Recent advances in Asian rhinoplasty

Asian rhinoplasty is an expanding topic in the field of rhinoplasty. Although the main principles of various rhinoplasty techniques apply equally to the Asian nose, Asian rhinoplasty is unique owing to its different anatomy and ethnicity. In recent years there have been some noteworthy developments in Asian rhinoplasty. Traditional techniques using alloplastic implants with endonasal approach are changing due to the advent of new beauty concept, introduction of new techniques, and development of newly improved materials.In this review, we will highlight some of the recent advances of Asian rhinoplasty with emphasis on dorsal augmentation, advances in implant material and tip surgery using autologous cartilage. Finally with increase of revision cases, issues relavant to revision rhinoplasty in Asians will be addressed.     

Saddle nose surgery: long term aesthetic outcomes of support grafts

Saddle nose surgery requires support grafts to improve the aesthestic of the nose such as the functional ventilation. Many kind of graft are available: Calvarial bone graft, iliac crest, septal cartilage, conchal cartilage, nasal hump, bony inferior turbinate. OBJECTIVES: To define the surgical strategy and long term aesthetic outcomes of rhinoplasty with support graft for saddle nose correction. MATERIAL AND METHOD: Retrospective study during the period 1985-2005: 160 patients underwent rhinoplasty with support graft for saddle nose correction. Patients were divided into 3 groups depending on the deformation (group I: Minor saddle nose; group II: Intermediate saddle nose; group III: Major saddle nose). Long term results were analysed at least 5 years after surgery, in 70 patients. RESULTS: An intranasal approach was performed in 92 cases, while an open approach was performed in 68 cases. A bony support graft was used in 85% of patients of group II and 94% of patients of group III. These grafts allowed a more rigid correction of the saddle nose than cartilage. For groups II and III patients, cartilage support grafts were not used because of the lack of quantity to correct the saddle nose. CONCLUSION: Calvarial bone support graft has a great role in saddle nose surgery. The postoperative aesthetic outcomes are interesting and its absorption is low.     

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.     

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.     

开放鼻整形术在歪鼻畸形矫正中的应用

目的探索开放鼻整形术在歪鼻畸形矫正中的应用。方法采用鼻开放入路,在直视下根据鼻梁畸形情况,对畸形的鼻骨性支架结构和软骨支架结构等对症处理,矫正鼻梁歪斜,改善通气功能。结果临床应用68例,效果满意。结论开放鼻整形术具有操作灵活、术野清晰、效果确切的临床效果。对歪鼻畸形,尤其是严重的歪鼻畸形,手术效果确切可靠。     

Autogenous auricular concha cartilage transplant in corrective rhinoplasty. Practical hints and critical remarks.

Numerous materials have been suggested for correction of nasal defects, especially for the saddle nose. We present here our experience with the autogenous cartilage transplant from the auricular concha in our collective of 32 patients. The concha cartilage is used for saddle nose corrections and reconstruction of the alar cartilages. Auricular concha cartilage is an almost ideal transplant material for corrective rhinoplasty because: 1. Harvesting of the material is a low-risk procedure that is not time-consuming and can be performed under local anaesthesia. 2. Concha cartilage is stable enough for support and elastic enough for contouring. 3. It can easily be shaped as desired. 4. Concha cartilage shows little tendency towards dislocation. 5. Resorption is negligible and thus plays no role in connection with these transplants. 6. Rejection or infection rarely occurs.     

Enbucrilate as cartilage adhesive in augmentation rhinoplasty

Enbucrilate (Histoacryl) as a cartilage adhesive in augmentation rhinoplasty was used in 39 cases. The unique properties of this tissue adhesive enhances the ability to augment the nose during cosmetic and reconstructive rhinoplasty. Enbucrilate interacts superbly well with local tissues, causing no systemic or local untoward effects. Its main attribute stems from its ability to bond cartilage instantaneously and with great reliability, which allows for intricate fabrication of cartilage implant components. Five subcategories of dorsal, tip, and columella augmentation are presented with their technical details outlined. The aesthetic and functional results in 39 cases were deemed excellent, safe, and effective.     

运用自体鼻中隔软骨行外伤性鞍鼻矫形隆鼻术30例

目的：探讨运用自体鼻中隔软骨对外伤性鼻骨骨折合并鼻中隔骨折致鼻部塌陷患者行鞍鼻手术的临床疗效。方法：30例鼻外伤患者的整个修复治疗过程中,均根据其实际状况及需求,同时有单纯鼻骨,忖折复位及鼻中隔骨折清理及矫正术,并使用鼻中隔软骨进行鞍鼻的修复＇冶疗。术后对患者进行随访观察及疗效评价。结果：全部患者一期修复效果均满意。随访3～42个月,28例（93．3％）远期效果满意。结论：运用A体鼻中隔软骨对外伤性鼻骨骨折合并鼻中隔骨折致鞍鼻患者进行矫治是修复鼻外伤的有效方法,倩得临床推广。     

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.     

Cartilage grafts in functional and aesthetic rhinoplasty

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.     

