Functional rhinoplasty: treatment of the dysfunctional nasal sidewall

Treatment of nasal obstruction caused by nasal valve dysfunction requires a thorough evaluation of the mechanics of normal nasal anatomy and function. Surgical correction of nasal valve dysfunction is based on determining the epicenter of dysfunction, whether it is a static obstruction of the internal nasal valve or a dynamic collapse of either the external nasal valve or the intervalve area. Spreader grafts, flaring sutures, and butterfly grafts are used to widen and support the narrow internal nasal valve. Alar batten grafts will add support to the collapsing nasal sidewall seen in external nasal valve and intervalve dysfunction. Correction of dynamic collapse from paradoxical concavity of the lateral crura may be obtained from the lateral crural flip-flop graft or by reconstructing the lateral crura using cartilage grafts. A strut graft may correct dynamic obstruction caused by a malformed, easily collapsible lateral crura. This article discusses the evaluation, treatment, and correction of the dysfunctional nasal sidewall and emphasizes the avoidance of iatrogenic damage to the sidewall while performing cosmetic rhinoplasty.     

Alar expansion and reinforcement: a new technique to manage nasal valve collapse

OBJECTIVE: To describe the new technique of alar expansion and reinforcement as a comprehensive approach to the surgical management of nasal valve collapse. METHODS: Alar expansion and reinforcement expands the narrow nasal valve and reinforces the floppy nasal sidewall. Forty-one patients underwent rhinoplastic surgery for nasal valve collapse between May 1, 2002, and April 30, 2005, using an external rhinoplasty approach; of these, 32 responded to our postoperative questionnaire. Twenty-four patients (75%) underwent primary surgery and 8 (25%) had undergone previous rhinoplasty. All patients had permanent adjustable expansion sutures. Twelve patients (38%) had an excessively floppy nasal sidewall that required a high-density porous polyethylene alar batten implant to anchor the expansion sutures. Patients underwent clinical review from 6 months to 3 years after surgery, and a telephone survey was used to evaluate their functional and cosmetic satisfaction rates. RESULTS: Thirty patients (94%) experienced good improvement in their nasal airway. The improvement in nasal airway patency was statistically significant (P<.001). Two patients (6%) reported no improvement. There were no complications. Cosmetic outcome was satisfactory in all 8 patients who also requested cosmetic improvement. Of the 24 patients who had surgery for nasal obstruction only, 10 (42%) rated their cosmetic appearance as better, with the remaining 14 (58%) indicating that they did not identify any significant change in their nasal appearance. CONCLUSION: Alar expansion and reinforcement is a safe, reliable, and effective technique to manage nasal valve collapse.     

Alar Batten Cartilage Graft: Treatment of Internal and External Nasal Valve Collapse

Background  The aim of this study was to describe the efficacy of alar batten graft in correcting internal and external nasal valve collapse (i.n.v. and e.n.v.) and evaluate the functional and aesthetic results. Methods  From July 2006 to September 2008, 80 patients (54 females and 26 males) underwent alar batten cartilage grafting. The patients were divided into three groups: (1) 55 patients with iatrogenic nasal valve collapse (80% i.n.v., 20% e.n.v.), (2) 15 patients with posttraumatic nasal valve collapse (45% i.n.v., 55% e.n.v.), and (3) 10 patients with congenital nasal valve collapse (100% e.n.v.). Patients were evaluated at 6, 12, 24, and some at 36 months after surgery. The final follow-up was at least 24 months. Results  The results of this study revealed a significant increase in the size of the aperture at the internal or external nasal valve after the application of alar batten grafts. All the patients noted improvement in their nasal airway breathing and in their cosmetic appearance. No major complication was observed. Conclusion  The alar batten graft is a simple, versatile technique for long-term reshaping, repositioning, and reconstruction of the nasal valve collapse.     

