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%.     

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.     

Surgical management of concavities of the distal nose

Normal topographic anatomy of the distal nose is a reflection of the delicate integration between the lower lateral cartilage, the upper lateral cartilage, the sep-tum, and skin. Understanding these relationships will help the rhinoplasty surgeon diagnose and treat con-cavities of the distal nose. Most patients present with a hybrid of these defects. For example, the patient in Fig. 19 presented for a primary rhinoplasty. A variety of concavities can be noted and include dorsal septal deflection, upper lateral cartilage avulsion on the left,bilateral lower lateral complete concavities, and the beginning of a dorsal depression (Fig. 19A-I). The nasal skeleton and the skin and soft tissue are normally in equilibrium, but trauma and reduction rhino-plasty disrupts this equilibrium. Skeletal distortion can lead to septal deflection, middle vault collapse, or alar buckling [20]. It is important to realize that correction of deflection or depression by excision needs to be balanced with augmentation, which provides balance for the previously disequilibrated skeletal and soft tissue forces. Augmentation can be done with spreader grafts, tip grafts, columellar strut, and dorsal grafts. A patient's soft tissue envelope will also play a major role in the success of a septorhinoplasty. The surgical principles of septorhinoplasty such as judicious resculpting of the cartilaginous framework, respect of major tip support, tip grafting technique, and postoperative tissue contraction still apply and must be placed in conjunction with repairing a pathological topographic concavity.     

Rhinoplasty: open tip suture techniques: a 25-year experience

Based on a 25-year experience, the author considers open tip suture techniques to be the best method of achieving consistent and reproducible tip changes that can please patients with a wide variety of tip deformities. The described technique consists of selecting the ideal combination of the following six sutures: (1) columellar strut and suture, (2) domal creation, (3) interdomal, (4) domal equalization, (5) tip position, and (6) lateral crural convexity. If additional definition is required, then tip refinement grafts can be added to accommodate thicker skin or lateral crura abnormalities.     

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.     

Nasal valve surgery

Nasal obstruction can be due to internal and external valve problems that can be seen before and after rhinoplasty. The main scope of this article is to concentrate on surgical solutions to these problems. To overcome nasal obstruction at the internal valve, spreader grafts, spreader flaps, upper lateral splay graft, butterfly graft, flaring suture, M-plasty, Z-plasty, and suspension sutures have been described. The management of the external valve problems is possible by using lateral crural dissection and repositioning, lateral crural strut grafts, alar battens, lateral crural turn-in flap, alar rim grafts, and various other methods. It is not easy to decide which techniques would work best in every case. After a thorough examination and analysis, the underlying cause of the nasal obstruction can be understood, and one or multiple procedures can be chosen according to each individual problem.     

Measurement of preoperative and postoperative nasal tip projection and rotation

OBJECTIVE: To measure the effect of columellar struts and cephalic trim on tip projection and tip rotation using digitized photographs. METHODS: Using photographs of 62 patients who underwent external rhinoplasty, we retrospectively analyzed nasal tip projection (the Goode method) and rotation (nasolabial angle) before and after surgery. A cartilaginous strut was used in 36 patients, whereas 26 patients did not receive a strut. Patients were categorized into 4 subgroups, depending on the placement of a strut (placement, strut+ vs nonplacement, strut-) and the removal of the cephalic margin (removal, cephalic+ vs nonremoval, cephalic-) of the lateral crus: strut-/cephalic-, n = 17; strut+/cephalic-, n = 23; strut-/cephalic+, n = 9; strut+/cephalic+, n = 12. RESULTS: Nasal tip projection, measured with the Goode method, increased from 0.58 to 0.60 (P = .02) in the strut+ group; in the strut- group, nasal tip projection did not change significantly. Nasolabial angle increased from 93.96 degrees to 100.92 degrees in the strut+/cephalic- group and from 88.30 degrees to 95.06 degrees in the strut+/cephalic+ group. Removal of the cephalic margin alone (strut-/cephalic+) hardly affected tip rotation (P = .05). CONCLUSIONS: The external rhinoplasty approach did not lead to a decrease in nasal tip projection. A cartilaginous strut slightly increased nasal tip projection and also increased nasal tip rotation. This effect was accentuated by the removal of the cephalic margin of the lateral crus.     

