The miniature lateral crural strut graft: Efficacy of a novel technique in tip plasty

Combining Preservation and Structural Rhinoplasty

Structural preservation rhinoplasty (SPR) uses structural methods and dorsal preservation. SPR approaches include (1) dorsal preservation techniques coupled with structural approaches to the lower third/nasal tip complex; (2) use of structural methods to convert a nasal dorsum to a preservation candidate; (3) preservation ideology applied to structural tip pasty, emphasizing suture modification and limited resection; (4) minimization of the degree of soft tissue disruption at the middle vault and dorsum in preservation and structural cases; (5) modified dorsal preservation techniques in which some components of the nasal dorsum are treated with structural methodology while others are treated with preservation methods.

Improving the Supraalar Groove Aesthetic Subunit and Lateral Crura Convex-Concave Deformity

BACKGROUND

Lateral crura surface problems are one of the most difficult challenges in nose tip surgery. Closed preservation rhinoplasty (CPR) is a revolutionary concept that keeps nose tip flexibility and elasticity. By solving lateral crura surface problems and keeping tip flexibility the surgeon will accomplish a sharper supraalar groove transition between the dorsum and the tip.

OBJECTIVES

The convex-concave lateral crura deformity (CCLCD) or S-shaped lateral crura is one of the biggest constraints to accomplishing a beautiful tip and dorsum-tip transition (DTT). This deformity is the reason for the commonly called parenthesis deformity of cephalic malposition. This LLC convex-concave shape creates a C-shaped shadow. This DTT is one of the key areas for accomplishing natural results, and it depends on different nose structures, not just the lower lateral cartilages (LLC).

METHODS

A total of 560 rhinoplasty cases were studied retrospectively between September and December 2023. Three hundred and twenty patients had at least 1 year of follow-up. Patients had follow-up at 2 weeks, 1 month, 3 months, 6 months, and 1 year after surgery. No secondary rhinoplasty was included. Only 2 secondary septoplasty cases were included, without any nose skin undermining in the previous surgery. Surgical details were documented, including the 6 fundamental steps of this technique: (1) mucosal lower lateral incision, (2) dorsum subperichondral dissection and vertical scroll release, (3) lateral crura tail caudal release, lateral crura steal and slide-under flap lateralization, (4) upper lateral caudal resection, (5) vertical scroll reconstruction, and (6) turning point extension graft.

RESULTS

Three hundred and twenty patients had at least 1 year of follow-up. In total, 516 patients underwent a closed approach and 47 patients an open approach. All patients had subperichondral dissection of the hump envelope. All patients who underwent a closed approach had a low-strip letdown dorsal preservation technique. All patients who underwent an open approach had a structural technique with spreader flaps or grafts at the keystone area. All the patients underwent osteotomies with a piezoelectric device. Twenty-three revisional surgeries were necessary.

CONCLUSIONS

CPR taught us how important ligament and soft tissue preservation are. We learned that the less damage you do to the nose soft tissues and scaffold, the less support you need for it. Surgeons have been overgrafting the lateral crura to solve postoperative problems mainly because of dissection problems and lack of lateral crura support. This paper describes how to solve lateral crura surface problems, keeping the tip flexible and elastic, and also creating a nice and natural supraalar groove transition, by applying 6 surgical maneuvers.

LEVEL OF EVIDENCE: 4 (THERAPEUTIC)

Patient Outcomes in Lateral Crural Repositioning and Reconstruction in Revision Rhinoplasty

Background: In revision rhinoplasty, lateral crural repositioning/reconstruction is considered a complex maneuver. The aim of this study is to measure patient outcomes after lateral crural repositioning/reconstruction in revision rhinoplasty. Methods: In this retrospective case series, patients who underwent revision rhinoplasty with lateral crural repositioning/reconstruction for functional, cosmetic, or combined purposes were reviewed. Preoperative Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) scores, functional and cosmetic visual analog scales (VAS-functional [F] and VAS-cosmetic [C]), and lateral wall insufficiency (LWI) grades were compared with their respective postoperative scores. Results: Forty-two patients were identified who underwent lateral crural repositioning. The mean postoperative follow-up for ≤6 months (PO1) and >6 months (PO2) was 3.1 (standard deviation [SD] 1.7) and 11.5 (SD 5.3) months, respectively. At both postoperative periods, significant improvement (p < 0.05) in patient-reported outcomes was observed in mean SCHNOS-Obstruction, SCHNOS-Cosmesis, VAS-F, and VAS-C scores. The postoperative changes in LWI scores (Δ) were significant on both sides at zone 1 at PO1 (p < 0.05) and PO2 (p < 0.05), and at PO2 on the left side (p < 0.05) only, for zone 2. Conclusion: Lateral crural repositioning with reconstruction is an effective maneuver in revision rhinoplasty in a subset of patients and specifically helps to improve nasal tip aesthetics while preserving function.