Nasal valves--importance and surgical procedures

One of the most difficult aspects in rhinoplasty is resolving and preventing functional compromise of the nasal valve area reliably. The nasal valves are crucial for the individual breathing competence of the nose. Structural and functional elements contribute to this complex system: the nasolabial angle, the configuration and stability of the alae, the function of the internal nasal valve, the anterior septum symmetrically separating the bilateral airways and giving structural and functional support to the alar cartilage complex and to their junction with the upper lateral cartilages, the scroll area. Subsequently, the open angle between septum and sidewalls is important for sufficient airflow as well as the position and function of the head of the turbinates. The clinical examination of these elements is described. Surgical techniques are more or less well known and demonstrated with patient examples and drawings: anterior septoplasty, reconstruction of tip and dorsum support by septal extension grafts and septal replacement, tip suspension and lateral crural sliding technique, spreader grafts and suture techniques, splay grafts, alar batten grafts, lateral crural extension grafts, and lateral alar suspension. The numerous literature is reviewed.     

Structural approach to endonasal rhinoplasty

The marriage of endonasal rhinoplasty with structural grafting has resulted in more consistent rhinoplasty results. The nasal base can be stabilized by tongue-in-groove techniques, a columellar strut, or extended columellar strut. The middle vault can be addressed with spreader grafts or butterfly grafts. Lower lateral cartilage weakness can be supported with alar batten grafts or repositioning of the lower lateral cartilages.     

Childhood nasal trauma with previous rhinoplasty and persistent deformity

This article reviews a case of a young woman with a history of childhood trauma resulting in nasal deformity along with chronic nasal obstruction. Discussion for correction of these problems includes septoplasty, tip shield graft, cap graft, alar batten graft, an crushed cartilage graft. Pre- and postoperative photographs are provided with corresponding preoperative diagrams and schematics.     

Analysis of outcomes after functional rhinoplasty using a disease-specific quality-of-life instrument

OBJECTIVE: To measure the efficacy of functional rhinoplasty techniques with a validated quality-of-life instrument. DESIGN: Prospective observational outcomes study of patients with severe nasal obstruction owing to septal deviation, internal or external valve collapse, and turbinate hypertrophy who subsequently underwent functional rhinoplasty. Preoperative and postoperative evaluations were performed using the Nasal Obstruction Symptoms Evaluation scale. RESULTS: Forty-one patients completed preoperative and postoperative evaluations. No complications occurred. There was a significant improvement in mean Nasal Obstruction Symptoms Evaluation score postoperatively for the entire cohort (P<.01). Nasal Obstruction Symptoms Evaluation scores were also examined based on the procedure performed, such as spreader grafting, septoplasty, external valve suspension, and turbinectomy. Each subgroup also demonstrated airway improvement. CONCLUSIONS: Functional rhinoplasty techniques are effective in improving nasal airway function as measured by a patient-based, disease-specific, quality-of-life instrument. The specific techniques considered to treat nasal obstruction can be tailored to address the areas of concern, including septal deviation, internal or external valve collapse, and turbinate hypertrophy.     

Evaluation of a new procedure for nasal alar rim and valve collapse: nasal alar rim reconstruction.

OBJECTIVE: A new operative technique to improve nasal valve collapse by placement of cartilage struts along the alar rim was compared with the standard nasal valve cartilage graft (NVG) technique. Methods And Patients: A retrospective study of consecutive patients with nasal valve collapse was performed at Stanford University Medical Center. Seventy-nine patients with nasal valve collapse underwent reconstruction with either the classic NVG technique or a newly developed nasal alar rim reconstructive (NARR) procedure. The mean age of the NARR group was 50.13 years (SD +/- 9.40), with 36 men (92.3%) and 3 women (7.7%). The mean age of the NVG group was 52. 14 years (SD +/- 10.83), with 36 men (90%) and 4 women (10%).Main Outcome Measures: These included functional and subjective evaluation of nasal valve collapse. RESULTS: Forty patients (50.6%) underwent the NVG technique, and 39 (49.4%) received the NARR procedure. The NVG technique revealed 0% worsened, 15.0% (6/40) unchanged, 25.0% (10/40) improved, and 60% (24/40) free of obstruction. The NARR procedure revealed 2.6% worsened, 2.6% unchanged, 7.7% improved, and 87.1% free of obstruction. CONCLUSIONS: Nasal alar cartilage struts placed along the caudal alar rim offers sufficient support to the alar rim and valve area. This procedure appears to be as effective as currently available reconstructive alternatives, while being technically uncomplicated.     