The 'butterfly' graft in functional secondary rhinoplasty

OBJECTIVE: To describe a surgical technique (the conchal cartilage "butterfly" graft) which, when used in properly selected patients, has been found to be a dependable method for alleviation of postrhinoplasty internal nasal valve dysfunction. STUDY DESIGN: Retrospective chart review. METHODS: Analysis of consecutive patients with weakness and/or collapse of the upper lateral cartilages following rhinoplasty. Seventy-two patients (37 women and 35 men, age range 17-76 y) had severe nasal obstruction and were found to have indications for this procedure. All patients had undergone at least one rhinoplastic procedure. All patients were followed for a minimum of 2 years after surgery. RESULTS: All 72 patients experienced significant subjective improvement in relative nasal obstruction. Two patients (3%) reported less than total resolution of their difficulty breathing through their nose; the remaining 70 patients (97%) reported complete resolution of their nasal airway problems. No patients reported their postoperative nasal obstruction as the same or worse than their preoperative baseline. Sixty-two patients (86%) reported improvement in the appearance of their nose, 8 patients (11%) felt that their appearance was unchanged, and 2 patients (3%) felt that the appearance of their nose was made worse by the procedure. CONCLUSIONS: Patients presenting with nasal obstruction after rhinoplasty are frequently found to have collapse and/or weakening of their upper lateral cartilages with resulting nasal valve dysfunction. The conchal cartilage "butterfly" graft is a technique which, when properly performed during revision rhinoplasty, yields predictable functional and cosmetic results with minimal morbidity.     

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.     

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。     

功能性鼻整形解剖学基础及进展

鼻整形按照手术目的可以分为美容性鼻整形和功能性鼻整形。功能性鼻整形是通过调整鼻部框架结构来改善鼻子的通气功能,手术过程中,外观也会发生改变。常见的功能性鼻整形病种有歪鼻、尾段鼻中隔偏曲、陈旧性鼻骨骨折、鼻软骨畸形、内外鼻瓣的塌陷和狭窄等。现将对功能性鼻整形的解剖学基础与进展作一综述,以提高对功能性鼻整形的认识。     

Septal cartilage reshaping with the use of an Erbium doped glass fiber laser. Preliminary results

STATEMENT OF PROBLEM: To evaluate the efficacy of Erbium doped glass fiber laser in patients undergoing nasal septal cartilage reshaping. METHOD OF STUDY: A prospective study was conducted in patients undergoing laser nasal septal cartilage reshaping. Microsurgical sponges soaked in a tetracaine solution plus adrenaline were applied in each side of the nose for ten minutes before the procedure. The cartilage of nasal septum was straightened and fixed in the median position using a modified nasal speculum. An optothermomechanical contactor with transparent indenter and thermocouple sensor was placed on septal regions of maximum mechanical stress. Patients were asked to evaluate the severity of pain during the procedure on a visual analog scale. A rhinomanometric evaluation was conducted preoperatively and postoperatively. All patients were asked to evaluate the improvement of their symptoms. All patients' data and potential complications were entered in a database and were statistically assessed. MAIN RESULTS: Our series consisted of 64 patients. Statistical analysis showed significant improvement of their symptoms and of rhinomanometric results. No complications or side effects occurred. The mean operative time was 35 minutes. PRINCIPAL CONCLUSION: Septal cartilage reshaping is an easy painless and bloodless method using en Erbium doped glass fiber Laser. Laser device LSC-701 (Arcuo Medical Inc.) is effective, safe and inexpensive medical equipment.     

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.     

Rolled auricular cartilage grafts for dorsal augmentation rhinoplasty

We present a technique, which has not been previously described in the literature, of using rolled autogenous conchal cartilage for dorsal augmentation via an endonasal or external rhinoplasty approach. This technique gives greater dorsal height compared with the more common layering techniques. It is most appropriate in the minimally or moderately saddled nose.     

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.     

Materialbedingte Gefahren der korrektiven Rhinoplastik

Summary The fate of any implant depends decisively on the interaction between the implant bed and the implant material.The existing deficiencies of bone and cartilage as human materials have constantly stimulated the search for other more suitable implants in rhinosurgery.In general, rigid and insufficiently elastic materials have proven a failure. Constant micro-traumas to the nose frequently lead to infections of the implant bed and finally to the loss of the implant. Angular or L-shaped implants have given inadequate results due to mechanical susceptibility.The modern plastic materials (either solid, elastic, mesh or sponge) can cause so many possible complications that their use (e.g. sponge) is indicated only in a few limited cases.Of all materials available today, cartilage can be called a relative first choice in rhinoplasty. Cartilage possesses an elasticity natural to the nose; it is easily carved into the desired shape, the healing process is almost always without complication, and it can be used for all different kinds of nasal implant beds. The essential disadvantage of cartilage is its partial resorption in zones of strain.The ideal implant without risks does not yet exist in rhinoplasty. Every material has its advantages and disadvantages, and these have to be considered carefully and individually in each case by the expert rhino-surgeon.     

Management of the Scoliotic Nose

The twisted nose represents an enigma to many rhinoplasty surgeons because of its frequent recurrence following correction. Reasons for failure include improper preoperative evaluation, failure to understand and compensate for the dynamics of cartilage and faulty surgical execution. One cannot expect a perfectly straight nose on all occasions but an analytic evaluation and appropriate surgical execution can routinely yield an apparently straight nose. The dynamics of the twisted nose are explored with special emphasis on the septal contribution to the scoliosis. The contribution of the bony and cartilaginous structures to the deformity is emphasized. An appreciation of the nasal cartilage-osseous unit is essential to understand the production of the twisted nose and its subsequent correction.