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.     

除皱术中多切口应用的探讨

目的　通过分析面部老年化的解剖学特征 ,在除皱术中应用多切口充分矫正面部老年化所带来的解剖学的改变 ,以达到年轻化效果。方法　行除皱术同时应用下睑缘切口、颏下切口或鼻翼缘切口以矫正面部老年化解剖学的改变。结果　自 1999年以来完成手术 18例 ,随访半年至 1年 ,效果满意。结论　在除皱术中应用多切口可更有效地矫正面部老年化解剖学的改变 ,以获自然、持久的术后效果。     

The oscillating micro-saw: a safe and pliable instrument for transverse osteotomy in rhinoplasty

Background: A low-to-low lateral osteotomy combined with a transverse osteotomy offers a reliable technique to mobilize the lateral walls in patients with broad bony vaults, but variable "brittling" characteristics of the nasal bones near the radix make it difficult to guarantee the result of manual transverse osteotomy. Objectives: The author describes a split-thickness transverse osteotomy with the aid of an oscillating micro-saw under video/endoscopic control to eliminate the risk of probable pitfall fractures on the structure of the bony nasal vault near the radix during blind manual osteotomy. Methods: The author reviewed 1550 consecutive rhinoplasty and septorhinoplasty operations performed between April 2005 and October 2010. Among these the transverse osteotomy was used bilaterally in 1374 cases. Split-thickness transverse osteotomy was carried out with a powered micro-saw system from an endonasal approach under video/endoscopic control. CT-based 3D models of 16 patients with different functional indications were used to assess the mean depth of the transverse osteotomy line. Results: The mean depth of the nasal wall at the thickest point of the transverse osteotomy line near the radix was 2.5 ± 0.66 mm. It decreased toward the medial canthus in all 16 patients. The mean thickness of bone was 1.2 ± 0.21 mm in the medial canthal area. Conclusions: The oscillating micro-saw is a safe and pliable instrument to aid in transverse osteotomy during rhinoplasty. Video endoscopy provides an excellent view of the osteotomy site, including direction and depth, in addition to providing documentation for and education about the procedure. Level of Evidence: 4.     

Augmentation mentoplasty with osteocartilaginous nasal graft

Objective

Augmentation mentoplasty is a common procedure, applied especially in conjunction with rhinoplasty. Although various materials have been used, autogenous nasal hump tissue has not been studied in a big series of patients. The main objective of this study was to evaluate the use of autogenous nasal hump in chin augmentation.

Study Design

Case series with chart review.

Setting

University hospital.

Subjects and Methods

The osteocartilaginous mentoplasty procedure was performed in 124 patients along with rhinoplasty in a series of 218 patients who had undergone combined rhinoplasty and mentoplasty with various techniques. The median follow-up was 58 months (range, 12-120 months) over a 10-year period. The procedure commenced under general anesthesia for all patients with large humps and poor chin projection. During the rhinoplasty procedure, the osteocartilaginous nasal hump was removed, tailored to achieve an anatomic mental form, and inserted into the mental pocket through a submental or an intraoral incision.

Results

Infection was detected in five patients, two of whom required graft removal. All other patients recovered normally along an almost painless process, without displacements or any other complaints.

Conclusion

Nasal hump in reduction rhinoplasty is a useful alternative for augmentation mentoplasty on patients with large humps and poor chin projection. It also avoids all the disadvantages of alloplastic materials and eases integration compared with other alternatives in selected cases.     

Rhinoplasty and the male patient

A review of male patients undergoing rhinoplasty indicates a surprising diversity of anatomy and especially skin coverage. When compared with rhinoplasty in the female adolescent, the goal must be more of a "balanced rhinoplasty" rather than a reductive rhinoplasty, and the techniques required are more diverse. Careful screening of patients is essential to eliminate a subgroup of men with severe psychologic obsessions.     

Rhinoplasty and the nasal SMAS augmentation graft: advantages and indications

We evaluated the nasal superficial musculoaponeurotic system (SMAS) as an autologous augmentation graft material in the thick-skinned patient undergoing cosmetic rhinoplasty using a retrospective review. Representative case reports demonstrated preliminary long-term results after augmentation with the nasal SMAS graft in an academic rhinoplasty practice. En bloc excision of the nasal SMAS in thick-skinned patients produced uniformly favorable improvements in nasal tip definition without adverse sequelae. Moreover, in 10 patients, the harvested material was also used for volume augmentation at various adjacent nasal sites, including the radix, nasal sidewall, and nasal dorsum. Long-term follow-up ranging from 1 to 3 years suggests stable volume augmentation in this initial patient series. No donor morbidity was observed in properly selected patients, and enhancements in nasal tip definition were uniformly favorable. Additional studies are needed to more accurately characterize long-term nasal SMAS graft survival in all patients.     