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 utility of concurrent rhinoplasty and sinus surgery: a 2-team approach

OBJECTIVE: To evaluate the safety and efficiency of and patient satisfaction with a 2-team approach for combined rhinoplasty and sinus surgery. METHODS: We conducted a retrospective medical chart analysis of consecutive patients with sinus disease and functional nasal obstruction. Forty-four patients (29 women and 15 men; age range, 22-75 years) had severe nasal obstruction with chronic sinusitis and were found to have indications for this procedure. All patients were followed up for a minimum of 6 months after surgery. Patients completed a standardized questionnaire at the time of medical chart review, and 36 patients completed a telephone interview. RESULTS: All 44 patients underwent rhinoplasty with an endoscopic sinus procedure. Twenty-seven procedures (61%) were endonasal, whereas 17 (39%) were open rhinoplasty. Patients with internal nasal valve collapse underwent 28 butterfly grafts, 6 spreader grafts, and 8 batten grafts. The endoscopic sinus procedures consisted of maxillary antrostomy (30/44 [68%]) and ethmoidectomy (28/44 [63%]). Overall, 20 (65%) of 31 patients reported a postsurgical nasal airway that was significantly improved. Most sinus symptoms were resolved postoperatively, with 25 (71%) of 35 patients describing their improvement as significant. Thirty-two (92%) of 36 patients stated that they would recommend the concurrent procedure. CONCLUSION: Patients presenting with nasal obstruction and chronic sinusitis tolerated combined rhinoplasty and sinus procedures without added morbidity.     

Surgical management of concavities of the distal nose

Normal topographic anatomy of the distal nose is a reflection of the delicate integration between the lower lateral cartilage, the upper lateral cartilage, the sep-tum, and skin. Understanding these relationships will help the rhinoplasty surgeon diagnose and treat con-cavities of the distal nose. Most patients present with a hybrid of these defects. For example, the patient in Fig. 19 presented for a primary rhinoplasty. A variety of concavities can be noted and include dorsal septal deflection, upper lateral cartilage avulsion on the left,bilateral lower lateral complete concavities, and the beginning of a dorsal depression (Fig. 19A-I). The nasal skeleton and the skin and soft tissue are normally in equilibrium, but trauma and reduction rhino-plasty disrupts this equilibrium. Skeletal distortion can lead to septal deflection, middle vault collapse, or alar buckling [20]. It is important to realize that correction of deflection or depression by excision needs to be balanced with augmentation, which provides balance for the previously disequilibrated skeletal and soft tissue forces. Augmentation can be done with spreader grafts, tip grafts, columellar strut, and dorsal grafts. A patient's soft tissue envelope will also play a major role in the success of a septorhinoplasty. The surgical principles of septorhinoplasty such as judicious resculpting of the cartilaginous framework, respect of major tip support, tip grafting technique, and postoperative tissue contraction still apply and must be placed in conjunction with repairing a pathological topographic concavity.     

鼻中隔偏曲畸形矫正同期鼻整形术

目的:探讨鼻中隔偏曲畸形矫正同期鼻畸形娇正的手术方法和效果.方法:采用鼻侧软骨和大翼软骨间切口,显露畸形的中隔软骨及鼻骨结构,松解牵拉力量,矫正鼻中隔畸形,截骨及复位鼻骨,使其解剖复位,重塑鼻支架.结果:本组39例,均获满意效果,无复发和并发症.结论:本手术方法矫正偏曲畸形的鼻中隔的同时,矫正外鼻的畸形,消除了引起畸形的原因,重塑外鼻支架,收到了恢复鼻腔通气功能与外鼻美容的双重效果.     

