Lengthening the short nose

The External Rhinoplasty Approach

The nose is a complex three-dimensional structure with critical structural and functional roles; its relationship to surrounding structures is, in part, responsible for a harmonious, pleasing visage as a whole. There are many variables and dimensions that can be adjusted to alter the esthetic appearance, structural components, and functional role of the nose and many tools and maneuvers available to the rhinoplasty surgeon to adjust these numerous variables. Although every rhinoplasty operation should be individualized, a systematic order and algorithm may be helpful in operative planning as well as establishing a logical progression of steps and maintaining stability. While each adjustment may have a primary anticipated effect, it will invariably have a secondary impact.

The Use of Expanded Polytetrafluoroethylene in Short Nose Elongation: Fourteen Years of Clinical Experience

BACKGROUND

Short nose elongation is a relatively common rhinoplasty procedure, especially in Asia. The selection of the adequate graft material is challenging. Previous reports have described the application of expanded polytetrafluoroethylene (ePTFE) for dorsal augmentation rhinoplasty, but studies using ePTFE for nose elongation are lacking. We propose ePTFE as an alternative treatment for short noses, describe the technique, and discuss outcomes, patient selection, and complications based on our 14-year experience.

METHODS

From February 2003 to December 2016, 206 patients with varying degrees of short noses were included in this retrospective study. All patients underwent nose elongation surgery using an ePTFE implant. Nasal lengths before and after surgery were measured using a 3-dimensional simulation technology. Outcomes and complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey.

RESULTS

Nasal elongation was successfully achieved using ePTFE. Mean increase in nasal length was 4.36 ± 0.85 mm. The mean follow-up period was 13.3 months, ranging from 6 months to 8 years. Follow-up examinations demonstrated stable results. The overall complication rate was 6.8%. Complications included infection, implant extrusion, migration, deviation, visibility, and/or prominence, tissue reaction, and reddening of the nasal skin. Most patients (93.6%) rated their outcome as improved and much improved.

CONCLUSIONS

Nasal elongation using ePTFE implantation is a feasible therapeutic approach for patients with short noses. Reliable outcomes and the absence of donor site morbidity contribute to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

Late Correction of Traumatic Nasal Deformities: A Surgical Algorithm and Experience in 120 Patients

BACKGROUND

Traumatic nasal deformities have a wide spectrum of presentations, which further complicates their management and preoperative planning. Although many methods and algorithms have been proposed for management of specific posttraumatic nasal deformities, such as twisted, deviated, saddle, or short nose, these algorithms usually focus on a specific deformity in isolation from the remainder of the nose.

OBJECTIVES

The aim of this study is to present an algorithm for traumatic nasal deformities and to evaluate the functional and aesthetic outcomes of this new algorithm by a preoperative and postoperative quality-of-life questionnaire.

METHODS

Patients with traumatic nasal deformity were operated on according to our surgical algorithm. Preoperative and postoperative Rhinoplasty Outcome Evaluation (ROE) scores, which is a rhinoplasty outcome survey, were evaluated.

RESULTS

A total of 120 patients were included in the study. The mean preoperative ROE score was 3.3 ± 1.9 and mean postoperative ROE score was 20.4 ± 3.2. There was a statistically significant difference between preoperative and postoperative ROE scores (P < 0.001). There was a negative, mild to moderate, statistically significant correlation between preoperative scores and benefit (difference between postoperative and preoperative scores) (r = -0.465, P < 0.001), which means patients with lower scores had more improvement from the surgery. During the follow-up period, relapse of deviation, hypertrophic inferior turbinate, and intranasal synechia were found in 9% (n = 11), 6.6% (n = 8), and 3.3% (n = 4) of patients, respectively.

CONCLUSIONS

In this study, a comprehensive surgical algorithm applicable to all traumatic nasal deformities is suggested, and the results of 120 patients with traumatic nasal deformities are presented.

LEVEL OF EVIDENCE 2

Use of Irradiated Homologous Costal Cartilage in Rhinoplasty: Complications in Relation to Graft Location

BACKGROUND

Nasal septal cartilage and conchal cartilages are preferred sources of grafts in augmentation rhinoplasty. Rib cartilage can also be used, but it may evoke a patient's concerns about a scar and an extensive surgery. In such cases, irradiated homologous costal cartilage (IHCC) can be a useful alternative. However, controversy still exists in many literatures regarding complications with use of IHCC. Therefore, the authors reviewed our experiences with IHCC in rhinoplasty and analyzed the complications in relation to graft location.

METHODS

A retrospective chart review was made of all patients who underwent rhinoplasty with IHCC between 2007 and 2015. A total of 323 patients were included. The authors considered the cases that required revision surgery for external aesthetic changes as complications. The authors defined major complications, including resorption, infection, fracture, or warping.

RESULTS

The total complication rate was 8%. Two fractures (0.6%), 4 fragmentation (1.2%), 4 resorptions (1.2%), 4 infections (1.2%), and 2 warpings (0.6%) were noted. Most of these complications occurred for the septal extension graft. Other complications, including 1 nasal obstruction, 2 visible contours, 3 caudal septal deviations, and 4 cases of unfavorable results (patient unsatisfactions), were noted.

CONCLUSIONS

Based on the outcomes of this study, the authors concluded that IHCC is a useful and reliable source of cartilage graft and can serve as an alternative graft material for rhinoplasty. However, care must be taken in use of IHCC graft in areas under tension such as septal extension graft, though its complication rate is low.

