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.     

Nasal valve malfunction resulting from resection of cancer

Following cancer resection of the nasal unit, nasal valve malfunction is manifested by the symptoms of nasal stuffiness or difficulty getting air into the nostril. These symptoms occur in cases in which the resection is in the alar crease at the junction with the lateral sidewall of the nose. Wound scar contracture elevates the alar margin and causes the alar and lateral cartilages to move inward forming a visible and palpable shelf on the lateral wall of the nasal vestibule. This displacement of the alar and lateral cartilages and the rigid scar formed between these cartilages render the nasal valve immobile. Since it is easier to prevent nasal valve malfunction than to repair it later, wounds that bridge the alar crease or are located in either the alae or lateral sidewall and come within 1 mm of the alar crease with a total diameter of 1.0 cm should be repaired to prevent nasal valve malfunction. In the process of repairing deep defects, the overlapping region of the lateral crus of the alar cartilage and the lateral cartilage may be stabilized by a conchal cartilage graft. This cartilage graft may be used in combination with reconstruction of the nasal skin with a forehead flap and repair of the nasal lining. In the event that the nasal lining is intact, the cartilage graft may be used with a full-thickness skin graft.     

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.     

鼻中隔软骨移植物在外伤后鼻背畸形修复中的应用

目的 探讨鼻中隔软骨移植物在外伤后鼻背畸形修复中的应用。 方法 自2014年1月至2016年12月为43例鼻外伤后鼻背畸形患者实施了鼻中隔软骨移植物的植入修复。外伤后鼻部骨性及软骨性鼻锥塌陷、变宽呈鞍型。根据鼻背凹陷的程度,选择没有破碎的鼻中隔软骨,按照鼻背凹陷的形态,修剪缝合成型,经由鼻翼缘切口置入软骨移植物矫正外伤后鼻背畸形塌陷。 结果 随访1~3年,9例患者因鼻部外观欠佳,实施二次鼻畸形修复手术,取得较好的鼻背外观。 结论 鼻中隔软骨移植物在外伤后鼻背畸形手术矫正中具有非常重要的应用价值,可对骨性和软骨性鼻锥的凹陷起到填充作用,使骨性和软骨性鼻锥保持连续性。但术后也存在软骨局部吸收变形、外观轮廓欠佳等不足,需通过填充材料的改进来进一步提高手术效果。     

Reconstruction of anterior nasal septum: back-to-back autogenous ear cartilage graft

OBJECTIVES/HYPOTHESIS: The ideal material for reconstructing the nasal septum in the deficient nose has not been found. Since 1986, the authors have used autogenous cartilage from the cavum conchae to successfully correct the anterior septum and the associated cartilaginous saddle. The long-term results in 26 patients with a destroyed septum and a saddle nose are reported. STUDY DESIGN: Retrospective study. METHODS: The mean age of the patients at surgery was 40.2 years, and the mean number of previous nasal procedures was 1.6. Because 11 patients had septal perforations and insufficient septal cartilage or bone, ear cartilage grafts from the cavum conchae were harvested through an anterolateral approach. A special incision was used to divide the concave ear cartilage while preserving the posterior perichondrium. This produced a stable, balanced back-to-back graft. The graft was 2.5 to 3 cm long, long enough to allow reconstruction of the anterior septum and to correct part of the saddle nose deformity. The rest of the conchal cartilage was used to fill the remaining cartilaginous saddle. Follow-up investigations included photographs and visual analogue scales of the patients' symptoms and satisfaction. RESULTS: After a mean interval of 36.7 +/- 22.3 months, the back-to-back grafts showed no macroscopic signs of resorption. Graft position and shape remained intact after transplantation. All noses were adequately projected and mobile. All patients but one were satisfied with the functional and esthetic result. With a score of 4 representing the level of satisfaction as "very good," the mean score of the patients was 3.2 +/- 0.79. The saddle of the nose completely disappeared in 65.4% of patients, was minimally visible in 23.1%, and was slightly present in 11.5%. Nasal breathing improved considerably in 21 patients, remained the same in 4 patients, and worsened in 1 patient. The mean score of all patients for nasal breathing was 7.3 +/- 1.87 on a visual analogue scale of 0 to 10, with 10 representing satisfaction as "very good". CONCLUSION: The back-to-back autogenous ear cartilage graft is a viable, stable, and balanced graft for functional and aesthetic reconstruction of the anterior nasal septum and cartilaginous saddle deformity in patients with a severely traumatized and deficient septum.     

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.     