鼻表浅肌肉腱膜系统在鼻成形术中的应用

目的　以鼻表浅肌肉腱膜系统为理论依据 ,进行鼻成形手术。方法　对本组 5 3 6例鼻成形手术患者假体置放层次进行回顾、比较和分析 ,并进而改为将假体放置在鼻表浅肌肉腱膜系统深面。结果　鼻模型假体放置在鼻表浅肌肉腱膜系统深面 ,成型更加自然、逼真 ,假体稳固 ,减少了并发症。结论　鼻成形手术理想的剥离平面应位于鼻表浅肌肉腱膜系统的深面 ,鼻SMAS对外鼻的形态学维持具有重要意义。     

Dislocations and fracture dislocations of the tarsometatarsal joints

Dislocations and fracture-dislocations of the tarsometatarsal joints are potentially disabling injuries that present challenging therapeutic problems. Early recognition is imperative and is based on a familiarity with the important anatomic features of this joint, mechanism of injury, and subtle radiographic changes that often accompany these lesions. Following injury, a precise anatomic reduction of the tarsometatarsal joint is critical if long-term disability is to be avoided. There appears to be a direct correlation between achieving an accurate reduction and a satisfactory clinical result. In our experience, surgical reduction offers the most effective and reliable means of achieving this goal. We have presented an approach for the management of these lesions, which we believe offers advantages over previously described techniques. Our experience has shown that accurate anatomic operative reduction and rigid internal fixation provide an increased assurance of a pain-free, durable, and functional foot in the great majority of cases.     

Tip grafts in revision rhinoplasty

In the patient who undergoes revision rhinoplasty, tip grafts are used often when overresection has resulted in structural deficit of deformity. As a result, the last 20 years have witnessed a progressive movement toward more conservative handling of the nasal tip. Still, as some surgeons have not adopted that philosophy and because many more surgeons have not adopted that philosophy and because many more surgeons now take on difficult primary tip problems because of the advent of the external approach, major tip problems continue to plague the final result. Despite these potential variables, when used correctly, the tip graft is critical in achieving the successful reconstruction of the nasal tip region. This article reviews the indications and techniques for tip grafts in revision rhinoplasty and explores how these indications and techniques for tip grafts in revision rhinoplasty and explores how these indications could be prevented in the primary setting.     

Tip nuances for the nose of African descent

Patients of African descent are seeking rhinoplasties today more than ever. As a result, the rhinoplasty surgeon must be aware of the ethnic, cultural, anatomic, and surgical issues pertaining to this patient population. In this article, the nuances of rhinoplasty as it pertains to the nasal tip in patients of African descent are discussed.     

Revision of the functionally devastated nasal airway

Functional rhinoplasty can be especially challenging in a patient who has had previous surgery, trauma, anatomic abnormalities, or systemic disease affecting the nasal mucosa. A thorough analysis of the type and location of the obstruction is critical, and only after identifying the precise anatomic cause of the problem can surgical planning begin. Scarring, altered anatomy, and disrupted tissue planes all complicate this process. Structural support and nasal mucosa often require augmentation with autogenous grafts from the ear, rib, or other portions of the nasal cavity. Attention to nasal support mechanisms, the internal and external nasal valves, and internal lining during primary surgery may help to avoid future complications. Through careful analysis and planning, proper function may be restored to a functionally devastated nasal airway.     

Aesthetic and reconstructive rhinoplasty: A continuum

The anatomy and aesthetics of the nose never change and are similar for cosmetic and reconstructive rhinoplasty. The disciplines differ in the cause of injury, which determines the site and degree of damage, the subsequent deformity, and the therapeutic approach to repair. The cosmetic surgeon modifies the bony-cartilaginous framework to support and mould the overlying skin. A thick, scarred or large skin envelope may limit the expected result but cannot be altered. When severe scarring or necrosis occurs after a cosmetic rhinoplasty or filler injection, missing external skin and internal lining become a controlling factor in achieving nasal shape and must be replaced in exact dimension and border outline, guided by the principles of aesthetic nasal reconstruction. This paper illustrates the use of a 3 stage forehead flap and anatomic reconstruction of the tip cartilages to repair a full thickness necrosis of the tip after a cosmetic filler injection. An overview of presentation and treatment of this complication is presented with reconstructive guidelines to direct the surgeon to successful repair.     

