Simultaneous Open Rhinoplasty and Alar Base Excision for Secondary Cases

Background: Simultaneous open rhinoplasty and alar base excision are a very safe procedure for protecting the vascular supply of the nasal dip and the columellar skin in primary cases when surgical dissection is performed below the musculoaponeurotic layer of the nose. Major arteries of the external nose lie above the musculoaponeurotic layer. However, secondary cases may pose increased risks to the blood supply of the nasal tip and columella skin because of the decreased vascular supply and increased scar tissue from the previous rhinoplasty. We studied our secondary cases of simultaneous open rhinoplasty and alar base excision, to assess the real risk for necrosis of the nasal tip and columellar skin.Methods: A total of 12 secondary patients (6 men and 6 women) underwent simultaneous open rhinoplasty and alar base excision in the past 3 years. Their average age was 27 years (range, 21–35 years). The average follow-up period was 15 months (range, 1–35 moths). A modified grading system, originally described by Bafaqeeh and Al-Qattan, was used for assessment of the blood supply in the nasal tip and the columellar skin.Results: Satisfactory results were obtained for our patients, with the exception of one case. Grade 3 vascular compromise to the nasal tip and the columella was observed in one case, but the patient healed well with wound care treatment.Conclusion: Simultaneous alar base excision and open rhinoplasty can be performed safely in secondary cases. However some surgical maneuvers such as subcutaneous pocket preparation for the tip graft in closed rhinoplasty and subdermal defatting in the first rhinoplasty as well as previous scarring on the nasal lobule can disrupt the vascular supply of the nasal tip and columella skin. Under these conditions, alar base excision should be deferred and then performed as an isolated excision procedure.     

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.     

The evolution of the combined use of endonasal and external columellar approaches to rhinoplasty

By individualizing rhinoplasty techniques for each patient and incorporating the lessons taught by the long-term follow-up on my rhinoplasty patients over the past 20 years, I have incorporated a blend of the endonasal and external columellar approaches to accomplish the desired aesthetic goals for my patients.By recognizing an increased need of spreader grafts for the midnasal vault, the placement of alar strut grafts to support the lateral crus, the use of alar spanning grafts and more suture grafts in the lobule, and refinement grafts in the nasal lobule, I have increased the use of the external columellar approach to approximately 50% of my rhinoplasties, which involves a significant number of secondary rhinoplasties and primary cases with specific indications. By paying attention to detail and using camouflage cartilage grafting, revision rates in my practice have fallen from approximately 7% to 4%.     

External Rhinoplasty for the Arabian Nose: A Columellar Scar Analysis

This study aimed to evaluate columellar scar problems after external rhinoplasty in the Arabian population, and to analyze the technical factors that help prevent such problems and maximize the scar cosmesis. The investigation was conducted in university and private practice settings of the author in Alexandria, Egypt. A total of 600 Arab patients who underwent external rhinoplasty were included in the study. All the patients underwent surgery using the external rhinoplasty approach, in which bilateral alar marginal incisions were connected by an inverted V-shaped transcolumellar incision. At completion of the procedure, a two-layer closure of the columellar incision was performed.At a minimum of 1 year postoperatively, the columellar scar was evaluated subjectively by means of a patient questionnaire, and objectively by clinical examination and comparison of the close-up pre- and postoperative basal view photographs. Objectively, anything less than a barely visible, leveled, thin, linear scar was considered unsatisfactory. Subjectively, 95.5% of the patients rated the scar as unnoticeable, 3% as noticeable but acceptable, and 1.5% as unacceptable. Objectively, the scar was unsatisfactory in 7% of the cases. This was because of scar widening with or without depression (5%), hyperpigmentation (1.5%), and columellar rim notching (0.5%). The use of a deep 6/0 polydioxanon (PDS) suture significantly decreased the incidence of scar widening (p < 0.005).The columellar incision can be used safely in the Arab population regardless of their thick, dark, and oily skin. Technical factors that contributed to the favorable outcome of the columellar scar included proper planning of location and design of the incision used, precise execution, meticulous multilayered closure, and good postoperative care.     