Alternatives in nasal reconstruction (“five flaps and a graft”)

Five pedicle flaps and one auricular composite graft deserve increased use and attention in nasal reconstructive surgery. All have in common the high possibility of superior functional and esthetic results while requiring the payment of a minimum penalty of tissue sacrifice. A composite graft of conchal cartilage and adherent post-auricular skin serves well in the saddle nose deformity of childhood, creating satisfactory tissue augmentation and recreating cartilaginous support for the airway. The sublabial mucosa of the upper lip provides superior tissue for pedicle flap repair of nasal septal perforations. Tunneled through a small oronasal fistula, the flap is elevated and transposed as a one-stage procedure. No closure of the donor site is required. Forehead flaps derived from the precise midline or the non-hair-bearing bay of forehead skin (the sickle flap), are useful, non-delayed flaps carrying considerable tissue of superior color match to nasal defects. A major advantage is the excellent camouflage possible at either donor site area. When nasal reconstruction of greater dimensions becomes necessary, the scalping flap is advantageous. Flap reliability is of a high order, and flap blood supply is unequaled.     

Management of severe bilateral nasal wall collapse

OBJECTIVE: The aim of this study was to examine and analyze the pathology contributing to severe bilateral nasal wall collapse seen in certain revision rhinoplasty patients and identify those surgical maneuvers in the previous nasal surgery, which may have contributed to this complication; suggest alternatives or modifying steps in nasal surgery to prevent lateral wall collapse; analyze consecutive revision rhinoplasties and identify those patients who have complete bilateral nasal collapse at the internal nasal valve; and analyze the results achieved after surgical reconstruction of complete bilateral nasal collapse. PATIENTS: We identified 49 patients, who presented from 1990 to 2000 for revision surgery, who had bilateral collapse of the upper lateral cartilage. All patients had at least one previous rhinoplasty and all but 14 patients had undergone two or more procedures. The patients were reconstructed with a conchal cartilage graft placed through an external rhinoplasty approach. RESULTS: All patients complained of nasal obstruction with forced nasal inspiration. The collapse was visualized on inspiration and when prevented with intranasal positioning of a bayonet, all patients experienced an immediate improvement in nasal breathing. Postoperatively, all patients experienced this same improvement in their nasal airway. Collapse was not identified in any of the patients after surgery. Two patients underwent revision because of cosmetic asymmetries. CONCLUSION: We strongly recommend a cartilage overlay to reconstitute the rigid midline continuity of the upper lateral cartilages. Unfortunately, with any significant hump removal, this structural interruption is, to varying degrees, inevitable in most rhinoplasty techniques. The upper lateral cartilages can be sutured to circumvent some of the inferior drift, but this will not reconstitute the rigid lateral cantilever effect of the intact cartilage.     

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.     

The effect on snoring of structural nasal valve dilatation with a butterfly graft

OBJECTIVE: To evaluate the effect on snoring of structural nasal valve dilatation with butterfly spreader grafts in patients with nasal valve insufficiency. DESIGN: Retrospective medical chart review and telephone follow-up; mean +/- SD follow-up time, 20.7 +/- 11.34 months (range, 3-48 months). SETTINGS: Tertiary care referral center. SUBJECTS: A total of 37 snoring patients with nasal valve insufficiency who underwent nasal valve dilatation with a butterfly spreader graft. INTERVENTIONS: The conchal cartilage butterfly graft technique was performed during rhinoplasty through either an external or endonasal approach. MAIN OUTCOME MEASURE: To establish through a retrospective review that butterfly graft conchal cartilage nasal reconstruction is effective in reducing snoring. RESULTS: After surgery, 30 patients (81%) had significant improvement in breathing, 5 (14%) had slight improvement, and 2 (5%) had no benefit in breathing. Snoring stopped completely in 11 (30%) of the patients after surgery. The improvement in snoring was significant in 13 patients (35%) and slight in 3 (8%). Twenty-six patients (70%) reported tiredness and grogginess on awakening before the surgery. Surgery significantly improved patients' tiredness and grogginess on awakening in 15 cases (58%), slightly improved them in 5 (19%), and did not change the patients' tiredness and grogginess in 6 cases (23%). CONCLUSION: The conchal cartilage butterfly graft yields successful results not only in breathing but also in snoring symptoms in patients with nasal valve insufficiency.     

Correction of saddle nose deformity

Selection of the procedure for correction of saddle nose deformity should be determined by the severity of the deformity. Cartilage inlay grafts are satisfactory in the repair of minor supratip depressions. Moderate deformity of the cartilaginous septum is readily reconstructed by transposition of the upper lateral cartilages. Marked saddle nose deformity with destruction of large portions of the cartilaginous and bony nasal septum requires bone grafting procedures.     

