Quantitative study of nasal tip support and the effect of reconstructive rhinoplasty

Outcomes Following Rhinoplasty Using the Combined Septal Extension-Columellar Strut Graft

Background: A novel single-unit septal extension-columellar strut graft was designed to overcome limitations of traditional techniques in rhinoplasty. Objective: To evaluate the outcomes of rhinoplasty utilizing the novel graft, focusing on nasal support, obstruction, and cosmetic results. Methods: A retrospective analysis included patients who underwent rhinoplasty with this graft between 2020 and 2022, with a minimum 1-year follow-up. Pre- and postoperative nasal obstruction symptom evaluation (NOSE) surveys and standardized photographic assessments were employed. Results: A total of 32 patients (mean age 32.8 ± 11.9 years; 96.9% female, 87.5% Caucasian) underwent primary rhinoplasties (68.8% cosmetic, 31.3% functional). Mean follow-up was 13.4 ± 4.9 months (range 12 to 29). Postoperatively, NOSE scores significantly decreased from 34.4 to 4.84 (p < 0.001). Independent reviewers observed improved nasal aesthetics (preop mean 11.96 ± 3.53, postop 1.83 ± 1.6, p < 0.001) without a loss of nasal tip support. No revisions were required. Conclusions: Rhinoplasty using the septal extension-columellar strut graft, in combination with other techniques, provides durable support to nasal tip structures and contributes to improved nasal tip aesthetics.

Composite Thickness and Stiffness Analysis of the Nasal Septum

Background: The nasal septum supports the structure of the nose and is frequently manipulated during septorhinoplasty. Objective: To compare measurements of thickness and compressive Young's modulus (YM) between different regions of nasal septa from human anatomic specimens. Study Design: Case series. Methods: Cartilaginous septa from human anatomic specimens were dissected. Septum thickness was measured at 24 points with regular intervals using a digital caliper. Compressive YM was determined at 14 regions using a force gauge. Two-tailed student's t-tests were used to compare the average thickness and YM between different regions. Results: Septa from 40 human anatomic specimens were included, with age ranging from 50 to 89. Fifty percent of specimens were female. The mean (standard deviation) thickness of the septum was 1.75 (0.76) mm. The mean YM was 2.38 (1.29) MPa. The septum was thickest near the maxillary crest (3.09 [1.17] mm) and the keystone area (2.52 [0.91] mm) and thinnest near the anterior septal angle (1.29 [0.58] mm). The septum was most stiff posteriorly (2.90 [1.32] MPa) and least stiff anteriorly (1.80 [1.15] MPa). Conclusion: The nasal septum is thickest posteriorly, inferiorly, and along its bony edges. The septum is stiffest posteriorly, ventrally, and along its bony edges.

Double Columellar Strut: A New Method for Tip Surgery-A Study of 642 Cases with a 15-Year Follow-up

GOAL

Of the first nasal tip modeling procedures performed, the Anderson tripod concept is the most well known, and many anatomy-related studies have analyzed the components involved in tip surgery. The main goals of nasal tip surgery are to stabilize the tip complex, which largely affects the shape, projection and rotation of the nasal tip.

OBJECTIVE

The present study describes a new, original method, the double columellar strut and its main advantages compared to conventional techniques used for structural rhinoplasty.

METHODS

The study involved 642 patients (496 women and 146 men, with an average age of 38.67 years) who underwent surgery between 2004 and 2018 by two operators. The patients were re-examined to evaluate the outcomes at least 1 year after surgery, and long-term results (15 years) were recorded for the oldest patients in regard to esthetics (projection, shape, rotation) and breathing function.

RESULTS

Of the 642 patients, 34 required a surgical revision for minor defects of the tip due to asymmetry, and the natural appearance after the first surgery was not affected. For the primary rhinoplasties, there were no breathing disorders that required revision surgery due to systematic restoration or preservation of the middle third.

