Alar and columellar refinement in rhinoplasty

This paper emphasizes the value of surgical techniques of nasal sculpturing with special attention to the structural details in primary and secondary rhinoplasty to achieve a perfect aesthetic as well as functional result. The marginal resection of the alae and the columella allows the appropriate reduction adapting the nostril contour to the new proportions of the nose at the end of a rhinoplasty or to equalize the height of the alar rim in cases of harelip nose. In order to perfect the nasal contour, we also introduce cartilaginous onlays into the anterior part of the columella emphasizing the lobulo-columellar double-angle in a harmonious profile. In case of moderate fibrocicatricial retraction of the alar border, a vestibular advancement flap is dissected through the inter-cartilaginous incision and a thin cartilage graft fills the loss of tissue as a spacer. It is then held in place using transalar mattress sutures. Important losses of alar tissue necessitating composite graft are not especially considered in the paper which essentially concerns refinement procedures. The finesse of the latter seems to be indispensable to adapt the alar-tip-columellar complex to the bony structures of the nose and to ensure the harmonious equilibrium of the rhinoplasty.     

长盾形和多层盖板耳廓软骨移植物在鼻尖整形中的应用

目的:探讨长盾形和多层盖板耳廓软骨移植物在鼻尖塑造中的应用。方法:在分离、修整、缝合下外侧软骨穹窿部的基础上,于耳后颅耳沟切口切取耳廓软骨,修剪成长盾形及2~3块盖板移植物,用于鼻尖的塑形。结果:共11例患者,随访时间6~24月,效果满意,无严重并发症发生。结论:长盾形和多层盖板耳廓软骨移植物可以良好的修饰鼻尖,取材方便,操作简单,效果肯定。     

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.     

Mini-forum: rhinoplasty by external approach. External or endonasal approach for rhinoplasty?]

There appears to be a renewed interests in the external approach to rhinoplasty, first described 60 years ago, despite the external columellar incision, due to the excellent exposure of the cartilaginous structures provided by this approach. Progress has been made in rhinoplasty. Cartilage grafts are much more widely used than in the past and surgeons try to reconstruct a normal anatomy of the skeleton, which has become easier with this approach. However, the closed approach has demonstrated its efficacy for a long time and allows correction of a large range of deformities. The open rhinoplasty should not be the standard procedure and its indications should only be based on limitations of the closed approach. The external procedure is particularly indicated in some difficult cases of nasal tip surgery and secondary rhinoplasty.     

The management of alar columellar disproportion in revision rhinoplasty

An otherwise attractive nose can be diminished aesthetically if the relationship of the nostril border and ala to the columella is not refined and proportional. Compared with other aspects of rhinoplasty, there has been little attention devoted to the proper diagnosis and treatment of alar columellar disproportion. This article highlights the relevant anatomic components, defines the proper alar columellar relationship, systematically analyzes the different types of alar columellar dis proportion, and stresses the importance of identifying the causative factors in formulating the optimal treatment plan, with particular emphasis on applications to revision rhinoplasty.     

Revision rhinoplasty using the endonasal approach

Revision rhinoplasty often requires the performance of a limited number of corrective tasks on a patient's nose that otherwise has many favorable characteristics. The endonasal approach can be applied in situations where there is a desire to maintain favorable attributes of the nose while revising the unfavorable aspects. Through endonasal incisions, the surgeon can correct limited dorsal abnormalities, middle vault abnormalities, and asymmetries of the lower third of the nose. This article reviews several of the common unfavorable sequelae of rhinoplasty and suggests endonasal approaches to their correction.     

