~2018年20 例陈旧外伤性歪鼻畸形患者的临床资料,所有患者均行全麻下鼻小柱倒“V”型切口暴露松解并切除偏曲的鼻中隔软骨及骨质,针对不同患者设计使用不同软骨（鼻中隔软骨、耳软骨和肋软骨）矫正鼻中隔骨性或软骨性支架,对鼻尖、鼻背及外鼻重新塑形。结果随访3~12个月,行鼻内镜下自体软骨鼻整形同期鼻中隔偏曲矫正术的患者鼻外形及通气均有明显改善,手术效果更好,无鼻腔粘连、鼻中隔血肿及穿孔。结论鼻内镜下自体软骨鼻整形同期鼻中隔偏曲矫正治疗外伤性歪鼻畸形同期解决了鼻部畸形和鼻通气功能,实现了美容和功能的统一,同时减少了手术治疗的次数和费用,可行性高。     

Stabilizing cartilage grafts in functional-aesthetic rhinoplasty

BACKGROUND: While traditionally most rhinoplastic operations were dominated by tissue resection, more and more surgeons emphasize the importance of restructuring and stabilizing the nose by cartilage grafts and suture techniques. This development in rhinosurgery is the result of long term experience showing that insufficient stabilization of nasal structures often leads to sequelae such as nasal valve collapse and tip ptosis, even decades after surgery. METHOD: Brief survey of five of the most important stabilizing cartilage grafts, i. e. spreader grafts, lateral crural grafts, alar batten grafts, the columellar strut graft, and the septal extension graft, with presentation of case reports. RESULT AND CONCLUSION: Cartilage grafts play a key role in the pursuit of obtaining functionally and aesthetically durable long term results in rhinoplasty.     

Management of the keel nose and associated valve collapse

OBJECTIVES: To analyze the anatomical abnormality of the keel nose and correlate the findings with etiologic maneuvers of a routine rhinoplasty procedure; to identify the contributing factors and offer suggestions to avoid or decrease the severity of these surgical complications; and to present an effective revisional procedure to correct the functional and cosmetic consequences of this deformity. PATIENTS AND METHODS: A total of 47 patients (31 women and 16 men; age range, 18-71 years) with a keel-appearing nose presented for revision rhinoplasty. All had undergone at least 1 rhinoplasty procedure, and 39 had undergone 2 or more previous nasal procedures. All patients had bilateral lateral nasal wall collapse and an associated severely compromised internal nasal valve. All patients underwent reconstruction with a conchal cartilage overlay graft. RESULTS: All patients had a moderate to excellent cosmetic improvement; the subjective improvement in nasal airway was more dramatic. Since patients with a keel nose have an associated internal valve collapse, both abnormalities are addressed simultaneously with the conchal cartilage overlay repair, which results in minimal morbidity with no major complications. CONCLUSIONS: Conchal cartilage overlay repair uses a cartilage graft from the auricle with a recommended external rhinoplasty for placement. Appropriate sizing and fashioning precede the precise placement and suture fixation. This technique addresses both functional and cosmetic abnormalities.     

Cartilage grafts for the nasal tip

Control over nasal tip projection is essential in rhinoplasty. Nasal projection is defined as the length of the perpendicular drawn from the anterior facial plane to the tip-defining point. Between 1989 and 1991, 300 patients underwent an external rhinoplasty. In 94 (31%) an autologous graft for the nasal tip was used. The aesthetic result was pleasing to the vast majority of the patients. Nasal tip rigidity resolved in all patients within one year post-operatively. One patient needed revision surgery, because of graft resorption. The nasal lobule shield-type graft, made of autologous cartilage, is one of the most important methods to maintain projection. The graft may also control length, (counter)rotation of the nose and refinement of the tip. The external approach facilitates in-situ suturing and sculpting of the graft.     

Algorithm for the treatment of external nasal valve insufficiency

IntroductionNasal obstruction is one of the most prevalent complaints in the population. The main causes of nasal obstruction are inflammatory, infectious or anatomical alterations. Anatomical alterations include nasal septum deviation, turbinate hypertrophy, and nasal valve insufficiency (external and/or internal). The diagnosis of nasal valve insufficiency remains a clinical one and is based on inspection and palpation of the nose, evaluating both its static and dynamic functions. The literature presents several options for the correction of external nasal valve insufficiency. These are chosen according to the choice and experience of each surgeon.ObjectiveTo create a practical algorithm for the treatment of external nasal valve insufficiency that can guide nasal surgeons in their choice of treatment for the different anatomical alterations found in patients with these disorders.MethodsWe used the treatment options found in the literature and correlated them with our surgical options for each type of anatomical alteration found. Therefore, we used basically three parameters related to physical examination findings (degree of insufficiency and characteristics of the lower lateral cartilage) and the patient's complaint (present or absent aesthetic complaint regarding the nasal tip).ResultA practical algorithm was developed for the treatment of external nasal valve insufficiency according to the degree of insufficiency (mild-to-moderate or severe), aesthetic complaint of the nasal tip (present or absent) and characteristics of the lower lateral cartilage (size and orientation).ConclusionThrough this simple algorithm, one can use each type of graft and/or maneuver according to the patients’ complaints and the anatomical alterations found.     

Semilunar conchal cartilage graft in saddle nose reconstruction

IntroductionThe saddle nose deformity is easily recognized by the loss of septal support and nasal dorsal height with adverse functional and aesthetic consequences.TechniqueWe treated a 50-year-old woman and a 54-year old man that presented with a moderate saddle nose deformity following a previous septorhinoplasty (female patient) and a posttraumatic severe saddle nose deformity (male patient). The patients were treated by open approach rhinoplasty under general anesthesia, and the saddle nose deformity was reconstructed with a semilunar conchal cartilage graft. A semilunar part of the conchal cartilage is excised, lending its name to the graft. A smaller leaf shaped cartilage part is excised and sutured upside-down with PDS 5-0 sutures on the opposite of the cartilage, so that the concave surfaces are facing each other. The newly formed graft is then sutured in its place on the nasal dorsum in the supratip saddle area over the triangular cartilages to widen the inner nasal valve angle. The lateral tips of the semilunar graft are placed below the lateral alar crura to improve external nasal valve functionality.DiscussionThis modified conchal cartilage graft presents itself as an excellent reconstructive option, especially considering its low morbidity, availability and ability to retrieve an adequate amount of cartilage in the vast majority of patients. These modifications of the conchal cartilage are previously unreported, and provide the needed height and elasticity in saddle nose reconstruction without the need for additional grafting. It is important to stress that when positioned properly, a beneficial effect in peak nasal inspiratory flow may be observed, adding to its usefulness in repairing both function and aesthetics.