Nasal hump removal in Asians

Conclusion. When performing nasal hump reduction in Asians, the amount of hump resection should be tailored based on the predicted amount of dorsal augmentation and tip projection needed. Common complications of hump removal can be prevented by conservative hump removal and efficient use of spreader graft or camouflage cartilage grafts. Objectives. The authors present surgical features and results of nasal hump reduction in 51 Asian patients. Subjects and methods. Fifty-one consecutive patients who underwent nasal hump reduction were analyzed retrospectively. Characteristics of the nose accompanying the hump, approaches and techniques used, combined procedures, results and complications were evaluated. Preoperative and postoperative standardized photographs of the face were evaluated to judge objectively the aesthetic outcomes of the surgery. Results. The most frequent aesthetic characteristic accompanying the hump nose was a relatively low nasal dorsum and tip projection compared to the ideal Asian aesthetic norms. An endonasal approach was used for 22 patients (43%) and an external approach for 29 patients (57%). En bloc resection of the bony and cartilaginous hump, followed by rasping was the most commonly used methods for hump resection. Combined procedures included septoplasty (89%), dorsal augmentation with cartilage graft (73%), lateral osteotomy (69%), nasal tip surgery (49%) and spreader graft (39%). Objective evaluation showed complete correction of the hump in 70%, slight under-correction in 26%, and persistent hump (although less than preoperative) in 4%. Complications such as "inverted V" deformity, saddle nose, and nasal obstruction were not encountered.     

The fate of an amputated nose after replantation

Traumatic amputation of the nose is a challenging management problem. We describe the case of a 69-year-old woman who had a dog-bite nasal amputation. The avulsed piece, including the lobule, and approximately half of the columella and alae, was replanted within 2 hours of the trauma. Hyperbaric oxygen therapy was administered for 12 daily sessions. Skin gradually necrosed, and the eschar was tangentially excised. Almost all of the mucosa and of the cartilage layers survived and the final defect was smaller than the original. A 3-stage repair was performed by a paramedian forehead flap to replace cover. Lining was by approximation of native tissues, whereas framework was reinforced by conchal and septal cartilage grafts. The outcome was functionally and aesthetically satisfactory. Our case confirms that replantation of an amputated nose as a composite graft is worthwhile. Although the skin necrosed and required reconstruction, most of the lining and of the cartilage support survived, greatly improving the ease of reconstruction, as well as nasal function.     

The over-projecting nasal tip: Precise reduction without rotation

Excessive projection of the nasal tip is a relatively uncommon deformity, often referred to as the “Pinocchio” nose. When this unaesthetic appearance is secondary to abnormally long medial and lateral crura of the lower lateral cartilages, and when tip rotation is undesirable, surgical correction can represent a challenging problem. A simple and reproducible method via the open septorhinoplasty approach is described for correction of this deformity. In this technique, preoperative photographs are analyzed to calculate the exact length of cartilage to be excised from the medial and lateral crura. The results of this procedure are critically analyzed in six consecutive patients followed for 7 to 19 months. Based on this experience, the operation is recommended as a reliable method for correction of the over-projecting nasal tip when minimal or no rotation is desirable.     

Saddle nose deformity: etiology, prevention, and treatment; augmentation rhinoplasty with polyamide

Saddle nose deformity is characterized by an abnormally concave dorsum with an apparent upward tilting of the nasal tip; the osseous or the cartilaginous vault or both regions may be affected. Over the years, the etiology has changed: formerly syphilis was a major cause of destruction of the nasal supporting structures; today, mechanical and surgical trauma to the nose, fractures, septal hematoma, and racial features are the primary causes of saddle nose deformity; the incidence is increasing as fractures from high-speed automobile accidents increase, and as Orientals and Negroes seek elective nasal plastic procedures. Prevention involves early treatment of nasal injuries in childhood, which affects the growth centers in the nose; treatment of hematoma that may follow injury at any age; avoidance of excessive hump removal during rhinoplastic operations. Treatment of saddle nose deformity, either for physiologic and/or for cosmetic reasons, is augmentation rhinoplasty. Filler materials range from human living or cadaveric tissue — autografts or homografts of bone or cartilage —, heterografts — animal cartilage or processed bone; and inorganic implant materials — metals, synthetic alloplastics. A brief review of the materials and their use during the years gives evidence that the “ideal” material is still to be found. The author's experience with the alloplastic, polyamide mesh, in 30 patients within the last two years has led to initial satisfactory results in 27 patients and subsequently satisfactory results in two patients; one patient awaits a reimplantation. In the three patients who had initial failures there was underlying infection. In all 30 patients the polyamide mesh was well tolerated by the human host; there were no foreign body reactions, no rejections. It was found that the host tissues actually invaded the implant, giving it stability and incorporating it into the host tissues. No implant became displaced. The polyamide mesh has approximately the same flexibility as the host tissues, and the naturally semimobile part of the nose can be readily moved around, providing a repair that approaches the normal nose. The cosmetic effects are entirely satisfactory, and the author believes that polyamide mesh is a valuable adjunct to augmentation rhinoplasty and expects to continue to use it for correction of saddle nose deformity and also to document the results over a long postoperative period. All augmentation materials have advantages and disadvantages; these are summarized in Table I.     