CONCLUSION

The double columellar strut could be performed in the same conditions that the others conventional structural grafts. As a polyvalent alternative, it can be used with closed or open approaches and involves the use of only a limited amount of cartilaginous material. This anatomical approach yields natural results, acting as a foundation for controlling the shape, projection and rotation of the nasal tip. In addition, with or without complementary techniques such as the "tongue-in-groove" technique or tip grafts, the double columellar strut can be considered a "multifunction pocket knife" for tip surgery.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Open Structure Approach to the European or Caucasian Nose

This article discusses common abnormalities found in the European or Caucasian nose. The treatments of the disorders via open structure rhinoplasty techniques are presented in a case-based manner. Multiple references are provided for further study of these techniques.

Evaluation of Nasal Tip Support in Septorhinoplasty

BACKGROUND

A good understanding of nasal tip support mechanisms is essential for achieving successful and functional rhinoplasty results. The loss of nasal tip support resulting from different maneuvers adopted during rhinoplasty and how this loss is affected by reconstructive applications should be known. This study evaluated and compared changes in nasal tip support perioperatively after different techniques were used during septorhinoplasty.

METHODS

Patients who underwent primary open rhinoplasty between January 2018 and March 2018 in a tertiary medical center were included in this prospective blind case series. Nasal tip resistance measurements were taken after perioperative maneuvers by creating enough force to achieve 1 mm, 2 mm and 3 mm of displacement at the tip region. Measurements were obtained during six different stages using a Newton meter: preoperatively, after caudal septal resection, after skin flap elevation, after the columellar strut or tongue-in-groove procedure, after tip suturing and postoperatively. Our hypothesis was that during septorhinoplasty, each maneuver used changes the tip support intraoperatively. The predictor variables were the different rhinoplasty techniques used. The outcome variable was nasal tip resistance to compression intraoperatively and immediate postoperatively. Appropriate statistics were computed, and a p < 0.05 value was considered significant.

RESULTS

Ten of the 15 patients were female, and 5 were male. The patient age ranged from 19 to 40 (mean 24.8 ± 4.9). The tongue-in-groove technique was applied in 5 of the patients, while columellar strut grafting was performed in 10. The application of columellar strut grafting did not create a significant increase in nasal tip support (p > 0.05). An increase in nasal tip support was observed at each stage (85%, 53%, 35%) after application of the tongue-in-groove technique (p < 0.05).

CONCLUSIONS

A novel and reproducible technique for digitally evaluating manual force is presented for determining changes in nasal tip support with different maneuvers applied in living patients undergoing rhinoplasty. No significant difference was noted between the preoperative and postoperative measurements for columellar strut grafting. The tongue-in-groove technique is an important maneuver that has a significant effect on nasal tip support. According to our data, the interdomal and intercrural ligaments, the medial crus-septum connections and the connections between alar cartilage and overlying skin and muscle tissue are important structures for tip support.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Changes in Nasal Tip and Lateral Nostril Characteristics After the Semi-Tongue-in-Groove Technique in Open Rhinoplasty Surgery

INTRODUCTION

This study aimed to evaluate postsurgical changes of nasal tip and lateral nostril characteristics after semi-tongue-in-groove (TIG) technique in open rhinoplasty surgery.

MATERIALS AND METHODS

This prospective observational study was performed in a before-after setting on 22 patients who underwent open rhinoplasty surgery using semi-TIG technique. Postoperative photographs were analyzed for nasal tip and lateral nostril changes at several time points (1, 4, and 12 weeks after surgery) and were compared with preoperative photographs. Nasal tip support change after the surgery was also assessed using a purpose-designed device.

RESULTS

In total, 22 patients were studied (20 females, 2 males). The tip support increased by 98%, 291.8%, and 377% at certain time points after the surgery. The tip rotation increased significantly at all measuring time points, postoperatively. The length of upper lip increased at all time points after semi-TIG technique. Columellar show and nostril length and height decreased significantly after the surgery.

CONCLUSION

The characteristics of the nasal tip and lateral nostrils along with nasal tip support showed significant improvement after the semi-TIG technique. Therefore, this technique is recommended in selected rhinoplasty cases to achieve more favorable objective results.

