Aesthetic reconstruction of the platyrrhine nose.

The platyrrhine nose is characterized by a hypoplastic nonprojected nasal tip, wide flaring alae, underdeveloped premaxilla, and lack of nasal dorsal support. Aesthetic nasal reconstruction is performed utilizing the external rhinoplasty technique. Precise placement of nasal augmentation grafts is facilitated by this technique. The harvesting and utilization of a large autogenous nasal fibrofatty graft for finesse dorsal contouring is described. Seventy-five patients underwent aesthetic reconstruction of the platyrrhine nose. Follow-up ranged from 2 to 7 years. No major complications, including extrusion or significant resorption of augmentation grafts, have been observed. Minor complications included notching of the transverse columella incision in 5% (4/75) of cases, observable suture tract marks along the alar closure incision in 4% (3/75) of cases, and alar incision granuloma in 1% (1/75). A modification of our technique, utilizing a two-layer tension-free closure of the columella and alar incisions, has alleviated these complications.     

Surgery of the nasal tip

Summary  The nasal tip is considered most difficult area in entire rhinoplasty. The shape of the nasal tip is altered primarily by changes of lower lateral cartilages. or by badly performed surgery. For the assessment of the tip, its shape must be considered in relationship to the rest of the nose and face. Various types of tip deformities may be encountered. Tip may be overprojected, underprojected, bulbous or retruded columella may be deformed or there may be alar flaring. Tip surgery should be properly planned and accomplished meticulously to achieve pleasing results. Delivery flap technique provides excellent exposure and can deal with most of the tip deformities successfully.     

The hanging columella

A hanging columella significantly detracts from otherwise pleasing nasal esthetics. Preoperative assessment of the nasal base is crucial to determine the etiology of a pre-existing hanging columella, and to assess the potential for creating such a deformity with rhinoplasty. Prevention or correction of a hanging columella requires surgical techniques that take into consideration the anatomic tip dynamic factors involved. We discuss the anatomy of the nasal base, define the hanging columella, and distinguish this entity from others with which it can be confused. We propose a methodical approach to the evaluation of the hanging columella, and recommend corrective techniques which we have found successful in achieving good cosmetic results.     

The Rintala flap: a versatile procedure for nasal reconstruction

Introduction

For the nasal reconstruction, local flap using the adjacent tissue is selected from an esthetic viewpoint. The Rintala flap is a useful option, and reconstruction of the glabellar over the nasal tip with this flap is ideal, for which the procedure was modified to increase the blood flow to the Rintala flap to extend its clinical applications.

Methods

For defects of the glabellar over the middle one third of nasal dorsum, the Rintala flap is transferred employing the original design and technique dissected on supraperiosteal plane. For defects of the lower one third of nasal dorsum over the nasal tip, blood supply through the lateral nasal artery is added to the distal end of the flap, preparing a long flap with stable blood supply like Maruyama described in 1997.

Results

This procedure was applied for nasal reconstruction in 15 patients. The Rintala flap was applied in 12 and the modified Rintala flap with adding blood flow from the lateral nasal artery was applied in 3. Blood supply to the flap was very stable in all patients, and favorable outcomes were achieved.

Conclusions

Using this procedure, the natural contour and morphology of the glabellar over the nasal tip may be reconstructed. The technique is simple and easy. Using this procedure, clinical applications of the Rintala flap can be extended, showing that it is a useful nasal reconstructive procedure.     

An alternative technique to define and visualize columellar and nasal tip vectors. Improvement of mestizo nose

Background

With some frequency, in mestizo rhinoplasty, we focus much of our attention on the nasal tip. This work also highlights the importance of obtaining a proper balance of the columella, achieving a pleasing visual effect of the vector lines that make up the nasal profile (columella and nasal tip vectors).

Methods

We performed a complete medical history in all patients and developed a surgical plan after nasal anatomy analysis. Pre- and postoperative photographs were obtained for medium and long term control.

Results

We treated 112 patients with this surgical technique, 77 with an open approach and 35 with a closed approach. The results were documented in the short and long term with a range of 6 months to 5 years.

