Columella lengthening in nasal tip plasty of Orientals

Tip extension suture: a new tool tailored for Asian rhinoplasty

BACKGROUND

Recent changes in the release and rebuilding of the tripod structure during Asian rhinoplasty have allowed for additional lengthening and rotation of the nasal tip. To rebuild the nasal tip framework, we used the tip extension suture technique alone or in combination with other procedures. A retrospective, longitudinal study was conducted to evaluate the safety and efficacy of the tip extension suture technique for use in Asian rhinoplasty.

METHODS

From May of 2008 to December of 2011, 283 Asian patients underwent the tip extension suture technique and were postoperatively monitored for 6 months or longer. The tip extension suture surgical technique involves advancing the lateral crus, which is fully released from the pyriform margin-supported hinge areas, and fixing it to the caudal septum. The patients' medical charts and serial photographs were analyzed to assess outcome stability, complications (pinched deformity, skin necrosis, airway problems, or nasal valve collapse), patient satisfaction, and the need for revision surgery.

RESULTS

This technique allowed most patients to retain an altered nasal tip shape during the follow-up period. The nasal tip was incompletely corrected in 14 patients (4.9 percent), and surgical revision owing to development of pinched deformities was required in eight patients (2.8 percent). Ultimately, 92 percent of the patients were satisfied with their outcomes. Complications, such as circulation or airway problems, did not occur.

CONCLUSION

This study describes and recommends a new tip extension suture procedure for rebuilding the released nasal tip framework during Asian rhinoplasty, with fewer aesthetic and functional complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Columella lengthening by a vascularized preauricular flap

BACKGROUND

A short columella can result in significant cosmetic and functional deformities. Various techniques such as local flap transfer and composite grafts have been reported for columellar lengthening, but the overall results remain unsatisfactory. Transferring a local flap cannot provide new tissue for the columella, which limits its application. Composite grafting can provide new tissue volume, and the composite tissue from the preauricular region has an excellent color and texture match. However, the lack of a stable blood supply for the composite graft restricts its clinical application due to problems such as viability, dimensions, and atrophy. To overcome these limitations, the authors harvested a vascularized preauricular flap for columella lengthening.

METHODS

Based on the superficial temporal vessels, the vascularized preauricular flap was harvested as a free flap and transferred to the columella region. The recipient vessels were angular vessels or facial vessels, and microsurgical anastomosis was performed between recipient vessels and the pedicle. The lateral femoral circumflex vessels were used as vascular grafts when the pedicle was not long enough.

RESULTS

Eight patients who had short columellas were reconstructed with vascularized preauricular flaps. Six flaps were harvested in a reverse fashion, and the remaining two flaps were harvested in an anterograde direction. All the flaps survived well and showed a good color and texture match without hypertrophic scars. An average of 13.3 mm improvement in length was obtained for the eight patients. Two patients underwent a secondary debulking procedure to thin the flap.

CONCLUSION

The free vascularized preauricular flap procedure is a reliable method for columellar lengthening and has wide clinical application.

LEVEL OF EVIDENCE V

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 .

Correction of unilateral secondary cleft lip nose deformity by a modified Tajima's method and several adjunctive procedures based on severity

BACKGROUND

It is generally accepted that the developmental deficiency of the unilateral perinasal skeleton, cartilages, and skin originates from the secondary cleft nasal deformity. To date, numerous attempts have been made to correct these deformities, but no clinical data are available about the simpler, comprehensive, and patient-customized methods for correction of the secondary cleft nasal deformity. In the correction of Asian patients with secondary cleft nasal deformity, the clinical experience with the simplified Tajima method and several adjunctive procedures based on the severity of the disorder were retrospectively reviewed.

METHODS

During the period January 1982 to May 2009, 197 consecutive patients underwent repair through the modified Tajima method followed by several adjunctive procedures.

RESULTS

These series had no recurrence requiring surgery except for cases in which the nasal ala was depressed to some extent. The mean degree of patient satisfaction as rated on the 5-point Global Aesthetic Improvement Scale (GAIA) was 3.88 ± 0.59.

CONCLUSIONS

Various types of surgical procedures were performed using the modified Tajima method depending on the degree of alar cartilage displacement. These procedures were effective in achieving symmetry of the nasal tip for patients with secondary unilateral cleft lip.

Long-term evaluation of elongating columella using conchal composite graft in bilateral secondary cleft lip and nose deformity

BACKGROUND

A short columella is one of the most severe problems in bilateral cleft lip and nose deformity. In particular, with tissue insufficiency or scar contracture on the upper lip, it is very hard to achieve a good nasal profile with conventional methods.

METHODS

One hundred thirty-seven patients with a short columella were operated on from February of 1987 to December of 2008. The average age at operation was 7.3 years. The conchal cartilage was harvested. The preauricular or postauricular skin-subcutaneous fat composite tissue was harvested. Through a transcolumellar incision, the conchal cartilage was inset and the defect was covered with skin-fat composite tissue. The serial nasal profiles were evaluated before and after surgery. Also, the postoperative nasal profiles were compared with normal profiles. The postoperative color difference with surrounding skin was measured by the L*a*b* photographic analysis method.