Nasal Tip Plasty Using Various Techniques in Rhinoplasty

Rhinoplasty is one of the most common aesthetic surgical procedures in Korea today. However, simple augmentation rhinoplasty results often failed to satisfy the high expectations of patients. As a result, many procedures have been developed to improve the appearance of the nasal tip and nasal projection. However, the characteristics of Korean nasal tips including the bulbous appearance (attributable to the thickness of the skin), flared nostrils, and restriction of the nasal tip attributable to an underdeveloped medical crus of the alar cartilage and a short columella have made such procedures difficult. Currently, most plastic surgeons perform rhinoplasty simultaneously with various nasal tip plasty techniques to improve the surgical results. An important part of an aesthetically pleasing result is to ensure an adequate nasal tip positioned slightly higher than the proper dorsum, with the two tip defining points in close proximity to each other, giving the nose a triangular shape from the caudal view. From June 2002 to November 2003, the authors performed rhinoplasty with simultaneous nasal tip plasty using various techniques according to the tip status of 55 patients (25 deviated noses, 9 broad noses, 15 low noses, and 6 secondary cleft lip and nose deformities). The surgery included realignment of alar cartilage by resection and suture, fibroareolar and subcutaneous tissue resection, tip graft, and columellar strut. The postoperative results over an average period of 10 months were entirely satisfactory. There were no patient complaints, nor complications resulting from the procedures. Good nasal tip projection, natural columellar appearance, and improvement of the nasolabial angle were achieved for most patients. In conclusion, rhinoplasty with simultaneous nasal tip plasty, achieved by a variety of techniques according to patients tip status, is an effective method for improving the appearance of the nose and satisfying the desires of the patients.     

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。     

The remucosalizing alar cartilage flap: a reconstructive option for repairing nasal septal perforations

The objective of this study is to assess the results of repairing septal perforations with a vascularized pedicled alar cartilage island flap. Using the external rhinoplasty approach, a vascularized flap of alar cartilage, harvested as a cephalic trim and pedicled on the ascending columellar branches of the superior labial artery was raised. Bilateral mucoperichondrial septal flaps were elevated and the alar flap was transposed and secured within the defect and bilaterally overlaid with temporalis fascia. Silastic sheets were placed and remained in situ until the grafts were revascularized from the peripheries of the defect as well as centrally from the alar flap. The revascularized temporalis fascia acted as a scaffold for nasal remucosalization. The alar flap also increased the long-term structural robustness of the repair. Between 1999 and 2003, 14 patients with septal perforations ranging from 10 to 31 mm underwent septal reconstruction using this technique. There were nine males and five females. The flap was successfully raised in all cases and long-term closure was maintained in 12 patients (86%). The alar cartilage flap is an effective technique for repairing septal perforations in selected patients. It provides vascularized tissue which nourishes the grafts during remucosalization, and a cartilaginous framework, which affords long-term structural support to the repair. It also obviates the need to transpose nasal mucosa and create a secondary defect. The rhinoplasty approach furthermore permits additional nasal deformities to be corrected at the same time. Presented at the British Association of Plastic Surgeons Summer Scientific Meeting, Sheffield, UK (12 July 2006).     

Management of the cleft lip nasal deformity

Management of the cleft lip nasal deformity offers a unique and ongoing challenge in facial plastic surgery. Although there has been no consensus regarding the optimal timing and technique for surgical repair of this deformity, the authors have found a three-tiered approach to be satisfactory. This approach involves a primary rhinoplasty performed at the time of the initial cleft lip repair to address reconstruction of the nasal floor and sill, columellar lengthening, repositioning of the alar base, and repositioning of the skin and mucosa of the lower lateral cartilage. Following alveolar bone grafting, an intermediate rhinoplasty is often performed at 6 to 10 years of age through an open approach to correct the cartilaginous lower nasal deformity. A delayed rhinoplasty is then performed in the later teenage years to correct the bony dorsal deformity and the various causes of nasal obstruction.     