Conclusions

We feel that the use of an angulated extended columellar graft is highly polyfunctional, providing length, definition and support to nasal tip grafts. Because of the graft design, it is possible to predetermine the new columella length/tip, thus visualizing the columella and nasal tip vectors of the nasal profile. The angulated extension prevents cephalic–lateral–caudal displacements of the tip graft, and to some degree it is possible to increase or decrease nasal length depending on the angularity of the extension.     

Enbucrilate as cartilage adhesive in augmentation rhinoplasty

Enbucrilate (Histoacryl) as a cartilage adhesive in augmentation rhinoplasty was used in 39 cases. The unique properties of this tissue adhesive enhances the ability to augment the nose during cosmetic and reconstructive rhinoplasty. Enbucrilate interacts superbly well with local tissues, causing no systemic or local untoward effects. Its main attribute stems from its ability to bond cartilage instantaneously and with great reliability, which allows for intricate fabrication of cartilage implant components. Five subcategories of dorsal, tip, and columella augmentation are presented with their technical details outlined. The aesthetic and functional results in 39 cases were deemed excellent, safe, and effective.     

Planning and intraoperative controls in rhinoplasty

We present a technique to quantify computer simulation in rhinoplasty and to make individual templates to be used intraoperatively. With these templates the exact position and shape of the nasal dorsum, tip, columella and anterioar nasal spine can be controlled and adjusted. Due to our experience this techniques contributes to precise surgical outcome and patient's satisfaction.     

Use of silicone sheets for dorsal augmentation in rhinoplasty for Asian noses

CONCLUSION: While the complication rate for silicone sheets was similar to that reported for silicone rubber, there are several advantages to the use of silicone sheets for correcting minor dorsal irregularities. Therefore, silicone sheets can be used as a versatile graft material for dorsal augmentation in rhinoplasty. OBJECTIVES: Silicone implants mostly in the form of prefabricated silicone rubber remain the most commonly used materials for nasal augmentation in Asians. The present study analyzed the use of silicone sheets rather than silicone rubber for nasal dorsal augmentation rhinoplasty. MATERIALS AND METHODS: Data from 27 patients who underwent dorsal augmentation with silicone sheets between April 2003 and July 2005 were retrospectively reviewed. RESULTS: All patients received silicone sheets to augment the nasal dorsum and/or radix. Twenty-four patients had satisfactory outcomes. One patient (3.7%) complained the implant was too visible, one experienced infection, and one experienced endonasal extrusion of the implant. All three cases were readily managed by implant removal and administration of antibiotics.     

Recent advances in Asian rhinoplasty

Asian rhinoplasty is an expanding topic in the field of rhinoplasty. Although the main principles of various rhinoplasty techniques apply equally to the Asian nose, Asian rhinoplasty is unique owing to its different anatomy and ethnicity. In recent years there have been some noteworthy developments in Asian rhinoplasty. Traditional techniques using alloplastic implants with endonasal approach are changing due to the advent of new beauty concept, introduction of new techniques, and development of newly improved materials.In this review, we will highlight some of the recent advances of Asian rhinoplasty with emphasis on dorsal augmentation, advances in implant material and tip surgery using autologous cartilage. Finally with increase of revision cases, issues relavant to revision rhinoplasty in Asians will be addressed.     

Advances in nasal tip surgery. The lateral crural steal

Increasing nasal tip projection, rotation, and definition have classically been attempted through a variety of lobular cartilage incising or excising techniques. Resultant long-term complications, including bossing, alar notching, pinched tips, and alar collapse, have occasionally resulted from the use of these techniques. The majority of these complications have arisen secondary to a loss of structural support following the interruption of the lower lateral cartilages. This article describes the "lateral crural steal," a method of increasing nasal tip projection and nasal tip rotation while preserving the integrity of the lobular cartilage complex. The procedure uses the external rhinoplasty approach for exposure. By elevating both the dorsal and the vestibular skin from the domes of the lobular cartilages, the lateral crura may be advanced onto the medial crura to further project the nasal tip and to reorient the tip upward. This technique along with its philosophy and long-term follow-up results are presented.     

