Management and Aesthetic Results of Support Grafts in Saddle Nose Surgery

To define the surgical management and long-term aesthetic results of patients undergoing rhinoplasty with support graft for saddle nose, 147 patients have been included in this retrospective study. One hundred forty-four autogenous grafts (bone or cartilage) and three processed irradiated bovine cartilage grafts have been used during the period 1980–1997. Two approaches have been employed: open rhinoplasty and endonasal approach. Most of cases have been treated with bony grafts (116 bone graft versus 26 cartilage grafts). Global follow-up after surgery for long-term aesthetic study was 8.5 years. Among the different autogenous that have been used in our series, the calvarial bone had the most interesting results in terms of resorption. In patients with important saddle nose deformity, we recommend calvarial bone as a material of choice for dorsonasal reconstruction. It provides excellent and natural long-term feel to the nasal complex.     

Short columella nasolabial complex in aesthetic rhinoplasty

Many papers describe different approaches for short columella in cleft lip or Negroid noses. Very little has been found in international literature related to these aesthetic rhinoplasties. The scarce skin of the columella, the firm union between the nasal tip and the lip, due to the hypertrophy of the depressor septi nasi muscle, and the low projection of the nasal tip, consequence of the open position of the caudal part of the medial crura, are the cause of this problem. Therefore, the skin, muscle, and cartilage were treated simultaneously. Herein is described a VY composite advanced flap for projecting the tip, suturing both divergent medial crura together and adding the skin and muscle tissues of the lip to the columella. With this flap the tip was projected, the columella was narrowed, the nasolabial angle improved, and the upper lip elongated. Good results could be achieved without using any other cartilage graft or silastic strut. Standard rhinoplasty and septumplasty could be combined with this technique. Inconspicuous scars were observed.     

Use of umbrella graft for nasal tip projection

An adequate nasal tip projection is of the utmost importance for good nasal aesthetics. Conventional rhinoplasty procedures are not adequate for achieving nasal tip projection in tips with inadequate projection (TIP). This article describes our technique of using an umbrella-shaped cartilage graft to the tip. The graft is carved from caudal septal and alar cartilages. The results and advantages of the technique are discussed.     

Saddle Nose: Our Approach to the Problem

Saddle nose is usually caused by a trauma or by excessive resection of the septal cartilage. Nevertheless, there are other, less frequent causes of injury, such as congenital, syphilis, leishmaniosis, and leprosy. Within this context, it is very likely to see widening of the bony bridge and dropping of the tip of the nose. For this clinical status, we found extremely satisfactory a therapy in which we use a dorsum cartilage graft, followed by narrowing of the nasal bridge and shortening of the nose. To achieve this aim, different kinds of materials were employed. The authors usually prefer rehydrated (0.9% saline solution) human costal cartilage. This material was used in a study of a series of patients with saddle nose in which we used open rhinoplasty and cartilage homografts.     

Motivation for Rhinoplasty: Changes in 5970 Cases, in Three Groups,1964 to 1997

The motivational factors were divided into three categories: (1) independent decision, (2) observation of previous patients, and (3) external influences. The results of the percentage breakdown of the patients in our present study are compared with previous results are presented in 1983 in this journal. Once again, the independent decision of the patient was the most important factor in deciding to have cosmetic rhinoplasty, followed by their observation of results in other patients. These two factors have been the motivation in approximately 80% of all the patients in all three studies. The age breakdown of cosmetic rhinoplasty patients shows that after the age of 21, as patients get older, a smaller and smaller percentage of patients was motivated for surgery by independent decision alone. These older patients need external influences to motivate them to have surgery. In most cases, the desire for surgery had smoldered in them since adolescence, and they needed an external ``OK' to have it done.     

Tip Points: Defining the Tip

At the center of the tip, the tip points (TPs) are the single most defining feature of a nose. In a random survey (N= 146; females, 76; males, 70), TPs were 8.9 ± 1.6 mm apart. TP quality was graded into four categories based on the criteria of presence, interdomal crease, base width, and distinction. The distributions of TPs according to TPG were as follows: I, 12%; II, 50%; III, 30%; and IV, 8%. The TPG system was applied to a collection of photographs of female Caucasian magazine models, which had a distribution similar to that of the Caucasian females in the study population, demonstrating the effectiveness of grading. Surgical guidelines for the preservation and generation of TPs are presented, especially the geometric consequence of various surgical maneuvers, e.g., dome division and tip graft.     

Increasing the Length of the Middle Crura for Better Tip Projection in Primary Rhinoplasty

Cartilage grafts have been a very popular method for achieving tip projection in difficult noses. Sometimes asymmetries and graft visibility are undesirable complications. Remodeling the alar cartilages, using a cartilage flap from the lateral crura, rotated over the original domes, is another alternative for achieving tip refinement and projection. The surgical technique is described and clinical results are presented.     