自体软骨与膨体聚四氟乙烯在鼻整形手术中的应用

目的：通过应用自体鼻中隔软骨和耳软骨及膨体聚四氟乙烯解决鼻部美容整形的问题,以形成较理想的鼻形。方法：以鼻小柱飞鸟形切口加鼻翼软骨缘切口,切开分离鼻背皮肤,显露两侧鼻翼软骨及侧鼻软骨,中线分离弓形取出深部鼻中隔软骨,鼻中隔软骨雕刻塑形后插入两鼻翼软骨之间,并贯穿缝合形成中隔软骨＋鼻翼软骨为新的鼻小柱。将取下的耳软骨雕刻成杏仁状固定缝合于鼻小柱前端,雕刻好的膨体聚四氟乙烯插入鼻背固定,缝合切口。结果：20例美容就医者鼻部整形术后效果良好,自然美观,手感良好,无不良并发症发生,术后恢复时间略长。结论：应用自体鼻中隔软骨和耳软骨及膨体聚四氟乙烯行鼻部美容整形,能从根本上改变外鼻形态,是较理想的手术方法。     

Surgical Correction of the Overgrown Columellar Labial Junction: Complementary Method

The overgrown columellar labial junction remains a controversial and neglected aspect of rhinoplasty. The authors encountered this problem in a large number of their patients and found that routine techniques were not sufficient to correct it. They therefore developed a complementary method in rhinoplasty that is safe and easy to handle, with long-lasting, satisfactory results for both the patient and the surgeon. This method has provided not only better stability on the columellar base, but also good aesthetic results. The study involved 43 rhinoplasty patients with a follow-up period of approximately 1.5 years. This report analyzes the surgical anatomy related to the overgrown columellar labial junction. Pre- and postoperative aspects of cases involving overgrown columellar labial junctions and surgical procedures are discussed.     

鼻翼及鼻尖肥大的美容整复

目的:探讨矫正鼻翼鼻尖肥大的最佳手术方法。方法:依鼻翼、鼻尖肥大的特点,采取横向缩小鼻翼法,并注重鼻翼外侧脚的移位。鼻尖整形行开放式手术入路,重塑鼻翼软骨,并把切除下的鼻翼组织块去表皮后置到鼻假体上。结果:30例鼻翼鼻尖肥大患者均取得了良好的手术效果。结论:鼻翼、鼻尖肥大要整体诊治,才能取得良好的手术效果。     

New concepts in nasal tip contouring

Control of nasal tip contour has always been a key component of a successful rhinoplasty. Typically, this procedure is performed with an emphasis on narrowing the nasal tip structure. Creating a natural-appearing nasal tip contour is a complex task and requires a 3-dimensional approach. In an effort to identify the characteristics that make an ideal nasal tip, I evaluated numerous aesthetically pleasing nasal tips. After extensive study, I created a series of images to demonstrate how specific contours create highlights and shadows that will help guide the surgeon in creating a natural-appearing nasal tip contour. Many commonly used nasal tip techniques can pinch the tip structures if an overemphasis is placed on narrowing. These changes isolate the dome region of the nasal tip and can create an undesirable shadow between the tip lobule and alar lobule. Prior to contouring the nasal tip, the surgeon must stabilize the base of the nose with a columellar strut, suturing the medial crura to a long caudal septum, caudal extension graft, or an extended columellar strut graft. Stabilizing the nasal base will ensure that tip projection is maintained postoperatively. To contour the nasal tip, dome sutures are frequently used to flatten the lateral crura and eliminate tip bulbosity. Placement of dome sutures can deform the lateral crura and displace the caudal margin of the lateral crura well below the cephalic margin. This can result in a pinched nasal tip with the characteristic demarcation between the tip and the alar lobule. Alar rim grafts can be used to support the alar margin and create a defined ridge that extends from the tip lobule to the alar lobule. This form of restructuring can create a natural-appearing nasal tip contour with a horizontal tip orientation continuing out to the alar lobule. When dome sutures alone are inadequate, lateral crural strut grafts are used to eliminate convexity and prevent deformity of the lateral crura. Shield tip grafts can be used in patients with thick skin and an underprojected nasal tip. Whenever a shield tip graft is used, it must be appropriately camouflaged to avoid undesirable visualization of the graft as the postoperative edema subsides. When contouring the nasal tip, the surgeon should focus more on creating favorable shadows and highlights and less on narrowing. Nasal tips contoured in this manner will look more natural and will better withstand the forces of scar contracture that can negatively affect rhinoplasty outcomes.     