Effects of the Nasal Muscles on the Nasal Airway

Background

The nasal muscles and their function are not clearly defined. The nasal muscles generally are thought to act synergistically to produce mimetic motion and affect the nasal airway. We proposed direct examination of the effects of the nasal muscles on the nasal airway.

Methods

Rhinomanometry was performed on volunteers. After paralysis of the nasal muscles with lidocaine, rhinomanometry was performed again to measure nasal airway function with the patient at rest and attempting to flare his/her nostrils. Each patient's rhinomanometric results (at rest and attempting to flare the nostrils) taken before injection of lidocaine served as the control for comparison of his/her results postinjection. The structural tension of the ala at rest and with active flaring of the nostril was measured also, and the results pre- and postparalysis with lidocaine were compared.

Results

The data from both the stiffness (structural tension) and the airflow portions, taken together, support the following conclusions. First, the paralysis was significant, although not complete. Clinical and stiffness data supported complete paralysis. Airflow data, which we think most sensitive, support a statistically significant affect of the injection, although incomplete paralysis.

Conclusion

All of the evidence supports an important role for the nasal muscles when actively used to increase nasal airflow. Second, the majority of the evidence supports an important resting nasal muscle tension that opens the nasal airway.

Essential Anatomy and Evaluation for Functional Rhinoplasty

The nose, a prominent facial feature in defining facial beauty, is responsible for the fundamental physiologic functions of heating, humidifying, and filtering inspired air. When the normal balance of laminar and turbulent airflow become disturbed due to anatomic abnormalities, nasal obstruction may result. To successfully restore these basic physiologic functions, the surgeon must have a detailed understanding of the nasal anatomy and be able to successfully identify the specific cause of the nasal obstruction. This article discusses the fundamental surgical anatomy and the various diagnostic techniques and instruments at the surgeon's disposal.

Association of Lateral Crural Overlay Technique With Strength of the Lower Lateral Cartilages

IMPORTANCE

The lateral crural overlay technique is a powerful technique for altering nasal tip projection and rotation. By overlapping and thus shortening the lateral crura, the nasal tip is shortened and rotated upward, thus decreasing projection and increasing rotation. There is no data to show the association of this technique with the strength of the lower lateral cartilage. Strengthening of the lower lateral cartilages would presumably lead to resistance to external nasal valve collapse and improved airway.

OBJECTIVE

In this cadaver study, we set out to determine the differences in the strength and resilience of the lateral crura after performing lateral crural overlay using 2 different techniques.

DESIGN, SETTING, AND PARTICIPANTS

Seven individual lower lateral cartilages were harvested from 6 cadavers for analysis. Each of the 7 cartilages was included sequentially in 3 test groups in the following order: a preprocedure group (preP), a postprocedure group (postP) in which the lateral crural overlay technique was performed, and a postprocedure with glue group (postPG) in which cyanoacrylate glue was added to the postP cartilages to simulate cartilage healing. A force gauge was used to measure the force required to deflect the lower lateral cartilages distances from 1 to 6 mm.

MAIN OUTCOMES AND MEASURES

Differences measured in newtons (N) for strength and resilience of lateral crura between the preP, postP, and postPG groups.

RESULTS

A statistically significant increase in lower lateral cartilage resilience was noted between the preP and postPG groups at all distances of tip deflection (1 mm, 0.20 vs 0.70 N; P < .001; 2 mm, 0.26 vs 1.13 N; P < .001; 3 mm, 0.31 vs 1.53 N; P < .001; 4 mm, 0.41 vs 2.05 N; P < .001; 5 mm, 0.68 vs 2.60 N; P < .001; 6 mm, 1.49 vs 3.26 N; P = .03). There was a statistically significant difference between the postP and postPG groups in the amount of force required to deflect the cartilages 1 to 5 mm (1 mm, 0.24 vs 0.70 N; P < .001; 2 mm, 0.34 vs 1.13 N; P < .001; 3 mm, 0.51 vs 1.53 N; P < .001; 4 mm, 0.77 vs 2.05 N; P < .001; 5 mm, 1.32 vs 2.60 N; P = .01), but not 6 mm (2.33 vs 3.26 N; P = .31).