Beurteilung von Form und Funktion der Nase nach offener Rhinoplastik bei einseitigen Lippen-Kiefer-Gaumen-Spalten

Secondary septorhinoplasty in patients with cleft lip and palate (CLP) is performed to improve nasal form and function. The purpose of this study was to compare the initial findings and the surgical outcome in 30 patients with unilateral CLP. Open rhinoplasty was carried out to correct nasal deformity. Nasal soft tissue analysis was done by measurement of standardized raster photographs of the nose and lateral teleradiography. Deviations from the ideal form regarding nasal symmetry, nasal width, and alar base line were determined. The nasal profile was assessed by measuring the nasofacial and nasolabial angle, the angle between the upper lip and the Frankfurt horizontal plane (FHP), and the angle between the columella and the FHP. Nasal patency was evaluated by rhinomanometry. The overall flow (cm3/s) was determined and the flow of the cleft side and non-cleft side compared. Evaluations were made immediately before and 6 months after surgery. In the frontal plane, nasal symmetry was significantly improved and the alar form adjusted. The deep position of the columella was corrected. The acute nasofacial angle and the drooping ala were not significantly improved. An increase in the overall flow and correction of the quotient cleft/non-cleft side was achieved by the surgical procedure. In this study, aesthetically and functionally relevant findings were objectified and can be used for quality control.     

External rhinoplasty: a critical analysis of 500 cases

The study presents a comprehensive statistical analysis of a series of 500 consecutive rhinoplasties of which 380 (76 per cent) were primary and 120 (24 per cent) were secondary cases. All cases were operated upon using the external rhinoplasty technique; simultaneous septal surgery was performed in 350 (70 per cent) of the cases. Deformities of the upper two-thirds of the nose that occurred significantly more in the secondary cases included; dorsal saddling, dorsal irregularities, valve collapse, open roof and pollybeak deformities. In the lower third of the nose; secondary cases showed significantly higher incidences of depressed tip, tip over-rotation, tip asymmetry, retracted columella, and alar notching. Suturing techniques were used significantly more in primary cases, while in secondary cases grafting techniques were used significantly more. The complications encountered intra-operatively included; septal flap tears (2.8 per cent) and alar cartilage injury (1.8 per cent), while post-operative complications included; nasal trauma (one per cent), epistaxis (two per cent), infection (2.4 per cent), prolonged oedema (17 per cent), and nasal obstruction (0.8 per cent). The overall patient satisfaction rate was 95.6 per cent and the transcolumellar scar was found to be unacceptable in only 0.8 per cent of the patients.     

Lateral crural steal and lateral crural overlay: an objective evaluation

OBJECTIVE: To assess objectively the effect of 2 cartilage-modifying techniques, lateral crural steal (LCS) and lateral crural overlay (LCO), on the degree of nasal tip projection and rotation. DESIGN: A prospective trial using computer imaging techniques for assessment. SETTINGS: Half of the patients were seen at a university hospital and the other half at a private practice. PATIENTS: A selected series of 30 patients seeking rhinoplasty mainly for nasal tip repositioning. Only patients with no history of previous nasal operations were included. INTERVENTION: All patients were operated on using an external rhinoplasty approach. Only 1 of the 2 techniques was adopted for each patient. The technique selected depended purely on clinical judgment. MAIN OUTCOME MEASURES: The nasofacial angle and the Goode ratio were used to assess tip projection, and the nasolabial angle and rotation angle were used to assess tip rotation. RESULTS: The use of the LCS technique resulted in an increase in both nasal tip projection and rotation, but the use of the LCO technique resulted in an increase in tip rotation and a decrease in tip projection (P<.001). Additionally, the LCO technique resulted in significantly higher degrees of rotation than the LCS technique (P<.001). CONCLUSIONS: The LCS procedure is indicated when a moderate increase in nasal tip projection and rotation is desired. The LCO technique is useful in patients where severe underrotation is associated with overprojection.     