The extended columellar strut-tip graft

The extended columellar strut-tip graft is a structural unit used in endonasal rhinoplasty that combines the attributes of the columellar strut and the tip graft. It is used to provide projection and contour to the nasal tip. Our goal with this study was to evaluate a 15-year experience with 155 patients who underwent rhinoplasty with the extended columellar strut-tip graft. Of these, 110 underwent secondary rhinoplasty, and 45 underwent primary rhinoplasty. There were 6 patients in the secondary rhinoplasty group who experienced complications: in 3, the graft became visible postoperatively, and 3 patients had graft placement asymmetry. These 6 patients underwent surgery in the initial years of graft development. One patient with graft edge visibility and 1 patient with graft asymmetry underwent revision surgery with satisfactory results. The extended columella strut-tip graft is a reliable method to provide nasal tip projection and contour. The successful use of the graft requires precise diagnosis and surgical technique.     

Treatment of nasal obstruction from nasal valve collapse with alar batten grafts

Nasal obstruction may require treatment with rhinoplasty techniques. One cause of nasal obstruction is known as nasal valve collapse. This refers to narrowness and weakness at the nasal valve, the narrowest part of the nasal airway. There are a number of surgical approaches available to treat nasal valve collapse. Selection of the appropriate surgical intervention depends on proper identification of the anatomic cause of the collapse. Alar batten grafts are especially useful for addressing nasal valve collapse caused by a weak nasal sidewall. In this report, we review the senior author's experience with the use of alar batten grafts for nasal valve collapse. Twenty-one patients had septoplasty with placement of alar batten grafts; all patients noted improvement in their nasal breathing. Seven patients underwent ear cartilage harvest with alar batten grafts, and five of them noted improvement, one noted partial improvement, one noted no improvement. Six patients underwent revision septorhinoplasty with alar batten grafting, and ten patients underwent revision septorhinoplasty with ear cartilage harvest and alar batten grafting. These patients all reported improvement in their nasal breathing postoperatively. Six patients underwent revision rhinoplasty (no septoplasty) with ear cartilage and battens. These patients hold special interest because no other intranasal procedures were performed that affected nasal breathing. All six of these patients reported significant improvement of their nasal breathing and all patients were satisfied with their postsurgical cosmetic appearance. The nasal valve area is considered to be the location of the least cross-sectional area in the nose. When narrowing of the nasal valve is a result of collapse of the nasal sidewall, alar batten grafts are a useful technique to address the patient's nasal obstruction.     

Aesthetic rhinoplasty: Avoiding unfavourable results

Rhinoplasty is one of the most challenging surgical procedures in plastic surgery. It is not surprising that a significant number of patients end up with unfavourable outcomes. Many of these unfavourable outcomes could be the result of poor judgment and wrong decision making. Most frequently, the unfavourable outcome is the result of errors in surgical technique. In this paper, unfavourable outcomes resulting from errors in surgical technique are discussed under the heading of each operative step. Poor placement of intra-nasal incision can result in internal valve obstruction. Bad columellar scars can result from errors during open rhinoplasty. Unfavourable results associated with skeletonisation are mentioned. Tip plasty, being the most difficult part of rhinoplasty, can result in lack of tip projection, asymmetry and deformities associated with placement of tip grafts. Over-resection of the lower lateral cartilages during tip plasty can also result in pinched nose, alar collapse causing external valve obstruction and other alar rim deformities. Humpectomy can result in open roof deformity, inverted V deformity and over-resection resulting in saddle nose. The so-called poly beak deformity is also a preventable unfavourable outcome when dealing with a large dorsal hump. Complications resulting from osteotomies include narrowing of nasal airway, open roof deformity, inverted V deformity and asymmetry of the bony wall resulting from incomplete or green stick fractures. Judicious use of grafts can be very rewarding. By the same token, grafts also carry with them the risk of complications. Allografts can result in recurrent infection, atrophy of the overlying skin and extrusion resulting in crippling deformities. Autografts are recommended by the author. Unfavourable results from autografts include displacement of graft, visibility of the graft edges, asymmetry, warping, and resorption.KEY WORDS: Aesthetic rhinoplasty, hump resection, osteotomy, radix, unfavourable results     