Nasal trauma, two prior rhinoplasties

This article reviews a case of a woman presenting with nasal deformity following childhood nasal trauma and two subsequent rhinoplasties. Discussion for correction of these problems includes tip dome graft, shield and cap graft, superior and inferior cartilage onlay grafts, spreader graft, columellar strut, and lateral osteotomies. Pre- and postoperative photographs are provided with corresponding preoperative diagrams and schematics.     

Management of the septum during rhinoplasty

Septal deviation is the rule more than the exception in most cases of rhinoplasty. When deviation of the septum precludes a good rhinoplasty's functional and aesthetic results because of impairment of nasal air flow, residual deviation, or inadequate medialitation of the lateral nasal wall, a modified submucous resection of the deviated part is certainly indicated. If possible, a dorsocaudal L-strut of cartilage should be maintained, but, if necessary, it can be resected partially or totally and the support of this area reestablished by dorsal and columellar cartilage grafts. The authors recommend a bilateral mucoperichondrial-mucoperiosteal dissection of the septum from its caudal edge to the most posterior deviated part, because it provides easy septal resection in a good surgical field.     

Functional rhinoplasty: treatment of the dysfunctional nasal sidewall

Treatment of nasal obstruction caused by nasal valve dysfunction requires a thorough evaluation of the mechanics of normal nasal anatomy and function. Surgical correction of nasal valve dysfunction is based on determining the epicenter of dysfunction, whether it is a static obstruction of the internal nasal valve or a dynamic collapse of either the external nasal valve or the intervalve area. Spreader grafts, flaring sutures, and butterfly grafts are used to widen and support the narrow internal nasal valve. Alar batten grafts will add support to the collapsing nasal sidewall seen in external nasal valve and intervalve dysfunction. Correction of dynamic collapse from paradoxical concavity of the lateral crura may be obtained from the lateral crural flip-flop graft or by reconstructing the lateral crura using cartilage grafts. A strut graft may correct dynamic obstruction caused by a malformed, easily collapsible lateral crura. This article discusses the evaluation, treatment, and correction of the dysfunctional nasal sidewall and emphasizes the avoidance of iatrogenic damage to the sidewall while performing cosmetic rhinoplasty.     

Reconstructive surgery of the leprosy nose: a new approach.

There has still been no reduction in the detection rate worldwide for leprosy, despite supervised multi-drug therapy. In time, leprosy can result in a severe saddle-nose deformity leading to functional problems, disfiguration and stigmatization. In severe cases, only the nasal skin tissue and the lower lateral cartilages are preserved. In such cases, the ideal would be to restore the cartilaginous skeleton but, by contrast with other causes of saddle-nose deformities, this is complicated by the quantity and the poor quality of the remaining nasal mucosa. Leprosy-related saddle-nose deformities are therefore challenging and difficult to reconstruct with the techniques that have been proposed in the past. In this study, 24 patients underwent rhinoplastic surgery involving the use of autogenous costal and/or auricular cartilage or composite grafts. The nasal septum, the upper laterals and the anterior nasal spine were reconstructed with a dorsal onlay attached to a columellar strut with an extension on the proximal side. Before surgery, the saddle-nose deformities were classified according to severity with a new system based on clinical symptoms and signs. Postoperative evaluation was performed at least two years after surgery (N=17). Functional and aesthetic improvement, resorption rate, warping, infection and extrusion were analysed. Functional and aesthetic improvements were achieved in 15/17 patients. None of the patients developed an infection and extrusion or warping of the implants was not observed. The resorption rate depended on the localization and the type of cartilage implant. In general, auricular conchal cartilage implant grafts resulted in less resorption than costal cartilage. Least resorption (4/17 patients) was observed in the dorsal onlay grafts of both conchal (1/6) and costal cartilage grafts (3/11). Resorption of columellar strut implants and shield grafts was observed in 7/17 patients. No resorption was seen of composite grafts (0/4) and alar battens (0/7). Autogenous cartilage implants can be used to reconstruct saddle-nose deformities in leprosy with a minimum risk of complications. The preoperative grade of severity was used as a basis for the development of guidelines for optimal long-term functional and aesthetic outcome.     