Mammareconstruction with skin-expander and silicone prostheses: 15 years' experience

We report on 170 breasts that were reconstructed with Skin-Expander and silicone implants over a period of 15 years [1,2]. Reconstruction occurred primarily in only about one-third of the cases, since the information provided by the first doctor in charge regarding the possibilities of breast reconstruction was rather scanty. In cases treated with radiotherapy, reconstruction with Skin-Expander should not be excluded, but it is necessary to proceed with extreme caution and to give patients exact information. The complication rate is higher here than in cases which have not been exposed to radiotherapy. The final result depends directly on the primary surgery and the skin as well as the contralateral breast quality [3]. In most cases reconstruction with Skin-Expander and silicone implants meets the patients' desires: low-risk operation, fewer additional scars, and similar and improved breasts on both sides.     

鼻尖上旋畸形的整形治疗

目的 探讨鼻整形术中鼻尖上旋畸形的安全有效矫正方法.方法 11例原发性鼻尖上旋畸形及5例继发性鼻尖上旋畸形均采用自体耳软骨移植或与多孔高密度聚乙烯(Medpor)置入相结合的方法,重建鼻下部的支撑结构,使鼻尖获得足够的向前下方的支撑力,增加鼻尖高度及纠正鼻尖上旋,同时行"盾牌状"、"帽状"移植,以进一步上旋及突出鼻尖的形态,对于鼻尖过低者结合应用穹窿部垂直切断术.结果 16例受术者术后形态满意,鼻尖上旋纠正,鼻唇角基本正常,随访6个月至1年,鼻尖部形态稳定,无并发症发生.结论 鼻尖上旋畸形的纠正需要强有力的向前与向下方的支撑力,需要重建鼻下部的支撑结构,才能得到安全与有效的矫正,适量的软骨移植可进一步提高矫治效果.     

Treatment of depressed scars with a dissecting cannula and an autologous fat graft

Contemporary options for the improvement of depressed scars include scar revision with an elliptical excision, z-plasty, w-plasty, and geometric broken-line closure. Dermabrasion and laser treatment has been used to obtain a uniform skin surface. When scars are hypertrophic, intralesional steroids and silicone pressure therapy may be useful. Occasionally, scars may be adherent to the underlying fascia. The resulting depression along the length of the scar worsens the aesthetic deformity. Fat injection is an established method for treating depressions and contour deformities. We report encouraging results with the use of this fat injection technique into a pocket made with a sharp cannula in treating 30 patients with postsurgical scars that were depressed and adherent to the underlying fascia. This technique is a useful addition to the surgeon's resources when treating scars.     

Nose Surgery (Rhinoplasty) Without External Immobilization and Without Internal Packing: A Review of 812 Cases

In a review of 812 cases of rhinoplasty, none of our patients had early bone or septal displacement; swelling, bruising, and pain were almost nonexistent. This confirms that an external split would not have been of any benefit in these cases. Packing should help prevent epistaxis, synechiae, and early bone and septal displacement. Not using any packing, we have not encountered these complications. Besides, we have not seen a single submucosal hematoma or a septal necrosis. Therefore, we doubt the value of packing in our patients. The inconveniences and complications of external splits and internal packing are described. Early postoperative photographs show the reduced swelling and bruising, and late photographs show the final results. Difficult primary and secondary rhinoplasty cases are demonstrated.     

The History of Aesthetic Rhinoplasty: Special Emphasis on the Saddle Nose

The author, after a brief review of the main ideal size, proportion, and units of measurement of the nose, describes the historical techniques employed for cosmetic rhinoplasty. Particular attention is given to Sanvenero-Rosselli's cases. A paragraph is reserved for the history regarding the correction of saddle-nose and the main materials employed for the correction (autografts, allografts, xenografts, and implants). For each procedure, they were mentioned the first time they were employed.     

New Surgical Concepts: Nasal Tip Function

Since the birth of plastic surgery, rhinoplasty has been an outstanding chapter. Facial balance has been endeavoured with two parameters: size and shape. Now, however, the criterion for harmony has involved two more parameters: position and function. Position is related to other facial elements, such as, upper maxilla, upper lip, forehead, and frontonasal sulcus. Function is important because nasal superficial musculoaponeurotic system (SMAS) muscles are important for Nasal tip movement. To understand this better, we must analyze the nasal SMAS, which consists of primary or intrinsic and secondary or extrinsic muscles. When the extrinsics contract, they allow function of the intrinsics. They are the ala nasalis dilator, the ala nasalis elevator, the tranversus, and the tip depressor. Obvious hypertrophies of the dilator and the elevator has been observed in young athletes. Our method combines conventional, new, and modern aspects. It is conventional because the alar cartilages have been completely freed by intercartilaginous and marginal approaches, and the upper or lower border trimmed according to the case. It is more important to measure how much cartilage is left, than how much is removed. The new aspect is consideration of nasal SMAS to treat short noses that display a tendency to descend with laughter, and the modern aspect is the evaluation of dynamic surgical results, apart from the static.     