RESULTS

The mean height and width of skin-subcutaneous fat composite tissue were 9.81 and 22.14 mm, respectively. The preoperative and postoperative measuring for columella height was 5.1 + or - 1.1 mm and 14.2 + or - 1.5 mm. The columella-lip angle was 120.30 + or - 12.97 preoperatively degrees and 98.76 + or - 10.98 degrees postoperatively, whereas the angle of columellar-alar triangle was 111.56 + or - 11.39 degrees and 97.91 + or - 11.49 degrees, respectively. None of the postoperative profiles were different from those of normal Korean people of the same age except in the 0- to 6-year-old group (p < 0.05). The color match was best with preauricular composite tissue. Complications included total necrosis in three cases and partial necrosis in 12 cases that were treated conservatively.

CONCLUSION

Elongating columella using a composite graft can be a satisfying alternative, especially for a severe short columella with upper lip tissue deficiency.

Nasal tip surgery using a modified septal extension graft by means of extended marginal incision

BACKGROUND

The columellar strut is considered one of the standard procedures in nasal tip surgery, as it provides a structural foundation for the nasal tip. Although effective for most Caucasians, the columellar strut often results in a suboptimal outcome and does not provide an adequate foundation in Asian tip surgery. For an optimal outcome, the authors propose a different surgical paradigm for Asian tip surgery.

METHODS

Using an extended marginal incision, a wide-field endonasal dissection is performed and the distal nasal framework including the alar cartilages and the caudal septum is exposed widely. A septal extension graft is made from a preoperatively designed paper template, with markings for anchoring the alar cartilage and overlapping with the caudal septum. The extension graft is fixed to the caudal septum and the alar cartilages are sutured to the extension graft at the precise position using markings transferred to the extension graft.

RESULTS

This procedure was applied in 217 Asian rhinoplasties, with all patients having substantial improvement in their nasal tip shape. The advantages of this technique are numerous and include stable tip support and versatility in nasal tip modification. The same basic techniques and sequence can be applied to correct a wide range of tip deformities found in Asian noses.

CONCLUSIONS

The authors' surgical paradigm combining the modified septal extension graft with wide-field endonasal dissections provides a unique opportunity to gain greater control and a more predictable outcome in Asian tip surgery. Stable septal support is crucial to the success of this technique.

Aesthetic rhinoplasty of the Asian nasal tip: a brief review

Tip surgery, the most important part of the rhinoplasty procedure, has entered a new era in the past few decades. Various treatment protocols have been attempted. To date, however, opinions on the management of the Asian tip have not been solidified. To generalize and provide appropriate guidelines for the treatment of typical Asian tips, an English literature search from 1977 to March 2007 was conducted. Finally, a total of 26 papers were selected for review. The full text of each paper was read carefully, and data were extracted. Then all extracted information was imported into Microsoft Excel. Nine articles treating 11 groups of patients described the suitable techniques for Asian nasal tips, with 81.8% of the groups advocating that the protocol include a grafting technique, 64% reporting use of the grafting technique alone, and 9% applying cartilage reduction and a suturing technique. Of the 11 (18%) groups, 2 attempted more than one technique. Because of the Asian nasal tip's innate qualities, success with nasal tip plasty for Asians depends on the combined application of appropriate suturing, grafting, and defatting, with grafting techniques contributing the most.

Correction of the nasal tip and columella in Koreans by a complete septal extension graft using an extensive harvesting technique

The nose of most Koreans is characterised by a low nasal dorsum, retracted columella, and an acute columella-labial angle. For the surgical correction of the tip and columella, a complete septal extension graft, along with augmentation rhinoplasty has been developed. However, the use of this type of graft is frequently problematic because the septal cartilage is not large enough. In a study involving 10 cadavers, a complete septal extension graft was achieved in two of them by using septal cartilage harvested according to standard techniques. Therefore, the septal cartilage was harvested, leaving a 5-mm L-shaped strut, and a complete septal extension graft was implanted. The present report describes the results obtained in 34 patients and offers an analysis of the results as judged by the columella-labial angle and three proportional indices (nose height index, nasal bridge length index, and nasal tip projection index), measured by photogrammetry. The postoperative values obtained in these four categories increased significantly compared to the preoperative ones, thus confirming that the projection of tip was augmented, the nose was lengthened, and the columella was advanced caudally. Moreover, these positive outcomes were maintained during long-term follow-up, and no side effects, such as saddle nose deformity, were reported.