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     

Open tip rhinoplasty.

An open tip rhinoplasty was used to correct moderate to severe secondary cleft lip nasal deformities in 122 patients from January 1986 to January 1988. The results of the surgery on 92 patients who were followed for 1 year or more were evaluated. When the surgery was performed after the age of 3 years, 60% of the patients had a satisfactory result. The pathology of the deformity included 32% with deficiencies of the nasal lining, 35% needed framework support such as a columellar strut, and 45% required correction of columellar deficiencies. Patients using a postoperative nasal stent had a 71% satisfactory result compared with a 37% satisfactory result when the stent was not used. The pathology and techniques to correct the nasal deformity are described.     

Augmentation Rhinoplasty with a Combination of Triple Cartilage Grafts for Secondary Rhinoplasty in a Middle-Aged Population

Because of physiologic changes with advancing age as well as previously traumatized and then healed tissues, secondary rhinoplasty for a middle-aged patient is a challenging procedure. Depending on both factors, changes in the midvault can cause a functional airway disorder, and the nose also may need a complete correction for cosmetic purposes. To achieve aesthetic and functional outcomes, augmentation rhinoplasty using a combination of triple cartilage grafts, namely, spreader, columellar, and dorsal onlays, was performed for 12 patients. Sufficient nasal airways with satisfactory appearance were achieved for 11 of 12 patients. Only one patient had improved but still insufficient nasal function with a good aesthetic result. Augmentation rhinoplasty using a combination of triple cartilage grafts for middle-aged patients could be considered an effective procedure for improving the patient’s nasal airway and appearance.     

Augmentation of nasal tip projection using the inferior turbinate: review of technique and evaluation of long-term success

OBJECTIVES: To introduce the use of inferior turbinate bone as an alternative autograft for augmentation of nasal tip projection and to assess maintenance of nasal tip projection, bone remodeling, graft shaping, and ease of harvesting. METHODS: Thirteen consecutive patients in need of increased nasal tip projection underwent closed rhinoplasty during a prospective nonrandomized study in a university teaching hospital setting. An autologous demucosalized inferior turbinate bone graft was used as a columellar strut. Measurements of nasal tip projection were obtained using the Goode ratio. Photodocumentation and lateral soft tissue radiographs were obtained before surgery and between 30 and 38 months after surgery. RESULTS: In all patients, the results were as follows: (1) the inferior turbinate bone graft was easily harvested and molded into the appropriate-sized columellar strut; (2) the immediate postoperative nasal tip projection, as measured by the Goode ratio and visual assessment, was increased; and (3) the tip projections were maintained at the 30-month follow-up examination. Paired t tests revealed a statistically significant difference (P = .001 and P = .009) between preoperative and both immediate and long-term measurements. Comparison of immediate postoperative radiographs with those taken 2 years later demonstrated no remarkable change in appearance of the graft. CONCLUSIONS: The interior turbinate bone is a viable graft for augmenting nasal tip projection. Moreover, it maintains tip projection and needs little to no remodeling. The graft is easy to harvest, prepare, and place and can be used without requiring a second operative site.     

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.     

Open Rhinoplasty Through a Forked Flap Incision

Surgical elongation of the short columella is a challenging problem for the surgeon. Although some flaps from the upper lip are successfully used to correct this deformity on cleft lip patients with a scarred upper lip, these methods cannot be applied to noncleft patients with a smooth upper lip. Distant flaps and composite grafts do not give the best aesthetic results. The use of an external approach for rhinoplasty is preferred by many surgeons, especially for difficult or secondary cases. Most incisions for open rhinoplasty are placed on the columella. This report describes a new incision for open rhinoplasty to be used on patients with a short columella. The incision is a standard forked flap with a columellar base but the legs of the flap extend to the nostril bases instead of to the upper lip. This method was used on eight aesthetic rhinoplasty patients with a short columella between March 1995 and March 1998. The results of the method are discussed.