Endoscopic endonasal approaches to the cavernous sinus: surgical approaches

OBJECTIVE: After completion of an earlier endoscopic transsphenoidal anatomic study, we studied various endoscopic transsphenoidal approaches using cadaveric specimens to develop endoscopic endonasal surgical approaches to the cavernous sinus. METHODS: Ten cavernous sinuses in five artery-injected adult cadaveric heads were studied with 0-, 30-, and 70-degree angled 4-mm rod-lens endoscopes. The extent of the surgical exposure, the skewed endoscopic anatomic view, and the maneuverability of surgical instruments through their relative operating spaces were studied after various endoscopic endonasal approaches via one nostril. RESULTS: The paraseptal approach was used between the nasal septum and the middle turbinate and provided exposure at the anteromedial portion of the cavernous sinus. The contralateral paraseptal approach rendered a slightly more medial view at the cavernous sinus than did the ipsilateral approach. This approach offered limited surgical access to the lateral vertical compartment. The middle turbinectomy approach allowed surgical access to the lateral wall of the cavernous sinus, except for the superior orbital fissure and the orbital apex. The middle meatal approach, which was made between the middle turbinate and the lateral nasal wall, revealed the entire lateral vertical compartment of the cavernous sinus, including the orbital apex and the superior orbital fissure. However, its lateral tangential surgical trajectory and the absence of dedicated surgical tools limited the surgeon's surgical maneuverability. A combination of the middle turbinectomy and middle meatal approaches increased the operating space. CONCLUSION: Various endoscopic endonasal surgical approaches to the cavernous sinus were studied using adult cadaveric head specimens.     

The evolution of open structure rhinoplasty

Modifications and innovations in open structure rhinoplasty that have occurred as this technique has evolved are discussed. In addition, the philosophy and fundamentals of open structure rhinoplasty are reexamined. A retrospective review of representative patients in a private practice setting was performed. All surgical procedures were conducted in a freestanding private surgery center. The preoperative and long-term results of each patient are compared to demonstrate the effectiveness of the described techniques. The fundamental philosophy of open structure rhinoplasty is the maintenance of the integrity and strength of the nasal skeleton. Modifications of tip grafting techniques, along with additional domal grafting techniques, and a stronger focus on domal suturing techniques result in a softer contour and lack of tip tensions while maintaining structural support.     

The evolution of the endonasal approach for craniopharyngiomas

Craniopharyngiomas have always been an extremely challenging type of tumor to treat. The transsphenoidal route has been used for resection of these lesions since its introduction. The authors present a historical review of the literature from the introduction of the endonasal route for resection of craniopharyngiomas until the present. Abandoned early due to technological limitations, this approach has been expanded both in its application and in its anatomical boundaries with subsequent progressive improvements in outcomes. This expansion has coincided with advances in visualization devices, imaging guidance techniques, and anatomical understanding. The progression from the use of headlights, to microscopy, to endoscopy and fluoroscopy, and finally to modern intraoperative magnetic resonance-guided techniques, combined with collaboration between otolaryngologists and neurosurgeons, has provided the framework for the development of current techniques for the resection of sellar and suprasellar craniopharyngiomas.     

Miniforum: rhinoplasty by external approach. Technical aspects of rhinoplasty by external approach]

The authors present the principle techniques of external transcolumellar rhinoplasty and stress the excellent exposure it provides, allowing effective treatment under direct vision of the anatomical structures of the nose tip, nasal spine and septum. Based on a series of 186 operated cases with a follow-up of between one and more than six years, the advantages and indications of this technique are briefly defined. The best indications are difficult nose tips, whether rhinoplasty is primary or, more particularly, when it is secondary.     

The use of external ultrasound combined with superficial subdermal liposuction

Superficial subdermal liposuction (SSL) was presented by the authors as an evolution in traditional liposuction in 1989. It allows one to treat the superficial fat to obtain better skin retraction during every liposuction procedure. The use of ultrasound (US) in liposuction began 10 years ago as the direct application of this energy to the adipose tissue using a probe to obtain the selective destruction of fat, followed by its aspiration. This technique gave rise to many complications and thus many concerns. The external delivery of US has been proposed to overcome some of the drawbacks associated with this procedure. The authors investigate the role of external ultrasound (EU) used in conjunction with SSL. When comparing EU and SSL with SSL alone, pretreatment with EU results in less bleeding during liposuction, aspirated fat that is clearer and more oily, and less bruising and swelling during the early postoperative period. EU is an ideal complementary procedure to SSL because the crumbling of the fat induced by US permits a more uniform aspiration of the subdermal fat layer, making skin retraction more even and effective.     