Reconstruction necessitated by severe hypoplasia or a columella defect

In reconstruction necessitated by severe hypoplasia or a columella defect, the surgeon must consider various factors in each case, such as the characteristic columellar shape, color match, texture, patient age, original disease, and surrounding scars. In these cases, reconstruction of both the cartilaginous strut and the overlying skin is necessary and important to obtain good results. The authors report three cases of reconstruction of the columella with satisfactory results. Case 1 involved a 6-year-old girl with complete bilateral cleft lip and severe hypoplasia of the premaxilla and prolabium. Columellar reconstruction was performed with small triangular flaps at the columella base, together with a rib chondral graft for cartilaginous support. Case 2 involved a 12-year-old girl with a complete bilateral cleft lip and cleft palate. Columellar reconstruction was performed with small triangular flaps at the columella base, together with bilateral conchal cartilage grafts. Case 3 involved a 17-year-old boy with a right complete cleft lip and columellar defect caused by previous infection after secondary cheiloplasty. Columellar reconstruction was performed using a left nasal vestibular flap and septal cartilage grafting, together with a bilateral conchal cartilage graft beneath the flap. The authors consider the unilateral nasal vestibular flap to be very useful in carefully selected unilateral cleft cases.

Nasal tip plasty using various techniques in rhinoplasty

Rhinoplasty is one of the most common aesthetic surgical procedures in Korea today. However, simple augmentation rhinoplasty results often failed to satisfy the high expectations of patients. As a result, many procedures have been developed to improve the appearance of the nasal tip and nasal projection. However, the characteristics of Korean nasal tips including the bulbous appearance (attributable to the thickness of the skin), flared nostrils, and restriction of the nasal tip attributable to an underdeveloped medical crus of the alar cartilage and a short columella have made such procedures difficult. Currently, most plastic surgeons perform rhinoplasty simultaneously with various nasal tip plasty techniques to improve the surgical results. An important part of an aesthetically pleasing result is to ensure an adequate nasal tip positioned slightly higher than the proper dorsum, with the two tip defining points in close proximity to each other, giving the nose a triangular shape from the caudal view. From June 2002 to November 2003, the authors performed rhinoplasty with simultaneous nasal tip plasty using various techniques according to the tip status of 55 patients (25 deviated noses, 9 broad noses, 15 low noses, and 6 secondary cleft lip and nose deformities). The surgery included realignment of alar cartilage by resection and suture, fibroareolar and subcutaneous tissue resection, tip graft, and columellar strut. The postoperative results over an average period of 10 months were entirely satisfactory. There were no patient complaints, nor complications resulting from the procedures. Good nasal tip projection, natural columellar appearance, and improvement of the nasolabial angle were achieved for most patients. In conclusion, rhinoplasty with simultaneous nasal tip plasty, achieved by a variety of techniques according to patients' tip status, is an effective method for improving the appearance of the nose and satisfying the desires of the patients.

Nasal reconstruction based on aesthetic subunits in Orientals

Reconstruction based on the aesthetic subunit principle has yielded good aesthetic outcomes in patients with moderate to severe nasal defects caused by trauma or tumor resection. However, the topographic subunits previously proposed are often unsuitable for Orientals. Compared with the nose in white patients, the nose in Orientals is low, lacks nasal muscle, and has a flat glabella; the structural features of the underlying cartilage and bone are not distinctly reflected in outward appearance. The authors devised aesthetic subunits suitable for Orientals, and they used these units to reconstruct various parts of the nose. The major difference between these units and those presented previously is the lack of soft triangles and the addition of the glabella as an independent unit. The authors divided the nose into the following five topographic units: the glabella, the nasal dorsum, the nasal tip, and the two alae. The border of the nasal dorsum unit was extended to above the maxillonasal suture. The basic reconstruction techniques use a V-Y advancement flap from the forehead to reconstruct the glabella, an island flap from the forehead to reconstruct the nasal dorsum and nasal tip, a nasolabial flap to reconstruct an ala, and a malar flap to reconstruct the cheek. A combination of flaps was used when the defect involved more than one unit. This concept was used for nasal reconstruction in 24 patients. In one patient undergoing reconstruction of the nasal dorsum and in one undergoing reconstruction of the nasal tip, the texture of the forearm flap did not match well, which resulted in a slightly unsatisfactory aesthetic outcome. In one patient in whom the glabella, nasal dorsum, and part of the cheek were reconstructed simultaneously, a web was formed at the medial ocular angle, and a secondary operation was subsequently performed using Z-plasty. In one patient undergoing reconstruction with a forehead flap, defatting was required to reduce the bulk of the subcutaneous flap pedicle at the glabella. However, suture lines were placed in the most inconspicuous sites in all patients, and the use of a trapdoor contraction emphasized the three-dimensional appearance of the nose. The use of these aesthetic subunits for reconstruction offers several advantages, particularly in Oriental patients. Because the nasal dorsum is reconstructed together with the side walls, tenting of the nasal dorsum is avoided, which prevents a flat appearance of the nose. A forehead flap is useful in the repair of complex defects. Defects of the alae should be separately reconstructed with a nasolabial flap to enhance the effect of the trapdoor contraction and to highlight the three-dimensional appearance of the nose. Candidates for reconstruction should be selected on the basis of nasal structure. The results suggest that these units can also be used in some white patients.