鼻翼软骨缝合与鼻中隔软骨移植并用纠正女性鼻头宽大低垂

目的：探讨鼻翼软骨缝合与自体鼻中隔软骨移植并用,纠正女性鼻头宽大低垂的整形手术方法。方法：设计鼻小柱开放式切口,自体鼻中隔软骨做鼻小柱支柱和盾形移植,同时进行鼻翼软骨内侧脚顶缝合。结果：本组就医者22例,术后随访3～24个月,全部就医者术后鼻部美学效果明显改善,形态自然。结论：自体鼻中隔软骨做鼻小柱支柱和盾形移植,同时进行鼻翼软骨内侧脚顶缝合,是纠正女性鼻头宽大低垂有效的手术方法。     

Rhinolift operation in the treatment of the aging nose

Disturbance of the normal relationship between the caudal border of the upper lateral cartilage and the cephalic margin of the lobular cartilage--the so-called "cul-de-sac" area--can result in alar collapse and nasal airway obstruction. This may be caused by either the aging process or trauma, both surgical and nonsurgical. Rhinolift is a surgical procedure that was developed for the treatment of the aging ptotic nasal tip. We have applied this technique to patients with nasal airway obstruction resulting from alar collapse. Elevation of the cephalic margin of the lobular cartilage to a position superficial to the upper lateral cartilage restores the normal relationship between these two structures. The upper lateral cartilage then assists in stenting the vestibule open, and thereby improves nasal breathing. Over the past 10 years, 20 patients have had rhinolifts at our institution for the relief of nasal airway obstruction. Concomitant surgery included nasal septal reconstruction in 12 patients, polypectomy in one patient, and placement of a silicone rubber septal prosthesis for closure of a large septal perforation in three patients. Rhinolift was the sole procedure used for the correction of valvular pathology in 10 patients. The other 10 patients had modifications made in their upper lateral cartilage along with the rhinolift. Five patients described restoration of normal nasal breathing, while 14 patients showed partial symptomatic improvement. One patient reported no improvement in nasal breathing. Rhinolift is a safe effective surgical technique for functional improvement of nasal breathing in patients with alar collapse resulting from inadequate cartilaginous support.     

鼻翼及鼻尖肥大的美容整复

目的:探讨矫正鼻翼鼻尖肥大的最佳手术方法。方法:依鼻翼、鼻尖肥大的特点,采取横向缩小鼻翼法,并注重鼻翼外侧脚的移位。鼻尖整形行开放式手术入路,重塑鼻翼软骨,并把切除下的鼻翼组织块去表皮后置到鼻假体上。结果:30例鼻翼鼻尖肥大患者均取得了良好的手术效果。结论:鼻翼、鼻尖肥大要整体诊治,才能取得良好的手术效果。     

Auricular cartilage in revision rhinoplasty

Revision rhinoplasty is a challenge in reconstruction to the rhinoplasty surgeon, both in the techniques of repair and the choice of implant material for augmentation grafting. Often, patients seeking revision or reconstructive rhinoplasty have previously undergone septoplasty with sacrifice of major amounts of septal cartilage. These situations confront the surgeon with the need for a decision about the material that will be used for structural grafting. The senior author follows the time-tested approach of generations of surgeons who have used exclusively autogenous material for nasal reconstruction because of its superior long-term survival characteristics, its ready availability in the head and neck region, its resistance to infection and resorption, and its bendability and flexibility when implanted in the nose. With this in mind, the subject of this article is the use of auricular cartilage in revision rhinoplasty. Careful strategic planning must be undertaken to get the maximal and ideal benefit from the auricular cartilage. The revision rhinoplasty surgeon must understand the anatomy of the external ear and must be able to manage the precious cartilage supply to get the maximum use of it in reconstructive rhinoplasty.     

The evolution of the combined use of endonasal and external columellar approaches to rhinoplasty

By individualizing rhinoplasty techniques for each patient and incorporating the lessons taught by the long-term follow-up on my rhinoplasty patients over the past 20 years, I have incorporated a blend of the endonasal and external columellar approaches to accomplish the desired aesthetic goals for my patients.By recognizing an increased need of spreader grafts for the midnasal vault, the placement of alar strut grafts to support the lateral crus, the use of alar spanning grafts and more suture grafts in the lobule, and refinement grafts in the nasal lobule, I have increased the use of the external columellar approach to approximately 50% of my rhinoplasties, which involves a significant number of secondary rhinoplasties and primary cases with specific indications. By paying attention to detail and using camouflage cartilage grafting, revision rates in my practice have fallen from approximately 7% to 4%.     