Tip-Oriented Closed Rhinoplasty Built on Septocolumellar Suture and a New Caudal Septal Graft Technique

BACKGROUND

A beautiful and appealing nose receives the greatest contribution from the nasal tip subunit, which should be regarded as the primary center of attention during a rhinoplasty procedure. In achieving the desired shape and position of the nasal tip during closed rhinoplasty, the septocolumellar suture functions as the major determinant together with the caudal portion of the septal cartilage, which has a significant influence on the versatility of the septocolumellar suture. The purpose of this study was to present the analysis of the indications, the technical steps, and the advantages of caudal septal graft and septocolumellar suture utilization in closed rhinoplasty.

METHODS

The septocolumellar suture with or without the caudal septal graft combination procedure has been performed in 2286 patients via a closed rhinoplasty approach. Intraoperatively, the septal cartilage at hand was thoroughly evaluated and one of the 5 types of caudal septal grafts was used when necessary. After the establishment of a strong and straight septal cartilage with sufficient height and length, 4 different septocolumellar sutures in a specific order were used to modify the relationship between the lower lateral cartilages and the nasal septum.

RESULTS

Of the 2286 cases, 1837 (80.3%) were primary and 449 (19.7%) secondary rhinoplasties, which have been followed up for 9 to 48 months. The caudal septal graft was combined to the septocolumellar suture in 621 (27.1%) patients. Of the caudal septal grafts, 69.7% were used for primary rhinoplasty cases, and 30.3% for secondary rhinoplasties. At the 18th month postoperatively, tip projection was found to be satisfactory for 98% of the patients.

CONCLUSIONS

The septocolumellar suture combined with caudal septal graft in closed rhinoplasty substantially facilitates the achievement of a cosmetically and functionally pleasing end result, bringing the solution for a wide array of problems such as short nose, supratip deformity, nasolabial angle change, or columellar bowing. Nevertheless, the technique has a steep learning curve; therefore, a meticulous preoperative evaluation should be exerted, a precise surgical planning should be prosecuted, and an excessive reduction of the nasal tip or exaggerated columellar retraction should be avoided.

Oriental nose elongation using an L-shaped polyethylene sheet implant for combined septal spreading and extension

BACKGROUND

The currently recommended strategies for short nose elongation were designed primarily for the Caucasian nasal framework. For Oriental patients, more elongation often is required because a hypoplastic septal cartilage requires more elongation, resulting in a higher risk of complications. This report proposes a modified technique for Oriental nose elongation, which adjusts the pressure points after nasal elongation using an L-shaped implant.

METHODS

Between January 2007 and December 2009, 58 patients underwent Oriental nose elongation using an L-shaped, porous, high-density polyethylene sheet implant. Augmentation rhinoplasty and conchal cartilage shield grafts were performed depending on the nasal shape. Pre- and postoperative nasal length, height, and projection as well as columella-labial angle, columella-lobular angle, and nasal tip angle were measured and compared. A patient satisfaction survey was performed postoperatively. All occurring complications were recorded.

RESULTS

The postoperative nasal length was significantly elongated from 47.0±10.4 mm to 49.3±10.1 mm (p=0.003), and the nasal height increased significantly from 48.5±9.1 mm to 50.4±8.5 mm (p=0.011). The initially obtuse columella-labial angle improved significantly from 100.8°±12.1° to 92.5°±15.5° (p=0.014). No significant changes were found regarding nasal projection, nasal tip angle, or columella-lobular angle. The majority of the patients (91.3%) were highly satisfied or satisfied with the aesthetic results. A major complication in terms of implant exposure was observed in one case. The minor complications included stiffness of the nasal tip (3 patients) and tip redness (1 patient).

CONCLUSIONS

In Oriental nose elongation, the use of an L-shaped graft is a feasible and safe treatment option that allows for an excellent aesthetic outcome and reduces the incidence of complications.

LEVEL OF EVIDENCE V

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Secondary Asian rhinoplasty: lengthening the short nose

BACKGROUND

Short nose deformity results from primary short nose, previous rhinoplasty, or trauma. A septal extension graft using rib cartilage can be placed to address this deformity. Indications for this procedure include previously damaged septal cartilage, innate septal issues, saddle nose deformity, skin problems, and secondary deformities of the cleft lip and nose.

OBJECTIVES

The authors describe their experience using rib cartilage grafts for septal extension to correct short nose deformity in Asian patients.

METHODS

From January 2005 through February 2010, the authors used a rib cartilage graft for septal extension in 38 consecutive Asian rhinoplasty patients with primary (n = 5) or secondary (n = 33) short nose deformity. In cases where the septum had been overresected in a previous rhinoplasty, a reinforcement procedure was performed using additional supportive rib cartilage grafts.

RESULTS

The mean duration of follow-up was 2.5 years. Of the 38 treated patients, 7 were male and 31 were female (mean age, 28.5 years). A single septal extension graft with rib cartilage was used in 32 cases, whereas a double graft was used in 6 cases. The average external lengthening of the nose from nasal root to tip was 8 mm. All patients were satisfied with the shape of the lengthened nose. There was 1 case of pneumothorax, but complications were otherwise rare. Neither cartilage exposure nor infection was observed.

CONCLUSIONS

The authors have obtained good aesthetic results using a rib cartilage graft for septal extension in the treatment of short nose. This technique may be particularly useful in cases where the septal cartilage is unavailable for harvest because of previous rhinoplasty or trauma.