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.     

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.     

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.     

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。     

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.     

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.     

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.     

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.     

Spreader graft in septo-rhinoplasty

Background The aim of study was to evaluate the effects of spreader graft in septorhinoplasty. Materials and Methods The study group comprised of 33 patients of various nasal deformities who underwent consecutive septorhinoplasty at Asan Medical Center, University of Ulsan, College of Medicine, Republic of Korea (South Korea). All the patients had undergone open rhinoplasty procedure. The submucous resection of septum was done, leaving 1 to 1.5 cm. of septal cartilage for dorsal and caudal support. The spreader graft was harvested from septal cartilage in 31 cases and costal cartilage in 2 cases. All the patients had undergone endonasal high to low to high osteotomy, paramedian osteotomy and percutaneous transverse osteotomy.The periosteum was not elevated in any case. The spreader graft was placed and secured with septal cartilage and upper lateral cartilage with suture material. Crushed small pieces of septal cartilage were used for dorsal augmentation. The tutuplast fascia lata was used to camouflage the dorsal irregularity. Conclusion All the cases had good aesthetically dorsal line, opening of internal nasal valve area and good septal support, which was weakened by the removal of deviated septum.     

Treatment of external nasal valve (alar rim) collapse with an alar strut

Alar (external valve) collapse may be iatrogenic or can occur as a consequence of ageing or trauma. We have utilized an autogenous cartilage graft inserted as an underlay graft to the alar rim to treat 17 patients who have presented with nasal obstruction due to alar collapse. We report the short- and medium-term functional results and the cosmetic sequelae of our approach and conclude that this procedure offers an improvement in nasal airway performance in patients with external valve collapse without producing serious adverse cosmetic sequelae.     

Restorative rhinoplasty in the aging patient

OBJECTIVE: The objective of this study is to review our favorable experience in performing rhinoplasty in aging patients. METHODS: All patients aged 65 years or greater who underwent rhinoplasty, either esthetic or functional, by the senior author (Y.D.) from August 1997 to July 2005 with a minimum follow up of 1 year were retrospectively reviewed. RESULTS: A total of 51 patients met the inclusion criteria and had complete records available for review. The average age was 69.5 years (range, 65-82 years) with 24 female and 27 male patients. All but two patients underwent open rhinoplasty. Eighteen procedures represented secondary rhinoplasties. Seven patients required auricular cartilage grafts, and 11 patients required costal cartilage grafts. One costal cartilage graft was aborted as a result of excessive calcification. All patients underwent columellar strut placement, 92% underwent internal valve grafts, and 80.4% underwent grafting of the external nasal valves. Nasal osteotomies were performed in only 23.5% of patients, all with the percutaneous technique. Revision surgery was necessary in only three (5.8%) patients, all of whom required grafting of the external valve (not performed primarily). In each of these cases, no significant external valve collapse was noted preoperatively. Premaxillary augmentation with diced or crushed cartilage grafts was performed in 81.8% (n = 18) of patients with an edentulous maxillary arch. CONCLUSIONS: Aging patients present unique technical challenges in rhinoplasty that warrant a comprehensive approach to restore internal and external valve competency and tip support. Consideration of prophylactic external valve grafts in addition to the routine use of internal valve grafts and columellar struts may help decrease the need for revision surgery in this patient population. Reasonable functional and esthetic outcomes can be expected in the aging patient.     

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.     

Sub-alar batten grafts as treatment for nasal valve incompetence; description of technique and functional evaluation

OBJECTIVE: To describe and evaluate the functional results of a surgical technique for treating nasal valve incompetence, in which a cartilage graft called a sub-alar batten graft is placed along the undersurface of the lateral crus of the lower lateral cartilage. METHODS: The functional outcomes of 27 patients who had sub-alar batten grafts placed on 39 sides were evaluated by means of clinical examination and subjective self-assessment. RESULTS: Of a total of 39 sides operated upon, 10 (26%) were rated as optimal, 15 (39%) as improved, 13 (33%) as equal and 1 (2%) as worse. Overall on 25 sides (65%) the post-operative situation was considered to be better than pre-operatively. In all cases in which there was a wish for cosmetic improvement, besides the functional indication, this was obtained, and in no case did the grafts give cause to cosmetic grievances or other complications. CONCLUSION: Placement of sub-alar battens had a positive effect on nasal valve function in roughly two thirds of cases in this series. Although in our opinion this result was slightly disappointing from a purely functional point of view, they can improve the cosmetic result and continue to be considered in cases in which avoidance of surface irregularities is a primary concern or as a preventative measure in rhinoplasty patients at risk for post-operative valve collapse.     