Historical notes and actual observations on the nasal septal abscess especially in children

The recognition of the nasal septal abscess is traced back to 1810 when Cloquet healed an abscess by drainage. This therapy does not prevent the saddle nose deformity and its functional problems in many cases. Since 1963 the immediate reconstruction of the destroyed septum in the acute phase of the septal abscess by means of homologous cartilage has proved to prevent long-term effects of the abscess especially in the growing nose. This is underlined by some of our own long-term results and histological findings. Finally, some new pathogenetic aspects are discussed based on histological and enzymatic findings of the human septal cartilage.     

Repair of nasal septal perforations using auricular conchal cartilage graft in children: report on three cases and literature review

OBJECTIVES: Repair of nasal septal perforation is a challenging procedure. Numerous methods have been described to close nasoseptal perforations with varying degrees of success. The lack of a consensus on nasoseptal perforation repair reflects the shortcomings of each method. There has been a paucity of literature on nasoseptal repair in the paediatric age group. We report our experience of repair of nasal septal perforation secondary to button battery injury using auricular conchal cartilage in the paediatric population. METHODS: Retrospective review of case notes and close regular follow-up of the patients since their first presentations with button batteries as foreign bodies in the nose. RESULTS: Three out of the three children who underwent repair of the nasal septum achieved successful closure of the nasal septum. One child with a large septal perforation required three procedures to achieve closure of the perforation. CONCLUSIONS: Repair of nasal septal perforations is a challenging procedure especially in children. Good results can be achieved with auricular conchal cartilage graft.     

Use of iliac bone graft for saddle nose deformity

The reconstruction of the saddle nose deformity presents an arduous task for the reconstructive surgeon. A large variety of graft materials have been used for augmentation rhinoplasty. The modern trend is to prefer autologous material. Iliac bone grafts are extremely suitable for augmenting moderate to severe saddle nose deformity. In our study, autogenous iliac bone grafts were used in the nasal reconstruction of 14 patients. The follow up has been from l–4 years, with no significant resorption noted during that time. Complication was limited to one hematoma on the donor side.     

Three-step reconstruction of complex saddle nose deformities

OBJECTIVE: To evaluate a reproducible surgical technique for augmentation rhinoplasty of complex saddle nose deformities, which are characterized by substantial loss of nasal structural support and result in multiple nasal abnormalities. DESIGN: Case series and surgical outcome study. SETTING: Tertiary referral center. PATIENTS: A total of 43 patients (32 female and 11 male; mean +/- SD age, 36 +/- 12 years) with complex saddle nose deformities and extensive loss of nasal volume, shape, and support who underwent reconstructive surgery between 1997 and 1999. INTERVENTION: A standardized 3-step surgical procedure using autogenous costal cartilage. MAIN OUTCOME MEASURES: Assessment of additional nasal abnormalities, graft recipient site conditions, postoperative complications, postoperative analgesic consumption, and subjective outcome assessed with a standardized telephone interview 2 years following surgery. RESULTS: Besides nasal abnormalities characteristic of complex saddle nose deformities, several additional nasal abnormalities were frequently encountered. Forty of the 43 patients had undergone previous septorhinoplasty, 26 of whom through multiple procedures. One transplant extrusion was recorded, which required revision surgery. In 8 patients, minor surgical corrections were performed. Nasal airflow was judged satisfactory or good by 30 of the 37 patients who were contacted by telephone and aesthetic appearance was considered good by 17, satisfactory by 10, and unsatisfactory by 10. CONCLUSIONS: Three-step nasal reconstruction with costal cartilage is indicated in severe saddle nose deformities. It is a comparatively reliable surgical procedure yielding satisfying results even in patients with severe deformities and unfavorable recipient site conditions.     

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.