CONCLUSIONS AND RELEVANCE

The lateral crural overlay technique affords increased strength and resilience to the lateral crura of the lower lateral cartilages, which should in turn decrease the likelihood of external nasal valve collapse postoperatively.

LEVEL OF EVIDENCE

NA.

Assessment of Aesthetic Results of 100 Patients Who Underwent Rhinoplasty-Rhinoplasty Outcome Evaluation

BACKGROUND

To assess the long-term aesthetic results of rhinoplasty and predict the final outcome.

METHODS

The sample was composed of 100 patients (34 men and 66 women) between 23 and 57 years old (mean, 34.8) operated on exclusively for aesthetic reasons. The time elapsed from the operation ranged from 3 to 13 years with a mean of 6.8 years. The study used Rhinoplasty Outcome Evaluation questionnaire, a simple, reliable, validated, and widely used inventory.

RESULTS

The vast majority of patients (93%) were satisfied postoperatively with scores > 50% (67 patients had scores > 80%). Only 7 patients had scores less than 50%. The mean score was 82.4 ± 1.7% with a median of 87%. In addition, it seems that the results of the operation remain high through time with a small decline along age groups and years elapsed. Women were found more satisfied than men (P = 0.03).

CONCLUSIONS

The study concludes that the results of aesthetic rhinoplasty, if performed by skilled and experienced surgeons, are very satisfying and stable throughout time.

Estimation of Nasal Tip Support Using Computer-Aided Design and 3-Dimensional Printed Models

IMPORTANCE

Palpation of the nasal tip is an essential component of the preoperative rhinoplasty examination. Measuring tip support is challenging, and the forces that correspond to ideal tip support are unknown.

OBJECTIVE

To identify the integrated reaction force and the minimum and ideal mechanical properties associated with nasal tip support.

DESIGN, SETTING, AND PARTICIPANTS

Three-dimensional (3-D) printed anatomic silicone nasal models were created using a computed tomographic scan and computer-aided design software. From this model, 3-D printing and casting methods were used to create 5 anatomically correct nasal models of varying constitutive Young moduli (0.042, 0.086, 0.098, 0.252, and 0.302 MPa) from silicone. Thirty rhinoplasty surgeons who attended a regional rhinoplasty course evaluated the reaction force (nasal tip recoil) of each model by palpation and selected the model that satisfied their requirements for minimum and ideal tip support. Data were collected from May 3 to 4, 2014.

RESULTS

Of the 30 respondents, 4 surgeons had been in practice for 1 to 5 years; 9 surgeons, 6 to 15 years; 7 surgeons, 16 to 25 years; and 10 surgeons, 26 or more years. Seventeen surgeons considered themselves in the advanced to expert skill competency levels. Logistic regression estimated the minimum threshold for the Young moduli for adequate and ideal tip support to be 0.096 and 0.154 MPa, respectively. Logistic regression estimated the thresholds for the reaction force associated with the absolute minimum and ideal requirements for good tip recoil to be 0.26 to 4.74 N and 0.37 to 7.19 N during 1- to 8-mm displacement, respectively.

CONCLUSIONS AND RELEVANCE

This study presents a method to estimate clinically relevant nasal tip reaction forces, which serve as a proxy for nasal tip support. This information will become increasingly important in computational modeling of nasal tip mechanics and ultimately will enhance surgical planning for rhinoplasty.

LEVEL OF EVIDENCE

NA.

Quantifying Optimal Columellar Strut Dimensions for Nasal Tip Stabilization After Rhinoplasty via Finite Element Analysis

IMPORTANCE

The contribution of columellar strut grafts (CSGs) to nasal tip support has not been determined via structural mechanics. Optimal graft dimensions have yet to be objectively determined.

OBJECTIVES

To use a finite element model (FEM) of the human nose to (1) determine the effect of the CSG on nasal tip support and (2) identify how suture placement contributes to tip support.