State of the Evidence for Preservation Rhinoplasty: A Systematic Review

Preservation rhinoplasty encompasses a number of techniques that minimize disruption of the native cartilaginous and soft tissue nasal architecture. These techniques have gained popularity resulting in an increase in publications relevant to preservation rhinoplasty. However, many studies that present patient outcomes are of low-level evidence and do not incorporate validated patient-reported outcome measures. While these studies do consistently report positive outcomes, there are few high-level comparative studies that support the theoretical benefits of preservation relative to structural rhinoplasty. As contemporary preservation rhinoplasty techniques will continue to evolve and become incorporated into clinical practice, there will be the need for parallel emphasis on robust clinical studies to delineate the value of these methods.

Surgical treatment of dynamic nasal collapse

Nasal obstruction is a prevalent issue that significantly impacts patient quality of life and contributes to a large-scale financial burden. Internal or external nasal valve collapse may play a role in nasal obstruction, with varying etiologies. Surgical correction of nasal valve collapse is indicated when septal and/or turbinate surgery alone are not sufficient in correcting the nasal obstruction. The choice of how to address nasal valve repair depends on presenting findings, associated aesthetic concerns, particularly of the nasal tip, patient anatomy, and surgeon preference. This article provides a methodical approach to the diagnosis of nasal valve collapse, indications for repair, and provides detailed explanation of the operative techniques used to address nasal valve collapse, while also discussing the advantages and disadvantages of each approach.

Effects of Functional Rhinoplasty on Nasal Obstruction: A Meta-Analysis

BACKGROUND

Functional rhinoplasty (FRP) is used to improve nasal ventilation by correcting problems with the nasal valves. It has not been systematically reviewed on a large scale.

METHODS

A comprehensive literature search was conducted in the PubMed, EMBASE, and Cochrane Library databases to identify studies evaluating nasal obstruction before and after functional rhinoplasty in patients with nasal valve problems.

RESULTS

A total of 57 cohorts from 43 studies involving 2024 patients were included in the current meta-analysis. The Nasal Obstruction Symptom Evaluation (NOSE) scores indicated significant improvement in nasal obstruction at the 1-month follow-up (WMD = 38.12; 95% CI, 29.15-47.10; I²= 83.6%; P = 0.00), 3-month follow-up (WMD = 48.40; 95% CI, 43.16-53.64; I²= 69.1%; P = 0.00), 6-month follow-up (WMD = 44.35; 95% CI, 36.65-52.04; I²= 96.6%; P = 0.00), 12-month follow-up (WMD=43.07; 95% CI, 26.56-59.58; I²= 97.9%; P = 0.00), and the last follow-up (WMD = 46.90; 95% CI, 43.92-49.88; I²= 95.9%; P = 0.00) with respect to the preoperative baseline. The Visual Analogue Scale (VAS) scores indicated a similar trend at the 1-month follow-up (WMD = 4.68; 95% CI, 3.79-5.57; I²= 86.8%; P = 0.00), 3-month follow-up (WMD = 4.46; 95% CI, 3.19-5.74; I²= 93.3%; P = 0.00), 6-month follow-up (WMD = 4.91; 95% CI, 4.04-5.78; I²= 88%; P = 0.00) and last follow-up (WMD = 4.22; 95% CI, 3.12-5.32; I²= 97.1%; P = 0.00). Nasal obstruction was obviously relieved through rhinomanometry (SMD=0.56; 95% CI, 0.27-0.84; I²= 0.0%; P = 0.00) but not through peak nasal inspiratory flow (PNIF) (SMD=-1.51; 95% CI, -3.10 to 0.07; I²= 98.9%; P = 0.09).

CONCLUSION

FRP may have a positive effect on nasal obstruction caused by nasal valve problems. Broader and well-designed studies are needed to shed more light on the relationships in this area.

LEVEL OF EVIDENCE III

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 .