Expanded endonasal approaches to middle cranial fossa and posterior fossa tumors

Skull base lesions that involve the middle and posterior cerebral fossae have been historically managed through extensive transcranial approaches. The development of endoscopic endonasal techniques during the past decade has made possible a vast array of alternative routes to the ventral skull base, providing the ability to expose lesions in difficult-to-access regions of the cranial base in a less invasive manner. In this review, the authors detail the endoscopic surgical anatomy and the operative nuances of the expanded endoscopic endonasal approaches to tumors of the middle and posterior cranial fossae. These techniques offer excellent exposure of the targeted regions yielding optimal resections, while avoiding the morbidity associated with transcranial surgical approaches.     

The McCoy laryngoscope, external laryngeal pressure, and their combined use

The efficacy of the McCoy laryngoscope, external laryngeal pressure, and their combination to improve the laryngoscopic view was evaluated in 219 patients and compared with the Macintosh laryngoscope. An experienced laryngoscopist performed laryngoscopy twice using the Macintosh laryngoscope and the McCoy laryngoscope in a random sequence, and external laryngeal pressure was applied in each laryngoscopy with the laryngoscopist's right hand. The laryngoscopic view obtained was graded on our modified Cormack's method. Without external laryngeal pressure, the McCoy laryngoscope provided a better laryngoscopic view than that obtained by the Macintosh laryngoscope (P < 0.001, signed rank test), but the view was worse than that with the Macintosh laryngoscope under external laryngeal pressure (P < 0.001). The McCoy laryngoscope combined with external laryngeal pressure provided a better view than the Macintosh laryngoscope with external laryngeal pressure (P < 0.001).     

The use of spreader grafts in primary rhinoplasty

Some candidates for primary rhinoplasty are at greater risk of postoperative complications due to the presence of certain very specific anatomic characteristics. The authors describe their experience with spreader grafts in primary rhinoplasty and provide an analytic method of identifying the types of patient needing such grafts who present a high risk of complications. Sixty patients were treated with spreader grafts during primary rhinoplasty. Bilateral spreader grafts were used in cases of "narrow nose syndrome" (short nasal bones, long and weak upper lateral cartilages, thin skin) and in cases of disproportionate nose with narrow middle vault and bulbous tip. Unilateral spreader grafts were placed on the concave side in cases of crooked nose. After an average follow-up of 17 months, all the patients reported improvement in functional and esthetic problems, with no complications related to the preoperative features.     

Spreader graft placement in endonasal rhinoplasty: Technique and a review of 100 cases

BACKGROUND:

Spreader grafts are widely considered to be the mainstay of treatment for insufficient internal nasal valve and are commonly placed preventively during rhinoplasty, after hump removal, to avoid middle vault collapse. Although the placement and suturing of spreader grafts in open rhinoplasty is fairly easy, their positioning and stabilization in endonasal rhinoplasty is associated with a learning curve.

METHODS:

A review of the technique with tips for the novice surgeon is presented, particularly as pertains to correct placement. The technique can be used to insert spreader grafts irrespective of whether the nasal dorsum is addressed. Suturing is usually unnecessary. A retrospective review of 100 patients in whom spreader grafts were placed was undertaken to evaluate complications such as poor placement, displacement or other complications.

RESULTS:

Although there is a learning curve to ensure the dorsal mucosal attachment is maintained while developing the pocket sufficiently dorsally for proper graft placement, the technique is easy to learn, effective, quick and technically simple to perform. Of 100 patients, three had a cartilaginous dorsal spur as the cephalic edge of the graft became visible. One patient developed an ecchymosis along the dorsum that caused a hump that resolved in two months. There were no other aesthetic or functional complications.

CONCLUSION:

The endonasal placement technique provides for simple, safe and easy placement, as well as stabilization of spreader grafts during endonasal rhinoplasty, with few complications.