Improving Nasal Tip Projection and Definition Using Interdomal Sutures and Open Approach Without Transcolumellar Incision

The object of this study was to maximally take advantage of the combination of two surgical techniques to manage the nasal tip. For this, an approach similar to the open tip approach without a transcolumellar incision was performed and the management of the alar cartilages with multiple combined sutures was carried out. This study represents more than two years of work where 57 primary and secondary rhinoplasty patients were operated on. In all of them, the nasal tip was managed by means of utilizing different types of sutures in the alar cartilages, according to the characteristics and needs of each patient. At the same time, an extensive lipectomy was performed on the nasal tip, if indicated. All of the nasal tip surgeries were performed with an open approach without transcolumellar incision. This approach has been previously described, is highly simple, and it eliminates the principal disadvantage of a transcolumellar scar that arises from the open approach technique. Although the scar is hardly noticeable in Caucasian patients, in non-Caucasians it could constitute an important undesirable effect. This approach permits us to manage the cartilages using sutures in many diverse types and variations in a more complete form, similar to which one could achieve using the classical open approach technique. The results are highly satisfactory and result in a definition and rotation of the nasal tip which would be difficult using the closed technique. Therefore, this study represents another alternative surgical technique in the surgical management of the nasal tip.     

以鼻中隔软骨为鼻小柱支撑移植物在鼻尖整形中的应用

目的:探讨以鼻中隔软骨为鼻小柱支撑移植物在东方人鼻尖整形中的应用。方法:在50例鼻尖整形患者中,均以鼻中隔软骨为鼻小柱支撑移植物,使用固定悬浮型移植27例,延伸型移植13例,鼻中隔延伸型移植10例。结果:除1例因术后鼻尖突出度不足,经二次手术纠正外,余49例鼻尖成形良好,患者对手术效果满意。结论:根据不同情况,以鼻中隔软骨的不同植入形式进行鼻小柱支撑移植是鼻尖整形中一项良好的手术技术。     

Biomechanics and Classification of the Cartilaginous Structures to Project the Nasal Tip

The present paper is the long-term conclusion of our preliminary presentation at the 1992 ISAPS Congress (Guadalajara, Mexico). This is the result of 29 cadaver dissections of different ages and both sexes. We have observed that length, thickness, and resistance correlate with the possibility to project the nasal tip with the mere structure of the alar cartilage and its medial crurae. We also demonstrated the existence and antagonistic action of Pitanguy's ligament as well as the depressing ligament to project the nasal tip. In this study, besides focusing on classifying the medial crus according to its thickness, length, and resistance, which is already different from any previous classification, we also focused on its surgical utility, and its interaction with other anatomic elements, to achieve the desired projection. Clinically, we present a 12-year experience with 1653 cases operated under this premise.     

Effect of Aesthetic Rhinoplasty on Respiratory Functions

Joseph's rhinoplasty operation, with minor modifications, was performed on 20 patients for aesthetic reasons. Various tests of the patient breathing though the nose were carried out both in the preoperative period and 10, 30, and 90 days after surgery. Respiratory-function test results improved in the majority of patients after rhinoplasty. FVC increased in 65% of the cases at day 10, in 85% at day 30, and in 75% at day 90. FEV1 increased in 65% of the cases at day 10, in 65% at day 30, and in 70% at day 90. FEV1/FVC increased in 60% of the cases at day 10, in 65% at day 30, and in 70% at day 90. The only statistically significant increase when compared with preoperative values was the increase in the values of FEV1/FVC at the 30th postoperative day. Decreases in respiratory function test values were insignificant in most of the patients. FEV1/FVC × 100 decreases of more than 10% were seen in three patients, indicating increased nasal resistance, at the 90th postoperative day. However, the lowest value was 50.4 and none of the patients reported subjective nasal obstruction. In conclusion it was observed in this study that properly executed cosmetic rhinoplasty did not have any significant negative effects on respiratory functions in most patients, and improved respiratory functions in most.     

Correction of the Bony Rings During the Aesthetic Rhinoplasty: Apologia of the Transpalpebral Osteotomy

It is observed that in many cases of rhinoplasty, the final aesthetic result on the face of patients was not satisfactory. The reason is the persistence of ``rings' making a shadow beside the root of the nose. These ``rings' seem to be palpebral but are actually made by the frontal process of the maxilla. Osteotomy in rhinoplasties classically involve the nasal bones. However, the osteotomy in our cases is made on the frontal process of the maxilla. This surgical refinement is detailed with regard to a minute palpebral incision, precisely placing the lateral osteotomy on each frontal process of the maxilla, in-fracture and rasping equally. While the osteotomy procedure is well documented in rhinoplasties, the improvement of the patients' final appearance at the root of the nose after rhinoplasty is less clearly established. This report will detail an innovation based on the author's 15-year surgical experience with primary and secondary rhinoplasty. The improved result is remarkable on the final appearance of the nose. Close-up photography demonstrates the anatomy as well as the technique.