Dorsal Preservation Rhinoplasty: Method and Outcomes of the Modified Subdorsal Strip Method

There has been particular recent interest in dorsal preservation rhinoplasty techniques because of claims of superior functional and aesthetic results relative to conventional hump reductions. The septum in dorsal preservation rhinoplasty is managed in a variety of ways with differences largely based on the location of septal excision (subdorsal resection, midseptal resection, and inferior septal resection). The technical considerations of a modified subdorsal strip method using a structural preservation technique are described. This technique maintains a subdorsal and caudal strut of cartilage. Patient-reported measures demonstrate significantly improved functional and aesthetic outcomes postoperatively with this procedure.

Effect of Lateral Crural Procedures on Nasal Wall Stability and Tip Aesthetics in Rhinoplasty

OBJECTIVES/HYPOTHESIS

To evaluate the lateral nasal wall stability, nasal function, and cosmesis when creating an aesthetically pleasing nasal tip subunit utilizing lateral crus (LC) altering procedures.

STUDY DESIGN

Retrospective cohort.

METHODS

In this retrospective cohort study, cosmetic rhinoplasty patients undergoing LC procedures with available lateral wall insufficiency (LWI) scores were included. An LWI grading system was used to evaluate internal (zone 1) and external (zone 2) nasal valves objectively. Secondarily, Nasal Obstruction Symptom Evaluation (NOSE) Score, Visual Analog Scale (VAS) and Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) results were evaluated. Based on the LC intervention, the cohort was divided into six groups: lateral cural strut graft (LCSG), mini-LCSG, lateral crural overlay (LCO) with and without additional support, cephalic trimming, and cephalic turn-in flaps.

RESULTS

Subjects undergoing LCO with and without support, LCSG, and mini-LCSG showed significant improvement in zone 1 LWI (P = .042, P = .041, P < .001, and P < .001, respectively), while cephalic trimming and turn-in/hinged flaps had no effect. Subjects undergoing LCO with support and LCSG showed significant improvement in zone 2 LWI (P = .022, P = .004), while LCO without support, mini-LCSG, cephalic trimming, and turn-in flaps showed no effect on LWI. The SCHNOS-C and VAS-C showed significant improvement in all subgroups (P < .05) when comparing pre- to postoperative values. Alar-spanning sutures did not significantly change zone 1 scores but did conceal zone 2 improvements in LCSG and LCO with support groups.

CONCLUSIONS

Selected LC procedures are robust techniques for improving tip cosmesis independently without compromising nasal lateral wall stability. Some LC procedures can improve nasal valves patency in tip surgery. Laryngoscope, 131:E1830-E1837, 2021.

Impact of rapid palatal expansion on the internal nasal valve and obstructive nasal symptoms in children

OBJECTIVE

The aim of this study is to evaluate the impact of rapid palatal expansion (RPE) on the nasal airway subjectively by utilizing patient-reported outcome measures (PROM) and objectively by evaluating validated internal nasal valve (INV) measurements obtained from cone beam computed tomography (CBCT) in pediatrics.

MATERIALS AND METHODS

In this retrospective cohort study, subjects who underwent RPE from March to December 2018 with cone beam CT and Nasal Obstruction Symptom Evaluation (NOSE) scores were included. Exclusion criteria included craniofacial deformity, allergies, asthma, recent nasal trauma, or surgery. INV measurements (angle and cross-sectional area), diastema, midpalatal suture opening, and NOSE scores were evaluated.

RESULTS

Fifty-one subjects met the inclusion criteria with a mean age of 10.1 ± 2.6. Pre-expansion mean NOSE score was 32.55 (moderate) while post-expansion was 13.92 (mild). Mean NOSE score improved significantly by an average of 18.63 following post-expansion (P < 0.0001). The patients' right and left INV angles increased significantly by a mean of 2.42° and 2.65° respectively (P < 0.0001). Right and left INV cross-sectional areas increased significantly by an average of 14.35 mm² (P < 0.0001) and 14.17 mm² (P < 0.0001) respectively. An average expansion of the diastema and the suture was 1.60 mm and 3.05 mm respectively (P < 0.0001), with an average of 6.29 mm of expansion. We found the amount of diastema expansion to correlate with change in NOSE score (R = - 0.32, P = 0.022). Age and diastema showed a negative correlation (R = - 0.44, P = 0.0019), while INV angle and diastema showed a statistically significant positive correlation (R = 0.28, P = 0.048).

CONCLUSIONS

RPE showed improvement in both NOSE scores and objective measures of the INV. This may show the possibility of considering RPE in managing resistant pediatric nasal airways. Future studies should include collaboration with pediatric otolaryngologists, with the inclusion of pediatric patients with persistent nasal obstruction.