DESIGN, SETTING, AND PARTICIPANTS

A multiple-component FEM of the human nose consisting of bone, skin/soft tissue, and cartilage was rendered from a computed tomographic scan. Then, CSGs of varying sizes were created, ranging from 15 × 4 × 1 mm to 25 × 8 × 1 mm, and placed in the model between the medial crura. Two FEMs were constructed for each strut size: (1) CSGs that were physically attached to the nasal spine, medial crura, and caudal septum and (2) CSGs that were not in direct contact with these structures and free to move within the soft tissue. A control model was also constructed wherein no graft was placed.

MAIN OUTCOMES AND MEASURES

Nasal tip support for each model was assessed, and the resultant distribution of von Mises stress, reaction force, and strain energy density with respect to the alar cartilages were calculated.

RESULTS

Compared with the control, the reaction force increased with increasing strut volume, while the strain energy density (calculated over the alar cartilages) generally decreased with increasing CSG volume. Simulations with struts that had suture attachments along the entire length of the graft generated a larger reaction force than the models without any suture attachments. Models with anteriorly placed sutures generated reaction forces similar to that of the fully sutured model, whereas the models with posterior sutures showed reaction forces similar to the fully disconnected model.

CONCLUSIONS AND RELEVANCE

Insertion of CSGs does effect the amount of force the nasal tip can withstand post rhinoplasty. Moreover, anteriorly placed sutures incur reaction forces similar to struts that are fully connected to the alar cartilage. Thus, our simulations are congruent with clinical practice in that stability increases with graft size and fixation, and that sutures should be placed along either the entire CSG or the anterior most portion for optimal support.

LEVEL OF EVIDENCE

NA.

Quantifying Changes in Nasal Tip Support

IMPORTANCE

Imparting surgical change to the nasal tip remains one of the most challenging aspects of rhinoplasty. The surgeon must assess the tip preoperatively and execute the necessary maneuvers to impart the desired change.

OBJECTIVE

To assess nasal tip resistance to compression in a cadaveric model before and after specific rhinoplasty maneuvers using a novel method.

DESIGN, SETTING, AND MATERIALS

Open rhinoplasty maneuvers were performed at an academic tertiary care center on 6 fresh-thawed cadaver heads. Assessment of tip support was performed with a motorized, computer-controlled test stand equipped with a digital load cell. Tip support was assessed by compression to a depth of 2.5 mm from contact both preoperatively and after each surgical maneuver. All force data were recorded in pound-force and converted to newtons (N) following analysis.

MAIN OUTCOMES AND MEASURES

Nasal tip support, measured as resistance to compression, before and after various rhinoplasty maneuvers.

RESULTS

Following the elevation of the skin-soft-tissue envelope with septoplasty, resistance to compression (1.82 N) was not significantly different from the preoperative assessment (1.60 N for all specimens). Tip support following placement of a caudal extension graft was significantly different from all other conditions (3.16 N; P < .01), showing support increased by more than 66% from preoperative assessment. Placement of columellar strut (1.28 N) did not show significant increase in tip support. Tip support was decreased slightly after placement of intradomal sutures, which was significant (1.22 N; P < .01).

CONCLUSIONS AND RELEVANCE

This study demonstrates the use of materials testing equipment to assess and quantify change in tip support after several rhinoplasty maneuvers. Minor supporting maneuvers that rely on healing and scar do not significantly alter tip support in a cadaveric model. Caudal extension graft is an important maneuver imparting significant effect on nasal tip support.

LEVEL OF EVIDENCE

NA.

Dynamometric Analysis of Normative Auricular Stiffness and Comparison With Operated Prominent Ears

AIM

Stiffness of the auricular cartilage is the main determining factor for the choice of operative technique of the prominent ear deformity. The aim of this study is to evaluate the stiffness of normal appearing ears objectively and quantitatively, compare the results with the operated prominent ear patients, and present prospective short-term dynamometric evaluation of the operated prominent ear patients.