Comparative Columellar Scar Analysis Between Transverse and Inverted-V Incision in Open Rhinoplasty

BACKGROUND: Rhinoplasty can be performed using both open and closed approaches. A visible scar on the columella is the major disadvantage of open rhinoplasty. Different columellar incision types have been used in open rhinoplasty. In this retrospective study, we compare transverse and inverted-V columellar incisions with a scar assessment scale. METHODS: In this retrospective study, open rhinoplasty was performed on 84 patients between 2001 and 2006. The transverse incision was used on 39 patients (18 males, 21 females). The inverted-V incision was used on 45 patients (21 males, 24 females). The entire surgical procedure was performed by a single surgeon. The columellar incision was closed using 6-0 interrupted polypropylene sutures. All sutures were removed on the fifth postoperative day. With this assessment scale, we observed satisfactory scar, pigmentation, and notching. RESULTS: We compared both groups and found that the inverted-V incision resulted in better scar formation (p < 0.05) and less notching (p < 0.07). Scar pigmentation was found to be irrelevant to the incision technique employed (p < 0.3). CONCLUSION: As a result of this study we concluded that the inverted-V incision might be a better choice in open rhinoplasty.     

Anatomic basis of notch deformity in open rhinoplasty

Notch deformity at the columella after the stairstep incision is an unsightly sequel that fuels negativism for open rhinoplasty critics. Obvious causes cited include surgical misadventures involving division of the foot of the medial crus and poor healing. The authors offer yet an additional etiology based on the contraction distortion caused by the depressor septi nasi muscle. The purpose of this study is to investigate the anatomic basis for notch deformity after stairstep technique in open rhinoplasty. For this anatomic study, 10 fresh cadavers were used. Dissections were performed, exposing the columellar components. The macroscopic and microscopic photo documentation gathered supports the authors' theory that depressor septi nasi action causes skin-edge deformation that leads to closure malalignment and notch deformity. Pre-incision landmark defining tattoo or sutures will assure proper alignment at closure.     

Combined use of triple cartilage grafts in secondary rhinoplasty.

Secondary rhinoplasty on a patient with a middle vault deformity is one of the most challenging procedures for a plastic surgeon. In order to achieve proper nasal aesthetics and airway function, a surgeon most commonly chooses to engraft the nose with a spreader, dorsal onlay, or columellar graft. This paper examines the aforementioned techniques in the management of 25 patients who presented with a severe middle nasal vault deformity. METHODS: During the last 5 years, 25 patients received secondary rhinoplasty using triple cartilage grafts to repair severe middle vault deformities. Patients were then questioned at least 3 months postoperatively about both airway problems and cosmetic satisfaction. RESULTS: All the 25 patients indicated cosmetic satisfaction with 23 of the patients also achieving complete nasal airway function. Only two patients persisted to have an insufficient nasal airway. An endonasal examination revealed a slight nasal synechiae in one patient, while no anatomic problem was identified in the second patient. From a cosmetic standpoint, a straight dorsum with improved dorsal aesthetic lines and nasal profile, along with nasal-facial balance were achieved. When indicated, secondary rhinoplasty to repair a middle vault deformity using the combination of spreader, dorsal onlay, and columellar grafts to augment the nose has shown to have both functional and cosmetic benefits.     

Calibrated nasal tip: Review of 100 cases

Asymmetry of the alar cartilages is a common finding in primary rhinoplasty in Caucasian patients. The “delivery” technique provides good exposure of the alar cartilages which allows examination and tailoring in better surgical conditions than those of the “closed” technique and also avoids the “open” nose approach in the majority of rhinoplasty cases.