Surgical anatomy of the sphenopalatine artery in lateral nasal wall

OBJECTIVE: We investigated the surgical anatomy of the sphenopalatine artery. First, the location of the sphenopalatine foramen on the lateral nasal wall and the pattern of the main branches of the sphenopalatine artery from the sphenopalatine artery were studied. Second, the course of the posterior lateral nasal artery with respect to the posterior wall of the maxillary sinus, the perpendicular plate of the palatine bone, and the pattern of distribution of its branches on the fontanelle was determined. Third, the distribution pattern on the inferior turbinate was analyzed. STUDY DESIGN: Fifty midsagittal sections of randomly selected Korean adult cadaver heads with intact sphenoid sinus and surrounding structures were used in the study. METHODS: The mucosa on the sphenopalatine foramen and its surrounding mucosa were removed with a microscissors, a fine forceps, and a pick to expose the sphenopalatine artery under an operating microscope (original magnification x6). RESULTS: The feeding vessels of the superior turbinate were from the septal artery in 36 cases (72%). The feeding vessels to the middle turbinate branch originated from the proximal portion of the posterior lateral nasal artery just after exiting the sphenopalatine foramen in 44 cases (88%). Some portion of the posterior lateral nasal artery ran anterior to the posterior wall of the maxillary sinus in 38%. The major feeding arteries to the fontanelle were from the inferior turbinate branch in 25 cases (50%). In most cases, the inferior turbinate branch was the end artery of the posterior lateral nasal artery (98%). CONCLUSIONS: The study provides detailed information concerning the sphenopalatine artery, which we hope will help explain the arterial bleeding that may occur during ethmoidectomy, middle meatal antrostomy, conchotomy, and endoscopic ligation of the sphenopalatine artery.     

Evaluation of nasal tip surgery.

Nasal tip surgery has been evaluated with respect to correction of the lower lateral cartilages. Indications, techniques, results, and complications related to three generic approaches to the lower lateral cartilages are described. In 673 consecutive rhinoplasties the commonest type of nasal tip surgery was excisional, utilizing either a marginal or cartilage splitting technique. These techniques were utilized: 1. to accomplish debulking, and 2. to accomplish the installation of facets. The excisional technique found its greatest utility in primary rhinoplasties. The version technique, utilizing a change of direction of the thrust of the lower lateral cartilages was utilized in a variety of situations, particularly for the correction of moderately congenitally hypoplastic tip cartilages. It also found great utility in surgery of the Negro or cleft palate nose, increasing tip projection, correcting unacceptable bifidity, and in revision rhinoplasty. Augmentation rhinoplasty, utilizing conchal cartilage as an elastic strut was particularly useful for severe hypoplastic cartilage deficits, the Negro nose, columellar retraction, and alar rim deficits. The overall complication rate of lower lateral rhinoplasty was 17.4 percent. The rate of unacceptable complications related to lower lateral rhinoplasty was 2.7 percent.     

Cosmetic rhinoplasty using the external approach

Although the external rhinoplasty remains controversial it is difficult to understand why. The columella scar is of little significance since this becomes nearly invisible if the closure is carefully performed. There is a relative postoperative prolongation of nasal tip swelling in comparison with the closed technique, however this also becomes negligible with time. On the other hand, in our experience the open approach will achieve better understanding of the patient's individual anatomy and thus lead to a more predictable result through increased exposure and precision tailoring. The external technique facilitates the application of the great variety of tip refinements that have been developed over the years to allow facial plastic surgeons to get consistently excellent results in rhinoplasty.     

Rhinoplasty tip ptosis: Etiology and prevention

Commonly, 12-18 months must elapse before the final postoperative result following rhinoplasty may be judged. Unless actively compensated for during surgery, an inconstant degree of nasal tip ptosis (“settling”) may lead to displeasing nasal profile characteristics. Supra-tip rounding accentuates tip ptosis, creating the undesirable “pollybeak” deformity. Generally, these two complications of rhinoplasty are predictable and preventable, providing that their various etiologies are clearly understood. Nasal tip ptosis in the postoperative healing period occurs if false projection of the tip confuses the surgeon. Operative tip swelling (infiltration anesthesia and edema) along with malpositioned columellar “bunching” sutures and “orthopedic” septocolumellar sutures create spurious tip projection. Loss of normal tip support occurs when incisions interrupt the attachment of the lower lateral cartilages to the upper lateral cartilages as well as the “wrap-around” relationship of the feet of the medial crura to the caudal cartilaginous septum. Complete transfixion incisions should be avoided when possible. Cartilaginous or bony shoring struts increase tip support. Modeling of the lower lateral cartilage should not include over-generous removal of the lateral crura, thus further weakening tip support. Unfavorable healing factors contributing to tip ptosis include linear contraction of the transfixion incision scar, the natural downward torque influence of the lower lateral cartilages, and detrimental synergistic activity of specific muscles of facial expression. Tip ptosis may accentuate the undesirable formation of supra-tip prominence, thus unmasking the eventual stigma of “pollybeak” deformity. Supra-tip prominence may develop as the result of: 1. Inadequate lowering of cartilaginous dorsal hump. 2. Inadequate lowering of upper lateral cartilages. 3. Insufficient nasal skin undermining. 4. Failure to excise adequately redundant mucous membrane projecting above the newly-established profile line. 5. Inadequate tip splinting. Preventive operative maneuvers can reduce the incidence of displeasing profile relationships, leading to a natural and harmonious postoperative rhinoplasty appearance.     