An anatomic basis for revision rhinoplasty

As the popularity of rhinoplasty has increased, so have the expectations of both patients and surgeons alike. Revision rhinoplasty has become an evolving field with unique challenges. One must first address the patient's specific concerns and emotional issues. To properly repair the inadequacies of a failed rhinoplasty, the surgeon must thoroughly analyze and understand the anatomic causes leading to why the patient needs revision surgery.     

The use of spreader grafts in primary rhinoplasty

Some candidates for primary rhinoplasty are at greater risk of postoperative complications due to the presence of certain very specific anatomic characteristics. The authors describe their experience with spreader grafts in primary rhinoplasty and provide an analytic method of identifying the types of patient needing such grafts who present a high risk of complications. Sixty patients were treated with spreader grafts during primary rhinoplasty. Bilateral spreader grafts were used in cases of "narrow nose syndrome" (short nasal bones, long and weak upper lateral cartilages, thin skin) and in cases of disproportionate nose with narrow middle vault and bulbous tip. Unilateral spreader grafts were placed on the concave side in cases of crooked nose. After an average follow-up of 17 months, all the patients reported improvement in functional and esthetic problems, with no complications related to the preoperative features.     

Deprojection of the nasal tip in revision rhinoplasty

Overprojection in revision rhinoplasty can be the result of underaddressed anatomic variations, iatrogenic causes including overresection of the nasal dorsum, or the healing process. Management of nasal tip overprojection in revision rhinoplasty can be very difficult, and the revision rhinoplasty surgeon must have a multitude of techniques available to treat the various causes of nasal tip overprojection. An algorithm is presented to properly approach and treat nasal tip overprojection.     

Functional considerations in revision rhinoplasty

The development of nasal obstruction after rhinoplasty is associated with significant patient dissatisfaction. Correction of nasal obstruction requires a thorough evaluation to determine the ANATOMIC EPICENTER of obstruction. The offending structure can usually be traced to abnormalities in the internal nasal valve, intervalve area, or the external nasal valve and may be static or dynamic. Surgical correction of the internal nasal valve using spreader grafts, flaring sutures, and butterfly grafts has been shown to increase the cross-sectional area of this nasal valve, improving nasal airflow and patient satisfaction. External valve dysfunction from cicatricial stenosis may be addressed with local flaps; however, larger stenoses may require composite grafts. Alar base malposition can be addressed by repositioning of the alar base with local island flaps. Intervalve dysfunction involves the important area between the external and internal valves, under the supra-alar crease, and is the most common site of obstruction. Its correction often involves alar batten grafts and reconstruction of the lateral crura. Inferior turbinate hypertrophy and concha bullosa may be addressed as adjunctive therapy to increase nasal airflow. This article on nasal obstruction after rhinoplasty emphasizes the precise anatomic diagnosis and describes successful methods used to correct the dysfunction.     

The preplanned rhinoplasty

In aesthetic rhinoplasty performed by the extramucosal method, the skeletization of the nose that is obtained allowsmeasurements during the operation. Thereby, it is possible and useful to preplan the rhinoplasty with more accuracy and to inform the patient about the choice to be made. This new approach to rhinoplasty is safer and more precise and provides for (1) a choice of preplanned result (based on artistic technique and psychological reasons), (2) measurements for the plan, and (3) transfer of this plan to the patient during the operation.     

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     

Nose and paranasal augmentation: autogenous, fascia, and cartilage

The up-to-date plastic surgeon should consider using augmentation rhinoplasty with relative frequency. In selected cases, for improving the face integrally, it is desirable to augment the paranasal area. In the author's hands, grafts of cartilage and fascia are the preferred tissues, based on the experience of many years. Fascia can be used alone or combined, and in the last few years we have used it alone quite often. A temporoparietal fascia graft has great versatility in the correction of a number of nasal deformities. A depressed nasal dorsum can be augmented by utilizing fascia grafts. A depressed nasal radix can be corrected successfully by utilizing fascia grafts. Submucosal placement of strips of fascia has proved to be an effective method of reconstructing the roof of the middle cartilaginous vault. For augmenting the nasal dorsum when it is a case of primary rhinoplasty, the author prefers the use of fascia alone, but if the patient is having a secondary rhinoplasty, then the graft of fascia and cartilage combined is preferred.