A novel intranasal stent for functional rhinoplasty and nostril stenosis

Objectives/Hypothesis: The surgical correction of nostril stenosis and external nasal valve collapse typically involves the addition of tissue to widen and strengthen these areas. However, over the ensuing months, postoperative scar contracture may act to reverse the surgical modifications. This study aimed to determine the safety and efficacy of the use of nasal stents fashioned from a nasopharyngeal airway tube to prevent postoperative contracture at these sites. Study Design: Retrospective review of six patients who underwent functional rhinoplasty with alar batten graft placement for nasal valve collapse and one patient who underwent composite graft repair of unilateral nostril stenosis. Methods: Patients completed a survey inquiring about the ease of use, discomfort, presence of infection, and ability to breathe with these nasal stents. Patients also completed the NOSE (nasal obstruction symptom evaluation) instrument to compare their overall level of preoperative and postoperative nasal breathing. The functional rhinoplasty patients were examined for degree of dynamic airway nasal wall collapse and position of the lateral nasal wall on intranasal examination. Results: Six of seven patients overall reported no to minimal discomfort, easy application, and no to minimal obstruction of nasal breathing with the use of the stents. One patient reported difficulty with application. Preoperative NOSE scores averaged 67.1 (SD 10.4), 18.6 (SD 14.6) at the time of splint removal, and 21.4 (SD 15.2) at 3 months after stent removal. Paired t test analysis showed significant differences between the NOSE scores preoperatively as compared with the time of splint removal (P = .0002) or 3 months after splint removal (P = .0003). All patients demonstrated a significant reduction of lateral nasal wall collapse with inspiration on physical examination. Conclusions: The use of nasal stents made from nasopharyngeal airway tubes is a safe, convenient, and economic treatment for the prevention of contracture after surgical correction of nostril stenosis or nasal valve insufficiency.     

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.     

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。     

自体软骨在外伤性歪鼻合并鼻通气障碍患者鼻整形术中的应用探讨

目的探讨自体软骨在外伤性歪鼻合并鼻通气功障碍患者鼻整形术中的使用方法和效果。方法回顾性分析2017年1月至2019年4月,在陆军军医大学大坪医院耳鼻咽喉头颈外科收治的30例鼻外伤患者的病例资料,其中男21例,女9例,年龄21~50岁,平均34.9岁,病程6 d至14年。全部患者均伴有不同程度的歪鼻畸形及鼻通气障碍,分为轻、中、重三类,其中轻度8例,中度11例,重度11例,均同期行开放性鼻整形术及鼻中隔偏曲矫正术。对于轻、中度歪鼻畸形及鼻通气障碍,采用耳软骨修饰鼻尖及加强鼻中隔软骨支撑、修饰鼻背凹陷畸形。对于重度歪鼻畸形及鼻通气障碍,将肋软骨雕刻成"Y"字型整体支架或者片状肋软骨构成2+1或4+1支架,将肋软骨支架与鼻中隔软骨尾端贯穿缝合固定,重塑加固鼻中隔支撑架及鼻小柱,避免鼻背塌陷。术前、术后测量鼻外观偏离值,并分别进行鼻外观视觉评分量表(VAS)、鼻腔通气VAS评分。采用Stata 15统计软件对术前与术后的测量数据行配对资料的t检验,VAS评分行卡方检验。结果30例患者中,3例术后出现鼻中隔血肿,经清理后正常恢复。术后随访2个月至2年,所有患者均无鼻中隔穿孔、鼻梁塌陷等并发症发生。术后治愈率为60.0%(18/30),所有患者术后歪鼻程度下降Ⅰ级,有效率为100%(30/30)。患者术后测量鼻外观偏离值低于术前,差异有统计学意义[(2.40±1.58)mm比(6.85±2.43)mm,t=8.42,P<0.001]。术后鼻外观VAS评分高于术前,差异有统计学意义[(6.60±1.16)分比(1.93±1.31)分,t=-14.59,P<0.001]。患者术后鼻腔通气VAS评分高于术前,差异有统计学意义[(6.53±1.04)分比(1.97±1.07)分,t=-16.78,P<0.001]。结论自体软骨在外伤性歪鼻合并鼻通气功障碍患者鼻整形术中使用疗效好,同期行开放性鼻整形术及鼻中隔偏曲矫正手术,可缩短治疗时间,及时改善患者鼻外观及鼻通气功能。     

Alar batten grafting for management of the collapsed nasal valve

OBJECTIVE: The purpose of the study is to describe a commonly overlooked etiology of nasal airway obstruction. Collapse of the nasal valve can be corrected with precise placement of cartilage grafts. This study demonstrates the surgical technique, rarely described in the literature, of placing a contoured cartilage graft in the nasal valve region for the improvement of the nasal airway. STUDY DESIGN: Retrospective review of surgical results of the 21 patients who underwent alar batten grafting performed over a 3-year period at the Geisinger Medical Center (Danville, PA). METHODS: A retrospective review was conducted of 21 patients surgically treated with alar batten grafts for nasal valvular collapse between the 1997 and 1999. The surgical technique is described, and our results are analyzed including for both functional and aesthetic outcome. RESULTS: All patients treated with alar batten grafting at the nasal valve improved with regard to their airway obstruction. There were no complications, and there was only minor aesthetic fullness in six cases. CONCLUSIONS: Alar batten cartilage grafting is an easy, highly effective therapeutic measure in the treatment of nasal valve collapse. The surgical technique is demonstrated.     

Nasal valve physiology. Implications in nasal surgery

Knowledge of the structure and function of the nasal valve region is required by all who operate on the nose. This article defines and classifies nasal valve region abnormalities; discusses principles, goals, and details of surgery in this area; and considers strategies to avoid or minimize complications, especially in cosmetic rhinoplasty.