Does the open rhinoplasty incision decrease nasal projection?

To evaluate the effects of open rhinoplasty incisions on tip projection using digitized photographs. Thirty-one patients, who underwent open technique rhinoplasty were prospectively included in the study. The lateral aspect photographs were taken before the operations. Following midcolumellar incision septal elevation was done until septal cartilage was shown. After replacing the skin totally back and suturing midcolumellar incision, the intraoperative photographs were taken. The projection indexes were measured by Goode method from the photographs and the measurements were compared. A statistically significant decline of the nasal projection was established after open technique approach. Open rhinoplasty approach led to the decrease of the nasal tip projection. This result was thought to be the effect of ligamentous disruption.     

Alar setback technique: a controlled method of nasal tip deprojection.

OBJECTIVES: To describe an alar cartilage-modifying technique aimed at decreasing nasal tip projection in cases with overdeveloped alar cartilages and to compare it with other deprojection techniques used to correct such deformity. DESIGN: Selected case series. SETTINGS: University and private practice settings in Alexandria, Egypt. PATIENTS: Twenty patients presenting for rhinoplasty who had overprojected nasal tips primarily due to overdeveloped alar cartilages. All cases were primary cases except for one patient, who had undergone 2 previous rhinoplasties. INTERVENTION: An external rhinoplasty approach was used to set back the alar cartilages by shortening their medial and lateral crura. The choice of performing a high or low setback depended on the preexisting lobule-to-columella ratio. Following the setback, the alar cartilages were reconstructed in a fashion that increased the strength and stability of the tip complex. MAIN OUTCOME MEASURES: Subjective evaluation included clinical examination, analysis of preoperative and postoperative photographs, and patient satisfaction. Objective evaluation of nasal tip projection, using the Goode ratio and the nasofacial angle, was performed preoperatively and repeated at least 6 months postoperatively. RESULTS: A low setback was performed in 16 cases (80%) and a high setback in 4 (20%). The mean follow-up period was 18 months (range, 6-36 months). The technique effectively deprojected the nasal tip as evidenced by the considerable postoperative decrease in values of the Goode ratio and the nasofacial angle. No complications were encountered and no revision surgical procedures were required. CONCLUSIONS: The alar setback technique has many advantages; it results in precise predictable amounts of deprojection, controls the degree of tip rotation, preserves the natural contour of the nasal tip, respects the tip support mechanisms, increases the strength and stability of nasal tip complex, preserves or restores the normal lobule-to-columella proportion, and does not lead to alar flaring. However, the technique requires an external rhinoplasty approach and fine technical precision.     

Objective assessment of the accuracy of computer-simulated imaging in rhinoplasty

OBJECTIVE: The objective of the study was to evaluate the accuracy by which computer-simulated rhinoplasty images reflect surgical results in 6-month postoperative photographs. METHODS: We performed a retrospective, objective evaluation of 5 features of the facial profile in the computer-simulated images and in the 6-month postoperative photographs of 36 rhinoplasty patients. Data recorded for the nasolabial angle, nasofrontal angle, columella tip angle, columella/infratip lobule ratio, and an established method of assessing tip projection were subjected to statistical analysis by 2-tailed t test and analysis of variance testing. RESULTS: Simulated and actual measurements of columella tip angle were found to be significantly different (P = .021). The set of measurements taken from computer-simulated images at the nasolabial angle (P = .301), nasofrontal angle (P = .471), columellar/infratip lobule ratio (P = .402), and tip projection ratio (P = .547) were not statistically different from the respective measurements recorded from the 6-month follow-up images. CONCLUSIONS: No significant difference was found between the measurements recorded from computer-simulated images and those recorded from 6-month postoperative photographs in 4 of the 5 features of the facial profile studied. The accuracy and predictive value of computer-simulated images is demonstrated and quantified for the first time.