PATIENTS AND METHODS

A total of 190 volunteers without ear deformities were recruited and 9 age groups were formed: group (5-9), group (10-14), group (15-19), group (20-24), group (25-29), group (30-34), group (35-39), group (40-49), and group (50+). Total 28 ears (14 patients) with otoplasty were included in the study as group (operated 5-9) and group (operated 10-14). In addition, 3 patients with prominent ear deformity were prospectively followed for dynamometric changes that occur with otoplasty operation. The auriculocephalic angle (ACA) was measured once and auricle to scalp distance was measured at 4 different standardized levels. Ear stiffness was measured on each ear individually at 4 different points over the antihelix using digital computer-aided dynamometry. Each ear was compared in terms of ACA, distance, and dynamometric values.

FINDINGS

Dynamometric values tend to increase with age, which increase and peak around 35 years of age and declines after 40 years of age. Measurements of the first 2 age groups were statistically different compared with the other groups. Postoperative dynamometric measurements (DNM) of group (operated 5-9) were similar with normative values of group (5-9) and postoperative satisfaction visual analogue scale (VAS) score was 92.8%. Postoperative DNM of group (operated 10-14) were higher compared with normative values of group (10-14) for each different measuring level and the postoperative satisfaction VAS score was 75.3. A total of 3 patients with prominent ears had lower dynamometric values preoperatively; these values approached closer to normative values of their age group postoperatively.

CONCLUSIONS

Results show that auricular cartilage stiffens and malleability decreases with increased age. This stiffness peaks in the 35-39 age group and declines after 40 years of age. Dynamometric values increase, at all levels, suggesting increased cartilage stiffness is related to age. In the scope of these results, cartilage sparing techniques are more suitable for 5 to 14 years of age and cartilage-cutting techniques are more suitable for older patients.

Structural grafts and suture techniques in functional and aesthetic rhinoplasty

Rhinoplasty has undergone important changes. With the advent of the open structure approach, requirements for structural grafting and direct manipulation of the cartilaginous skeleton through suture techniques have increased substantially. The present review analyzes the current literature on frequently referenced structural grafts and suture techniques. Individual techniques are described and their utility is discussed in light of available studies and data.

The tripod theory of nasal tip support revisited: the cantilevered spring model

OBJECTIVE

To extrapolate on the tripod concept to create a more universal and multiethnic model that includes common anatomical configurations and strategies to avoid certain unwanted surgical outcomes.

METHODS

Analysis of current surgical methods, scientific studies, and predominant theories to produce a new model of nasal tip support based on the biomechanical properties of the nasal cartilages.

RESULTS

The nasal tip acts as a cantilevered spring that associates with other rigid and semirigid regions of the nose. Application of these concepts resulted in preservation of projection and tip rotation in appropriately selected patients.

CONCLUSION

The cantilevered spring tripod provides a more universal model for explaining nasal tip dynamics in a contemporary multiethnic population of patients seeking functional or cosmetic rhinoplasty correction.

Defining nasal cartilage elasticity: biomechanical testing of the tripod theory based on a cantilevered model

OBJECTIVE

To define the modulus of elasticity for nasal septum, auricular, upper lateral, and lower lateral cartilages.

METHODS

Prospective enrollment of sequential patients undergoing septorhinoplasty. Test samples were obtained through routine surgical interventions using atraumatic harvesting techniques. The modulus of elasticity was determined using a customized biomechanical testing device. A clinical analysis of nasal tip strength and "ethnic" nasal categorization was performed.

RESULTS

Five sequential patients were enrolled; 4 underwent biomechanical testing of harvested cartilage. All 4 patients were classified as having a leptor-rhine nasal architecture. The modulus of elasticity for the lower lateral cartilages was 1.82 to 15.28 MPa. Values for auricular, nasal septum, and upper lateral cartilages (medial and caudal) were also determined.

CONCLUSIONS

This is the first biomechanical study performed on human auricular, lower lateral, and upper lateral cartilages. The elastic modulus can be determined from samples obtained during routine septorhinoplasty. The modulus of elasticity for all areas was significantly higher than values previously demonstrated for bioengineered elastic cartilage and carved human nasal septal specimens. Shaving the lateral portions of the nasal septum may significantly reduce tensile strength, which may affect graft performance in vivo. Further refinement of testing methods and an increase in the number of analyzed samples are required for formal statistical analysis and further determination of clinical relevance in different nasal subtypes.