The remucosalizing alar cartilage flap: a reconstructive option for repairing nasal septal perforations

The objective of this study is to assess the results of repairing septal perforations with a vascularized pedicled alar cartilage island flap. Using the external rhinoplasty approach, a vascularized flap of alar cartilage, harvested as a cephalic trim and pedicled on the ascending columellar branches of the superior labial artery was raised. Bilateral mucoperichondrial septal flaps were elevated and the alar flap was transposed and secured within the defect and bilaterally overlaid with temporalis fascia. Silastic sheets were placed and remained in situ until the grafts were revascularized from the peripheries of the defect as well as centrally from the alar flap. The revascularized temporalis fascia acted as a scaffold for nasal remucosalization. The alar flap also increased the long-term structural robustness of the repair. Between 1999 and 2003, 14 patients with septal perforations ranging from 10 to 31 mm underwent septal reconstruction using this technique. There were nine males and five females. The flap was successfully raised in all cases and long-term closure was maintained in 12 patients (86%). The alar cartilage flap is an effective technique for repairing septal perforations in selected patients. It provides vascularized tissue which nourishes the grafts during remucosalization, and a cartilaginous framework, which affords long-term structural support to the repair. It also obviates the need to transpose nasal mucosa and create a secondary defect. The rhinoplasty approach furthermore permits additional nasal deformities to be corrected at the same time. Presented at the British Association of Plastic Surgeons Summer Scientific Meeting, Sheffield, UK (12 July 2006).     

Open vs closed approach to the nasal pyramid for fracture reduction

OBJECTIVE: To compare an open vs a closed approach to the nasal pyramid for the initial repair of nasal fractures. METHODS: Retrospective medical record review of 49 patients with acute nasal fractures treated by a single surgeon during a 5-year period. Patients underwent a closed approach to the nasal pyramid (Boise elevator only) or an open approach using rhinoplasty techniques, including rasping, osteotomies, and cartilaginous resection or augmentation. Patients were further categorized based on whether septoplasty was performed. The primary outcome measure was the revision rate (RR). RESULTS: All 49 patients with acquired nasal deformities underwent repair within 3 weeks of the date of injury. The cohort was filtered into the following 5 groups: group 1 (closed approach to the nasal pyramid; RR, 1/15 [6.7%]), group 2 (closed approach to the nasal pyramid with septoplasty; RR, 3/4 [75.0%]), group 3 (open approach to the nasal pyramid; RR, 0/10 [0.0%]), group 4 (open approach to the nasal pyramid with septoplasty; RR, 1/15 [6.7%]), and group 5 (prior cosmetic septorhinoplasty; RR, 5/5 [100.0%]). CONCLUSION: In patients with nasal fractures and associated septal deviation requiring septoplasty, RRs may be notably reduced by using an open approach to the nasal pyramid at the time of the initial repair.     

耳软骨在二次隆鼻术及鼻尖成形术中的应用

目的：探索二次隆鼻术及鼻尖成形术的方法。方法：采用鼻小柱“飞鸟”形切口加鼻翼软骨缘切口,切开分离皮肤、皮下组织,显露假体并取出,分离两侧鼻翼软骨及侧鼻软骨等,将取下的耳软骨缝合固定于新雕刻假体的顶部及短壁上,插入鼻背固定,缝合双侧穹窿部鼻翼软骨,缝合切口。结果：自2010年6月～2013年6月对46例不满意隆鼻术行二次隆鼻及鼻尖成形术,获得满意的手术效果。术后鼻尖形态自然、鼻长度延长、高度增加、歪鼻也得到矫正等。结论：用自体耳软骨及硅胶假体行二次隆鼻术及鼻尖整形术,能解决鼻尖不良形态,矫正鼻偏斜、鼻孔外露、增加鼻长度,获得鼻部整体形态自然协调的效果,是一种理想的手术方法。